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Pharmacology Reasoning Bradycardia Suggested Answer Guidelines Marilyn Fitch, 78 years old

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Pharmacology Reasoning Bradycardia Suggested Answer Guidelines Marilyn Fitch, 78 years old © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieva... l system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN Pharmacology Reasoning Bradycardia Suggested Answer Guidelines Marilyn Fitch, 78 years old Medication Categories: Concepts/Content: Antidysrhythmics ACE Inhibitors Beta Blockers Statins Oral Anticoagulants Diuretics Electrolytes Assessment Drug-drug interactions Evaluation of desired outcomes Monitoring for adverse effects Emergency treatment of dysrhythmias Client education 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% XI. 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: History of hypercholesterolemia, HTN and heart failure Feeling dizzy, almost passed out Six month history of paroxysmal atrial fibrillation, had synchronized cardioversion last week Pulse 52, BP 94/52 O2 sat 98% on room air She has many health risk factors that could be contributing to her symptoms The nurse should place the patient on high fall risk precautions A fib can cause irregular heart rhythms, along with her history of HF, she may have poor cardiac output contributing to her dizziness Her pulse and BP are both low, which helps support the theory that her cardiac output is low It is important to note her oxygenation status, the nurse wants to be sure that the tissues (especially heart and brain) are being perfused as they should RELEVANT Data from Social History: Clinical Significance: Widow and lives alone Denies smoking, drinks wine occasionally It is important to ensure that the patient will be safe once returning home Smoking and alcohol increases risk of cardiac issues, but the patient states she does not smoke and does not drink very much alcohol 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 Hypertension Heart failure Atrial fibrillation Apixaban 2.5 mg po bid Captopril 100 mg po BID daily Amiodarone 100 mg po bid Hydrochlorothiazide 50 mg po daily Atorvastatin 10 mg po daily Carvedilol 6.25 mg po bid As the nurse responsible for this patient, you promptly review the medical history and current home medications in the medical record: Applying your knowledge of pharmacology, to provide safe patient care, answer the following essential information: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 System Impacted Common Side Effects: (1- 3) Nursing Assessments: Apixaban 2.5 mg po bid Anticoagulant Used to decrease the risk of thrombus formation in those with a-fib Blocks clotting factor Xa, which decreases clotting cascades CV Bleeding, bruising Monitor for any signs and symptoms of bleeding, promote fall risk safety, use of electric razor and soft toothbrush Captopril 150 mg po daily ACE inhibitor Used to control BP, helps decrease workload on the heart for those with HF Blocks angiotensin I from turning into angiotensin II, therefore decreasing renin and aldosterone levels, causing decreased BP CV Dry cough (harmless, but annoying), can lead to HYPOtn, can lead to hyperkalemia Monitor BP daily, monitor weights daily, monitor for dry cough, be aware of K+ supplements and K+ sparing diuretics Amiodarone 100 mg po bid Antidysrhythmic, potassium channel blocker Used to control dysrhythmias Slows heart rate by prolonging the action potential of the cardiac cells CV Bradycardia, ARDS, HYPOtn, dizziness, syncope Monitor BP while on this medication, monitor heart rate, teach the patient to not take medication with grapefruit juice can cause prolonged QT intervals, so EKG monitoring may be necessary Hydrochloro thiazide 50 mg po daily Thiazide diuretic Helps to manage BP, also helps to manage fluid overload in those with HF Causes the kidneys to excrete sodium and water, thus decreasing fluid volume and controlling BP CV, renal HYPOtn, dizziness, electrolyte imbalances, most commonly HYPOnatremia, kalemia and magnesia, can also cause dehydration if too much fluid is lost Give medication at the same time daily, monitor BP and hold is SBP <90, monitor electrolytes Carvedilol 6.25 mg po bid Beta blocker Helps control BP and heartrate in those with HTN, HF and after MI Blocks beta receptors, which decreases the stimulation of the cardiac muscles, which lowers BP and heart rate CV Bradycardia, pulmonary congestion (contraindicated in CHF), heart block, can mask signs and symptoms associated with DM Usually contraindicated in CHF, monitor BP and HR regularly, monitor glucose closely in those with DM (can mask s/sx), monitor I and O daily Atorvastatin HMG COA Used to control Blocks cholesterol formation in Hepatic Muscle weakness Teach the patient10 mg po daily reductase inhibitor cholesterol in those with hypercholesterole mia the liver by inhibiting the HMG COA enzyme (rhabdomyolysis)! to report any muscle pains/weakness, monitor kidney and liver functions, use cautiously in those with kidney failure 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? Yes, there are a lot of medications that are prescribed that do similar things (control BP and heart rate). It is concerning, especially now with the presenting signs and symptoms that she has. Also, there is a medication that is contraindicated in those with HF. 