VERBAL PRESE

NTATION

331774053 Hae Jin Chung

 PATIENTS PROFILE
Name: Mr. P
Sex: Male
Chief complains:
Age: 85

worsening SOB,
productive cough
Ethnicity: Medical history:
CHF, CKD
NZ European

IHD-previous NSTEMI and CABG in 2003

Occupation: Retireme T2DM on insulin
Diabetic retinopathy
nt (registered blind)
Family/Social situation: PVD toe amputation 2005

Lives alone in rest hom

e
VITAL SIGNS CLINICAL ASSESSMENT
BP: 178/85mmHg

HR: 110bpm

Temp: 36.5c, afebrile

Respiratory quality
RR: 24 per minute, regular, - few bibasal crepitation
shallow
JVP: +6cm
Sp02: 94% on air
Capillary refill: <2seconds
Blood sugar level: 14.4mm
ol/l
ECG rate/ rhythm: 116, A f
ibrillation
Weight: 110kg (was 102k
g)
Significant bilateral pitting
oedema up to knees
 RELEVANT LABORATORY
FINDINGS
Bloods Results Normal range Significance
Sodium 128 135-145mmol/L Confusion, loss of
energy, restless &
muscle weakness
Creatinine 183 50-110umol/L Impaired kidney
function or kidney
disease
eGFR 26 80-120ml/min/1.73m2 severe loss of
kidney function
Troponin I 1130 0.9ug/L Damage to the
heart muscle
(myocardium)
NT- 1358 <35 pmol/L Degree ofheart
proBNP failure
Concerto haematology results, 2016
 PLEURAL EFFUSION DUE TO HEART FAILU
RE
Most common cause of transudate pleural effusion

pulmonary interstitial fluid

capillary in the pleural
pressure space

This leads to continued sodium retention resulting in perip

heral edema and, ultimately, in the development of pleural
effusions.

Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Pathologic Basis of Disease (8th ed.). Philadelphia, PA: Saunders/Elsev
ier.
 BLOOD TESTS

N-terminal pro
b-type natriuretic
peptide (NT-
proBNP)

Evaluate the severity of heart failure with pleural effusion

Porcel, J. (2010). Pleural effusions from congestive heart failure. Seminars in Respiratory and Critical Care Medicine , 31(6),689-697.
Primary Diagnosis:

Exacerbation of congestive heart failure

Mild pleural effusion

INITIAL TREATMENT PLAN

Diuretic medications commenced on IV furosemide
Fluid restriction 1.2L/day

Daily weight

Monitor bloods
 THE LOOP DIURETICS
Furosemide
Bumetanide

Ethacrynic acid

Torsemide

Acts in the thick ascendi

ng limb of the loop of H
enle

25% of the sodium of the glo

merular filtrate is
reabsorbed

Burchum, J., & Rosenthal, L. (2014). Lehne's pharmacology for nursing care (9th ed.). St.Louis: Elsevier
Health Sciences.
 FUROSEMIDE THE LOOP DIURETICS
The most commonly used diuretics for HF

Absorbed from the gastrointestinal tract

The bioavailability of furosemide : 10-90%

95% of Furosemide binds to plasma proteins.

50% furosemide metabolized by kidney

Onset Peak Duration

Oral 1hour 1-1.5hours 6-8hours
Intravenous 5minutes 10- 2hours
30minutes
Oh SW, Han SY. (2015). Loop Diuretics in Clinical Practice. Electrolyte Blood Press.13(1),17-21.
 RISK FACTORS
Medication Patient

Side effect
Electrolyte imbalance
hyponatremia
hypokalemia
Ototoxicity Postural hypotention
Hypotension High falls risk
Dehydration - Toe amputation, blind

thrombosis
embolism

Burchum, J., & Rosenthal, L. (2014). Lehne's pharmacology for nursing care (9th ed.). St.Louis: Elsevier Health
Sciences
Berry, S., Zhu, Y., Choi, H., Kiel, D., & Zhang, Y. (2013). Diuretic initiation and the acute risk of hip fracture.
Osteoporosis International, 24(2),689-695.
 INTRAVENOUS TREATMENT
11days of furosemide treatment

IV Furosemide Furosemide
120mg & 80mg infusion10mg
BD over 24hours
Day 1-3 Day 4-5

Furosemide infusion Furosemide

20mg infusion 15mg
Over 24hours Over 24hours
Day 8-11 Day 6-7
 TREATMENT PROGRESS..

No change of patients weight

No improve of shortness of breath

Still present with pitting oedema

 CHANGE MEDICATION..

