Nursing Diagnosis for Dysrhythmias | Risk for Poisoning

Nursing diagnosis: risk for Poisoning [Digoxin Toxicity]

Risk factors may include

Limited range of therapeutic effectiveness, lack of education or proper precautions, reduced vision, cognitive limitations

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Medication

Verbalize understanding of individual prescription, how it interacts with other drugs or substances, and importance of maintaining prescribed regimen.

Recognize signs of digoxin overdose and developing heart failure and identify what to report to physician.

Cardiac Pump Effectiveness

Be free of signs of toxicity; display serum drug level within individually acceptable range.

Nursing care plan intervention with rationale:

1. Explain client’s specific type of digoxin preparation and its specific therapeutic use.

Rationale: Reduces confusion due to digoxin preparations varying in name (although they may be similar), dosage strength, and onset and duration of action. Up to 15% of all clients receiving digoxin develop toxicity at some time during the course of therapy because of its narrow therapeutic range.

2. Instruct client not to change dose for any reason, not to omit dose—unless instructed to, based on pulse rate—not to increase dose or take extra doses, and to contact physician if more than one dose is omitted.

Rationale: Alterations in drug regimen can reduce therapeutic effects, result in toxicity, and cause complications.

3. Advise client that digoxin may interact with many other drugs, such as barbiturates, neomycin, cholestyramine, quinidine, and antacids, and that physician should be informed that digoxin is taken whenever new medications are prescribed. Advise client not to use OTC drugs, such as laxatives, antidiarrheals, antacids, cold remedies, diuretics, and herbals, without first checking with the pharmacist or healthcare provider.

Rationale: Knowledge may help prevent dangerous drug interactions.

4. Review importance of dietary and supplemental intake of potassium, calcium, and magnesium.

Rationale: Maintaining electrolytes at normal ranges may prevent or limit development of toxicity and correct many associated dysrhythmias.

5. Provide information and have the client and SO verbalize understanding of toxic signs and symptoms to report to the healthcare provider.

Rationale: Nausea, vomiting, diarrhea, unusual drowsiness, confusion, very slow or very fast irregular pulse, thumping in chest, double or blurred vision, yellow or green tint or halos around objects, flickering color forms or dots, altered color perception, and worsening HF, such as dependent or generalized edema, dyspnea, decreased amount or frequency of voiding, indicate need for prompt evaluation and intervention. Mild symptoms of toxicity may be managed with a brief drug holiday. Note: In severe or refractory heart failure, altered cardiac binding of digoxin may result in toxicity even with previously appropriate drug doses.

6. Discuss necessity of periodic laboratory evaluations, as indicated: Serum digoxin (Lanoxin) or digitoxin (Crystodigin) level

Rationale: Digoxin has a narrow therapeutic serum range, with toxicity occurring at levels that are dependent on individual response. Laboratory levels are evaluated in conjunction

with clinical manifestations and ECG to determine individual therapeutic levels and resolution of toxicity.

7. Electrolytes, blood urea nitrogen (BUN), creatinine, and liver function studies

Rationale: Abnormal levels of potassium, calcium, or magnesium increase the heart’s sensitivity to digoxin. Impaired kidney function can cause digoxin (mainly excreted by the kidney) to accumulate to toxic levels. Digitoxin levels (mainly excreted by the bowel) are affected by impaired liver function.

8. Administer medications, as appropriate, for example: Other antidysrhythmia medications, such as lidocaine (Xylocaine), propranolol (Inderal), and procainamide (Pronestyl)

Rationale: May be necessary to maintain and improve cardiac output in presence of excess effect of digoxin.

9. Digoxin immune Fab (Digibind)

Rationale: A digoxin/digitoxin antagonist that increases drug excretion by the kidneys in acute or severe toxicity when standard therapies are unsuccessful.

10. Prepare client for transfer to critical care unit (CCU), as indicated, such as for dangerous dysrhythmias, exacerbation of heart failure.

Rationale: In the presence of digoxin toxicity, clients frequently require intensive monitoring until therapeutic levels have been restored. Because all digoxin preparations have long serum half-lives, stabilization can take several days.