C H A P T E R 4 4
Cardiotonic agents
691
G.J. was treated with diuretics and was redigitalised in the
hospital with close cardiac monitoring.
After her condition stabilised, G.J. reported that she
knew she had been taking her digoxin every day because
she recognised the pill. The only difference she could
identify was that she was given the pill in the afternoon
with a dish of ice cream, while at home she always took
it on an empty stomach first thing in the morning. The
nursing home staff confirmed that G.J. had received the
drug daily in the afternoon and that it was the same brand
name she had used at home.
CRITICAL THINKING
What care interventions should be made at this point?
Think about the signs and symptoms of HF and how they
show its progression.
How could the change in the timing of drug administration
be related to the decreased serum digoxin levels noted
on G.J.’s admission?
Consider the factors that affect absorption of a drug. What
alterations in dosing could be suggested that would
prevent this from happening to G.J. again?
What potential problems with trust could develop for
G.J. on her return to the nursing home? Suggest an
explanation for what happened to G.J. and possible
ways that this problem could have been averted.
DISCUSSION
G.J.’s immediate needs involve trying to alleviate the
alteration to her cardiac output that occurred when
she lost the therapeutic effects of digoxin. Positioning,
cool environment, small and frequent meals, and
rest periods can help to decrease the workload on
her heart. Digoxin has a narrow margin of safety and
requires an adequate serum level to be therapeutic.
G.J. was not absorbing enough digoxin to achieve a
therapeutic serum level; consequently, her body began
to go through the progression of HF, first right-sided
and then left-sided.
CARE GUIDE FOR G.J.: DIGOXIN
Assessment: History and examination
Assess the person’s health history for allergies to any
digitalis product, renal dysfunction, idiopathic
hypertrophic subaortic stenosis (IHSS), pregnancy,
breastfeeding, arrhythmias, heart block and electrolyte
abnormalities.
Focus the physical examination on the following areas:
Cardiovascular: blood pressure, pulse, perfusion, ECG
Neurological (CNS): orientation, affect, reflexes, vision
Skin: colour, lesions, texture, perfusion
Respiratory system: respiratory rate and character,
adventitious sounds
GI: abdominal examination, bowel sounds
Laboratory tests: serum electrolytes, body weight
Implementation
Administer a loading dose to provide rapid therapeutic
effects.
Monitor apical pulse for 1 full minute before administering
to assess for adverse and therapeutic effects.
Check dose very carefully.
Provide comfort and safety measures: give small, frequent
meals; ensure access to bathroom facilities; avoid
intramuscular injection; administer intravenously over
5 minutes; keep emergency equipment on standby.
Provide support and reassurance to deal with drug effects.
Provide teaching regarding drug, dosage, adverse effects,
what to report, safety precautions.
Evaluation
Evaluate drug effects: relief of signs and symptoms of HF,
resolution of atrial arrhythmias, serum digoxin levels
0.5 to 2 ng/mL.
Monitor for adverse effects, including arrhythmias, vision
changes (yellow halo), GI upset, headache, drowsiness.
Monitor for drug–drug interactions as indicated for each
drug.
Evaluate the effectiveness of teaching program.
Evaluate the effectiveness of comfort and safety measures.
TEACHING FOR G.J.
• Digoxin is a digitalis preparation. Digitalis has many
helpful effects on the heart; for example, it helps the heart
to beat more slowly and efficiently. These effects promote
better circulation and should help to reduce the swelling
in your ankles or legs. It also should increase the amount
of urine that you produce every day.
• Digoxin is a very powerful drug and must be taken exactly
as prescribed. It is important to have regular medical
checkups to ensure that the dose of the drug is correct for
you and that it is having the desired effect on your heart.
• Do not stop taking this drug without consulting your
healthcare provider. Never skip doses and never try to
“catch up” any missed doses, because serious adverse
effects could occur.
• Learn to take your pulse. Take it each morning before
engaging in any activity. Write your pulse rate on a
calendar so you will be aware of any changes and can
notify your healthcare provider if the rate or rhythm of
your pulse shows a consistent change. Your normal pulse
rate is __________.
• Try to monitor your weight fairly closely. Weigh yourself
every other day, at the same time of the day and in the
same amount of clothing. Record your weight on your
calendar for easy reference. If you gain or lose 1.5 kg or
more in 1 day, it may indicate a problem with your drug.
Consult your healthcare provider.
