Critical Thinking Case Studies Dealing With Cardiac Glycosides PDF

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Case Study regarding cardiac medications!...

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Carciac Glycosides CRITICAL THINKING CASE STUDY 1 1. A patient is admitted to the hospital emergency room with shortness of breath, cold, clammy skin, a heart rate of 100 beats/minute, and a cough producing pink, frothy sputum. A probable diagnosis of heart failure and pulmonary edema has been established. What nursing procedures might be taken immediately to make her more comfortable? What drugs are likely to be needed?  You would give the patient nitroglycerin, oral diuretics, beta blockers, ace inhibitors, and vasodilators.  In order to make her more comfortable, you would give her oxygen. 2 A patient comes into the emergency room in a state of extreme anxiety, expressing a fear that he is dying. His pulse is thready, rapid, and irregular with a rate of 150 beats/minute. A probable diagnosis of atrial fibrillation is established. What drugs are likely to be needed? What other techniques are known to be useful in stopping an attack such as this? 

You will need cardiac glycosides and calcium channel blocker. Some other techniques to use are to limit salt intake to 2 g a day, avoid excessive alcohol, fluid intake restriction, smoking should be avoided, mild exercise, saturated fat intake should be decreased, and obese patients should modify unhealthy behaviors.

3 A patient appears chronically ill. He has recurrent chest pain and reports shortness of breath. The probable diagnosis is angina. What drugs are likely to be useful in managing his condition? 

Nitrates would help relieve the patients pain, and beta blockers and-calcium channel blockers would be useful to manage his conditions.

4 After a heart attack, a patient was placed on warfarin (Coumadin), 10 mg per day. He has returned to work and feels well. However, he is annoyed that he has to have periodic blood tests and checkups. How can you help him understand the need for these tests? 

Warfarin (coumadin) is a anticoagulant, which may cause bleeding on the inside of your body. This can result in death. We need to draw blood so we make sure you aren’t bleeding internally and make sure that the drug is in therapeutic range.

5 The patient comes to the office to have his rash checked. He fears he may be allergic to his warfarin (Coumadin). You see that he has large, deep-red spots on his forearms, some measuring 10 cm in diameter. What is the cause of the rash? What should be done? 

The cause of the rash is due to bleeding somewhere deep in his arm. He should stop taking the coumadin so he can prevent further damage.

CRITICAL THINKING CASE STUDY 2

1.A nurse administered 125 mg of digoxin instead of 0.125 mg of digoxin intravenously. The patient has developed a severe heart block dysrhythmia, and the slow heart rate has not responded to administration of atropine and other measures. What will the nurse expect to give next? How could this situation have been prevented? 

The nurse should give phenytoin and lidocaine next. This could have been prevented by double checking the dosage of the medication and check for leading zeros if there wasn’t one.

2 The nurse is making morning medication rounds. One patient, a 78-year-old man, states that he has been nauseous and without an appetite and has experienced some diarrhea. He has been taking digoxin for the past few weeks for the treatment of recently diagnosed heart failure. What should the nurse do next? Explain. 

The nurse should get an order to check the patients serum digoxin levels and report these signs and symptoms to a health care provider. Since this patient is older, he is more prone to digoxin toxicity.

3 A patient is receiving an ACE inhibitor, a diuretic, and a beta-blocker as treatment for mild heart failure. He has a history of hypothyroidism, which is controlled by thyroid replacement hormones, and chronic bronchitis. He states that he stopped smoking a year ago after smoking two packs a day for 30 years. This morning he complains of a dry cough but says he does not feel short of breath, even when getting up to go to the bathroom. He is unable to produce any sputum. When the nurse listens to his lungs, his breath sounds are clear except for very few scattered rhonchi bilaterally. His weight is the same as yesterday's weight, and his ankles show only trace edema (2 days ago he had 21 edema on the edema scale). His temperature is 98.4° F (36.9° C), his pulse is 88 beats/min, and his blood pressure is 124/86. He says to the nurse, “This cough is awful! Is my heart failure getting worse, or am I getting pneumonia?” What is the nurse's best answer? 

“You do not have any worsening symptoms of heart failure, and no current symptoms of pneumonia are present either. The cough you are experiencing is most likely due to your chronic bronchitis, and is getting worse due to the ace inhibitor.”

