Module 5 Pharmacology Reasoning Bradycardia

Module 5 Pharmacology Reasoning Bradycardia Suggested Answer Guidelines Marilyn Fitch, 78 years old Medication Categories: Concepts/Content: Antidysrhythmics Assessment ACE Inhibitors Drug-drug interactions Beta Blockers Evaluation of desired outcomes Statins Monitoring for adverse effects Oral Anticoagulants Emergency treatment of dysrhythmias Diuretics Client education Electrolytes Psychosocial support NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% X • Safety and Infection Control 9-15% X Health Promotion and Maintenance 6-12% X Psychosocial Integrity 6-12% X Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% X • Reduction of Risk Potential 9-15% X • Physiological Adaptation 11-17% X © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN I. Initial Presentation: Marilyn Fitch is a 78-year-old Caucasian woman with a history of hypercholesteremia, hypertension, and heart failure and has NKDA. She was brought in by her daughter after Marilyn complained of feeling dizzy several times this morning and then almost passed out at home. Marilyn has a six-month history of paroxysmal atrial fibrillation. Her heart rate has been regular and she has had no episodic dizziness since she had a synchronized cardioversion one week prior to this visit. Her initial VS in triage were: T: 98.9 F/37.2 C (oral) P: 52 R: 16 BP: 94/52 and O2 sat: 98% room air. Personal/Social History: Marilyn is a widow and lives alone in her own home. She denies smoking and admits to drinking one glass of wine with her dinner. 1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: • Hypercholesterolemia Hypertension Heart failure • Dizziness/ almost passing out • 6-month paroxysmal A fib • Synchronized cardioversion • Pulse of 52, BP 94/52 • All of these are risk factors (especially when combined) for heart attack and stroke • Concerning signs of heart rhythm changes • Vitals of low HR and Low BP, usually if one of these two vitals changes, the other will increase to compensate. RELEVANT Data from Social History: Clinical Significance: • Widow and lives alone • Drinking wine with dinner • Shows the pt doesn’t have much of a support system, and there could be psychosocial aspects to include in her care • Drinking 1 glass of wine with dinner is usually ok, in a healthy individual. Since she has heart problems, cholesterol issues and hypertension, she should restrict alcohol use. 2. What is the RELATIONSHIP of the past medical history and current medications? Why is your patient receiving these medications? (Which medication treats which condition? Draw lines to connect) Medical History (PMH): Home Medications: Hypercholesteremia Apixaban 2.5 mg po bid Hypertension Captopril 100 mg po BID daily Heart failure Amiodarone 100 mg po bid Atrial fibrillation Hydrochlorothiazide 50 mg po daily Atorvastatin 10 mg po daily Carvedilol 6.25 mg po bid 3. List each home medication from the scenario and answer the following: (NCLEX Pharmacologic and Parenteral Therapies) Home Medication : Pharm . Class: Indication(s): Mechanism of Action In OWN WORDS: Body Syste m Impacte d Common Side Effects: (1- 3) Nursing Assessments: Apixaban 2.5 mg po bid Anticoagulant Decreases risk of stroke/systemic embolism associated with nonvalvular atrial fibrillation It’s a highly selective and reversible inhibitor of factor Xa. It prevents the conversion of prothrombin to thrombin. CV, HEMA -Bleeding. Symptoms may include: nosebleeds bruising more easily heavy menstrual bleeding bleeding of your gums when you brush your teeth Assess patient for symptoms of stroke or peripheral vascular disease periodically during therapy. Assess for increased bleeding due to anticoagulant therapy Captopril 150 mg po daily Antihypertensive Hypertension, HF, LVD after MI, diabetic nephropathy, Supresses RAAS, inhibits ACE but preventing Angiotensin I from converting into angiotensin II CNS, CV, GI, GU, HEMA, INTEG, RESP -Dizziness, lightheadedness, or loss of taste may occur as your body Monitor blood studies (platelets, WBC, neutrophils proteinurea adjusts to the etc..), monitor medication. BP, check or - Dry cough may Orthostatic also occur. hypotension, monitor for HF (dyspnea, jugular vein distension, weight gain, edemas, lung sounds), monitor renal studies (protein, BUN, creatinine) and renal symptoms: polyurea, oliguria, potassium. Establish a baseline before studies begin. Amiodaron e 100 mg po bid Class III antidysrhythmic Used for ventricular dysrhythmias • Mainly blocks potassium channels in the heart, affecting the action potential and cardiac rhythm. • Can also affect sodium/calcium channels and A & B adrenergic receptors. CNS, CV, EENT, ENDO, GI, GU, INTEG, -Cough. -dizziness, lightheadedness, or fainting. Monitor: -electrolytes -Thyroid function tests MS, RESP. -fever (slight) -CNS symptoms -numbness or (confusions,depr tingling in the esssion) fingers or