Dec 14, 2022
Video OER - Pharmacology CHF Case Study
In this episode, we continue our dive into Cardiac System pharmacology. You can find all the cardiac episodes here at https://www.memorizingpharm.com/oer6
In this video, we go over a CHF Case Study to better understand the process of finding issues in the therapy and treatment of our patient
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Auto Generated Transcript:
Welcome to the Memorizing Pharmacology podcast. I’m Tony Guerra, pharmacist and author of the Memorizing Pharmacology book series, bringing you mnemonics, cases, and advice for succeeding in Pharmacology. Sign up for the email list at memorizingfarm.com to get your free suffixes cheat sheet or find our mobile-friendly self-paced online pharmacology review course at residency.teachable.com forward slash P forward slash mobile. Let’s get started with the show. Hey, welcome to Memorizing Pharmacology podcast. What we’re going to do is do a case study nursing care of the adult heart failure patient in a long-term care setting LTC and what we want to do is maybe not take a shortcut as much as see maybe how a pharmacist can see it sometimes where they just look at the medication record and they’re already looking at a couple of interactions that are common and of concern and they lead you to the answer without necessarily having to do all of this stuff with the case but we’ll go through the whole thing just for the um activity itself. So what we’re going to do is we’re going to try to provide care for an adult patient long-term care with a history of heart failure. We’re going to identify some common assessment findings and we’re going to talk about some common interventions as we go forth. So here’s the patient Hector Fernandez is a 62 year old male patient who has recently admitted to a long-term care center for frequent Falls. This video I’m not going to play because if YouTube hears the video or its AI hears the video it’ll shut this one down but you can go to chapter 6 14 module learning activities and play the video but the big thing is that the patient didn’t want the TED hose on there and then there’s some other pieces that we’ll kind of go through now. Alright so here are some questions that kind of came from it so what is the underlying pathophysiology behind heart failure? A is it the heart muscle fibers shorten resulting in decreased filling volume? B, the muscle fibers are overstretched or weakened resulting in a decreased force of contraction and injected volume? Three, the contractility of the heart increases or four, the heart muscle is increased force of contraction due to overloading of the ventricles? So when you’re talking about heart failure you want to think about that word failure and the word failure is really talking about how it’s failing to do its job and it’s failing to do its job because those muscle fibers are stretched and weakened so you have a decreased force of contraction and ejected volume and the big thing is that if you’re getting less volume you’re getting less oxygen not only to the body but to the heart itself because the heart feeds itself through the coronary arteries so we’ll check that and we see that oops I got a I didn’t never push the button okay so here we go. The muscle fibers are stretched patient and heart failure has a reduced force of muscular contraction okay uh next question is what do you expect to find on your assessment when the nurse states the resident has two plus pitting edema? So is it that applied pressure leaves an indentation of three to four millimeters that rebounds in less than 15 seconds? Does applied pressure leave an indentation of five to six millimeters that takes up to 30 seconds to rebound? The patient has swelling around the nail beds? The residence pulses must be found with a Doppler? Okay so what we’re really doing is what’s the difference between two plus and three plus pitting edema so Here is the corrected version of your text: The two plus pitting edema would be when we apply the pressure leave an indentation of three to four millimeters that rebounds in less than 15 seconds. The five to six millimeters with 30 seconds, that would have been three plus pitting edema. As you recall, the reporting nurses described that Hector refused to allow her to apply his TED hose this morning. Okay, and then the purpose of the TED hose is to increase arterial blood return to the heart and so that’s the thing that we really want to look at, is it arterial or venous blood? So if we think about how blood comes back to the heart, arterial blood is ejected out very high pressure system but when we talk about coming back it’s that the veins with their valves are just not doing it. They’re not able to, you know, the patient’s not walking a ton and it’s just really difficult for that blood to fight gravity and go back up. So the TED hose are really to increase the ability of venous blood to come back. So we would call this false. Okay, check it and yes, alright.Here is the corrected version of your text:
"And then based on the report that was received, what are the priority focused assessments that you would do with Hector? Well, would we do abdominal renal and neurological assessments? Would we assess H-E-E-N-T head eyes ears nose throat neurological and skin assessment? Or cardiac respiratory and renal? And so because we have a patient that does have that heart failure background, we would definitely check the cardiac respiratory and renal assessment. Okay, alright so let’s proceed to the next slide.