Antianginals CRITICAL THINKING CASE STUDY 1 D.K., a 72-year-old man, had an MI 5 years ago. He has been having angina attacks at night and at rest while watching television. He complains of stabbing pain in the chest that lasts 5 minutes. Pain does not radiate to the arm. D.K. is prescribed propranolol (Inderal), 20 mg q.i.d. His vital signs are blood pressure 108/58; pulse 56 (at times irregular); and respirations 28. His clinical history indicates that he has mild asthma. 1.

What other clinical information is needed in regard to D.K.'s health problem and drug?

2. Of the various types of angina, D.K.'s angina occurrence may indicate which type? Explain your answer. D.K.’s angina occurrence indicates he has variant angina due to all of his angina attacks occurring while he is resting and not doing anything that requires stress. 2. What assessments should the nurse make while D.K. is taking propranolol? Is propranolol an appropriate anginal drug for D.K.? Explain your answer.  Vitals should be monitored closely , and he should be tapered off of propranolol so he does not experience a rebound effect. Propranolol is not an appropriate drug for D.K. due to it being a beta blocker which is not efficient in the treatment of variant angina. 3. What client teaching should be included for D.K. in regard to his health history and drug?  

D.K. notified the health care provider that he was having “dizzy spells.” His blood pressure was 86/50, pulse 46, and respirations 30. His propranolol was stopped, and diltiazem (Cardizem), 30 mg q.i.d., was ordered. He is experiencing an increasing amount of wheezing. 5.

What are the correlations between D.K.'s dizziness, wheezing, and vital signs and propranolol? 

Propranolol can cause bronchospasm, a decrease in blood pressure and heart rate. Bronchospasms cause the wheezing, and decrease in blood pressure causes the dizziness. Vital signs should be monitored.

6. Is the diltiazem ordered for D.K. within the therapeutic dosage range? In what ways could this drug benefit D.K.? 

Yes, the diltiazem is in therapeutic dosage range. This can benefit him due to it being effective in treating variant angina. It will relax the coronary arteries, which decrease vasospasms and increases oxygen supply.

7. List the side effects of diltiazem that should be included in client teaching. What other pertinent information should the nurse include in the teaching data for D.K.? 

8.

Peripheral edema, changes in liver and kidney function, headache, dizziness and flushing of the skin. D.K. should not stop taking this medication altogether. He should talk to the doctor about getting off of it, and he will be tapered off. What other drug regimen might be helpful to D.K.?

 CRITICAL THINKING CASE STUDY 2 1. Mrs. A. has been shoveling snow all morning. As you work on the snow in your yard, you see her suddenly sit down in her driveway. When you go over to check on her, she says that she has



nitroglycerin tablets in her jacket pocket but she forgot how to take them. What is the best action at this time? Get Mrs. A inside and get her to sit down. Let her know that she needs to take them sublingually. She should put one under her tongue and let it dissolve. She should also know it does not need to be swallowed because it’ll be less effective.

2 Your patient has been switched from oral nitroglycerin capsules to a transdermal form. What are the priorities for patient teaching regarding transdermal nitroglycerin therapy? 

When the patches are discontinued, the dose needs to be tapered over several weeks to prevent severe pain. The onset of action is 4-6 hours, and needs to be applied once a day, but should be removed at night.

3 Mr. J. is a 45-year-old man with stable angina who has recently been prescribed sublingual nitroglycerin tablets for the relief of his anginal attacks. He asks you how many milligrams of nitroglycerin are in his tablets. All the bottle says is “1/150 grain tablets.” How many milligrams of nitroglycerin are in Mr. J.'s 1/150 grain tablets? 

Mr. J’s tablets are 0.4 mg. (Figure out by multiplying 1/150*60).

Diuretics CRITICAL THINKING CASE STUDY 1 S.T., a 64-year-old woman, has heart failure (HF), which has been controlled with digoxin, furosemide (Lasix), and a low-sodium diet. She is taking potassium chloride (KCl) 20 mEq orally per day. Three days ago, S.T. had flulike symptoms of anorexia, lethargy, and diarrhea. Her fluid and food intake was diminished. She refused to take the KCl, stating that the drug makes her sick. She has taken the digoxin and furosemide daily. The nurse's assessment during the home visit includes poor skin turgor, poor muscle tone, irregular pulse rate, and decreased bowel sounds. The nurse obtained a blood sample for serum electrolytes; results indicated potassium (K) 2.9 mEq/L, sodium (Na) 137 mEq/L, and chloride (Cl) 96 mEq/L. 1. List reference values for serum potassium (K), serum sodium (Na), and serum chloride (Cl). Are S.T.'s electrolytes within normal range? Explain your answer. K: 3.5-5.0 mEq/L, Na: 13*-145 mEq/L, Cl: 96106mEq/L. S.Ts sodium level is normal. His potassium levels are low due to them being under 3.5, and his chloride levels are right on the dot. 2.

