Digoxin in Atrial Fibrillation Management - Case Study Example

Digoxin in Atrial Fibrillation Management Name Institution Date Table of Contents Table of Contents 2 Introduction 3 Rationale 4 Use of digoxin in management of atrial fibrillation 4 Nursing observations undertaken prior to administering digoxin 4 Nursing observations undertaken to evaluate the effectiveness of digoxin and the appearance of adverse effects 5 Signs and symptoms that indicate that Mr. T may have digoxin toxicity 6 Nursing actions for Mr. T when his pulse rate is 55 beats per minute 6 Conclusion 7 Introduction Normally, the heart relaxes and contracts to a beat that is regular (Duncan & Cunnington, 2013). Specific cells in the heart make signals that are electric causing the heart to contract thus pump blood. The electrical signals are indicated on the ECG recording. It is possible to read the ECG to establish whether the signals are abnormal or normal. During atrial fibrillation (AF), the two small superior chambers known as atria do not beat as they should beat. Instead of a regular pattern, there is an irregular beat of the atria (Rich, 2012). An individual can live with atrial fibrillation, but it may result in other rhythm issues, heart failure, chronic fatigue, and the worst of it all is stroke (Duncan & Cunnington, 2013). This paper will discuss the use of digoxin in management of AF with regards to the case study, and provide various nursing intervention before and during digoxin administration in AF management. AF is the leading cardiac arrhythmia which means a heart beat that is irregular (Duncan & Cunnington, 2013). AF is associated with chest pain, fainting, CHF, and palpitations. On the other hand, in a couple of people AF is brought about by benign or idiopathic conditions. AF raises stroke risk; the extent of risk of stroke can be around 7 times compared to the average populace, depending on existence of extra risk factors like hypertension (Khoo & Lip, 2009). In AF situation, the standard regular impulses that are electric produced by sinoatrial node are overpowered by electrical impulses that are disorganized normally coming from the pulmonary veins’ roots, resulting in irregular impulses’ conduction to ventricles which produce the heartbeat (Rich, 2012). There may be occurrence of AF in episodes persisting in paroxysmal, or be lasting in nature. There are some medical conditions that raise AF risk, specifically mitral stenosis (mitral valve narrowing). Rationale Use of digoxin in management of atrial fibrillation Digoxin is extorted from the plant called foxglove and it facilitates the heart to beat more powerfully, within a slower HR (Lleva, et al, 2009). Digoxin is frequently used in patients with AF and in those who have heart failure. On the other hand, it may be challenging to use effectively since there exists a slight range of dose at where it is considered effective, and going beyond this range can be very dangerous. Digoxin helps in slowing the HR by blocking electrical impulses’ number that pass via the node of AV into the ventricles (Duncan & Cunnington, 2013). Additionally, digoxin can strengthen contractions of the ventricles to help the heart pump extra blood with every beat (Gheorghiade, et al, 2004). The reason why digoxin is used is because it slows the HR and fortifies contractions of the heart in individuals who have AF. In addition, dogoxin can be applied in treatment of heart failure; therefore, it is helpful for treating individuals with both heart failure and AF. Symptoms of AF may be improved by digoxin through slowed heart rate and reinforced contractions of the heart (Duncan & Cunnington, 2013). Nursing observations undertaken prior to administering digoxin Before administering digoxin, there are some nursing considerations that are very imperative. It is normal practice in nursing to do an assessment of apical heart rate (Allen, et al, 2008). Once the rhythm of the patient is AF and the HR is below 60 beats per minute, or the rhythm turns out to be regular, it is vital for the nurse to withhold the drug and give a notification to the physician, since these sings imply the progression of conduction block of AV (Duncan & Cunnington, 2013). Even though digoxin withholding is a frequent practice, the drug does not require being hold back for a HR that is below 60 bpm in case the patient is within sinus rhythm since digoxin does not influence automaticity of SA node (Duncan & Cunnington, 2013). PR interval measurement for individuals with heart monitoring is regarded more essential compared to apical pulse in establishing whether digoxin needs to be held. It is important for the nurse to be acquainted with the baseline data of the patient including blood pressure, serum electrolytes, clinical symptoms, creatinine clearance and peripheral pulses’ quality, as a basis for making proper assessments (Duncan & Cunnington, 2013). Nursing observations undertaken to evaluate the effectiveness of digoxin and the appearance of adverse effects The nurse should assess the client’s clinical reaction to digoxin treatment through evaluation of symptom’s relief like orthopnea, crackles, peripheral edema, dyspnea, and hepatomegaly (O’brien, et al, 2012). It is important to monitor the client for factors which raise toxicity risk such as: reduced level of potassium (hypokalemia), which might be brought about by diuretics. Hypokalemia raises digoxin action and predisposes an individual to dysrrhythmias and digoxin toxicity (Gheorghiade, et al, 2004); Medications’ use that increase digoxin effect, including cardiac drugs and oral antibiotics that slow conduction of AV and can reduce the heart rate further; renal failure that is impaired, specifically in individuals who are 60 years old or older (Franken, et al, 2012). Since elimination of digoxin takes place in the kidneys, serum creatinine (renal function) is monitored; hence digoxin