what conclusion should the nurse draw when a client's digoxin level is reported to be 2.2 ng/ml?
Full general
High Warning Medication: This medication bears a heightened adventure of causing meaning patient harm when information technology is used in error.
**BEERS Drug**
Pronunciation:
di-jox-in
Trade Name(southward)
- Lanoxin
- Toloxin
Ther. Course.
antiarrhythmics
inotropics
Pharm. Class.
digitalis glycosides
Indications
- Heart failure.
- Atrial fibrillation and atrial palpitate (slows ventricular rate).
- Paroxysmal atrial tachycardia.
Action
- Increases the strength of myocardial contraction.
- Prolongs refractory menstruum of the AV node.
- Decreases conduction through the SA and AV nodes.
Therapeutic Effect(south):
Increased cardiac output (positive inotropic event) and slowing of the heart rate (negative chronotropic effect).
Pharmacokinetics
Absorption: sixty–80% captivated after oral administration of tablets; 70–85% absorbed after administration of elixir; 80% absorbed from IM sites (IM route not recommended due to hurting/irritation).
Distribution: Widely distributed; crosses placenta and enters breast milk.
Metabolism and Excretion: Excreted almost entirely unchanged by the kidneys.
One-half-life: 36–48 hour (↑ in renal impairment).
Fourth dimension/ACTION Contour (antiarrhythmic or inotropic furnishings, provided that a loading dose has been given)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| Digoxin–PO | 30–120 min | 2–eight hr | 2–four days† |
| Digoxin–IM | thirty min | 4–6 hr | 2–four days† |
| Digoxin–IV | 5–30 min | 1–4 hr | 2–4 days† |
Contraindication/Precautions
Contraindicated in:
- Hypersensitivity;
- Uncontrolled ventricular arrhythmias;
- AV block (in absence of pacemaker);
- Idiopathic hypertrophic subaortic stenosis;
- Constrictive pericarditis;
- Known alcohol intolerance (elixir only).
Use Cautiously in:
- Hypokalemia (↑ risk of digoxin toxicity);
- Hypercalcemia (↑ hazard of toxicity, specially with mild hypokalemia);
- Hypomagnesemia (↑ risk of digoxin toxicity);
- Diuretic use (may cause electrolyte abnormalities including hypokalemia and hypomagnesemia);
- Hypothyroidism;
- Myocardial infarction;
- Renal impairment (dose ↓ required);
- Obesity (base dose on platonic body weight);
- OB:Monitor neonates for signs/symptoms of digoxin toxicity; monitor levels in mother during pregnancy as levels may fluctuate during pregnancy and post-partum periods; may lead to ↑ risk of arrhythmias during labor and commitment;
- Lactation: Like concentrations in serum and breast milk result in subtherapeutic levels in infant, use with caution;
- Geri:Very sensitive to toxic effects; dose adjustments required for historic period-related ↓ in renal function and torso weight.
Adverse Reactions/Side Effects
CV: ARRHYTHMIAS, bradycardia, ECG changes, AV cake, SA block
EENT: blurred vision, xanthous or green vision
GI: anorexia, nausea, vomiting, diarrhea
Hemat: thrombocytopenia
Metabolic: electrolyte imbalances with astute digoxin toxicity
Neuro: fatigue, headache, weakness.
* CAPITALS bespeak life-threatening.
Underline indicate most frequent.
Interactions
Drug-Drug
- Thiazide andloop diuretics,piperacillin/tazobactam,amphotericin B,corticosteroids, and excessive use oflaxatives may cause hypokalemia which may ↑ gamble of toxicity.
- Quinidine andritonavir may ↑ levels and lead to toxicity; ↓ digoxin dose by 30–50%.
- Amiodarone may ↑ levels and lead to toxicity; ↓ digoxin dose by 50%.
- Cyclosporine,itraconazole,mirabegron,propafenone,quinine,spironolactone, andverapamil may ↑ levels and lead to toxicity; serum level monitoring/dose ↓ may exist required.
- Levels may be ↓ by someantineoplastics (bleomycin,carmustine,cyclophosphamide,cytarabine,doxorubicin,methotrexate,procarbazine,vincristine),activated charcoal,cholestyramine,colestipol,metoclopramide,penicillamine,rifampin, orsulfasalazine.
- In a small percentage (10%) of patients gut bacteria metabolize digoxin to inactive compoundsmacrolide anti-infectives (erythromycin,azithromycin,clarithromycin) andtetracyclines, by killing these bacteria, will cause ↑ levels and toxicity; dose may need to be ↓ for up to 9 wk.
- Condiment bradycardia may occur withbeta blockers,diltiazem,verapamil,clonidine,ivabradine, and otherantiarrhythmics (quinidine,disopyramide).
- Concurrent use ofsympathomimetics may ↑ risk of arrhythmias.
