Situation: Mrs. Brown is a 62 year old female patient who frequently is seen in the emergency department for heart failure. She presents with complaints of shortness of breath and leg swelling. Background: Mrs. Brown has been seen multiple times in the Emergency department for heart failure and was discharged from the hospital 10 days ago. Today she states: I cant catch my breath and my legs are as big as tree trunks. She reports strict adherence to her prescribed fluid and salt intake however also reports that since discharge she has noticed her weight go up 1-2 pounds every day. Questions: 1. What is the most appropriate fluid and salt intake recommendations for a patient with heart failure and why is this important? 2. What information do you feel Mrs. Brown may not have understood from her discharge teaching? 3. What are key assessments you would perform? 4. What is heart failure and what are you most concerned about? 5. Are there any specific lab tests you would anticipate? 6. What would be your priorities? During your initial inpatient admission history, your medication reconciliation is completed and Mrs. Brown gives you the following medication list: (please list the indications for these based on the current information you have on Mrs. Brown) Enalapril 5 mg PO bid: Pioglitazone 45 mg PO every morning: Furosemide 40 mg PO every day: Potassium Chloride 20 mEq PO every day: 7. How do ACE inhibitors work to reduce heart failure? 8. What is one side effect of ACE Inhibitors and how would you anticipate it being treated? The physician orders Enalapril 5 mg PO bid, carvedilol 3.125 mg PO bid, Glipizide 10 mg PO every morning, Furosemide 80 mg IVP now and then 40 mg/day IVP, Potassium chloride 20 mEq PO daily. 9. What class of medication is furosemide and what do you need to monitor for? 10. What is the rationale for changing the route of administration for the furosemide? 11. What are 3 parameters that you would use to monitor the effectiveness of the furosemide? 12. What lab tests would you anticipate being ordered and need to monitor for this patient related to her furosemide? 13. What is the purpose of administering a beta blocker for this patient? 14. Carvedilol is a new medication for Mrs. Brown. What would be contraindications to administering this medication? What would you teach Mrs. Brown about this medication? The following day, Mrs. Brown continues to still have some difficulty. She has shown slight improvement however the provider comes and assesses Mrs. Brown and orders her digoxin 125 mcg by mouth daily. 15. What is the action of digoxin? 16. What is the rationale for administering digoxin? 17. What do you need to monitor for when patients are being administered digoxin? What assessment findings would indicate there is concern regarding digoxin administration? Are there any laboratory findings you would be concerned about? 18. You go to administer digoxin; it is available in Pyxis as Digoxin 2.5 mg tablet. Calculate the dose and explain how you would administer this. 19. What are necessary teaching points to consider for Mrs. Brown as it relates to digoxin? Mrs. Browns symptoms do improve, and she is getting ready for discharge. She has been able to transition to PO furosemide and has noted a 15-pound weight loss since admission. Her breathing status is much improved, and her labs identify improvement in her status. 20. What are the key teaching elements for Mrs. Brown to be successfully discharged? 21. How would you assess her understanding of this teaching? 22. What are some potential barriers that you would need to assess for for this patient at home so they can monitor their health and or be successful in their discharge? 23. Using the LACE tool: Length of stay 5 days. Score 4 Acuity of admission through the ED Score 3 Comorbidities. Score 3 (CHF, Diabetes without complication) Emergency Department Visits .. Score 4 Lace score of 14 24. Does this score indicate risk to the patient? 25. What would you anticipate for follow up? 26. Would you consider any additional resources for a successful discharge and prevention of readmission?
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