Critical Thinking Exercise

Situation:
Samuel, is 67-year-old with congestive heart failure who has been maintained on
digoxin 0.125 mg, per orem, daily for so many years without problem. He is now admitted at
MCMC with bilateral ankle edema, weight gain of 12 pounds, dyspnea on exertion and fatigue.
His admission electrocardiogran showed atrial fibrillation. His digoxin level was 0.9 ng/mL. He
was placed on the following medications.
 Digoxin 0.125 mg, p.o. daily
 Lanoxin 80 mg now then Lasix 40 mg, p.o. bid
 K-dur 20 mEq, p.o. daily
 Amiodarone 200 mg, p.o. daily
 Heparin 1,000 units/hour, IV after loading dose of 10,000 units)

1. What is the concern of giving digoxin and lasix together?

 Digoxin is given to patient with heart problems like atrial fibrillation and irregular heartbeats
(arrhythmias). It can also be used in conjunction with other medications to help manage the
symptoms of heart failure.
 On the other hand, Lasix is a loop diuretic which has a mechanism of action that prevents
the body from absorbing sodium and chloride in the distal tubules and the loop of Henle.
This drug is used to treat fluid retention (edema) in people who have heart failure, liver
disease, or a kidney disorder like nephrotic syndrome.
 When these two is given together, the amount of potassium in your blood may decrease. The
effects of your digitalis glycoside medicine may be amplified as a result of this. To take both
medications safely, you may need to make dose adjustments or undergo additional testing.
When furosemide and digoxin are taken together, your digoxin, potassium, and magnesium
levels may need to be checked more frequently.

2. What are the signs of digitalis toxicity?

Gastrointestinal effects (nausea and vomiting)
Hyperkalemia
 Cardiovascular effects
1. Bradydysrhythmia heart rate <60 or atrioventricular block
2. Tachydysrhythmias (ventricular tachycardia/fibrillation)
3. atrial tachycardia 
 Anorexia
 Nausea and vomiting
 Abdominal pain
 Visual disturbances
 Fatigue, weakness
 Ventricular arrhythmias
 Atrioventricular block
 Atrial arrhythmias
 Sinus bradycardia

Why is the above client receiving heparin?

Heparin is classified as anticoagulants or blood thinners. Patients who are diagnosed for heart
failure with atrial fibrillation are more likely to undergo into thrombus formation. Hence, heparin
is used to reduce morbidity and mortality to patients with chronic heart failure.

What consideration must be given to the dosage of either digoxin or amiodarone since they are
being administered together?
 Monitoring for alterations in normal vital signs.
 Allergy to digitalis preparations should be assessed.
 Monitor liver function tests.
 Observe for changes in levels of consciousness.

If the first dose of Lasix 80 mg IVF is given at 8 am, when is the next dose of heparin 40 mg,
IV?
 Heparin will be administered at 9 am.
If the above patient manifest heparin toxicity, what medication is to be given to reverse its
toxicology effect?
 The antidote to be administered for heparin toxicity is protamine sulphate, a cationic
polypeptide that will neutralize the effects of heparin.

If the first dose of amiodarone 200 mg, p.o. given at 9 am, when is the next dose of this drug?
 The next dose will be the following day, at 9 am since Amiodarone is only prescribed to
be given once daily.

Based on the situation above, formulate one (1) priority nursing diagnosis using Problem,
Etiology and Signs/Symptoms (PES) format
Nursing Problem: Excessive fluid volume
Etiology/Related to: use of diuretics
Signs/Symptoms: as evidenced by hypertension, weight gain, edema, and dyspnea.

Reviewing the situation above, find an acceptable medical abbreviation and give its definition.
 p.o – medication should be given orally or by mouth
 b.i.d – twice daily
 IVF – Intravenous fluid
 o.d – Once daily