TRINITY UNIVERSITY OF ASIA

St. Luke’s College of Nursing

E. Rodriguez Sr. Ave., Cathedral Heights
Quezon City, Philippines

A 62-Year Old Man with Atrial Fibrillation,

Depression, and Worsening Anxiety

Submitted by:

Khan, Iris Krystal

Labrador, April Mae
Lorenzana, Erika Pauline
Lozano, Blaise Tristan
Matados, John Michael

Batch Savere Vita

4NU01- RLE GROUP #4

Submitted to:
DENNIS ABELLERA, RN
Clinical Instructor

October 18, 2019

I. INTRODUCTION
A. PAST MEDICAL HISTORY:
● 62 year old man evaluated in the psychiatry clinic due to depression and
worsening anxiety.
● Patient was diagnosed with major depressive disorder 15 years ago after
learning that his wife was diagnosed with cancer during her pregnancy.
● Depression and anxiety symptoms diminished through the use of citalopram and
clonazepam.
● 20 months PTA, patient contacted his primary care physician for recurrent
anxiety, depression, and lethargy.
● Patient was prescribed citalopram and reported improved condition, but lethargy
persisted.
● ECG was taken and showed a new atrial fibrillation with rapid ventricular
response, hence metoprolol and dabigatran were prescribed.
● 18 months PTA, patient was evaluated in a cardiology clinic where he reported
daily palpitations (BP - 140/60, HR- 60, ECG- normal sinus rhythm with slightly
prolonged corrected QT interval)
● 5 months PTA, patient reported several weeks of heightened anxiety and
recurrent depressive symptoms due to financial stressors and the diagnosis of
cancer of his girlfriend.
● He reported weekly panic attacks characterized as “racing” heart,
light-headedness, restlessness, and shaking which would last 30 minutes
● 1 month later, the patient was evaluated at a psychiatry clinic and reported his
mood was depressed and anxious, his appetite was stable but had lost 6.4kg
during the past 18 months, weekly panic attacks.
● He had persistent anxiety and panic symptoms, worsened depressive symptoms,
including difficulty concentrating, low energy, low self worth, and sleeping for 2 to
3 hours more than usual each night.

B. HISTORY OF PRESENT ILLNESS:

● On examination v/s were taken accordingly: BP - 112-67 mm Hg, HR - 64 BPM.
● Patient was well groomed, alert, oriented, cooperative, and had fluent speech.
● Patients mood was sad and dysphoric, and his affect was flat.
● His thought process was goal-directed, and his attention was intact.
● He had good insight into his worsening depressive and anxiety symptoms.
● Thyroid function, kidney function, and liver function were normal, as were
electrolyte levels and the complete blood count.
● Treatment with clonazepam and citalopram continued, and aripiprazole was
initiated.
● 2 weeks later, the patient reported marked improvement in his mood and energy
and initiation of aripiprazole; did not report any further episodes of anxiety or
 panic, had stable hypersomnia, ongoing fatigue, and late day mental fogginess.
Metoprolol was discontinued due to fatigue.
● 3 weeks later, the patient reported that he had missed work because of
increasing anxiousness, with the feeling of a racing and “thumping” heart and
excessive worry.
● He also reported that aripiprazole was not controlling his anxiety symptoms and
stated that his mood was good and his energy, sleep, and appetite were
unchanged, but had noticed weakness in his legs, restlessness, and difficulty of
breathing related to his anxiety symptoms.
● Aripiprazole dosage was increased.

II. DIAGNOSTICS
● An ​electrocardiogram (ECG​) is a medical test that detects heart
problems by measuring the electrical activity generated by the heart as it
contracts.
○ showed new atrial fibrillation with rapid ventricular response.