IV Furosemide Oral Bumetanide

 BUMETANIDE- THE LOOP DIURETICS

Better oral bioavailability than furosemide

40 times more potent than furosemide

More useful in patients with fluid retention

Metabolised exclusively in liver

Vazir, A. and Cowie, M. (2013) The use of diuretics in acute heart failure: Evidence based therapy?. Wo
rld Journal of Cardiovascular Diseases, 3, 25-34.
DITIONAL P
LAN

Acute renal failure

Creatinine
330umol/L

Consulted to cardiology

Enalapril (ACE inhibitor)

Metolazone (Thiazide diuretic)

 ENALAPRIL ACE INHIBITOR
Absorbed from the gastrointestinal tract rapidly

Pro-drugs

Long half life (once daily)

 ENALAPRIL FOR CHF
Lowering arteriolar tone improve blood flow

Venous dilation reduce pulmonary congestion and

peripheral oedema

Dilating blood vessels in the kidney increase renal

blood flow

Suppressing aldosterone and reducing angiotensin

prevent pathologic changes in cardiac structure

Burchum, J., & Rosenthal, L. (2014). Lehne's pharmacology for nursing care (9th ed.). St.Louis: Elsevier Health Sciences.
 ACE INHIBITORS- SIDE EFFECTS
Cough most common

First dose hypotension

Hyperkalaemia - Nausea and vomiting

Renal failure

Angioedema

Fetal injury

Skin rash
 METOLAZONE - THIAZIDE DIURETICS

Act on the distal tubule

Inhibit 10-20% of Na+ reabsorption

Milder than loop diuretic.

Generic name Onset (hr) Duration (hr)

Metalazone 1 12-24

Babu, B., Muralidharam, S., Meyyanatha, S., & Suresh, B. (2010). Pharmacokinetic evaluation of metolazone tab
lets using healthy human volunteers. J Bioequiv Availab. 2(1), 15-17.
 DOUBLE DIURETIC THERAPY
LOOP+ THIAZIDE

Very effective in very low GFR (<30ml/min/1.73m2)

weight loss and reduce oedema

Double Sodium Excretion

Caution: hyponatremia, hypotension,

worsening renal function
 DRUG INTERACTION

ACE inhibitors + Loop diuretics + NSAIDs =

Triple whammy

Nephrotic
toxicity
Bryant, B. J., Knights, K. M., & Salerno, E. (2011), Valika, A., & Gheorghiade, M. (2013)
TREATMENT OUTCOMES BARRIERS

Medical Patient

Stress
Medical condition
CHF, CKD, T2DM
Misunderstanding
Significant risks of infection
Thoracentesis Depression
FOR BETTER TREATMENT OUTCOME..

Nurses- teamwork Collaboration with Patient

Close monitoring fluid restriction

Partnership
Daily weight
Participation
Protection
Monitoring bloods level
- Creatinine, GFR
 PATIENT EDUCATION
Dietary reduction in sodium (2000-3000mg/day)

Importance of fluid restriction

Possible of high blood sugar level

Check daily weight

Monitoring dizziness
 DISCHARGE PLAN

Discharge to private hospital

- GNS/NASC input

Frusemide 160mg BD, Metolazone 2.5mg mane

and enalapril 2.5mg

Check weight discharge weight 106.35kg

( If weight increase, consider increasing Metolazon
e to 5mg mane and 2.5mg nocte)
REFERENCES
Babu, B., Muralidharam, S., Meyyanatha, S., & Suresh, B. (2010). Pharmacokinetic evaluation of
metolazone tablets using healthy human volunteers. J Bioequiv Availab. 2(1), 15-17.

Berry, S., Zhu, Y., Choi, H., Kiel, D., & Zhang, Y. (2013). Diuretic initiation and the acute risk of hi
p fracture. Osteoporosis International, 24(2),689-695.

Bryant, B. J., Knights, K. M., & Salerno, E. (2011). Pharmacology for health professionals (3rd e
d.). Sydney: Mosby Elsevier

Burchum, J., & Rosenthal, L. (2014). Lehne's pharmacology for nursing care (9th ed.). St.Louis: El
sevier Health Sciences.

Damman, K., Kjekshus, J., Wikstrand, J., Cleland, J., Komajda, M., Wedel, H. (2016). Loop diureti
cs, renal function and clinical outcome in patients with heart failure and reduced ejection fractio
n. European Journal of Heart Failure, 18(3),328-336.

Moranvile, M., Choi, S., Hogg, J., Anderson, A., & Rich, J. (2015). Comparison of metolazone ver
sus chlorothiazide in acute decompensated heart failure with diuretic resistance. Cardiovascular
Therapeutics, 33(2),42-49.
Oh SW, Han SY. (2015). Loop Diuretics in Clinical Practice. Electrolyte Blood Press.13(1),17-21.
REFERENCES
Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Pathologic Basis of Disease (8th ed.). Philad
elphia, PA: Saunders/Elsevier.

Porcel, J. (2010). Pleural effusions from congestive heart failure. Seminars in Respiratory and Criti
cal Care Medicine, 31(6),689-697.
Valika, A., & Gheorghiade, M. (2013). Ace inhibitor therapy for heart failure in patients with imp
aired renal function: a review of the literature. Heart Failure Review, 18(2),135-140.

Vazir, A. and Cowie, M. (2013). The use of diuretics in acute heart failure: Evidence based therap
y?. World Journal of Cardiovascular Diseases, 3, 25-34.