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. ANS: After questioning, it was found that she was strictly following the restriction ordered on salt and fluid during her last visit. Also she had reported about gaining 1 to 2 pounds daily after her discharge

It is most likely that she did not understand the nurse, instructions properly. She was not able to distinguish between salt and food products that contain salt in her diet. The patient might have only avoided normal usable salt and not the food containing salt like preserved foods and fast food.

In addition, the patient might not have had a good understanding of the quantity of sad to be included in the diet. On discharge, she might have been instructed on the various food products that can be included or avoided. Had she followed the instructions thoroughly, she could have avoided this health complication.

2. ANS: Furosemide is prescribed to the heart patients to treat the fluid accumulation. Furosemide is used for edema in other health conditions also liver cirrhosis. This can be administer orally, intravenously (IV) or intramuscularlyn(IM). IV administration is preferred, when there is need of immediate effect. This is a loop diuretic, which works by decreasing the reabsorption of sodium in the kidney.

The assessment of the effectiveness of furosimide can be done by monitoring the patient. The expected outcome in this condition is reduced swelling in the legs of the patient. The urination frequency of the patient should also he observed as being a diuretic. Urination frequency of the patient should increase, if the drug is working.

Furosemide is an antihypertensive drug also. The hypertension is also treated with this drug, therefore, the blood pressure reduction is another sign that furosemide is working or being effective or not. The weight of the patient should also be continuously monitored for expected reduction in the same. This can be done later on.

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

4. ANS: 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. ANS: 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.

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