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? I have concern about the use of a CCB, BB and ACEI all together. They all lower BP in different ways, so that would lead me to believe why her pulse and BP are so low. On top of this, she is also taking a thiazide diuretic, which can cause hypokalemia, and now amiodarone, which blocks potassium channels in the cardiac cells, which would lead me to believe is also contributing to her pulse of 52.II.Present Problem: Cardiac Telemetry Strip-Six Seconds: Regular/Irregular: Regular, rate 50 P wave present? Yes PR: WNL QRS: WNL Interpretation: NSR, but at a slow rate Clinical Significance: The rhythm is normal, the timing of the intervals are expected, but the timing and space between the end of one beat (the t wave) to the start of the next beat (the p wave) is prolonged. . 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: Pulse 54 Respiration 14 and pulse ox 94% on room air BP 94/58 No pain Pulse is low, this could be due to overmedication Respirations are WNL, but her pulse ox has dropped from 98 to 94%. She is now showing sings of decreasing respiratory status, this could be due to her low pulse and BP, possibly fluid is backing up into her lungs; nurse needs to continue to monitor closely BP is low and should be monitored, also most likely due to overmedication it should be investigated and monitored further A lack of pain can help the nurse infer that she is most likely not experiencing some sort of MI Recognizing a potential problem, you place Marilyn on a cardiac monitor, collect a full set of vital signs and complete a nursing assessment: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: Appears in NAD AAOx4 Equal muscle strength Bibasilar crackles heart posteriorly +1 ankle edema bilaterally S1, S2 and S3 heart sounds auscultated No JVD noted Sinus bradycardia on the monitor Active bowel sounds, nontender Voiding w/o difficulty, clear yellow urine Skin warm, dry and appropriate color Patient is showing no signs of pain No neural deficits No musculoskeletal deficits Crackles can be an indicator of fluid buildup in the lungs, which would make sense if her cardiac output is low and fluid is building up Edema is a sign of fluid backing up in the periphery, because the heart is unable to effectively pump blood through the body as it should S3 heart sounds are not expected, and can sometimes be heard in those with heart failure JVD is an indicator of severe right sided heart failure, the patient is not to that point, yet at least, so it should continue to be monitored Bradycardia means that the heart is not beating as fast as it should, heart rate is important for cardiac output Abdominal assessment is remarkable There are no concerns for UTI at this time, it will be important to monitor output to ensure kidneys are functioning as they should Cardiac output is still sufficient enough to keep the tissues oxygenated and warm; it is important to monitor oral mucosa as well to help indicate the possibility of dehydration due to excessive diuresis 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: Patient is being over treated with medications She is diuresing too much, therefore there is not enough blood volume for the heart to work with On top of this, her blood pressure and pulse are both lowered; lower pulse causes When did she last take her medication? Does she have the ability to remember when she took her medications? Some older individuals may forget they have already taken their meds and end up taking a second, or even third dose What is her intake and output X-ray of the lungs to visualize pulmonary edema CBC to r/out infection of the lungs BMP to assess electrolytes Respiratory status needs to be closely monitored, especially since her pulse ox level is droppingdecreased cardiac output, decreased BP makes it harder for the blood to reach the target tissues and organs On top of the cardiac output not being up to par, there is fluid accumulation in the lungs, which are causing crackles and are now manifesting a dropping pulse ox level Cardiac Telemetry Strip: Interpretation: ventricular tachycardia Clinical Significance: V-tach can turn into a fatal rhythm called ventricular fibrillation, so it is important to monitor and treat it immediately. V-tach is caused by irritable cardiac cells, usually due to unstable electrolytes Situation: Name/age: Marilyn Fitch is a 78 year old female BRIEF summary of primary problem:.She presented today with dizziness and reported a near syncopal episode at home before arriving Background: Primary problem/diagnosis: She is showing signs of heart failure, there are crackles heard in the lungs and she has +1 pitting edema in the lower extremities. She has been feeling increasingly weak and had a brief episode of ventricular tachycardia and her blood pressure has dropped down to 82/50 RELEVANT past medical history: As you complete your assessment, Marilyn’s high priority alarm goes off and the telemetry monitor reveals the