Case Study: 83-year-old Male on Digoxin and Furosemide (Nursing)

00:00 Let's take a look at patient case #1. "Mr. George is an 83-year-old male patient. He has been diagnosed with congestive heart failure, diabetes, hypertension, and gout. He currently takes digoxin and furosemide daily. His weight is up 5 pounds over the last 2 days and the physician has ordered an increase dose of furosemide." Whoosh, I don't know about you but when you're taking a test question like this, I want to give you some pointers that you can make it to an entire paragraph like this and pick out the key points. First of all, we've read it through once we kind of have an overview. That's step 1. Now, let's go back to the beginning. Mr. George is an 83-year-old male client. So, he's elderly. Right? We know that, alright, we've got a client who's elderly, they react differently to drugs. Now he has some diagnoses; congestive heart failure, diabetes, hypertension and gout. Wow. He's got 4 diagnoses. Not uncommon for an elderly client; CHF, diabetes, hypertension, and gout. Now before I go on, those are diagnoses so I'm going to think "what is the worst case scenario?" Well for CHF, I'm always worried about fluid volume overload.

01:16 For diabetes, I'm worried about blood sugar control. Hypertension, I want to control that to be a normal level. And gout, I'm worried about that kind of uric acid build-up in him being in pain.

01:27 So, anytime you see a diagnosis stop and think through, "Hey what do I kind of know to be the worst case scenario for each one of those diagnosis?" So we've got that. Got an elderly client with these 4 diagnoses. I know what I'm thinking about. He currently takes digoxin. Okay, based on his diagnosis, what would he be taking that for? Oh yeah draw a line to congestive heart failure and furosemide daily. Okay, that should go to congestive heart failure too or it will also help with the hypertension. His weight is up 5 pounds over the last 2 days. Now that's a number. So circle the number 5 in your notebook. Anytime you see a number you want to ask yourself high, low, or normal. Up 5 pounds? High, way too high. Right? Now why am I worried about him gaining weight. Am I worried about what he's going to look like for bikini season? No. What I'm worried about is a congestive heart failure in the increase in weight might tell me that he is, wow, having some real problems with fluid volume overload. Now the physician has ordered an increased dose of furosemide. Well, that should be helpful because he is up 5 pounds, we think it's fluid. So that seems right in line, but before we go on think about is there anything you're concerned about.

02:51 Now let's take a look at some specific questions. Why his healthcare provider ordered an increase dose of furosemide? Right, he's up 5 pounds over the last 2 days. Remember that's a number.

03:07 We thought high, low, or normal. We recognize that was high so this indicates that he is retaining fluid. You really have to work at gaining 5 pounds of fat in 2 days. Not that it wouldn't be fun but that's not usually where that much weight increase comes from. What impact does furosemide have on the symptoms of CHF? Okay, well furosemide will help with the symptoms of CHF because congestive heart failure leads to fluid volume overload. So, furosemide is a loop diuretic that will help us get rid of that excess fluid. Now what impact will furosemide have on diabetes? Whoah, I know one of the side effects is high blood sugar so I'm going to want to watch their blood sugar very closely and monitor that. What impact does furosemide have on hypertension? Oh, it should help bring hypertension back to a more normal level because furosemide is a loop diuretic that will get rid of lots of extra volume. If I have less volume, then I have a lower blood pressure.

04:14 So furosemide should be good for hypertension. What impact does furosemide have on gout? Whoah, that's not so good because furosemide might cause a build-up of uric acid and that's what causes gout so that might make his gout worse. What risk or adverse effect should the nurse monitor for Mr. George in order to keep him safe and ensure the most effective treatment? Wow, look back at what Mr. George has going on. What are your thoughts? Here's just some ideas. How many of these did you get? I'm going to want to listen to his lung sounds because listening to lung sounds will let me know if he is in pulmonary edema, the worst case scenario for CHF. Edema in your ankles and your legs is bad but edema in your lungs affects the rest of your body because you're not going to be able to get good oxygenated blood adequately to all your tissues. Monitor fingerstick blood sugars more often because this might raise his blood sugar. We are going to monitor his blood pressure so we watch it coming down but not too far down to make him hypotensive. We want to teach Mr. George about orthostatic hypotension. Let him know that, wow because we're changing anytime you have fluid volume status changes with the diuretic it makes him more at risk for sitting or standing too quickly they might end up being real dizzy and falling and because Mr. George is 83 years old he likely has an increased risk for falls. We want Mr. George to understand what the symptoms of gout are, which I promise you he'll know if he has experienced it, but he needs to let us know if he is having worsening gout so we can address that with a healthcare provider.

05:56 Also you want him to recognize his signs and symptoms of low potassium and dig toxicity. Remember signs of dig toxicity are things like GI disturbances, you see those yellow halo visions or you have some weird heartbeats going on, some unusual experiences for the patient. So when you're looking at a question like this, I promise this is classic what you'll see in an NCLEX-type question. You'll have multiple diagnoses and multiple medications and they're going to want to test to see if you can sort few one of the most important things that you need to know to keep your patient safe.