Tag Archive for: course-NRS_420

I had a chance to take care of a patient who had multiple heart problems. He had CABG open hart surgery in the past. Now the patient developed heart valve problems and needed another surgery. However, the doctor stated that last surgery led to a complication that would not allow this patient to have another traditional open-heart surgery. Therefore, minimally invasive aortic and mitral valve replacement surgery was recommended. I was interested to find specific details about this procedure.

I found the article “Minimally invasive aortic valve replacement (MIAVR) – pros and cons of keyhole aortic surgery” that compares different approaches to heart surgeries and demonstrates the benefits of the latest approach that is minimally invasive (Kaczmarczyk, et al., 2015). This type of surgery has been evolving for the last twenty years and proves to safe, well-tolerated and efficient method. The authors explain that “minimally invasive” refers to any procedure not performed with a full sternotomy or cardiopulmonary bypass (Kaczmarczyk, et al., 2015).

There are two main types of MIAVR: partial sternotomy and intercoastal access. Lower hemisternotomy is the most popular partial sternotomy method. It provides excellent access to the heart and its vessels as well as stability of the rim of the upper limbs in postoperative period. Important advantages of this approach also include less surgical trauma, less postoperative bleeding and blood units transfused, faster recovery, shorter hospital stay and ICU stay, and less pain. It is however more technologically demanding and can often lead to failure if the surgeon does not have much experience.

Right anterior minithoracotomy scar vs. full sternotomy scar

References

Kaczmarczyk, M., SzaaÄski, P., Zembala, M., Filipiak, K., Karolak, W., Wojarski, J.,…Embala, M. (2015). Minimally invasive aortic valve replacement – pros and cons of keyhole aortic surgery. Cardiac Surgery, 12(2), 103-110.

Once upon a time there was an active 22 year old, African American male named Devone who loved playing basketball. His grandpa recently passed away from a pulmonary embolism.   He came into the ER today because he had a syncopal episode during the last quarter of the division finals for his basketball team. The nurse assessed the patient finding an irregular, thready pulse; he is pale and more fatigued than usual after a game, which has been worsening over the last week; his capillary refill is 3-4 second. His 12 lead EKG revealed atrial fibrillation with a heart rate of 140-157 bpm with no p waves.  The nurse began to assist the patient by attempting to stimulate the vagal response by having him blow through a straw which was successful in reducing heart rate to 80 bpm. The nurse also conferred with the physician to determine recommendation of anticoagulation therapy. The nurse also educated the patient on lifestyle modifications and the necessity of follow up appointment. As a result of these actions the patient was discharged with a follow-up appointment with primary physician, and prescription for 325mg of aspirin daily.

CHF—Once upon a time there was a 69-year old caucasian man named Donald Trump who had an orange comb-over. He was very angry. He reported high levels of stress. His favorite food was Freedom Fries and he ate them at almost every meal.

His health history included hyperlipidemia, a sedentary lifestyle, hypertension, obesity, heavy alcohol use and probable drug abuse. He had complaints of frequent awakening a night with shortness of breath, his favorite pink socks not fitting, recent weight gain of 7 lbs in the last week, dizziness, fatigue, weakness, a cough, chest pain, and heart palpitations

The nurse assessed the patient, finding dependent pitting edema, nocturnal paroxysmal dyspnea, confusion as evidenced by incoherent ranting about building walls and healthcare. He had obvious bilateral JVD with wheezing and bibasilar crackles. He appeared anxious and was leaning forward breathing heavily. He had a decreased urine output since admittance. His vital signs were:

Heart Rate: 127

Blood Pressure: 190/120

Spo2: 92%

Temp: 98.7

Resp Rate: 26

The nurse began to do a thorough medication history. Due to his recent stress and confusion, Trump had not been remembering to take his Carvedilol for his hypertension. He had been taking 800 milligrams of Ibuprofen 3 times a day for headaches. The patient was put on Lasix and Spironolactone. He was given oxygen via a nasal cannula. The head of his bed was elevated. The nurse educated the patient about taking his medications and lifestyle and diet changes.

As a result of these actions, the patient began to urinate, was able to sleep, maintained a normal blood pressure, reported no chest pain or shortness of breath and his lungs were clear. He lost the 7 lbs of weight he had gained over the next several days.

Recently, I watched a news clip about a restaurant in Las Vegas called “Heart Attack Grill”. Although I had heard about this restaurant a few years ago, I was surprised to see that it still currently going strong. On the website wwww.heartattackgrill.com, one finds a menu of 8,000 calorie burgers and French fries fried in lard, among other monstrosities such as full butterfat milkshakes. Additionally, customers weighing in over 350 pounds eat for free. The waitstaff are dressed up as nurses and “spank” you at the end of the meal if you do not finish your meal. Although I realize that the “concept” is supposed to be all in fun, the reality is that the sensationalism of this restaurant, the free food for obese patrons, and the cartoon-y brand-imaging of this establishment, all in the ends seem to glorify unhealthy eating choices. Since customers are REALLY being fed the funny items on the menu (even for free) and are rewarded for finishing (customer gets a glory-lap seated in a wheelchair) and for being morbidly obese, there is no realistic learning about cardiac health or anything else from this example. If a customer does not finish his/her meal, punishment is administered, reinforcing overeating.