Alright so again we’ve got kind of one of those uh videos I’m not going to play it but I’ll play uh the answers to the next pieces okay uh Hector reports that his heart skips a beat based on the statement what do you expect to find in your assessment? Difficulty ascultating his heart tones? An irregular heartbeat? A bounding pulse or a regular heartbeat? Okay so the skips a beat would probably be that irregular heartbeat that’s indicative of heart rate abnormality and so we would probably find some kind of abnormal heart rhythm as we palpate and ascultate.
We decided to take Hector’s Vital Signs and note the following results: blood pressure 158 over 100, heart rate of 58, respiratory rate of 18, temperature 37.5 Celsius, oxygen saturation 95 percent and pain level of zero. Okay, which of the Vital sign results are priority concerned for this patient? So again we’ve got a cardiac patient history of congestive heart failure so we would expect that this would it be the temperature? The oxygen saturation? The blood pressure or the respiratory rate? Kind of gave it away but the blood pressure would probably be the most significant with this particular patient. Alright so we complete the respiratory exam and it’s kind of cool here you can have a listen to uh would you say those were crackles diminished clear or wheezing okay I think we would go with crackles I was a little bit uh of sound in there it certainly wasn’t clear but we didn’t really hear wheezing in there I know it’s a little bit hard to hear but you can play the video on the slide as well okay what do crackles indicate about Hector’s condition? Does Hector have increased fluid in his lungs? Does he require IV antibiotics for his lung infection? Does he have pneumonia and does he have a cold? So those crackles are really just the difficulty of getting that air in with the fluid in the lungs alright then the last one after you hear the crackles in Hector’s lungs which are following priority assessments will you perform will you assessmentation strength and motor responses will you assess respiratory rate oxygenation status edema current shortness of breath signs of circulation assess capillary refill heart tones and signs of skin breakdown assess for signs of numbness and tingling and petal pulses yeah respiratory rate oxygenation status edema shortage of breath signs of circulation that would be right okay all right proceed to the next okay you assess Hector’s lower extremities and you have to see it to find the following and then how would you characterize Hector’s edema would it be one plus two plus three plus four plus again there’s a video so if you didn’t see it unfortunately yet I can’t um I can’t really show you all right and we’re gonna see up three plus pitting edema so uh it was pretty deep uh and uh didn’t really hear anything about the time with it but again you kind of do your best with the picture all right based on the information collected in your assessment you determine Hector’s condition is improved worsen or remains unchanged okay so because of what we’ve seen we’d probably say that this condition has indeed, worsened. Alright, having gathered your assessment information, you consult Hector’s admitting orders. What order takes priority at this time? Is it the Digoxin 0.25 milligrams PO daily, the daily weight, the Furosemide 40 milligrams every 12 hours by mouth, or Aspirin 81 milligrams by mouth daily? And so what we want to do is we’re going to look at the orders here and we see that we’re admitted to a virtual Skilled Nursing Facility. CBC chem 7 and every three months administer O2 via nasal cannula to maintain pulse
oximetry 95 percent or greater. Notify MD if O2 sat is less than 90 with oxygen. Cardiac diet 2 gram sodium low cholesterol low fat weight on admission and weekly weights. Physical Therapy consult. Now here are the medications: Aspirin enteric coated 81 milligrams one tab by mouth every day, Digoxin 0.25 milligrams every day, Furosemide 40 milligrams PO every 12 hours, Metoprolol 12.
5 milligrams by mouth every day, Lisinopril 10 milligrams by mouth every day, Atorvastatin 40 milligrams by mouth every day, Acetaminophen 500 milligrams by mouth two tabs every four hours for pain or fever as needed, TED hose on while awake. Elevate legs three times daily. And what we see here are some kind of classics. If I had seen an issue with the patient and some kind of cough I would have immediately gone to Lisinopril. If I had seen a diabetic patient I would have worried about masking hypoglycemia. If I’d seen a patient with muscle pain I
would have gone to Rhabdomyolysis with Atorvastatin but I see Digoxin and Furosemide and immediately I’m thinking hypokalemia before I even kind of go through to the next piece so let’s go back to the learning activity and let’s say Furosemide 40 milligrams every 12 hours but let’s figure out how how would I know that like how would I know what these medications are for so we’ve got Digoxin Furosemide Metoprolol Lisinopril Atorvastatin where would I you know look and what you want to look at here are
the endings the samide of Furosemide that’s what lets you know that it’s a loop diuretic the alol of Metoprolol and you had to memorize that it was second generation so this is a selective beta blocker the pril or Prill of Lisinopril and the vastatin of Atorvastatin and again you can find that sheet on the memorizing farm.
