Quality of life Scenario

PART ONE Medical-Surgical Cases
2. What is the rationale for changing the method of administering furosemide? [c] M.G. is fl uid overloaded and needs to decrease fl uid volume in a short period. IV administration is delivered directly into the vascular system, where it can start to work immediately. In HF, blood fl ow to the entire GI system is compromised; therefore the absorption of orally ingested medications may be variable and take longer to work.

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3. You administer furosemide 80 mg IVP. Identify three parameters you would use to monitor the effectiveness of this medication. [k]
• Daily weight
• I&O
• Decreased dependent edema
• Decreased SOB, decreased crackles in the bases of the lungs, and possibly decreased O2 demands
• Decreased JVD
4. What laboratory tests should be ordered for M.G. related to (R/T) the order for furosemide? [c]
Furosemide 80 mg is a potent diuretic, which may cause the loss of potassium and magnesium. These 2 electrolytes are important in maintaining a stable heart rhythm. These electrolytes will need to be supplemented if the levels are low.

✽ Note: Most HF admissions are R/T fl uid volume overload. Patients who do not require intensive care monitoring can most often be treated initially with IVP diuretics, O2, and angiotensin-converting enzyme (ACE) inhibitors.

5. How do ACE inhibitors help in HF? [k]
ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This results in systemic vasodilation, thereby reducing preload (reducing the volume of blood entering the left ventricle) and afterload (reducing the resistance to the left ventricular contraction) in patients in HF.

✽ Instructor Note: You could tell the students that the most frequent side effect of ACE inhibitors is a persistent, nonproductive cough. The intensity of the symptoms tends to be dose related; the higher the dose, the more intense the cough. An important alternative medication is an angiotensin II receptor blocker (ARB), often called “an ACE without a cough.” Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 3 chapter 1 Cardiovascular Disorders Case Study 1

6. M.G.’s symptoms improve with IV diuretics. She is ordered back on oral furosemide once her weight loss is deemed adequate to achieve a euvolemic state. What will determine if the oral dose will be adequate to consider her for discharge? [k] It is critical to help the primary care provider assess whether the change from IV to oral diuretics can maintain a stable weight. One of the fl uid management goals for patients in HF is to maintain a target weight. This is done by monitoring daily morning weight, keeping an accurate I&O, and recording subjective symptoms.

7. M.G. is ready for discharge. What key management concepts should be taught to prevent relapse and another admission?
✽ Hint: Use the mnemonic MAWDS. [k]
The most essential aspect of teaching hospitalized patients without overloading them is to focus on realistic key points. Teaching should be aimed at tips to improve symptoms and prevent readmission. The 5 most important concepts for patients with HF are included in MAWDS instructions.

Medications: Take as directed, do not skip a dose, and do not run out of medications. Activity: Stay as active as you can while limiting your symptoms. Weight: Weigh every morning. Call if you gain or lose 2 pounds overnight or 5 pounds from your target weight.

Diet: Follow a low-salt diet and limit fl uids to less than 2 quarts or liters per day. Symptoms: Know what symptoms to report to your provider; report early to prevent readmission.
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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The objectives of this project are briefly described below