Nursing Diagnoses

Nursing diagnoses differ from medical diagnoses. Simply put by NANDA (North American Nursing Diagnosis Association); "A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes." (1)

Nursing diagnoses are statements explaining the problem with relation to the source and if patient interaction has taken place, the addition of evidence (signs/symptoms) to support is preferred. For example, a person medically diagnosed with asthma could have a nursing diagnosis of ineffective airway clearance related to bronchial constriction, as evidenced by increased mucus and wheezing. Many medical diagnoses are one word pathologies. Nursing diagnoses are statements which include more depth, making the problem individualized to each patient. 

When considering diagnoses for atrial fibrillation there are several possibilities. The following are just some of these.

1. Activity intolerance related to decreased cardiac output

2, Decreased cardiac output related to altered electrical conduction

3. Fear related to threat of death, change in health status.

4. Risk for ineffective cerebral tissue perfusion related to decreased cardiac output.    

5. Ineffective health maintenance related to deficient knowledge regarding self-care with disease.

The 5th example can be universal to all conditions and I hope this blog is a source which provides the necessary knowledge to be effective with health maintenance for AF.

Ineffective health maintenance:

Actual or potential goals	Related to	Plan and outcome	Nursing intervention
·         Patient will explain in simple form what AF is and the risks involved ·         Patient will explain how anticoagulant therapy is crucial for health maintenance and the risks involved with not taking it as well as side effects possible from taking it ·         Patient will identify the lifestyle changes that will promote health maintenance for a person living with AF	·         Denial of disease ·         Disbelief in effectiveness of therapies ·         Cognitive impairment ·         Complicated grieving ·         Deficient communication skills ·         Diminished motor skills ·         Inability to make appropriate judgments ·         Ineffective coping ·         Insufficient resources (finances, equipment, etc…)	·         Discuss fear of or blocks to implementing health regimen ·         Follow mutually agreed on health care maintenance ·         Meet goals for health care maintenance	·         Educate about atrial fibrillation ·         Use teach back methods to confirm teachings have been understood ·         Provide resources for patient reference and ease of access

References:

1.     (2015, March 1). Retrieved February 26, 2015, from http://kb.nanda.org/article/AA-00266/0/What-is-the-difference-between-a-medical-diagnosis-and-a-nursing-diagnosis-.html
2.     Ladwig, G., & Ackley, B. (2011). Guide To Nursing Diagnosis (3rd ed., p. 52, 405). Maryland Heights, Missouri: Elsevier.

Nursing Care for AF

Nursing care for AF encompasses the entire individual with a focus on preventing the possible risks related to the arrhythmia and patient understanding of their pathology. Once a treatment plan has been established, the nurse's role is to help maintain the course of therapy. As there are several possible routes of intervention for AF, the nursing interventions depend upon these. (1)

Below is a table to summarize the nursing care which would accompany the form of treatment.

References:
1. Crawford, A., & Harris, H. (2009, May 1). Atrial Fibrillation: Nurses' guide to this common arrhythmia (M. Raymond, Ed.). Retrieved February 18, 2015, from http://www.modernmedicine.com/modern-medicine/news/modernmedicine/modern-medicine-feature-articles/atrial-fibrillation-nurses-guid?id=&pageID=3

Treatment: Medication	Treatment: Cardioversion	Treatment: Ablation
·         Antihypertensives (keep blood pressure in a healthy range) ·         Anticoagulants (prevent blood clotting) ·         Antiarrhythmics (prevent irregular heart conduction)	·         Conduction therapy to return the hearts rhythm back to normal	·         Destruction of malfunctioning heart cells
·         Monitor EKG rhythm, heart sounds, apical pulse, and vital signs ·         Monitor for signs and symptoms of drug side effects (hypotension, dizziness, syncope) ·         Monitor lab values; PTT and PT/INR	·         Assess patient status and determine if patient condition is declining, notify physician if cardioversion seems necessary ·         Prepare for administering sedation medication prior to cardioversion ·         Monitor vital signs before and after cardioversion ·         Assess sites of cardioversion on chest after procedure, treat with warm compress and/or analgesics if needed	·         Monitor vital signs, heart sounds, and apical pulse ·         Assess femoral insertion site for bleeding and clot formation, keep compressed ·         Assess calf and foot for signs of clot; check pulses for perfusion, pain and swelling

Treating AF

Treatment options for AF, like many diseases, depend on the severity, available treatments, and the person's desire/goal. We know how AF effects the heart and body, so we can narrow down what kind of treatments will help manage the disease and prevent progression of complications.