following strip below. Marilyn lies back and complains of feeling faint. This abnormal rhythm spontaneously resolves and returns to sinus bradycardia with a HR of 56. You immediately reassess her BP, which is 82/50. Recognizing that a problem is present, use SBAR concisely to communicate your concern to the emergency department physician.She has a history of HTN, hypercholesterolemia, heart failure and a-fib. She did have a cardioversion completed a week ago RELEVANT background data: Since the cardioversion last week, she has had no signs and symptoms noted until this AM Assessment: Most recent vital signs: Temp is WNL at 98.8, pulse has remained in the low 50’s, respirations are at 14, pulse ox has been around 94% on room air, when she came in it was at 98%, so I have been closely monitoring that. Her BP was in the 90’s when she arrived, but after the episode of v-tach, it dropped to 82/50. She is reporting no pain, just dizziness and lightheadedness RELEVANT body system nursing assessment data: She is AAOx4, no neural deficits. There are bibasilar crackles heard in both of her lungs, there is an S3 heard in all areas over the heart. She has +1 edema in her lower legs, no JVD noted. The monitor has been showing constant sinus bradycardia. Her cap refill has been less than 2 seconds. Her GI and GU exams have been unremarkable. RELEVANT lab values: Labs have not been obtained yet, but I have asked the physician for an order for a CBC and BMP TREND of any abnormal clinical data (stable-increasing/decreasing): O2 sats are on the lower side of normal, but since it has been trending down, I have continued to monitor it closely INTERPRETATION of current clinical status (stable/unstable/worsening):At this time, the patient is stable, but she requires close monitoring because of her decreasing O2 sat and the episode of v-tach that was shown on the telemetry Recommendation: Suggestions to advance the plan of care: Push for the BMP and CBC to be obtained ASAP, continue to monitor her O2 status and cardiac rhythm on the monitor, she may need some supplemental oxygen. I would also ask to obtain a chest x-ray to visualize the pulmonary edema.The emergency department physician agrees with your recommendations and orders the following: 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. 7. Bedrest 8. Crash cart/defibrillator to bedside. 1. Increasing her O2 will help decrease the workload on the heart and the lungs 2. An EKG will show if there is any infarct anywhere in the heart and will give a better picture of what rhythm she is in 3. BMP will visualize any electrolyte imbalances, cardiac enzymes will show if there is any damage to the cardiac cells, CBC will show if there is any signs if infection or even internal bleeding, BNP will show if the patient is actively in an episode of heart failure (cardiac muscle stretching) and mag will also support if there is any electrolyte imbalances 4. Chest x-ray will help to visualize the pulmonary edema and monitor for any infiltrates or signs of infection 5. An IV is important access to administer any STAT mediations 6. Continuous monitoring will show if there is any acute changes in patients status that need to be addressed immediately 7. Bedrest will help decrease the workload on the heart and lungs, also, since the patient is dizzy and lightheaded, there is a risk for falls 8. Crash carts need to be near by in the case that she would enter back into a dangerous rhythm 1. O2 sats will remain above 95% 2. Any acute changes will be noted promptly on the EKG 3. Labs will help guide care as they will show any electrolyte imbalances, signs of infection, or if acute MI is occurring 4. Chest x-ray will show area of infiltrate, confirming pulmonary edema or pneumonia 5. IV access will be obtained so medications can be given promptly 6. The nurse and providers will be able to note any changes in status of the patient 7. Bedrest will help allow the body to relax, also the patient will be safer from the risk of falling 8. The crash cart will be within close range so that it can be accessed in emergency 12 Lead EKG Inverted P waves, bradycardia Clinical Significance: Inverted P waves can be caused by electrolyte imbalancesThirty minutes later, the following diagnostic test results just posted in the electronic health record: Radiology: Chest X-Ray Results: Clinical Significance: Results: Mild cardiomegaly and small bilateral pleural effusions. Evidence of heart failure. Over time with heart failure, the heart enlarges. This is because the cardiac muscle has worked so hard over time, that it no longer can keep up with the bodies demands, but it remains large in size. Bilateral pleural effusions support heart failure and not pneumonia, because pneumonia is typically in one lung. Since the heart has been failing, blood from the right ventricle is being pumped into the lungs, but the left ventricle is unable to keep up, so fluid is backing up into the lungs 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 Troponin BNP Magnesium 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: HGB 10.2 and hct 28 Potassium 3.1 BNP 410 Mag 1.1 HGB and hct are not extremely low, but should continue to be monitored