Match S.T.'s physical findings with the corresponding electrolyte imbalance. 

3.

Hyperkalemia is the reason she has muscle weakness, anorexia, nausea and vomiting. Since her chloride levels are within normal limits but are on the lower side, it could be the cause of her lethargy and irregular pulse. What are the reasons for the electrolyte imbalance?

She stopped taking her potassium chloride which led to her electrolyte imbalance. Another reason could have been due to her food and fluid intakes being diminished. 4. S.T. said she was not taking KCl because the drug makes her sick. What information can you give her concerning the administration of potassium?  ST should be informed that since her potassium levels are already low, she needs to keep taking them. There are other medications that can be given to stop the nausea and vomiting she has. If she does not take them, her potassium will just get lower, creating more health problems. 5. What is the effect of furosemide on digoxin when there is a potassium deficit? Explain your answer.  Furosemide can cause potassium loss in the body. This can cause the digoxin to increase its effect in the cells. Therefore, it can cause digitalis toxicity. 6. The nurse should assess S.T. for digitalis toxicity. Why? List the signs and symptoms of digitalis toxicity.  Signs and symptoms of digitalis toxicity include bradycardia, diarrhea, vomiting, nausea, and anorexia. 

S.T. was referred to the health care provider because of her serum potassium deficit and its effect on digoxin. A repeat serum potassium determination was taken, and the result was 2.8 mEq/L. A liter of dextrose 5% in water with KCl 40 mEq/L was administered over 4 hours. 7. How many milliequivalents of KCl per hour would S.T. receive? Does this amount constitute an acceptable dosage? 

10mEq/100mL of KCl per hour. This amount does constitute as an acceptable dosage but it should not exceed 10mEq/hr for a 24 hour period.

8.Why is it important that the nurse monitor the rate of intravenous fluids containing potassium, the hourly urine output, and vital signs? 

The nurse should monitor the IV fluids containing potassium, the hourly urine output, and vital signs so they can monitor the potassium levels in the body to make sure she is not dehydrated.

9. Because of the low serum potassium level, what other electrolyte value should be checked? Explain your answer. 

Magnesium, Calcium, Chloride, and Sodium should also be checked to make sure they are in normal limits as well.

After S.T.'s serum electrolytes returned to normal, the health care provider instructed her to continue taking the prescribed KCl dosage daily with her other medications. 10.

S.T. asks you why she has to continue taking these drugs. What should be your response?

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“In order for you to recover faster, you must take the recommended dosage for the recommended time. This will be effective once you finish the dosage in the correct time frame.”

11. The nurse instructs S.T. to eat foods rich in potassium. Which foods are the richest sources of potassium? 

Tuna, fruits, and vegetables such as mangos, oranges, avocados, tomatoes, cucumbers, spinach, strawberries, and bananas.

CRITICAL THINKING CASE STUDY 2 1. After taking hydrochlorothiazide (HydroDIURIL) for hypertension for 1 year, a patient now comes to the office with complaints of fatigue and weakness and many somatic complaints that include nonspecific malaise. Her blood pressure is 130/80 mm Hg. The doctor orders serum electrolyte determinations. The results are sodium, 145 mEq/L; potassium, 2.8 mEq/L; chloride, 110 mEq/L; and carbon dioxide, 28 mEq/L. What may be her problem? How can it be helped?  2 A patient has noted nausea and vomiting since he has been taking nitrofurantoin (Furadantin) for a urinary tract infection. He is now concerned that he is coming down with an intestinal virus and asks you to see if the doctor will give him some trimethobenzamide hydrochloride (Tigan), which he says usually works for him. Would you have any other recommendations?  3 A patient wants to see if the doctor will give him a prescription for sildenafil citrate (Viagra). What questions should be asked about his medical history? 

If they have had any significant cardiovascular disease and if they have any atomic deformities or conditions that predispose him to priapism.

4 A patient is brought to the office by his mother. She expresses a great deal of annoyance with the child because no matter “what she does” he continues to wet the bed. The mother has been withholding fluids after 5 pm, waking him up three times a night, setting alarm clocks for him to wake up, and so on. Nothing seems to work. What discussion would be appropriate with this mother?  5 A patient presents with pitting edema of the lower extremities that has slowly worsened over the last 3 days. He is worried because he can't take “water pills”; his potassium goes down too low. Which of the diuretics may be of use this time? 