Common treatments for managing AF and preventing clot formation include anticoagulant therapy. Because the blood may pool in the heart during atrial fibrillation, these medications prevent the blood from clotting and causing a stroke/heart attack/pulmonary embolism. Side effects of these medications include the risk for bleeding. People taking these must be cautious with their physical activities to avoid injury and internal bleeding.

More invasive treatment options include cardioversion and surgical ablation. Cardioversion is an acute treatment option used to reset the hearts rhythm. It is usually done when the heart has been in AF for less than 48 hours. Time is a factor as cardioverting the heart after a prolonged arrhythmia may force a clot out of the heart and cause a stroke. Cardioversion may also fail to restore the hearts rhythm and possibly induce a more life threatening rhythm.

Ablation is becoming a common treatment option which is the closest treatment to a cure at the current time. This procedure is performed by a surgeon, with a rather quick recovery time for being considered a surgery. A catheter is threaded into the atria and destroys the problem tissue in the heart which is causing the electrical malfunctioning. Like any surgery there are risk factors, especially when the location is in the heart. Risks include stroke, trauma to the heart tissue, and cardiac tamponade (a life threatening problem which occurs when fluid accumulates in between the heart muscle and the lining sac which surrounds it).

These treatments can be extremely beneficial to the patient but anticoagulant therapy is often continued for life.


The following table presents a model for identifying whether a problem exists and the recommended options to pursue.

Signs and Symptoms

Signs and symptoms may vary among individuals with AF, as with many other pathologies. Some people experience symptoms and exhibit signs while some do not. Signs are objective findings which those assessing the person are able to identify. Symptoms are subjective experiences which the patient is aware of and must share if others are to know. The following are typical signs and symptoms of AF. (1)

Palpitations - when the person is able to feel abnormal and/or fast heart contractions. Feeling your heart beat is usually not normal. 

Shortness of breath

Weakness/exercise intolerance 

Chest pain

Dizziness/fainting

Confusion 

Many of these are common to a variety of diseases. The palpitations and feel of a rapid heart rate are hallmark for AF. Experiencing these symptoms benefits the person because they are able to recognize a change and will hopefully seek medical attention. Unfortunately, not everyone experiences symptoms, this increases the risk for complications such as stroke or heart attack because the person may not be aware of the arrhythmia and wait too long to seek help. (2)

References: 

1.      What Are the Signs and Symptoms of Atrial Fibrillation? (2014, September 18). Retrieved February 4, 2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/af/signs

2.      Atrial fibrillation symptoms [Motion picture]. (2012). Heart and Stroke Foundation.

How is AF diagnosed? How does it progress?

Due to the numerous causes of AF, diagnosing the disease may include several factors, including family history, signs and symptoms (palpitations, rapid heart rate, shortness of breath, etc...), physical exams, and most accurately an electrocardiogram or ECG. An ECG is a test which interprets and provides an illustration of the electrical rhythm of the heart. As we know, AF is an electrical disturbance in the heart, therefore this test provides the physician with the best presentation for determining a diagnosis. (1)

The disease typically progresses as aging progresses. Through early diagnoses, AF can usually be well controlled through lifestyle and medication. If those with AF follow their treatment plan and live a healthy life (eating well and exercising) to keep blood pressure in a healthy range and cholesterol/fat to a minimum, AF is less likely to progress into complications. The other factor influencing disease progression depends on which type of AF the person has (paroxysmal, persistent, or permanent) which we learned about last week. (2)

It is important to understand that you could have AF without knowing it. Not everyone experiences the symptoms and this can cause the disease to progress undetected. Be sure to visit your doctor for wellness and physical exams to assess your heart and promote the chance of early detection and treatment if required.

Here is an illustration of what an ECG would look like with AF in comparison to a normal rhythm. (3)

 References:

1.     How Is Atrial Fibrillation Diagnosed? (2014, September 18). Retrieved January 29, 2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/af/diagnosis
2.     Long-Term Progression and Outcomes With Aging in Patients With Lone Atrial Fibrillation. (2007, March 30). Retrieved January 28, 2015, from http://circ.ahajournals.org/content/115/24/3050.short
3.     Illustration of the electrocardiogram (ECG or EKG) in atrial fibrillation [Motion picture]. (2012). YouTube.