and should possibly be compared to previous baseline labs Potassium is low and magnesium is low; both are electrolytes that can cause dysrhythmias, such as what she is experiencing BNP >100 is indicative of heart failure, this is released when the cardiac muscle is being stretched too much 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. Administer potassium 20 mEq in 100 mL NS IV over 2 hours. Basic metabolic panel (BMP) after magnesium Both magnesium and potassium are ordered because they are both lower than should be. Magnesium and potassium are important in maintain normal cardiac cell function It is important to recheck electrolytes after administering them to ensure that they are now Magnesium and potassium levels will return to WNL You call the emergency physician and report the relevant results of the diagnostic testing and current VS: BP 90/58, HR 56 sinus bradycardia. The following orders are given:and potassium infusions complete. not too high, or to determine if more is needed, which is why there is another order in for magnesium if not above 1.5 Amiodarone needs to be held because it works to slow pulse by blocking potassium channels in the cardiac cells, which is why the patient is in the situation she is in now, with bradycardia and heart failure 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 Impacted Common Side Effects: (1-3) Nursing Assessments: Magnesium sulfate Electrolyte Treatment of HYPOmagnesia Magnesium helps to control the calcium channels of the cell, without magnesium, there would be hypercontraction of the cells CVV, neuromuscula r N/V/D, weakness, DECREASED reflexes, confusion Continue to closely monitor electrolytes, important to assess reflexes Potassium chloride Electrolyte Treatment of HYPOkalemia Increases action potential of the cardiac cells CV, neuromuscula r Pain at IV site, needs to be run through IV alone, numbness, tingling, palpitations Continue to closely monitor electrolytes 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: Heart failure It appears as though the patient has been overmedicated. Due to her medications, she is experiencing electrolyte imbalances. The imbalances are causing low heart rate, which in turn is causing decreased cardiac output. She is showing clinical symptoms of heart failure, such as dizziness, syncope, lung congestion, decreased pulse ox, and pitting edema in the legs. 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: Closely monitor the patient during her course of treatment, note any acute changes in her status GOAL of Care: Balance electrolytes, improved cardiac function, removing excessive fluid from the lungs Nursing Interventions: Rationale: Expected Outcome:Keep patient on continuous cardiac and oxygen monitoring Supplemental O2 as ordered Draw labs/call lab for draws Monitor I and O and daily weights Bedrest Incentive spirometry/deep breathing Any acute changes will be noted promptly Pulse ox levels will remain above 95% Electrolyte imbalances will be noted and treated Any fluid retention will be noted Bedrest will help allow the patient’s body time to rest, heal and decrease risk of falls until more stable Help the patient to cough up any sputum and decrease risk of pneumonia formation Patient will remain in NSR Pulse ox above 95% Electrolytes WNL Output > input Patient will remain safe and not overexerted Patient will remain pneumonia freeIV. 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 X Magnesium 1.5 X Telemetry: sinus brady, no further episodes of torsades de pointes X S3 gallup auscultated over apex X 1+ pedal edema X Bibasilar posterior crackles X O2 sat 96% on 2L NC X BP 98/56, HR 56 X 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: Status is slightly improving, but there are a lot of assessment findings that have not changed We need to decrease her fluid volume overload and increase the workload of her heart to help alleviate the fluid volume built up on her lungs After electrolytes have been stabilized for some time, the patient may need a potassium sparing diuretic to help reduce fluid volume 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? Comparing medications and critically thinking about how well or how safe the medications are to be used together I am also feeling more confident in assessing EKG strips I felt a gap in identifying what the additional interventions may need for Marilyn at the end of the case study. I know that the fluid overload needs to be treated, but I don’t want Marilyn to end up right where she was when she arrived. I also feel as though her low pulse and BP still needs to be treated, but I’m just not confident in what the course of care would be What did you learn? How will you apply learning caring for future patients? It is so important as the nurse to really critically think about how medications work and how they interact with each other. Sometimes doctors prescribe multiple medications for patients (or multiple doctors prescribe different things) and these medications will interact with each other. Nurses are the last line of defense to ensure that these meds are safe for the patients [Show More]

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