toes. -hypothyroidism -painful breathing. symptoms -sensitivity of the -hyper- skin to sunlight. thyroidism symptoms -pulmonary toxicity -monitor cardiac rate,respiration, rhythm, etc. -assess vision throughout -assess for Steven johnsons syndrome Hydrochlor o thiazide 50 mg po daily Thiazide Diuretic Helps manage mild-moderate hypertension. Tx of edema assoc. with HF, renal dysfunction, cirrhosis, glucocorticoid therapy, estrogen therapy. Inhibits sodium reabsorption in the distal tubule. Promotes excretion of chloride, potassium, hydrogen, magnesium, phosphate, calcium and bicarb. CNS, CV, GI, DERM, EENT, ENDO, HEMAT, MS, METAB nausea, vomiting, loss of appetite; diarrhea, c onstipation; muscle spasm; or. dizziness, headache. -Monitor BP, intake, output, and daily weight and assess for edema. -Monitor electrolyte and renal labs. -Monitor for signs of electrolyte imbalance, specifically potassium. -Assess for allergy to sulfonamides. -Monitor for ˆglucose,ˆbilirubi n, ˆcalcium, ûric acid, ˆcreatinine, ^serum cholesterol/LDL/ triglycerides. Carvedilol 6.25 mg po bid antihypertensive Hypertension, HF w/ digoxin, diuretics and ace- inhibitors. Left ventricular dysfunction after MI. A Atorvastati n 10 mg po daily Cholesterol 4. Based on this patient’s home medication list, does the nurse need to address the clinical concern of polypharmacy with the primary care provider? Captopril and carvedilol are both antihypertensive medications and both suppress the CNS, so should be questioned by the prescribing doctor. 5. Based on this patient’s home medication list, are there any concerning medication interactions that the nurse needs to communicate to the primary care provider? II. Present Problem: Cardiac Telemetry Strip-Six Seconds: Regular/Irregular: Regular Interpretation: regular sinus rhythm P wave present? yes PR: yes QRS: yes Clinical Significance: Her cardiac rhythm appears to be normal, which means that her dizziness could be a result of her low & blood pressure. . Current VS: P-Q-R-S-T Pain Assessment: Denies and pain or discomfort T: 98.8 F/37.1 C (oral) Provoking/Palliative: P: 54 (reg) Quality: DENIES PAIN R: 14 (reg) Region/Radiation: BP: 94/58 Severity: 0/10 SpO2: 94% on room air Timing: 1. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT VS Data: Clinical Significance: • BP 94/58 • SpO2 94% • Although her HR is 54 and WNL, it’s on the low end. • Her BP is consistently low, and is concerning. • Her oxygenation is getting slightly worse on room air. Current Assessment: GENERAL SURVEY: Pleasant, well-nourished older adult in no apparent distress. In semi-Fowler’s position on gurney, quietly talking with daughter. NEUROLOGICAL: Alert, oriented x4 (to person, place, time, and situation). PERRLA. Muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. Sclera white. Lips, tongue, and oral mucosa pink and moist RESPIRATORY: Bibasilar crackles posteriorly, otherwise clear with equal aeration throughout lung fields. Respiratory effort nonlabored. Denies dyspnea at rest on room air. CARDIAC: Skin pink, warm & dry, with 1+ ankle edema bilaterally. Radial, pedal. And post- tibial pulses +1 pulses on palpation. Cap refill <2 seconds. Heart tones regular, S1, S2, and S3 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 45 degrees. Cardiac monitor: sinus bradycardia. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants GU: Voiding without difficulty, urine clear amber. Genital exam deferred. INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. Decreased skin turgor: recoil 2 secs. No clubbing of nails. Hair soft, distribution normal for age and gender. 2. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Assessment Data: Clinical Significance: • Bibasilar crackles posteriorly • 1+ ankle edema bilaterally • Sinus bradycardia • Decreased skin turgor - Indication of fluid in the lungs - Potential fluid volume overload - Bradycardia can potentially turn into cardiac arrest in pts with HF - Indicates dehydration, OR potentially fluid shifts. 3. Interpreting relevant clinical data, identify potential problems. What additional data is needed to identify the priority problem and nursing priorities? (NCSBN: Step 2 Analyze cues/NCLEX Management of Care/Physiologic Adaptation) Likely Problems: Additional Clinical Data Needed: - Decreased oxygenation - Risk for infection (fluid in lungs) - Fluid volume increase which may lead to HF - O2 stats should be carefully monitored, as decreased respirations related to potential infection/fluid in lungs could alter oxygenation. - Labs should be drawn to see if there are infection markers (CBC) - Labs for electrolyte values, and kidney function. Cardiac Telemetry Strip: Interpretation: ventricular tachycardia Clinical Significance: Causes of ventricular tachycardia include: - CHF - Digitalis toxicity - Electrolyte imbalances - Medications that prolong QT interval - MI or infarct - Underlying heart disease usually