● A ​transthoracic echocardiogram (TTE) is the most common type of

echocardiogram, which is a still or moving image of the internal parts of
 the heart using ultrasound. In this case, the probe (or ultrasonic
transducer) is placed on the chest or abdomen of the subject to get
various views of the heart.
○ revealed left atrial and left ventricular dilatation, a low normal left
ventricular ejection fraction, mild left ventricular hypertrophy, and no
clinically significant valvular disease.
● A ​Holter monitor is a battery-operated portable device that measures and
records your heart's activity (ECG) continuously for 24 to 48 hours or
longer depending on the type of monitoring used. The device is the size of
a small camera. It has wires with silver dollar-sized electrodes that attach
to your skin.
○ the average heart rate was 65 beats per minute
○ the maximum heart rate was 84 beats per minute, and no episodes
of atrial fibrillation were detected.
● A ​psychiatric evaluation will look at symptoms and when they happen,
as well as what impact they have on family and work relationships.
○ The patient described his mood as depressed and anxious.
○ Difficulty concentrating
○ Low energy, low self-worth, and sleeping for 2 to 3 hours more than
usual each night.
○ He reported having a stable appetite but had lost 6.4 kg during the
preceding 18 months.
○ Patient reported, weekly panic attacks that were characterized by a
racing heart, light-headedness, restlessness, shaking, and
generalized weakness.
● Thyroid function tests are a series of blood tests used to measure how
well your thyroid gland is working. Available tests include the T3, T3RU,
T4, and TSH.
● Kidney function test performed through blood test: ACR (Albumin to
Creatinine Ratio) and GFR (glomerular filtration rate)
● Liver function tests ​also known as liver chemistries, help determine the
health of your liver by measuring the levels of proteins, liver enzymes, and
bilirubin in your blood.
● A ​troponin test measures the levels of troponin T or troponin I proteins in
the blood. These proteins are released when the heart muscle has been
damaged, such as occurs with a heart attack. The more damage there is
to the heart, the greater the amount of troponin T and I there will be in the
blood.
 ● Electrolyte test can help determine whether there's an electrolyte
imbalance in the body. Electrolytes are salts and minerals, such as
sodium, potassium, chloride and bicarbonate, which are found in the
blood.
● A ​toxicology screen is a test that determines the approximate amount
and type of legal or illegal drugs that you've taken. It may be used to
screen for drug abuse, to monitor a substance abuse problem, or to
evaluate drug intoxication or overdose.
● A ​complete blood count (CBC) is a blood test used to evaluate your
overall health and detect a wide range of disorders, including anemia,
infection and leukemia. A complete blood count test measures several
components and features of your blood, including: Red blood cells, which
carry oxygen.

III. DRUG STUDY

Drug Name Dosage & Route Mechanism of Action

Generic Name: SD: Linked to potentiation of

Citalopram 10 mg/5 mL; 10 mg; 20 serotonergic activity in the
mg; 40 mg central nervous system
Brand Name: resulting from its inhibition of
Celexa Recommended Dose: CNS neuronal reuptake of
20 mg orally once a day serotonin (5-HT).
Classification:
SSRI Route:
Anti-depressant Oral

Drug Name Dosage & Route Mechanism of Action

Generic Name: SD: Clonazepam works by
Clonazepam 1 mg; 0.5 mg; 2 mg; 0.25 increasing the activity of
mg; 0.125 mg gamma aminobutyric acid
Brand Name: (GABA). This is a chemical
Klonopin Recommended Dose: that sends signals
Initial dose: 0.25 mg orally 2 throughout your nervous
Classification: times per day system. If you don't have
Benzodiazepine Maintenance dose: 1 mg enough GABA, your body
Anti-seizure orally per day may be in an excited state.
Anti-epileptic Maximum dose: 4 mg/day This may cause you to have
Anxiolytics panic attacks or seizures.
Route:
Oral

Drug Name Dosage & Route Mechanism of Action

Generic Name: SD: Metoprolol belongs to a

Metoprolol 1 mg/mL; 50 mg; 100 mg; class of drugs known as
25 mg; 200 mg; 37.5 mg; 75 beta blockers. It works by
Brand Name: mg; 10 mg/mL blocking the action of certain
Lopressor natural chemicals in your
Toprol-XL Recommended Dose: body, such as epinephrine,
Metoprolol tartrate on the heart and blood
Classification: immediate release tablets: vessels. This effect lowers
Beta blocker 50 mg orally twice a day the heart rate, blood
Anti-angina -Metoprolol succinate pressure, and strain on the
extended release tablets: heart.
100 mg orally once a day

Maintenance dose: 100 to

400 mg per day

Route:
 Oral

Drug Name Dosage & Route Mechanism of Action

Generic Name: SD: Dabigatran (Pradaxa)

Dagibatran 75 mg; 110 mg; 150 mg reversibly binds to the active
site on the thrombin
Brand Name: Recommended Dose: molecule, preventing
Pradaxa 150 mg orally twice a day thrombin-mediated activation
of coagulation factors. ...
Classification: Route: Thrombin receptors.
Anti-coagulant Oral Dabigatran binds to the
active site, independent of
fibrin-binding, thereby
reducing conversion of
coagulation factors.