com webpage when you if you sign up for the email list I give you a big sheet like this and I’ll show you how it looks um so we see the simide part of the loop diuretic and we see that um the all here in Metoprolol and that’s a second generation beta selective and we see the Prill in an Ace inhibitor and then we see the well it’s going to be down here the vastatin of an hmg-coa reductase inhibitor which is also Lipitor the Atorvastatin here and then I think the anti-platelet was the Aspirin and then the cardiac glycoside is Digoxin so
using those endings makes it a lot easier to kind of understand okay I know what I’m dealing with with the medications right away don’t have to look anything up it just you just see the endings but again when you’re reading medications you’re probably going to want to read from right to left rather than left to right okay so going back to this I would say Furosemide that would be the big issue because a Furosemide is causing hypokalemia that’s a big deal when we see Digoxin okay so we’ll proceed to the
next uh we’re going to look at the lab results okay and we see here and we’ll make this a bit bigger that we have hemoglobin that is a little bit outside of range a little bit low we see hematocrit is a little bit low mean corpuscular volume 74.2 just a little bit low the red blood cells and then this is the CBC with differentials so we’ll go down to the next part which is the chem 7 and then we see the bun a little bit high at 30.
creatinine a little bit high at 1.6 but our real concern here is this potassium 3.3 that is under the 3.5 to 5.3 ml equivalents per liter and so when we see hypokalemia it’s probably caused by the loop diuretic and with Digoxin that’s a real big concern okay so after reviewing Hector’s laboratory results which is a priority concern the creatinine the potassium the glucose or the hemoglobin definitely say the potassium okay hypokalemia is what we’re worried about okay uh based on the laboratory results you
should notify the provider sure thing yep so what we’re looking at is what would have the greatest effect on the potassium and heart rate okay and that would be the Furosemide Digoxin and Metoprolol okay so the abnormal potassium level and heart rate require that Administration and modification at this time okay you gather information to phone to Hector’s provider regarding his current status what information would be a priority to report okay so would it be the current appetite and last bowel movement oxygen level and Pressure hemoglobin level and increased fatigue or the presence of crackles increased edema potassium level and heart rate. I think by now we’ve kind of got that this is a cardiac deal so presence of crackles increasing edema potassium level and heart rate this is worsening heart failure okay so this is just asking how you think the scenario went and then opportunity to give feedback so the big thing I kind of wanted to to kind of come back to was if you knew the stems you knew the digoxin was a cardiac glycoside aspirin was a blood thinner.
Furosemide was Loop diuretic metoprolol beta blocker second generation lysinopril ACE inhibitor and atorvastatin lipid or hmg-coa reductase inhibitor and the big thing is that if you know those it makes it so much easier and that’s kind of where this whole memorizing pharmacology comes from. I understand many of your professors are going to tell you not to memorize things but what we’re really saying is there are things you need to memorize as a foundation just like you have to know the alphabet to succeed in in vocabulary.
Or you have no medical terminology really to do super well in pathophysiology and Physiology and anatomy and what we’re trying to memorize is what’s the medication for and then as we kind of understand the systems then when we talk about side effects and therapeutic effects it really makes sense because you went through the whole process so when you understand heart failure and I guess I could have gone into you know what causes that hypokalemia when we get into the nephron and those types of things but maybe that’s for a different lecture.
Foreign pharmacology podcast you can find episodes cheat sheets and more at memorizingfarm.com again you can sign up for the email list at memorizingfarm.com to get your free suffixes cheat sheet or find our mobile friendly self-paced online pharmacology review course at residency.teachable.com forward slash P forward slash mobile thanks again for listening thank you.
Like to learn more?
Find my book here: https://geni.us/iA22iZ
and subscribe to my YouTube Channel TonyPharmD here: https://www.youtube.com/c/tonypharmd
Here is the Link to my Pharmacy Residency Courses: residency.teachable.com