present Marilyn could potentially be experience any of these causes from the list of meds she’s on, specifically digitalis toxicity, from the amiodarone. That, couples with the diuretics, could affect her electrolyte which only make her chances of V-tach higher. Situation: Name/age: Marilyn Fitch, 78 years old BRIEF summary of primary problem: Brought in by her daughter, complains of dizziness several times this morning/almost passing out. Background: • Primary problem/diagnosis: Currently experiencing episodes of ventricular tachycardia, 1+ pitting edema, Bibasilar crackles posteriorly, and has sinus bradycardia with decreased skin turgor • RELEVANT past medical history: HF, Hypertension, and hypercholesterolemia. Has a 6month history of paroxysmal AFIB. • RELEVANT background data: had no remarkable S/S since her synchronized cardioversion one week prior to visit. Assessment: Most recent vital signs: T- 98.8 F, Pulse- 54, RR-14, BP 94/58, SpO2- 94% RA RELEVANT body system nursing assessment data: Hearing bibasilar crackles posteriorly, 1+ ankle edema bilaterally, sinus bradycardia, and decreased skin turgor. RELEVANT lab values: none yet TREND of any abnormal clinical data (stable- increasing/decreasing): O2 saturation is trending down. INTERPRETATION of current clinical status (stable/unstable/worsening): Patient appears to be worsening, with bouts of ventricular tachycardia and decreased 02. Recommendation: Suggestions to advance the plan of care: I suggest putting the patient on oxygen, getting the patient on a heart monitor ( if they aren’t already) and then running labs to assess for infection risks in the lungs, (CBC), as well are kidney function tests and electrolytes. The physician then orders the following: 4. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Orders: Rationale: Expected Outcome: 1. Oxygen 2L per nasal cannula. Titrate to keep O2 sat >95% 2. Stat 12 lead EKG 3. Stat labs: Basic Metabolic Panel (BMP), cardiac enzymes, complete blood count (CBC), and Brain Natriuretic Peptide (BNP). Mag level 4. Stat portable chest x- ray (CXR) 5. Insert peripheral IV catheter to saline lock. 6. Continuous monitoring of telemetry, BP, and O2 sat. • To increase O2 sat • To monitor cardiac rhythms • To monitor kidney and cardiac function • To assess for fluid in lungs • For administration of fluids, meds, etc. • To assess for worsening vital signs • Marilyn is at risk for activity impairment due to her heart failure. • In case of emergency. -Increased O2 levels -Assess for emergency situations and worsening AFib -Lab values WNL -Decreased fluid volume overload -Vital signs stable 7. Bedrest 8. Crash cart/defibrillator to bedside. 12 Lead EKG Sinus bradycardia Clinical Significance: Having a regular sinus rhythm of Bradycardia, it’s possible that the medications that Marilyn is (such as the Beta blocker or any CNS depressant) are masking other cardiac issues she has. Which would be why shes having episodes of ventricular tachycardia. Radiology: Chest X- Ray Results: Clinical Significance: Results: Mild cardiomegaly and small bilateral pleural effusions. Evidence of heart failure. An enlarged heart and pleural effusions are indicative of Heart failure. Complete Blood Count (CBC) WBC HGB HCT PLTs MCV Current: 9.5 10.2 28 168 70 Basic Metabolic Panel (BMP) Na K Gluc. Creat . Current: 145 3.1 85 1.05 Cardiac & Magnesium Troponi n BNP Magnesiu m Current: 0.01 410 1.1 5. What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: • Low HGB • Low HCT • Low Potassium • High BNP • Low Magnesium • Low HGB and HCT indicates iron deficiency • Low potassium may be due to medications given. This is important • A high BNP indicates heart failure 6. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Orders: Rationale: Expected Outcome: Stat magnesium sulfate 1 Gm IV bolus. Give over 10 minutes. - Increase potassium and magnesium levels - The ensure that electrolytes are Labs WNL Cardiac function Administer potassium 20 mEq in 100 mL NS IV over 2 hours. Basic metabolic panel (BMP) after magnesium and potassium infusions complete. returning to therapeutic levels. - Amiodarone may be responsible for slowing the heart rate and can cause digitalis toxicity. return to WNL If Mg < 1.5, repeat 1 Gm IV bolus. Hold amiodarone. 7. