GROUP A BSN 4-B Manzano, Breechelle Mariano, Angela Mariano, Kristine Hazel Monje, Shiela Marie Nolledo, Junicar

Ocon, Femmie Marie Visaya, Marc Jay

Case Analysis Competency Appraisal

Situation
Berta Ruiz, 86, has become increasingly short of breath over the last three days. The home health nurse reported that Mrs. Ruiz has swelling of the ankles and seems to have less and less tolerance for activities as the days pass.
The nurse examines Mrs. Ruiz and notes that pedal edema is present, her color is poor and she does not seem as mentally alert as usual. Her pulse is weak and her repirations are somewhat labored. The physician is contacted, briefly examines the client, and request transfer to the hospital for the treatment of congestive heart failure. In the hospital a cardiologist examines the client, confirms the diagnosis and orders the following: Bed rest Vital signs QID Sodium restricted diet (1500mg) Digoxin (lanoxin) 0.125mg p.o daily tomorrow ECG STAT and tomorrow AM Furosemide (lasix) 20mg p.o OD

 Mrs. Ruiz improves steadily until the 8th day

of digoxin therapy. At the same time, she experiences nausea, vomiting, and anorexia. When the nurse checks her apical pulse before the daily dose of digoxin is administered, the rate is 60 bpm. This is lower rate than that recorded for the past few days.

Questions Discuss the indications of the drugs ordered for this particular patient. What might the gastrointestinal symptoms experienced on the 8th day of digoxin therapy mean? What drug-to-drug interaction might be present in this case? If you were the nurse who found Mrs. Ruiz apical pulse rate to be 60 beats per minute, what would you do about administering the daily dose of digoxin? What would you do about administering the daily dose of digoxin?

Case Findings:
86 years old female patient named Berta Ruiz, had experienced shortness of breath over the last 3 days. According to the home health nurse the situation of Mrs. Ruiz had affected his daily activities wherein swelling of the ankles is also present. Upon her physical assessment the nurse on duty finds out that she also had pedal edema, skin color is poor, vital signs also shows that she has a labored pulse rate and respiratory rate. Mrs. Ruiz also does not seem mentally alert. Her physician was contacted and request transfer to the hospital for treatment. Diagnosis: Congestive Heart Failure

Question Number1: Discuss the indications of the drugs ordered for this particular patient.
History shows that the client has congestive heart

failure. Lanoxin is a cardiac glycoside which leads to increased force of myocardial contraction, increased cardiac output and decreased heart rate because of these effects, there will be an improvement in circulation and tissue perfusion. Lasix is a loop diuretic which increases water excretion in the distal tubules of the kidney. There will be a decrease in the circulating blood volume, which results to decreased congestion in the heart so there would also be a decrease in myocardial contraction effort.

Number 2: What might the gastrointestinal symptoms experienced on the 8th day of digoxin therapy mean?
The GI symptoms experienced by the client on the 8th

day of digoxin therapy may indicate digoxin toxicity. The client is taking in furosemide (Lasix) which promotes potassium loss from the body. This results in hypokalemia, which leads to increased effect of digoxin at its myocardial cell site of action, resulting in digoxin toxicity. These GI symptoms (nausea, vomiting, anorexia) are due to direct action of digoxin to excite the chemoreceptor trigger zone in the area of postrema of the medulla.

Number 3: What drug-to-drug interaction might be present in this case?

Drugs that interact with digoxin: Antacids- these medicines may lower absorption of digoxin through the gastric system, if digoxin and antacids are prescribed, digoxin should be taken at least 2hours before antacids. Macrolide antibiotics- increases digoxin levels by interacting with liver enzyme that breakdown digoxin and affecting absorption in the gastric system at a protein called p-glycoprotein. Furosemide diuretics- reduced fluid levels in the body by increasing fluid excretion and may cause low potassium and magnesium levels at the same time. It is often prescribed for patients with heart failure who may also be taking digoxin. When potassium changes even in moderate amount, it can induce digoxin toxicity which may lead to heart failure and low blood pressure. Thiazide diuretics increase calcium levels when taken with digoxin.

Number 4: If you were the nurse who found Mrs. Ruizs apical pulse rate to be 60 beats per minute, what would you do about administering the daily dose of digoxin?
As a nurse, you should check the apical pulse rate

before administering digoxin. With hold the medication if the pulse rate is less than 60 bpm or lower and then notify the physician.

Number 5:What would you do about administering the daily dose of digoxin?
Explain to the client the importance of compliance with the

drug therapy. To avoid adverse drug and herb drug interactions, advise the client not to take OTC drugs without first consulting the health care provider. Instruct the client or SO to check the PR before giving the drug. Instruct client to report side effects: PR less than 60bpm, nausea and vomiting, headache, and visual disturbances. Advise client to eat foods rich in potassium: fresh and dried foods, fruit juices, vegetables including potatoes to prevent digoxin tocicity.