Question

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 every day since her discharge. You chart the medications M.G. brought with her: enalapril (Vasotec) 5 mg bid, digoxin 0.125 mg/day, rosiglitazone 4 mg, furosemide 40 mg/day, and potassium chloride 20 mEq/day. The admitting provider orders all the medications but changes the furosemide to 80 mg IV push (IVP) now, then 40 mg/day IVP.

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

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

3. How do ACE inhibitors help in HF?

M.G.'s symptoms improve with IV diuretics. She is ordered back on oral furosemide once her weight loss is deemed adequate to achieve a euvolemic state.

4. What will determine if the oral dose will be adequate to consider her for discharge?

5. What key management concepts should be included in discharge teaching to prevent relapse and another admission?

Answer 1

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

The teaching of fluid and salt restriction diet means the patient thoughts of only avoiding salt diet. The patient has to be clearly explained about sodium restriction so as to minimize the preserved food and junk foods which are rich in sodium. The patient also not educated about the risks of weight gain.. patient teaching has to provide in order to avoid complications and readmission.

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

Three parameters to monitor the effectiveness of furosemide

• Daily weight
• Decreased edema of the legs
• Decreased jugular venous pressure

3. How do ACE inhibitors help in HF?

ACE inhibitors promote the systemic vasodilation by inhibiting the conversion of angiotensin I to angiotensin II. Thereby it reduces the blood volume of the left ventricle. Further, it reduces the afterload. Thus the ACE inhibitors play an important role in Heart failure patients.

4. What will determine if the oral dose will be adequate to consider her for discharge?

The primary goal of the patient is to manage the patient with accurate weight, fluid and sodium restriction, and to prevent further symptoms. If the IV medication has changed to oral dose, it is the responsibility of the primary care provider to maintain the stable condition of the patient and maintain the correct weight.

5. What key management concepts should be included in discharge teaching to prevent relapse and another admission?

Patient teaching should focus on minimizing of associated symptoms and prevention of complication. Some of the patient discharge teachings include

• Take medication properly according to the chart and avoid skipping.
• Explain the action, duration, and frequency of medication and its importance.
• Daily monitor weight. if the weight has increased to 2 pounds reports to primary care provider immediately.
• Follow strictly the fluid and sodium restriction diet.
• Assess for signs and symptoms, side effects of medication, and report to the physician quickly.