A potassium-sparing diuretic.

CRITICAL THINKING CASE STUDY 3

J.Q., a 58-year-old man, has recently been diagnosed with hypertension. His resting blood pressure is 158/92. He has been prescribed hydrochlorothiazide (HydroDIURIL), 50 mg/day, and told to eat foods rich in potassium. 1. How does hydrochlorothiazide differ from furosemide? What are their similarities and differences? Furosemide acts on the loop of the Henle, and hydrochlorithiazide acts on distal tubules. Both decrease reabsorption of water, sodium, and potassium. 2. Why is it necessary for J.Q. to eat foods rich in potassium when taking hydrochlorothiazide? Explain your answer.  He needs to eat potassium rich foods because hydrochlorothiazide promotes the loss of potassium from the body. 3. What are the nursing interventions that should be considered while J.Q. takes HydroDIURIL?  Eat a high potassium diet, if he has hypersensitivity and watch for an imbalance in electrolytes. 

After a month on hydrochlorothiazide therapy, J.Q. becomes weak and complains of nausea and vomiting. His muscles are “soft.” His serum potassium level is 3.3 mEq/L. J.Q.'s diuretic is changed to triamterene/hydrochlorothiazide (Dyazide). Again, he is advised to eat foods rich in potassium. (Refer to Chapters 15 and 16 as needed.) 4. Explain the rationale for changing J.Q.'s diuretic.  The hydrochlorothiazide therapy was causing too much of a potassium loss in his body so they changed his diuretic to a potassium-sparing diuretic to help get rid of some of these side effects from not having enough potassium. 5. Should J.Q. receive a potassium supplement? Explain your answer.  No, because when you take a potassium-sparing diuretic along with a potassium supplement it leads to hyperkalemia, which is a potassium excess. 6. What nursing interventions should be followed for J.Q.?  The nurse should monitor JQs vital signs and serum electrolyte levels. Urine output, symptoms of hyperkalemia, and weight changes should also be monitored. 7. What care plan should the nurse develop for J.Q. in relation to client teaching?  8. What medical follow-up care is needed for J.Q.?  CRITICAL THINKING CASE STUDY 4 While assessing a patient who is taking a diuretic, the nurse notes the following blood pressure (BP) readings: BP while lying in bed: 134/86 BP while sitting on the side of the bed: 130/82

BP while standing: 108/62 In addition, the patient commented that he felt “woozy” while standing. What has happened, and what is the nurse's priority at this time? 

The patient had experienced a drop in orthostatic pressure. The patient should sit down in order to not feel woozy anymore. If the patient were to sit a minute or two before standing, the drop in blood pressure would not have occurred.

2 A patient has been given a new order for spironolactone (Aldactone), 50 mg daily. While reviewing the patient's orders, the nurse notes that the patient has an existing order for potassium chloride (K-Dur), 20 mEq daily. The patient's potassium level is 3.9 mEq/L. What is the nurse's best action at this time? 

Administer the medication, but notify the physician.

3 The nurse is administering a thiazide diuretic to a patient who has been receiving digoxin for several months as part of treatment for a cardiac dysrhythmia. What concerns should the nurse be aware of regarding these medications? 

Thiazides can cause hypokalemia, which enhances the action of digoxin, and digitalis toxicity can occur. Thiazides can also induce hypercalcemia, which enhances the action of digoxin, resulting in possible digitalis toxicity.

G.G., a 72-year-old African-American woman, has heart failure (HF) and diabetes. Her vital signs are blood pressure 176/94; pulse 92; respirations 30. Her medications include hydrochlorothiazide 50 mg/d, atenolol 50 mg/d, and digoxin 0.25 mg/d. 1. Why was hydrochlorothiazide prescribed for G.G.? Explain the effects of hydrochlorothiazide on blood pressure. (See Chapter 43.) 

It was prescribed to lower G.Gs blood pressure. Hydrochlorothiazide acts directly on arterioles to cause vasodilation, which can help lower blood pressure.

2. Abnormal electrolytes and other laboratory test results may occur when taking hydrochlorothiazide. Would the following serum electrolyte and laboratory values be expected to increase or decrease? a.

Sodium- decrease

b.

Potassium-decrease

c.

Calcium-increase

d.

Magnesium-decrease

e.

Glucose-increase

f.

Uric acid-increase

2. Why sho...