Which findings from M.G.s assessment would indicate an increased possibility of digoxin toxicity?
Case Study 1 Name_________________________________ Class/Group ______________________________ Date ___________
Scenario M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are as big as tree trunks.” After further questioning, you learn she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds (0.5 to 1 kg) every day since her discharge.
1. What error in discharge teaching most likely occurred? 2. An echocardiogram revealed that her ejection fraction (EF) is
30%, but it was 40% a month ago. What is EF, and what does the decreased number indicate?
Case Study Progress During the admission interview, the nurse makes a list of the medications M.G. took at home.
Chart View
Nursing Assessment: Medications Taken at Home
Enalapril (Vasotec) 5 mg PO bid
Pioglitazone (Actos) 45 mg PO every morning
Furosemide (Lasix) 40 mg/day PO
Potassium chloride (K-Dur) 20 mEq/day PO
3. Which of these medications may have contributed to M.G.’s HF? Explain.
4. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce HF? Select all that apply.
a. Cause systemic vasodilation b. Increase cardiac contractility c. Reduce preload and afterload d. Prevent the conversion of angiotensin I to
angiotensin II e. Block sympathetic nervous system stimulation to
the heart f. Promote the excretion of sodium and water in the
renal tubules
Case Study Progress After reviewing M.G.’s medications, the cardiologist writes the following medication orders.
Chart View
Medication Orders
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 3.125 mg PO twice daily
Metformin (Glucophage)
500 mg twice daily
Furosemide (Lasix) 80 mg intravenous push (IVP) now, then 40 mg/day IVP
Potassium chloride (K- Dur)
20 mEq/day PO
5. What is the rationale for changing the route of the furosemide (Lasix)?
6. You give furosemide (Lasix) 80 mg IVP. Identify at least 4 parameters you would use to monitor the effectiveness of this medication.
7. What lab tests should be ordered for M.G. related to the order for furosemide (Lasix)? Select all that apply.
a. Sodium level b. Potassium level c. Magnesium level d. Coagulation studies e. Serum glucose level f. Complete blood count
8. What is the reason for ordering the beta blocker carvedilol? a. Increase urine output b. Cause peripheral vasodilation c. Increase the contractility of the heart d. Reduce cardiac stimulation from catecholamines
9. You assess M.G. for conditions that may be a
contraindication to carvedilol. Which condition, if present, may cause serious problems if she takes this medication?
a. Angina b. Asthma c. Glaucoma d. Hypertension
Case Study Progress One day later, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders.
10. What is the mechanism of action of digoxin? a. Causes systemic vasodilation b. Increases cardiac contractility and cardiac output c. Blocks sympathetic nervous system stimulation to
the heart d. Promotes the excretion of sodium and water in the
renal tubules 11. Which findings from M.G.’s assessment would indicate an
increased possibility of digoxin toxicity? Explain your answer. a. Digoxin level 1.6 ng/mL (2.05 mmol/L) b. Serum sodium level of 139 mEq/L (138 mmol/L) c. Apical heart rate of 64 d. Serum potassium level of 2.2 mEq/L (2.2 mmol/L)
12. When preparing to give the digoxin, you notice that it is
available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg.
13. After 2 days, M.G.’s symptoms improve with intravenous diuretics and digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate for achievement of a euvolemic state. What will determine whether the oral dose will be adequate for discharge to be considered?
14. M.G. is ready for discharge. According to the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission?
15. After the teaching session, the nurse asks M.G. to “teach back” one important concept of care at home. Which statement by M.G. indicates a need for further education? Explain your answer.
a. “I will not add salt when I am cooking.”
b. “I will use a weekly pill calendar box to remind me to take my medicine.”
c. “I will weigh myself daily and tell the doctor at my next visit if I am gaining weight.”
d. “I will try to take a short walk around the block with my husband three times a week.”
Case Study Outcome After M.G. has been at home for 2 days, the STOP Heart Failure Nurse Navigator calls to ask about her progress. M.G. reports that her weight has not increased since she has been home and she is breathing more easily.