Question

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 that she is strictly following the fluid and salt restriction ordered during her last
hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.

1. . What error in teaching most likely occurred when M.G. was discharged 10 days ago?

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 20 mEq/day PO

2. Which of these medications may have contributed to M.G.'s HF? Explain.

3. . How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work
to reduce HF? Select all that apply. ACE inhibitors:
a. prevent the conversion of angiotensin I to angiotensin II.
b. cause systemic vasodilation.
c. promote the excretion of sodium and water in the renal tubules.
d. reduce preload and afterload.
e. increase cardiac contractility.
f. block sympathetic nervous system stimulation to the heart.

CASE STUDY PROGRESS
After reviewing M.G.'s medications, the physician writes the following medication orders.
Chart View
Medication Orders
Enalapril (Vasotec) 5mg PO bid
Carvedilol (Coreg) 3.125mg PO twice daily
Glipizide (Glucotrol) 10mg PO every morning
Furosemide (Lasix) 80mg intravenous push (IVP) now, then 40mg/day IVP
Potassium chloride (K-Dur) 20mEq/day PO

4. What is the rationale for changing the route of the furosemide (Lasix)?

5. . You administer furosemide (Lasix) 80mg IVP. Identify three parameters you would use to
monitor the effectiveness of this medication.

6.  What laboratory tests should be ordered for M.G. related to the order for furosemide (Lasix)?
Select all that apply.
a. Magnesium level
b. Sodium level
c. Complete blood count (CBC)

d. Serum glucose level
e. Potassium level
f. Coagulation studies

7. What is the purpose of the beta blocker carvedilol? It is given to:
a. increase the contractility of the heart.
b. cause peripheral vasodilation.
c. increase urine output.
d. reduce cardiac stimulation from catecholamines.

8. You assess M.G. for conditions that may be a contraindication to carvedilol. Which
condition, if present, may cause serious problems if the patient 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.
9. What is the action of the digoxin? Digoxin:
a. causes systemic vasodilation.
b. promotes the excretion of sodium and water in the renal tubules.
c. increases cardiac contractility and cardiac output.
d. blocks sympathetic nervous system stimulation to the heart.

10. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin
toxicity? Explain your answer.
a. Serum potassium level of 2.2mEq/L
b. Serum sodium level of 139mEq/L

c. Apical heart rate of 64 beats/minute
d. Digoxin level 1.6ng/mL

11. When preparing to give the digoxin, you notice that it is available in milligrams (mg) not
micrograms (mcg). Convert 125 mcg to mg.

12. M.G.'s symptoms improve with intravenous diuretics and the 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?

13. M.G. is ready for discharge. According to the mnemonic MAWDS, what key management
concepts should be taught to prevent relapse and another admission?

14. After the teaching session, which statement by M.G. indicates a need for further education?
a. “I will weigh myself daily and tell the doctor at my next visit if I am gaining weight.”
b. “I will not add salt when I am cooking.”
c. “I will try to take a short walk around the block with my husband three times a week.”
d. “I will use a pill calendar box to remind me to take my medicine.”

CASE STUDY OUTCOME
After 3  days, the STOP Heart Failure Nurse calls M.G. to ask about her progress. M.G. reports that her
weight has not changed since she has been home.

Answer 1

1. Mrs. M. G said that she had gained weight 1 - 2 pounds daily. After heart failure, any weight gain noticed should be informed the physician. If she recieved the proper health education regarding that, the second failure will not happen.

2. Answer is option B Pioglitazone (across) 45mg per oral daily morning. ACTOS, cause or exacerbate congestive heartfailure in some patients .After initiation of ACTOS, and after dose increases, monitor patients carefully for signs and symptoms of heart failure (e.g., excessive, rapid weight gain, dyspnea, and/or edema). ACTOS, like other thiazolidinediones, can cause dose-related fluid retention when used alone or in combination with other antidiabetic medications and is most common when ACTOS is used in combination with insulin. Fluid retention may lead to or exacerbate congestive heart failure. Patients should be observed for signs and symptoms of congestive heart failure.

3. Answer is option B, C and F

ACE inhibitors produce vasodilation by inhibiting the formation of angiotensin II. This vasoconstrictor is formed by the proteolytic action of renin (released by the kidneys) acting on circulating angiotensinogen to form angiotensin I. Angiotensin I is then converted to angiotensin II. Also Angiotensin II also facilitates the release of norepinephrine from sympathetic adrenergic nerves and inhibits norepinephrine reuptake by these nerves. This effect of angiotensin II augments sympathetic activity on the heart and blood vessels. Promote renal excretion of sodium and water (natriuretic and diuretic effects) by blocking the effects of angiotensin II in the kidney and by blocking angiotensin II stimulation of aldosterone secretion. This reduces blood volume, venous pressure and arterial pressure

4. Short courses of IV diuretics for volume management in patients with HF were safe and associated with significant urine output and weight loss across a wide range of maintenance diuretic doses and EF. This strategy may provide an alternative to hospitalization for the management of selected HF patients.

.

5.

6. Answer is option A, B and E

Diuretic use in the heart failure patient does carry certain risks. Various electrolyte abnormalities can occur. Inhibition of the Na-K-2Cl channel leads to increased sodium delivery to the distal tubule and cortical collecting duct. Via the ENaC channel (Na-K antiporter), distal sodium is reabsorbed at the expense of potassium loss, resulting in hypokalemia. Hypomagnesemia can occur as well, potentiating the hypokalemia. This imbalance may contribute to arrhythmias.

Chloride losses can lead to a hypochloremic metabolic alkalosis. Significant alkalosis can decrease respiratory drive in a patient with respiratory failure. Hyponatremia can also occur with diuretics.

7. Answer is option D

The precise mechanism by which beta-adrenoceptor blockers exert their beneficial actions in patients with heart failure remains unclear. Several possibilities have been proposed, including heart rate reduction, beta2-adrenoceptor-mediated modulation of catecholamine release, antagonism of the receptor-mediated toxic actions of norepinephrine on the myocardium, and favorable effects on myocardial energetics

8. Answer is option B

According to the FDA, carvedilol should not be used in people with bronchial asthma or bronchospastic conditions.

9. Answer is option B

Digoxin increases the strength and efficiency of heart contractions, and is useful in the treatment of heart failure and control the rate and rhythm of the heart. It is extracted from the leaves of a plant called digitalis lanata. Digoxin increases the force of contraction of the muscle of the heart by inhibiting the activity of an enzyme (ATPase) that controls movement of calcium, sodium, and potassium into heart muscle. Calcium controls the force of contraction. Inhibiting ATPase increases calcium in heart muscle and therefore increases the force of heart contractions.

10. Answer is option A

Chronic toxicity is often accompanied by hypokalemia.

11. 125 mcg = 0.125mg

1mcg. = 0.001mg

12. Absence of further weight gain or fluids accumulation in lower extremities indicate the dose of oral furosemide is effective

14. Answer is option A

If any weight gain, she should inform the physician immediately. Never wait for next appointment.