My initial reaction was that this would NOT be an establishment that should be around, especially if children are allowed to eat there! Not only are there terrible food choices, but no real no vegetarian options. In fact, there is a “Vegan” menu but it consists of a pack of cigarettes. To confirm that this place would be bad for a child, I found a Yelp posting stating:” You can get paddled by your waitress which was happening right next to us. We saw a little child get egged on by his family to get paddled and he screamed an agony.” I suppose this means that in addition to being offered poor food choices, a child could be bullied for not finishing the meal?

With faster lifestyles, cheaper fast food options and bad role modelling, it’s no wonder children have been given permission by example in today’s society. I was interested in finding out what the American Heart Association had to say concerning pediatrics and cardiovascular health so I went to their website at http://circ.ahajournals.org/content/110/15/2266.full. The fact that American children are experiencing increases in childhood obesity brings alarm to me. In fact on looking for the statistics, I found that obesity among children has more than doubled and in adolescents, has quadrupled in the past 30 years! (Ogden, 2012). For children, this means that they are more likely to experience high cholesterol, pre-diabetes, high blood pressure, low self-esteem, sleep apnea, bone and joint problems and more…conditions that are not usually associated with pediatric health, but in adults (Hayman, 2015). Pediatric cardiac health is detrimentally being affected, a fact supported by autopsy studies that show positive associations between established risk factors from childhood obesity and the presence and extent of atherosclerotic lesions in the aorta and coronary arteries of children (Berenson, Srinivasan, Bao, Newman, Tracy, 1998).

Although the Heart Attack Grill glorifies themselves and act tongue and cheek about their establishment, regular known customers have died. Sadly their chief spokesperson, a 575-pound, 29 year old male, passed away last year. This restaurant may have a “fun”, comical image, but if a regular customer that is obese regularly eats there and dies at 29 years old, how do we explain to the next generation that that’s ok, just laugh and eat there anyway? Unfortunately, restaurants such as the Heart Attack Grill are not helping our future generation to stay healthy, only providing yet another horrible choice to the young generation. I would rather see a restaurant make more efforts to glorify healthy choices and show the next generation options that directly affect cardiac health positively, and show them that their hearts will say thank you with a long, healthy life. On a last note, the waitstaff dress up as nurses…that makes me even more sad and concerned, as it pollutes the sincere desire of real nurses to educate and care for patients’ health.

References:

Castillo, S. (2014, August 9). Heart Attack Grill Killed 2 People, But Owner Says ‘Business Is Good’ . http://www.medicaldaily.com/jon-basso-owner-heart-attack-grill-comes-bad-his-high-calorie-burgers-new-showtime-series-297394.

CDC (2015, August 27). Childhood Obesity Facts. http://www.cdc.gov/healthyschools/obesity/facts.htm.

Hayman, L. (2015). A Statement for Health and Education Professionals and Child Health Advocates From the Committee on Atherosclerosis, Hypertension, and Obesity in Youth (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. http://circ.ahajournals.org/content/110/15/2266.full

Ogden C. (2012). Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association 2014;311(8):806-814.

I chose a Saturday to track my eating. I have done projects like this in the past, and I always find it interesting because so much of what I eat has no label and contains many ingredients, making it difficult to track contents exactly. For example, on this day my roommates and I made a giant bowl of ceviche for dinner, with fresh speared yellow tail and about a dozen other ingredients. It was too difficult to track every ingredient as several people worked on it. This brings me to a concern I have: When we tell people to closely constrict certain food components, are we sometimes dissuading them from eating fresh whole foods? On the flip side, during this process I thought a lot about how hard it can be to avoid certain food components if you do eat packaged or prepared food. As a new years resolution this year I gave up processed sugar, honey, syrup, and any other incredibly sugar dense foods. I have not regretted it since, but it can make it so difficult to buy certain foods and to eat out. Even things like multigrain flakes and whole grain bread have a surprising amount of sugar in them. When I buy these foods, I have to sort through so many labels to find one that works for me, even at a place like Whole Foods. Added salt is just as ubiquitous, so I imagine It must be very hard for people to select food with that restriction, especially if they shop at a store that doesn’t strive for healthy options.

Breakfast:
Whole wheat bagel with cream cheese, sprouts, tomato, cucumber, and onion
Coffee with cream

Snack:
Smoothie- whole milk yogurt, blueberries, banana, 2% milk

Lunch:
Large Salad- many veggies, sunflower seeds, avocado
dressing- olive oil, garlic, vinegar, hemp seeds, salt and pepper, miso

Dinner:
Ceviche with chips, salad, and beans

Approximate salt for day (not including ceviche): 1,687 mg
Approximate fat for day (not including ceviche): 104.g g

I think it is easier for me to limit salt because we make most food from scratch in our house. I did pretty good on the salt score. I was pretty high for fat though. However, a decent chunk of that came from olive oil and avocado. All in all, I think the take home is that it is very difficult to keep track and restrictions can be very limiting.