Subjective

Anorexia

Lethargy
poor skin turgor
poor muscle tone
irregular pulse rate
decreased bowel
sounds
felt uncomfortable

in
loss of appetite
nausea

vomiting, and
diarrhea as
gastrointestinal
motility
increases
blurred vision,
visual
disturbances
(yellow-green
halos and
problems with
color perception)
Insomnia
nightmares,
agitation, and
depression,

Objective

Problem Medis

Current Therapy

DRPs

potassium (K) 2.9 Heart failure (HF) digoxin (Lanoxin) Contraindication:

furosemide
mEq/L [under the Myocardial
digoxin and
infarction
(Lasix)
normal value]
furosemid
potassium
sodium (Na) 137
chloride (KCl )
mEq/L [normal]
chloride (Cl) 96
20 mEq perday
mEq/L [under
orally
the normal value]
blood pressure
174/94 mmHg []
pulse 56
beats/minute
irregular and
respirations
30/minute

Plan
Monitoring
1)monitoring k
concentration in
blood plasma
Because
digoxin
normally
competes with
K+ ions for the
same binding
site on the
Na+/K+
ATPase pump.
2) Can give
digoxin first
then monitor
the condition of
patient and
decide the
treatment with
diuretics
3)Therapeutic
drug
monitoring
(TDM) because
Furosemide
may increase
the risk of
digoxin toxicity

Suggestion
1)beta
blocker.such as
Bisoprolol,
carvedilol and
sustainedrelease
metoprolol
because are
specifically
indicated as
adjuncts to
standard ACE
inhibitor and
diuretic therapy
in congestive
heart failure.
2)furosemide
change to
compound
eplerenone (also
an aldosterone
antagonist) are
more selective
and lack many
of the side
effects and
actions of
spironolactone

due to
hypokalemia.
4) potassium
level

that are
undesirable in
that particular
patient
population that
have Potassium
sparing.
4) Change oral
KCl to
parenteral KCl.
If can use
orally,use K
sustain release
(without
grinding).

Spironolactone: is a potassium-sparing diuretic (water pill), prevent body absorb too much salt and keep potassium

levels from getting too low. Can use to treat fluid retention and treat or prevent hypokalemia (low potassium levels
in blood). Aldosterone antagonists improve survival in patients with severe heart failure and reduced systolic function. These
agents should not be used in patients with a serum creatinine >2.5 mg/dL or serum potassium >5.0 mEq/L. Aldosterone
receptor antagonists are the only diuretics that improve survival for people with heart failure. They lower the risk of death and
hospitalization and improve symptoms of heart failure.

Digoxin does not lower blood pressure or adversely affect renal function or electrolytes. Accordingly, it is easy to use in
combination with other heart failure therapies, including ACE inhibitors or ARBs, -blockers, and aldosterone antagonists.

nonpotassium-sparing diuretics may be harmful in heart failure, particularly when higher doses are used for worsening
symptoms
The addition of ARB therapy to ACE inhibitors in heart failure and reduced systolic function does not appear to reduce mortality
but has been associated with a decreased rate of worsening heart failure. addition of digoxin to ACE inhibitor therapy for
symptomatic heart failure, rather than the addition of an ARB, may be associated with a greater benefit and lower risk of side
effects.

http://circ.ahajournals.org/content/113/21/2556.full