doses are adjusted consequently. It is important for the nurse to monitor for GI side effects like nausea, anorexia, vomiting, abdominal distention, and pain (O’brien, et al, 2012). It is also vital to monitor for side effects that are neurologic like malaise, headache, forgetfulness, nightmares, depression, agitation, paranoia, confusion, social withdrawal, and reduced visual acuity (Duncan & Cunnington, 2013). Taking patient’s medical history, electrolyte balance and previous tolerance should also be considered prior to digoxin administration. Signs and symptoms that indicate that Mr. T may have digoxin toxicity Digoxin therapeautic level is normally 0.5-2.0 mg/ml. Samples of blood are normally obtained and evaluated to establish digitalis concentration at minimal 6-10 hours following the last dosage (Sanaei-Zadeh, et al, 2011). Toxicity might take place regardless of the normal levels of serum, and dosages that are recommended vary considerably. A very serious complication associated with therapy of digoxin is toxicity (Duncan & Cunnington, 2013). Digoxin toxicity diagnosis is grounded on the clinical symptoms of the patient which include nausea, hypersalivation, anorexia, fatigue, vomiting, malaise, and depression; changes in rhythm or heart rate; irregular rhythm onset; changes in ECG indicating AV or SA block; new irregular rhythm onset implying ventricular dysrrhythmias, and junctional tachycardia, atrial tachycardia that has block, and ventricular tachycardia (Sanaei-Zadeh, et al, 2011). When these symptoms present in Mr. T, then it can be established that there is digoxin toxicity. Advanced age (like Mr. T who is 60 years old) might predispose individuals to an elevated intoxication of digoxin that is connected with reduced renal function, abnormalities of conduction, and reduced lean body mass (Franken, et al, 2012). Nursing actions for Mr. T when his pulse rate is 55 beats per minute The normal heart rate is considered to be 60-100 bpm. However, in AF, the heart rate becomes 100-175 bpm (Khoo & Lip, 2009). When a patient has a heart beat below 60 bpm, digoxin should be withheld. This is because administering digoxin when there is a low pulse results in lowering the heart rate further, which may result in death (Sanaei-Zadeh, et al, 2011). Digoxin toxicity occurs when there is overdose of the drug. Toxicity of digoxin is treated through withholding the medication whereas monitoring the symptoms of the patient as well as the level of serum digoxin (Aronow, 2009). The nurse should inform the physician about digoxin withholding. In case there is severity in toxicity, Digibind, which is immune FAB of digoxin might be prescribed (Sanaei-Zadeh, et al, 2011). Generally, Digibind combines with digoxin, making it not available for use. The dosage of Digibind is grounded on the level of digoxin as well as the weight of the patient. Values of serum digoxin are not very accurate for a couple of days following Digibind administration since they do not distinguish between unbound and bound digoxin. Given that Digibind rapidly reduces the amount of digoxin available, a raise in ventricular rate because of AF and HF’s worsening symptoms may follow immediately following its administration (Sanaei-Zadeh, et al, 2011). Conclusion In conclusion, this paper has presented a discussion on digoxin with respect to AF management. Digoxin is considered a useful cardiac glycoside that is effective in management of both congestive heart failure and atrial fibrillation. Patients ought to be examined for any chronic condition, medical history, previous tolerance, and electrolyte balance prior to administering digoxin. This is important so as to avoid any unwanted effects on the patient. Toxicity of digoxin as a result of hypersensitivity or overdose needs to be handled as an emergency case in order to prevent fatal consequences on patients. Management by digoxin is essential since it brings back hemodynamics of the patient, by achieving normal function of the cardiovascular. Digoxin is therefore recommended with other typical medications like β blockers for effectiveness of AF treatment. However, caution about digoxin toxicity must always be considered for patient safety. References Lleva, P., Aronow, W. S., & Gutwein, A. H. (2009). Prevalence of inappropriate use of digoxin in 136 patients on digoxin and prevalence of use of warfarin or aspirin in 89 patients with persistent or paroxysmal atrial fibrillation. American Journal of Therapeutics, 16(6). Sanaei-Zadeh, H., Valian, Z., Zamani, N., Farajidana, H., & Mostafazadeh, B. (2011). Clinical features and successful management of suicidal digoxin toxicity without use of digoxin-specific antibody (Fab) fragments--is it possible?. Tropical Doctor, 41(2), 108-10. Khoo, C. W., & Lip, G. Y. (2009). Acute management of atrial fibrillation. Chest, 135(3), 849-59. Aronow, W. S. (2009). Management of atrial fibrillation in the elderly. Minerva Medica, 100(1), 3-24. Allen, L. N. M., Sun, J. L., Kaplan, S., d'Almada, P., & Al-Khatib, S. M. (2008). Rhythm versus rate control in the contemporary management of atrial fibrillation in-hospital. The American Journal of Cardiology, 101(8), 1134-41. Gheorghiade, M., Adams, K. F. J., & Colucci, W. S. (2004). Digoxin in the management of cardiovascular disorders. Circulation, 109(24), 2959-64. Rich, M. W. (2012). Atrial Fibrillation in Long Term Care. Journal of the American Medical Directors Association, 13(8), 688-691. O’brien, K., Alexander, E., & Patel, L. (2012). Efficacy and safety of pharmacological options for rate control in atrial fibrillation. Aacn Advanced Critical Care, 23(2). Franken, R. A., Rosa, R. F., & Santos, S. C. (2012). Atrial fibrillation in the elderly. Journal of Geriatric Cardiology : Jgc, 9(2), 91-100. Duncan, A., & Cunnington, C. (2013). A holistic approach to managing a patient with heart failure. Future Cardiology, 9(2), 189-92. Read More