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furosemide (Lasix)

Classification: loop diuretic

Mechanism of Action: Inhibits reabsorption of Na + H20 in the loop of Henle which causes increased urinary output, decreased edema and intrasvascular volume, decreased preload

Use: HTN, HF

Side/Adverse Effects: dehydration, circulatory collapse, BP/otrhostatic changes, hypokalemia

Nursing Implications: monitor all lytes, BUN, BP, HR (esp. elderly, dietary changes: increase K foods, decrease Na, possible fluid restrictions, signs and symptoms of hypokalemia, change position slowly


What do you do before giving digoxin?

Check the apical pulse for 1 minute before administering


Is furosemide (lasix) postassium wasting or potassium sparing?

potassium wasting so we will be worried about patient becoming hypokalemic


When would you hold digoxin?

Apical Pulse =

Adult: <60bpm

Infant: <90bpm

School Age: <75bpm

Adolescent: <60bpm


digoxin (Lanoxin)

Classification: cardiac glycoside, antiarrhythmic, positive inotropic

Mechnism of Action:  increases the cardiac force of contraction while slowing conduction through the AV node (slows HR)

Use: HF, atrial fibrillation/flutter, paroxysmal arterial tachycardia

Side/Adverse Effects: visual disturbances, narrow therapeutic index, AV block

Nursing Implications:

  1. Check apical pulse for 1 minute before administering
  2. Hold if:
    1. Adults <60
    2. Infants <90
    3. School Age <75
    4. Adolescents <60
  3. Monitor VS
  4. Take baseline serum digoxin/electrolyte levels
  5. Monitor for toxicity: anorexia, N/V/D, visual disturbances


What are signs of digoxin toxicity?

  • Anorexia
  • N/V/D
  • Visual disturbances


What is heart failure?

A progressive medical condition that is characterized by a complex pathophysiological syndrome which results in impaired cardiac function.


What is heart failure in adults usually associated with?

Heart failure in adults is associated with long standing hypertension, CAD, AMI.


What is heart failure in children usually associated with?

In children, heart failure is most often associated with congenital heart defects.


What are the two groups of heart failure?

  1. Conditions which impair cardiac function
  2. Conditions which cause excessive cardiac workload demands on the heart


What are some conditions that impair cardiac function?

  1. AMI
  2. Dysrhythmias
  3. CAD
  4. Congenital heart disease


What are some conditions that cause excessive cardiac workload demands on the heart?

  1. Anemia
  2. Excessive IV fluid
  3. Hypertension
  4. Infection


What is B-type Natriuretic Peptide (BNP)'s description and purpose?

BNP is a lab test. It's a rapid assay used in diagnosis of heart failure. BNP is a protein that is predominately produced in the left ventricle in response to pressure overload and volume expansion.


What is the physiologic basis for BNP test?

Hormones released as body tries to maintain homeostasis through counterregulatory hormonal processes. BNP and ANP are hormones produced by the heart muscle that promote venous and arterial vasodilation and thus decrease preload and afterload. These hormones will block the effect of aldosterone and RAAS and promote diuresis.


What are some conditions where you would see an elevated BNP?

  1. Heart Failure
  2. Pulmonary Edema
  3. HTN
  4. Renal Failure
  5. Acute myocardial infarction
  6. Structural and inflammatory conditions of the heart
  7. Fluid restriction


What is the normal BNP level?

< 100 pG/mL


What is pulmonary edema?

Pulmonary edema is a life threatening situation in which the lung alveoli and/or lung become filled with serosanguineous fluid. It is considered a medical emergency and must be recognized and treated promptly.


What are the most common causes of pulmonary edema?

Left sided heart failure associated with CAD and AMI


What are some other possible patient situations that could lead to pulmonary edema?

  1. Heart failure
  2. Overhydration with IV fluids (esp. in peds, elderly, renal disease)


What assessment data would help you recognize pulmonary edema?

  1. Anxious
  2. 1st would see a mild increase in RR and decrease in PaO2
  3. As condition worsens, RR would decrease with severe dyspnea, crackles, wheezing, rhonchi
  4. Cough with frothy blood tinged sputum
  5. Orthopnea
  6. Worsening PaO2
  7. Pale
  8. Possible cyanosis and mottling
  9. Increased HR
  10. Increased BP or Decreased BP


What is compensated heart failure?

Occurs when the compensatory mechanisms respond and maintain adequate cardiac output


What are the compensatory mechanisms of heart failure and why don't they work long term?

  1. In response to decreased cardiac output the body increases epinephrine and norepinephrine (fight or fight hormones) which increases HR, BP, contractility and vasoconstriction
    1. This increases the demand for O2 to the heart and decreases ventricular performance
  2. In response to decreased cardiac output the body starts RAAS and increases BP by increasing sodium and water retention and vasoconstricting
    1. This increases blood volume and preload and the heart ventricle will eventually hypertrophy.
  3. In response to an increase blood volume, the ventricle dilates as it is being stretched.
    1. The heart gets overstretched and pressure decreases reducing stroke volume and decreasing cardiac output
  4. In response to an increased workload the heart muscle increases muscle mass and wall thickness to increase cardiac output
    1. Eventually, the heart will build up too much muscle mass which will cause a decrease in contractility (overstreched muscle) which will decrease force contractility and stroke volume


What assessment data would indicate right sided heart failure?

Blood is not being pumped out to the lungs efficiently and therefore a normal amount does not reach the left side of the heart or the aorta. The blood backs up into the superior and inferior venacava and the rest of the  venous system.

  1. Right ventricular dysfunction causes blood to back up into the venous system
  2. Tachycardia (increasing HR because of decreased CO)
  3. Fatigue
  4. Peripheral Edema (blood backing up)
  5. JVD (blood backing up)
  6. Weight Gain (blood backing up, RAAS trying to increase volume by holding on to water and constricting blood vessels)
  7. Anorexia/nausea


What assessment data would indicate left sided heart failure?

Left sided heart failure causes a decreased cardiac ouput as well as blood backing up into the lungs.

  1. Most common form of heart failure
  2. Left ventricular dysfunction causes blood to back up into the lungs
  3. SOB
  4. Increase in RR (fluid build up, trying to catch breath and perfuse all extra blood with O2)
  5. Fatigue
  6. Crackles
  7. Tachycardia
  8. Orthopnea


What medications decrease preload?

  1. Diuretic therapy
  2. Vasodilator therapy
  3. Morphine
  4. High Fowler's position with feet dangling
  5. Fluid restriction
  6. Low sodium diet


What medications decrease afterload?

  1. Vasodilator therapy
  2. Morphine
  3. Diuretic therapy
  4. ACE-I/ARB


What are positive inotropes?

Medications or activities that improve cardiac contractility and increase cardiac ouput

  1. Digoxin
  2. Dopamine
  3. Dobutamine


How do vasodilators increase cardiac function?

  1. Increase venous capactity
  2. Decrease preload and improves ventricular function
  3. Avoids stimulation of neurohormonal responses
  • Nitrates


How do diuretics increase cardiac function?

  1. Decrease preload
  2. Improves cardiac


What are other nursing interventions other than medications that can be done for someone in heart failure?

  1. I/Os
  2. Weights daily
  3. Lytes and renal function
  4. Supplemental O2
  5. Rest/Activity
  6. 5 small meals/day
  7. Bedside commode


How is digoxin usually prescribed for and given to infants?

BID (twice daily) PO infants/small children. Elixer measures in 1 mL syringe

2 nurse check for digoxin to children *high alert med for children*

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