Etiology: What causes AF?

Referencing week one's post, we know AF is an electrical problem with the heart's pacemaker. This impulse can progress to AF from a few different causes. Chronic hypertension is very common, as long-term high blood pressure places an increased workload on the heart muscle, causing it to grow in size. Unfortunately, bigger is not always better, especially regarding the heart. Overtime, this leads to heart disease As the muscle grows, the neurons (electrical cells) are unable to deliver an adequate impulse to stimulate an efficient contraction of the muscle. This can eventually cause the pacemaker (SA node) to perform out of sequence, causing misfires. Another cause may be a problem with the actual structure of the heart, predisposing the individual to a greater risk of having the abnormal rhythm. This may be caused by family history and involve the valves of the heart or actual pacemaker. (2)

AF may present in three different categories; paroxysmal, persistent, and permanent. Paroxysmal AF may last up to a few days but stops on its own. This may progress to a more chronic type or could acute and triggered by over stimulation of the vagus nerve (affects the nervous system and blood vessels involved in heart rate and rhythm). Persistent AF is less common than paroxysmal but requires medical intervention in order to restore the hearts normal rhythm. Cardioversion is often used, this is electroshock therapy, a treatment which is intended to reset the heart back into its regular rhythm. Permanent AF is exactly what it sounds like. Cardioversion will not be effective for restoring the rhythm back to normal. This can occur over time with chronic episodes and poor controlled AF or failure to treat early onset AF. Lifelong treatment will be required. (1)

The biggest concern of being in an AF rhythm is the risk of blood clot formation. Because the atrial chambers are not distributing all their blood into the ventricle chambers, the risk of blood pooling inside the atria increases. If this is not resolved, the blood will clot and depending on which chamber the clot forms, the result could be either a pulmonary embolism (clot in the lung) or stroke (clot in the brain). 

Some of the Several Causes

References:

1.     Pathophysiology and Prevention of Atrial Fibrillation. (2001, January 1). Retrieved January 20, 2015, from http://circ.ahajournals.org/content/103/5/769.full#cited-by

2.     Kannel, W., & Benjamin, E. (2008, February 15). Final Draft Status of the Epidemiology of Atrial Fibrillation. Retrieved January 15, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2245891/#FN2

3.     Atrial Fibrillation, What Causes It? [Motion picture]. (2010). United States: EmpowHer.

Epidemiology: How common is it? Who is at risk? Morbidity and mortality.

I tend to think of an epidemic as a problem like the recent Ebola outbreak, or the influenza of 1918, or even the ever so popular idea of a zombie apocalypse. It is easy for every day morbidity's to become a normal part of life which we forget may be preventable to some extent. I think AF is one of these diseases.

When recognizing the statistical data it is obvious that AF is becoming more prevalent and we need to appreciate this. Today, approximately 2.3 million people in the US are diagnosed with AF, that's more than the population of King County! Estimated projections show this increasing to 5.6 million by 2050. Several factors are involved in the increasing prevalence of AF; chronic high blood pressure (hypertension), obesity, diabetes, cardiovascular disease, and advancements in diagnoses should be considered. (1) Most of these morbidity's are problems related to poor lifestyle habits with the exception of genetic predisposition and congenital heart defects. 

Sorry guys, we have a 1.5-fold greater likelihood of developing AF than women. (1) Though there is little research to explain why this is it suggests some relation to male genetics and/or lifestyle. 

Family history of AF also plays a role as it increases the risk for children whose parents have AF by 2-3-fold. (1)

As age increases, the occurrence and severity of AF increases. We know the risk factors include many chronic problems which may take years before causing complications with AF. The wear and tear of high blood pressure (hypertension) and fat accumulation on the heart over many years promotes AF. The disease can be controlled in many cases, preventing mortality with medication and lifestyle changes is most successful. Once diagnosed, the condition is a morbidity which usually requires attention for the remainder of life.

References:

1.     Kannel, W., & Benjamin, E. (2008, February 15). Final Draft Status of the Epidemiology of Atrial Fibrillation. Retrieved January 15, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2245891/#FN2