Drug Name Dosage & Route Mechanism of Action

Generic Name: SD: Aripiprazole blocks the

Aripiprazole 5 mg; 10 mg; 15 mg; 20 dopamine receptors in these
mg; 30 mg; 2 mg; 1 areas and so prevents the
Brand Name: mg/mL; 9.75 mg/1.3 mL; overactivity. This helps
Abilify, Abilify Discmelt 300 mg; 400 mg; 441 control the positive
mg/1.6 mL; 662 mg/2.4 symptoms of the disease
Classification: mL; 882 mg/3.2 mL;
Antipsychotic 1064 mg/3.9 mL; 675
mg/2.4 mL

Recommended Dose:
Initial dose: 2 to 5 mg
orally once a day
 (Doses may be adjusted
in increments up to 5 mg
per day at intervals of no
less than 1 week)

Maintenance dose: 2 to
15 mg once a day

Maximum dose: 15
mg/day

Route:
Oral

IV. NCP

Assessment Nursing Diagnosis Nursing Interventions

Subjective: Activity intolerance related 1. Assess patient’s ability to

Patient stated that he to malaise as evidenced perform ADL
is feeling a sensation by sensation of weakness 2. Promote ROM exercises
of weakness on his with intervals
legs 3. Assist patient in transferring
4. Kept side rails up and bed
at the lowest possible level
5. Kept necessary equipment
at a reachable distance

Assessment Nursing Diagnosis Nursing Interventions

Subjective: Ineffective breathing 1. Assess patient’s breathing
Patient stated that he pattern related to anxiety pattern, respiratory rate and
is having difficulty of as evidenced by complaint O2 saturation
breathing related to his of patient 2. Assist patient in assuming
anxiety comfortable position
3. Promoted deep breathing
exercises
4. Elevated the head of the
bed
5. Administer O2 as ordered

Assessment Nursing Diagnosis Nursing Interventions

Subjective: Fatigue 1. Assess patient’s ability to

Patient stated that he do ADL
is having a feeling of 2. Assess patient’s emotional
fatigue and has late response to fatigue
day mental fogginess 3. Promote bed rest
4. Allow patient to express
feelings towards fatigue
5. Promote ROM exercises

Assessment Nursing Diagnosis Nursing Interventions

Subjective data: Anxiety related to 1. Recognize awareness of

○ Patient reported situational crisis as the patient’s anxiety.
weekly panic evidenced by reported 2. Use presence, ​touch​ (with
attacks that were panic attacks permission), verbalization,
characterized by a and demeanor to remind
racing heart, patients that they are not
light-headedness, alone and to encourage
restlessness, expression or clarification
shaking, and of needs, concerns,
generalized unknowns, and questions.
weakness
 3. Interact with patient in a
○ Reported several peaceful manner.
weeks of 4. Accept patient’s defenses;
heightened do not dare, argue, or
anxiety due to debate.
financial stressors 5. Converse using a simple
and the fact that language and brief
his girlfriend of statements.
several years had 6. Assist the patient in
received a developing new
diagnosis of anxiety-reducing skills (e.g.,
recurrent cancer. relaxation​, deep breathing,
positive visualization, and
reassuring self-statements).

Assessment Nursing Diagnosis Nursing Interventions

Objective: Spiritual distress related to 1. Assess what spiritual

● Patient had chronic illness of others practices have offered
received a comfort and meaning to the
diagnosis of client’s life when not ill.
major 2. Encourage client to write a
depressive journal expressing thoughts
disorder after and reflections daily.
his wife had
received a 3. Discuss with the client what
has given comfort and
diagnosis of
meaning to the person in
cancer
the past.
● Difficulty
4. Suggest that the spiritual
concentrating
leader affiliated with the
● Low energy
facility contact the client.
● Feeling of low 5. Provide information on
self-worth referrals, when needed, for
● Sleeping for 2 religious or spiritual
to 3 hours information (e.g., readings,
more than
 usual each programs, tapes,
night community resources).
● Patient had lost
6.4 kg during
the preceding
18 months