Medical-Surgical Cases Cardiovascular Disorders Case Study with Rationals

1. What error in teaching most likely occurred when M.G. was discharged 10 days ago? A breakdown of successful communication occurred regarding when to call with early weight gain. It is imperative that patients understand when to call their provider after being discharged from the hospital for exacerbated HF. Comprehensive patient education starting at admission is considered a standard of care and is mandated by The Joint Commission when providing care to hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient selfmanagement, minimize symptoms, and prevent readmission. CASE STUDY PROGRESS During the admission interview, the nurse makes a list of the medications M.G. took at home. ■ Chart View 2. Which of these medications may have contributed to M.G.'s heart failure? Explain. Thiazolidinediones, such as pioglitazone, may increase the risk of heart failure and should not be used in patients with symptoms of heart failure. They commonly cause peripheral edema and weight gain (which are the result of both water retention and increased deposit of adipose tissue). 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 Difficulty: Beginning Setting: Emergency department, hospital Index Words: heart failure (HF), cardiomyopathy, volume overload, quality of life Case Study 1 Heart Failure 1 Cardiovascular Page 2 of 83 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce heart failure? (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. Answers: A, B, D ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This results in systemic vasodilation, thereby reducing preload (reducing the volume of blood entering the left ventricle) and afterload (reducing the resistance to the left ventricular contraction) in patients with HF. ACE inhibitors do not promote the excretion of sodium and water, and they do not cause increased cardiac contractility or block the sympathetic nervous system to the heart. CASE STUDY PROGRESS After reviewing M.G.'s medications, the physician writes these medication orders: ■ Chart View 4. What is the rationale for changing the route of the furosemide (Lasix)? M.G. is fluid overloaded and needs to decrease fluid volume in a short period. IV administration is delivered directly into the vascular system, where it can start to work immediately. In HF, blood flow to the entire gastrointestinal (GI) system is compromised; therefore, the absorption of orally ingested medications may be variable and take longer to work. 5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to monitor the effectiveness of this medication. • Increased urine output • Daily weight, looking for weight loss • Intake and output (I&O) • Decreased dependent edema • Decreased shortness of breath, diminished crackles in the bases of the lungs, decreased work of breathing, and decreased O 2 demands • Decreased jugular venous distention (JVD) 6. What laboratory tests should be ordered for M.G. related to the order for furosemide