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies) Medication: Pharm . Class: Indication(s): Mechanism of Action In OWN WORDS: Body System Impacte d Common Side Effects: (1-3) Nursing Assessments: Magnesium sulfate Minerals/electro lytes Treatment of hypomagnesemia Important role in neurotransmission and muscular excitability. CNS, RESP, CV, GI, MS, DERM, METAB heart disturbances, breathing difficulties, poor reflexes, confusion, weakness, flushing (warmth, redness, or tingly feeling), sweating, lowered blood pressure, Monitor pulse, BP, respirations, and ECG frequently throughout administration of parenteral magnesium sulfate. ● Monitor neurologic status before and throughout therapy. - Institute seizure precautions. Patellar reflex (knee jerk) should be tested before each parenteral dose of magnesium sulfate. ● Monitor intake and output ratios. Urine output should be maintained at a level of at least 100 mL/4 hr. ● Monitor serum magnesium levels and renal function periodically throughout administration of parenteral magnesium sulfate. Potassium chloride Mineral/electrol yte Treatment/prevention of potassium depletion. -Maintain acid-base balance, and function of balance of the cell. -essential to CNS, CV, GI, NEURO Arrythmias, abdominal pain, nausea, vomiting, diarrhea. -Assess for signs and symptoms of hypokalemia transmission of nerve and impulses; contraction hyperkalemia of cardiac, skeletal, -Monitor and smooth muscle; serum gastric secretion; renal potassium function; tissue before and synthesis; and periodically carbohydrate during therapy. metabolism. -Monitor renal function, serum bicarbonate, and pH. - monitor cardiac function III. Put it All Together to THINK Like a Nurse! 1. Interpreting all clinical data collected, what is the priority problem? What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation) Priority Problem: Pathophysiology of Problem in OWN Words: Episodes of Ventricular tachycardia, with sinus bradycardia and bibasilar crackles posteriorly with pedal edema There appear to be multiple factors in Marilyn problems. -She is 3rd spacing (pedal edema and pulmonary congestion) which is contributing to her HF. however is on a diuretic which may not be working. (should she be on a potassium sparing diuretic to salvage the electrolytes that she’s excreting?). overall, its hard to say what could be the causation of her dysrhythmia, is it her poly pharmacy? Or fluid shifts? Are imbalance of electrolytes contributing to her cardiac issues? 2. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX Management of Care) Nursing PRIORITY: Send Patient to ICU GOAL of Care: Nursing Interventions: Rationale: Expected Outcome: Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs. Monitor I & O’s Implement strategies to treat fluid and electrolyte imbalances. Assist the patient in assuming a high Fowler’s position. Reposition patient every 2 hours Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase activity as tolerated Continually use therapeutic communication and teaching when performing tasks with the patient. • Alleviate signs of hypoxia and subsequent activity intolerance. • Decreases the risk for development of cardiac output due to imbalances • Improve the patient’s ability to perform ADLs • Monitor for increased fluid retention. • Marilyn is likely feeling anxiety due to her worsening heart failure. It is important to make sure she feels supported and well taken care of throughout her stay at the hospital. • Increased ability to perform ADLs • Improved balance in I&Os and decreased fluid volume retention • Decreased anxiety IV. Evaluation: Two hours later… 1. After implementing the medical and nursing plan of care, EVALUATE by INTERPRETING relevant current clinical data to determine if status is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) Assessment Finding: Improving: Declining: No Change: Potassium 3.5 Improving Magnesium 1.5 Improving Telemetry: sinus brady, no further episodes of torsades de pointes Improving S3 gallup auscultated over apex Declining 1+ pedal edema No change Bibasilar posterior crackles No change O2 sat 96% on 2L NC improving BP 98/56, HR 56 No change 2. Has the overall status of your patient improved, declined, or remain unchanged? If your patient has not improved, what other interventions need to be considered by the nurse? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) Overall Status: Additional Interventions to Implement: Expected Outcome: Electrolytes have imporved, however heart failure status unchanged. Continue monitoring fluid volume retention and I&O. Monitor electrolyte values. Decreased fluid volume overload and electrolytes WNL. 3. To develop clinical judgment, reflect on your thinking by answering the following questions: What did you do well in this case study? What knowledge gaps did you identify? Labs are getting easier to distinguish, as well as connecting kidney issues with uts effects on the heart. I had a difficult time with all of the potential side effects from the medications that could have been causative factors for Marilyn’s symptoms, and not making assumptions that their potential side effects are the reason for her diagnoses. What did you learn? How will you apply learning caring for future patients? It is important to continuously review the potential side effects of medications and review how they might interact with each other. I will be sure to regularly review the side effects of medications and consider how they might be interacting with the patient current health assessments.