Case Study, Chapter 29, Management of Patients With Complications From Heart

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1. George Brown, 72 years of age, is a male patient who is admitted with the diagnosis of
acute pulmonary edema secondary to acute left ventricular heart failure. The patient has a
history of coronary artery disease that has been treated medically. The patient is anxious, pale,
cold, clammy, and dyspneic. The vital signs are: blood pressure, 88/50 mm Hg; heart rate, 110
bpm; respiratory rate, 32 breaths/min; and temperature, 97°F. There are bubbling crackles and
wheezing throughout the lung fields and the patient is raising frothy blood-tinged clear
sputum. The patient’s admission weight is 100 kg. (LO 1 and 6)

a. What first actions should the nurse take and what are the rationales for these
actions? (pp 824-825)
The first action would be to administer a diuretic, such as Lasix (Furosemide) to reduce fluid
volume overload of left ventricular heart failure. HF patients with severe volume overload
are generally treated with a loop diuretic first and the smallest dose necessary.

The physician prescribed furosemide (Lasix) 40 mg IVP STAT.

b. What are the actions of furosemide that will help the patient? (p 825)
Loop diuretics, such as furosemide (Lasix), inhibit sodium and chloride reabsorption mainly
in the ascending loop of Henle and water follows the electrolytes into the urine.

c. What nursing actions should be implemented when administering a diuretic?

(p 826)
Prior to administration, check lab results for electrolyte depletion, especially K, Na, and Mg.
Prior to administration, check for S/S of volume depletion, such as postural hypotension,
lightheadedness, and dizziness. Administer the diuretic at a time conducive to the patient’s
lifestyle—for example, early in the day to avoid nocturia. Monitor urine output during the
hours after administration, and analyze intake, output, and daily weights to assess response.
Monitor BP for orthostatic changes. Continue to monitor serum electrolytes for depletion.
Replace K with increased oral intake of food rich in K or supplements. Replace Mg as
needed. Monitor creatinine for increased levels indicative of diuretic-induced renal
dysfunction. Monitor for elevated uric acid level and signs and symptoms of gout. Assess
lungs sounds and edema to evaluate response to therapy. Monitor for adverse reactions such
as dysrhythmias. Assist patients to manage urinary frequency and urgency associated with
diuretic therapy.

2. Carl Edwards is a 75-year-old man with congestive heart failure. Having sustained three
myocardial infarctions in the last 10 years, he has decreased left ventricular function. Mr.
Edwards takes Digoxin, Capoten, Coreg, and Lasix for management of this disease. Today he
presents to the emergency department with fatigue, generalized weakness, and feelings of
“skipping” heartbeats. Upon arrival, he is placed on the cardiac monitor, his vital signs are
assessed, and an IV is inserted. He currently denies chest pain, but is experiencing some
shortness of breath, and is placed on 2 L of oxygen via nasal cannula. (LO 1)

a. Which of his medications might be contributing to his symptoms of generalized

weakness and heart irregularities? (p 831)
It is a combination of the Digoxin and Lasix. Excessive and repeated diuresis can lead to
hypokalemia. Signs include ventricular dysrhythmias, hypotension, muscle weakness, and
generalized weakness. In patients also receiving digoxin, hypokalemia can lead to digitalis
toxicity, which increases the likelihood of dangerous dysrhythmias. Patients with HF may
also develop low levels of magnesium, which can add to the risk of dysrhythmias.

b. For what clinical manifestations should you assess to correlate to his left-sided
heart failure? (p 828)
The patient is observed for restlessness and anxiety that might suggest hypoxia from
pulmonary congestion. The patient’s level of consciousness is also evaluated for any
changes, as low CO can decrease the flow of oxygen to the brain. The rate and depth of
respirations are assessed along with the effort required for breathing. The lungs are
auscultated to detect crackles and wheezes. Crackles are produced by the sudden opening of
edematous small airways and alveoli. They may be heard at the end of inspiration and are not
cleared with coughing. Wheezing may also be heard in some patients who have
bronchospasm along with pulmonary congestion.

c. How do his medications treat his congestive heart failure? (p 824)

Digoxin increases myocardial contractility and slows conduction through the AV node.
Capoten, an ACE-inhibitor, promotes vasodilation and diuresis by decreasing afterload,
which reduces the resistance to left ventricular outflow. ACE inhibitors also decrease
secretion of aldosterone resulting in sodium and water excretion and lower BP. Coreg is a
beta-blocker administered to patients with left-sided failure to slow heart rate and dilate
blood vessels, which decreases afterload. Lasix is a diuretic that decreases preload and
reduces fluid volume overload.

d. How does the hypokalemia affect the effects of Digitalis? (p 831)

In states of hypokalemia, or low potassium, digoxin toxicity is actually worsened
because digoxin normally binds to the ATPase pump on the same site as potassium. When
potassium levels are low, digoxin can more easily bind to the ATPase pump, exerting the
increased inhibitory effects.