Heart Failure Case Study DAY 2 Medication

Heart Failure Case Study DAY 2 Medication Administration Record Medication Lisinopril 20 mg PO daily Metoprolol 100 mg PO BID Warfarin Sodium 6 mg PO daily Furosemide 80 mg IV TID Atorvastatin 40 mg PO daily Diltiazem infusion 100 mg in 100 mL 0.9% NS Titrate up to 10 mg/hour to maintain HR less than 120. Heparin sodium 25,000 units in 250 mL of 0.9% NS per Cardiology Protocol Tylenol 650 mg PO q6h prn pain/fever >101 Diltiazem 60 mg PO q6h Furosemide 80 mg PO TID Day 2 0800 D/C Diltiazem drip Diltiazem 60 mg q6h, give first dose now D/C Heparin drip Change Lasix 80 mg PO TID Call lab results today. Name: Jingle, John Age: 68 Code Status: Full Code Allergies: NKDA Vital Signs Vitals / Date BP: HR: Temp: Respirations: O2 Sat: Weight Admission Day 1200 150/82 132 98.8 31 91% RA 210 Admission Day 1600 144/85 117 97.9 30 94% 2L NC Admission Day 2000 139/84 115 97.7 30 95% 2L NC Day 1 0000 122/70 108 98.2 28 96% 2L NC Day 1 0400 126/79 102 98.3 27 95% 2L NC 207 Day 1 0800 130/68 105 98.5 24 95% 1L NC Day 1 1200 124/76 94 98.9 22 94% 1L NC Day 1 1600 114/54 88 97.6 24 96% 1L NC Day 1 2000 111/72 80 98.6 19 96% 1L NC Day 2 0000 109/70 75 99 18 97% 1L NC Day 2 0400 106/64 68 98.1 20 95% 1L NC 202 Day 2 0800 99/58 58 98.5 16 94% RA DAY 2 Medication Administration Record Medication 1. Lisinopril 20 mg PO daily 2. Metoprolol 100 mg PO BID 3. Warfarin Sodium 6 mg PO daily 4. Furosemide 80 mg IV TID 5. Atorvastatin 40 mg PO daily 6. Diltiazem infusion 100 mg in 100 mL 0.9% NS Titrate up to 10 mg/hour to maintain HR less than 120. 7. Heparin sodium 25,000 units in 250 mL of 0.9% NS per Cardiology Protocol 8. Tylenol 650 mg PO q6h prn pain/fever >101 9. Diltiazem 60 mg PO q6h 10. Furosemide 80 mg PO TID LAB RESULTS Lab Admission Day 1 Day 2 BMP: Sodium 141 136 140 Potassium 4.3 3.6 2.8 Calcium 8.7 8.7 8.6 Carbon dioxide 26 26 25 Chloride 103 102 100 Glucose 98 110 116 BUN 18 16 18 Creatinine 1.0 1.1 1.4 Magnesium 2 1.4 BNP 8,446 CBC: WBC 6.0 5.9 6.2 RBC 5 5.3 5.1 HGB 14.5 13.9 14.2 HCT 44% 41% 44% Platelets 320,000 318,500 315,565 PT/INR: PT 10 sec 9.8 sec 12.5 sec INR 1.0 1.0 1.4 EKG: Atrial Fibrillation HR 130 Atrial Fibrillation 99 Normal Sinus Rhythm 64 HEALTH CARE PROVIDER NOTES Admission Note 1200 Mr. John Jingle was admitted to the telemetry unit today for new onset congestive heart failure. His wife is at bedside. He is alert and oriented x 4. He complained that he is getting shorter of breath every day and he feels like his heart is racing. On the heart monitor his heart rate is 132 running atrial fibrillation. Vitals signs are: RR 31, BP 150/82, T 98.8⁰ F, O2 sat 91% on room air. He is noted with 3+ pitting edema in bilateral lower extremities. Radial pulses and pedal pulses noted 2+. Capillary refill <3 seconds in all extremities. Breathing noted labored but symmetric rise and fall of chest noted. Lungs noted with crackles in bilateral lower lobes and scattered wheezes noted in all lobes bilaterally. Bowel sounds active in all quadrant. Abdomen noted distended. Pt stated he knew he had been gaining weight over the last month or so. He stated he normally weighs around 175 lbs. He has a history of hypertension for 12 years, osteoarthritis for 15 years, hypercholesterolemia for 18 years, and intermittent atrial fibrillation for 2 years. Home medications: Lisinopril 20 mg PO daily, Metoprolol 50 mg po BID, Warfarin sodium 6 mg PO daily, Atorvastatin 40 mg PO HS, meloxicam 15 mg PO daily PRN. -----------------------------------------------------------------------------------------------------------Dr. Smith, MD Day 1 0730 Mr. Jingle is progressing well. Vitals stable. EKG shows conversion to NSR but still having intermittent runs of atrial fibrillation. Will continue diltiazem drip for now. Weight has decreased by 3 pounds. Will increase IV Lasix to TID. Continue Heparin drip as well. Continue to monitor labs. Day 2 0800 Mr. Jingle continues to improve. Weight is down another 5 pounds. EKG shows NSR. Nurse reports no run of atrial fibrillation in the last 24 hours. Will stop diltiazem drip today and start PO diltiazem. Plan to change Lasix to PO to see if patient can tolerate and continue to lose fluid. Continue to monitor labs. Nursing to call labs when complete. At what point should the physician consider stopping the heparin drip the patient is receiving? Why?

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