00:00
Mr. Smith has been diagnosed with bipolar disorder, hypertension, diabetes, and is newly diagnosed
with CHF. Okay, so he's got 4 diagnoses right off the bat. He takes lithium, enalapril, and insulin
daily. He will now begin taking furosemide. Okay, now that is too much for your brain to keep
straight. So here's what I would recommend when you see a question like this. First of all, we
don't have any age of Mr. Smith, we just look at him as an adult male. Right? He has 4 diagnoses;
bipolar, hypertension, diabetes, and now we're adding CHF as a new diagnosis. Okay, so we've
got straight in our mind, we know bipolar disorder is a mood disorder. Hypertension means elevated
blood pressure. Diabetes, I'm going to be worried about maintaining normal blood sugars. And
CHF is a fluid volume overload risk and I'll be most concerned about pulmonary edema. So now
let's look at the medications he takes. Lithium, well that's for the bipolar disorder. Enalapril is
for the hypertension, it helps lower his blood pressure. And insulin is for the diabetes. Now we're
going to add a 4th medication, right? We're going to add furosemide, which is a loop diuretic.
01:17
So you should already be thinking through we're adding 1 more medication to this patient
who's pretty complex. What impact is furosemide going to have? So let's think about the most
important concepts to educate Mr. Smith about the impact of furosemide with his current medications
because as a nurse my job is to keep him safe and patient education is our responsibility and we've
just got to do a better job then printing things off and handing it to the patient as they walk
out the door. So let's take a look at each one of those medications and the possible impact with
furosemide. So first of all lithium. Lithium and furosemide puts the patient at increased risk for
lithium toxicity. Well, why is that? Well, remember, low sodium for any reason, a low serum sodium,
puts the patient who is taking lithium at increased risk for lithium toxicity. Furosemide's job
is to get rid of those extra electrolyte so the water will follow. So furosemide puts you at an
increased risk for low sodium. That's why lithium plus furosemide puts them at an increased risk
for lithium toxicity. So make sure Mr. Smith is aware what the signs and symptoms are of lithium
toxicity. Now I want to encourage you don't ever assume just because a patient has been on
the medication that they fully understand it. It's hard to process all these information and all
the things that are coming at a patient when they're being discharged. So make sure you just
ask a thoughtful, polite, and respectful questions about their understanding so you can make
sure they are safe taking this new medication. Now look at the next medication, enalapril. Enalapril
is given to lower blood pressure. Now if I give furosemide, that also has a potential to lower blood
pressure. Right? Because you're getting rid of volume and you'll have a lower blood pressure.
03:05
So this puts them at an increased risk for hypotension. Well I'm really worried about things like
orthostatic hypotension. Right? Going from lying to sitting or sitting to standing too quickly. So
I want to make sure that he knows to be very careful to take his time doing that so he doesn't
risk falling no matter what age he is. Let him know that he may sometimes feel dizzy if he is
getting up from a seated position and that's normal, he just needs to be cautious. Now what
about the last one, insulin plus furosemide. Well, insulin is given to control blood sugar but
furosemide has that potential to raise blood sugar. So someone on insulin who's taking furosemide
is at an increased risk for hyperglycemia. So you just want to let the patient know if he notices
that his blood sugars are kind of rising, he needs to contact the healthcare provider for followup.
03:57
Now the use of furosemide can cause electrolyte imbalances of potassium, calcium, sodium, and
magnesium. So what particular imbalance is most concerning with lithium? Let's see what you
remember. Right. Remember we just talked about furosemide can lower sodium and a low sodium leads
to less lithium excretion because the body will hang on to both sodium and lithium and that's what
increases the risk of lithium toxicity. So what are the signs and symptoms of lithium toxicity
that Mr. Smith would need to follow up immediately? Well, the signs and symptoms of lithium toxicity
progress from GI distress and tremors and muscle weakness to certainly see more CNS symptoms
like drowsiness, seizures, agitation, slurred speech, and a significant drop in his blood pressure.
04:52
So we want to make sure that Mr. Smith is very aware what the signs and symptoms are of lithium
toxicity and they'll progress from GI distress up to those CNS symptoms like drowsiness, seizures,
agitation, changes in his speech, and even a drop in blood pressure.