Assessment cues and anticipated nursing actions a nurse

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    Anticipated Nursing Actions

• Monitor the client's vital signs and cardiac rhythm closely.
• Obtain a serum digoxin level.
• Administer oxygen as needed.
• Administer antidigoxin antibodies (Digibind) as prescribed.
• Correct any electrolyte imbalances.
• Provide supportive care, such as rest and hydration.

Comparison and Contrast of Key Information and Nursing Considerations for Medications Utilized for Heart Failure

Medication	Key Information	Nursing Considerations
Digoxin	Cardiac glycoside that increases the force and contractility of the heart muscle.	Monitor vital signs and cardiac rhythm closely. Obtain a serum digoxin level. Administer oxygen as needed. Administer antidigoxin antibodies (Digibind) as prescribed. Correct any electrolyte imbalances. Provide supportive care, such as rest and hydration.
ACE inhibitors	Vasodilators that lower blood pressure and improve blood flow to the heart.	Monitor blood pressure closely. Educate the client about the potential for orthostatic hypotension. Assess for and manage cough and angioedema.
ARBs	Angiotensin receptor blockers that lower blood pressure and improve blood flow to the heart.	Monitor blood pressure closely. Educate the client about the potential for orthostatic hypotension. Monitor for and manage cough and angioedema.
Beta-blockers	Block the effects of epinephrine on the heart, which reduces heart rate and blood pressure.	Monitor heart rate and blood pressure closely. Educate the client about the potential for bradycardia and hypotension. Monitor for and manage bronchospasm.
Diuretics	Increase the excretion of urine and sodium from the body, which can reduce blood pressure and fluid overload.	Monitor electrolytes closely. Educate the client about the potential for dehydration and electrolyte imbalances. Assess for and manage signs of hypokalemia, such as muscle cramps and fatigue.
Aldosterone antagonists	Block the effects of aldosterone, a hormone that causes the body to retain sodium and water.	Monitor electrolytes closely. Educate the client about the potential for hyperkalemia, especially in combination with other medications that can cause hyperkalemia, such as ACE inhibitors and ARBs.

drive_spreadsheetExport to Sheets Conclusion Digoxin toxicity is a serious condition that can be fatal. Early assessment and treatment are essential to improve outcomes. Nurses play a vital role in assessing and managing clients with digoxin toxicity. Nurses should also be familiar with the key information and nursing considerations for other medications utilized for heart failure, such as ACE inhibitors, ARBs, beta-blockers, diuretics, and aldosterone antagonists.  

Sample Answer

   

Assessment Cues

• Cardiovascular: Bradycardia, arrhythmias, hypotension, edema
• Neurological: Nausea, vomiting, anorexia, diarrhea, visual disturbances, headache, confusion, seizures
• Other: Fatigue, muscle weakness, polyuria