Mrs. Kidway is a 71-year-old woman who lives at home with her daughter’s family. Her daily medications prior to admission include digoxin 0.125 mg once a day. Mrs. Kidway arrives in the emergency room with her daughter who explains, “She was fine this morning but then this afternoon she developed terrible abdominal pain and got short of breath.”

Case Study

Mrs. Kidway is a 71-year-old woman who lives at home with her daughter’s family. Her daily medications prior to admission include digoxin 0.125 mg once a day. Mrs. Kidway arrives in the emergency room with her daughter who explains, “She was fine this morning but then this afternoon she developed terrible abdominal pain and got short of breath.” Mrs. Kidway is lethargic. Her physical examination is unremarkable except for facial grimacing when palpating her abdomen. She is afebrile with a blood pressure of 105/50, pulse 60, and respiratory rate 18. Blood work on admission reveals a digoxin level of 3.8 ng/mL.

Questions

1. How does digoxin work in the body?

2. Why is Mrs. Kidway taking digoxin?

3. Given Mrs. Kidway’s digoxin level, briefly explain what electrolyte imbalance is of concern.

4. During a nursing assessment of Mrs. Kidway’s current medications, the nurse asks if Mrs. Kidway takes any over-the-counter medications or herbal remedies. Mrs. Kidway’s daughter says, “Is licorice considered an herbal remedy? My mother started taking licorice capsules about a month ago because we heard that licorice helps decrease heartburn.” Does licorice interact with digoxin? If so, explain.

5. Discuss what the terms loading dose and steady state indicate.

6. What are the onset, peak, and duration times of digoxin when it is taken orally?

7. If Mrs. Kidway was having difficulty swallowing her digoxin capsule and her health care provider changed her prescription to the elixir form of digoxin, theoretically would she still receive 0.125 mg?

8. What is a medication’s “half-life”? What is the half-life of digoxin? Theoretically, if Mrs. Kidway took her digoxin at 8:00 a.m. on a Monday, when will 75% of the digoxin be cleared from her body according to the half-life? Since the half-life of digoxin is prolonged in the elderly, use the high end of the range of digoxin’s half-life.

9. What is the normal therapeutic range of serum digoxin for a client taking this medication?

10. What symptoms may be noted when digoxin levels are at toxic levels?

11. At what serum digoxin range do cardiac dysrhythmias appear and what is the critical value for adults?

12. Mrs. Kidway’s heart rate drops to 50 beats per minute. Her potassium is 2.1 mEq/L. She is given four vials of intravenous digoxin immune fab (reconstituted with sterile water) and admitted to the intensive care unit for monitoring. Discuss how her digoxin toxicity will be treated.

13. What are the two highest priority nursing diagnoses appropriate for Mrs. Kidway’s plan of care

ANSWER

Managing Digoxin Toxicity in Mrs. Kidway: Nursing Care Priorities

Introduction

Mrs. Kidway, a 71-year-old woman, presented to the emergency room with abdominal pain and shortness of breath. She had been taking digoxin, a medication commonly prescribed for heart conditions. However, her digoxin level was found to be elevated (Cummings, 2023). This scenario requires immediate attention to manage digoxin toxicity and ensure Mrs. Kidway’s well-being. In this essay, we will discuss the nursing care priorities for Mrs. Kidway, focusing on the two highest priority nursing diagnoses.

Nursing Diagnosis 1

Impaired Gas Exchange Impaired gas exchange is a significant concern for Mrs. Kidway due to her presenting symptoms of shortness of breath. The decreased oxygenation caused by impaired gas exchange can lead to further complications and compromise the patient’s respiratory status.

Priority Nursing Actions

Monitor respiratory rate, oxygen saturation, and lung sounds at regular intervals to assess the severity of impaired gas exchange and guide treatment interventions (Bhutta, 2022).

Administer supplemental oxygen as prescribed to improve oxygenation and relieve dyspnea.

Encourage deep breathing and coughing exercises to promote effective lung expansion and prevent respiratory complications.

Assist with positioning Mrs. Kidway in an upright position to optimize lung ventilation and gas exchange.

Collaborate with the healthcare team to obtain chest X-rays and arterial blood gas (ABG) analysis to assess lung function and the adequacy of oxygenation.

Nursing Diagnosis 2

Risk for Cardiac Dysrhythmias Elevated digoxin levels can disrupt the electrical conduction system of the heart, leading to dysrhythmias and potential cardiovascular compromise (David, 2023). The risk for cardiac dysrhythmias in Mrs. Kidway necessitates vigilant monitoring and prompt interventions to maintain cardiac stability.

Priority Nursing Actions

Continuously monitor Mrs. Kidway’s cardiac rhythm through electrocardiogram (ECG) monitoring to detect any changes or abnormalities promptly.

Assess vital signs, particularly heart rate and blood pressure, at regular intervals to identify signs of worsening dysrhythmias or cardiac instability (Moss et al., 2017).

Collaborate with the healthcare provider to adjust or withhold digoxin doses as necessary, based on cardiac rhythm and serum digoxin levels.

Administer anti-dysrhythmic medications, such as beta-blockers or calcium channel blockers, as prescribed to control dysrhythmias and stabilize the heart rate.

Implement fall prevention strategies due to the risk of syncope or dizziness associated with dysrhythmias and digoxin toxicity.

Conclusion

Mrs. Kidway’s case highlights the importance of promptly identifying and managing digoxin toxicity to prevent further complications. The two highest priority nursing diagnoses for Mrs. Kidway’s plan of care are impaired gas exchange and the risk for cardiac dysrhythmias. By closely monitoring Mrs. Kidway’s respiratory status and cardiac rhythm, initiating appropriate interventions, and collaborating with the healthcare team, nurses can optimize patient outcomes and promote recovery.

References

Bhutta, B. S. (2022, August 9). Hypoxia. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK482316/ 

David, M. N. V. (2023, January 19). Digoxin. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK556025/ 

Moss, T. J., Clark, M. M., Calland, J. F., Enfield, K. B., Voss, J. C., Lake, D. E., & Moorman, J. R. (2017). Cardiorespiratory dynamics measured from continuous ECG monitoring improves detection of deterioration in acute care patients: A retrospective cohort study. PLOS ONE, 12(8), e0181448. https://doi.org/10.1371/journal.pone.0181448