- Thyroidhormones may ↓ therapeutic effects.
Drug-Natural Products:
- Licorice and stimulant natural products ( aloe ) may ↑ chance of potassium depletion.
- St. John's wort may ↓ levels and upshot.
Drug-Food:
Concurrent ingestion of a high-fiber meal may ↓ absorption. Administrate digoxin i hr before or 2 hrs after such a repast.
Route/Dosage
For rapid result, a larger initial loading/digitalizing dose should be given in several divided doses over 12–24 hr. Maintenance doses are determined for digoxin by renal function. All dosing must exist evaluated by individual response. In general, doses required for atrial arrhythmias are higher than those for inotropic effect.
Iv IM (Adults) : Digitalizing dose– 0.5–1 mg given as 50% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.
Four IM (Children >ten year) : Digitalizing dose– 8–12 mcg/kg given as l% of the dose initially and ane quarter of the initial dose in each of ii subsequent doses at vi–12 hour intervals.
IV IM (Children v–10 twelvemonth) : Digitalizing dose– fifteen–thirty mcg/kg given as 50% of the dose initially and one quarter of the initial dose in each of ii subsequent doses at 6–12 hr intervals.
Four IM (Children 2–five year) : Digitalizing dose– 25–35 mcg/kg given as fifty% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at half-dozen–12 hr intervals.
Iv IM (Children one–24 mo) : Digitalizing dose– 30–50 mcg/kg given as 50% of the dose initially and one quarter of the initial dose in each of two subsequent doses at 6–12 hr intervals.
IV IM (Infants –full term) : xx–30 mcg/kg given as 50% of the dose initially and ane quarter of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.
4 IM (Infants –premature) : Digitalizing dose– fifteen–25 mcg/kg given as l% of the dose initially and i quarter of the initial dose in each of 2 subsequent doses at 6–12 hour intervals.
PO (Adults) : Digitalizing dose– 0.75–1.5 mg given as l% of the dose initially and 1 quarter of the initial dose in each of 2 subsequent doses at six–12 hr intervals. Maintenance dose– 0.125–0.5 mg/day depending on patient's lean body weight, renal office, and serum level.
PO Geriatric Patients : Initial daily dose should not exceed 0.125 mg.
PO (Children >10 twelvemonth) : Digitalizing dose– 10–15 mcg/kg given equally fifty% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at six–12 hour intervals. Maintenance dose– 2.v–v mcg/kg given daily as a single dose.
PO (Children five–10 yr) : Digitalizing dose– 20–35 mcg/kg given as fifty% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at half dozen–12 hr intervals. Maintenance dose– five–x mcg/kg given daily in 2 divided doses.
PO (Children 2–five yr) : Digitalizing dose– 30–twoscore mcg/kg given as 50% of the dose initially and ane quarter of the initial dose in each of 2 subsequent doses at 6–12 hr intervals. Maintenance dose– 7.5–10 mcg/kg given daily in two divided doses.
PO (Children 1–24 mo) : Digitalizing dose– 35–sixty mcg/kg given as 50% of the dose initially and ane quarter of the initial dose in each of ii subsequent doses at half dozen–12 60 minutes intervals. Maintenance dose– 10–15 mcg/kg given daily in 2 divided doses.
PO (Infants –full term) : Digitalizing dose– 25–35 mcg/kg given equally 50% of the dose initially and one quarter of the initial dose in each of two subsequent doses at 6–12 hr intervals. Maintenance dose– 6–10 mcg/kg given daily in 2 divided doses.
PO (Infants –premature) : Digitalizing dose– twenty–30 mcg/kg given every bit 50% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at half dozen–12 hour intervals. Maintenance dose– 5–7.5 mcg/kg given daily in 2 divided doses.
Availability (generic available)
Elixir (lime flavor): 0.05 mg/mL
Cost:
Generic: $42.10/60 mL
Solution for injection: 0.25 mg/mL
Solution for injection (pediatric): 0.1 mg/mL
Tablets: 0.0625 mg, 0.125 mg, 0.25 mg
Cost:
Generic: All strengths $27.75/10
Assessment
- Monitor apical pulse for 1 full min before administering. Withhold dose and notify health care professional if pulse charge per unit is <60 bpm in an adult, <70 bpm in a child, or <xc bpm in an babe. Notify wellness care professional person promptly of any significant changes in charge per unit, rhythm, or quality of pulse.
- Pedi:Heart rate varies in children depending on age, enquire wellness care professional person to specify at what heart rates digoxin should be withheld.
- Monitor BP periodically in patients receiving IV digoxin.
- Monitor ECG during Four administration and 6 hr after each dose. Notify health care professional if bradycardia or new arrhythmias occur.
- Detect IV site for redness or infiltration; extravasation can lead to tissue irritation and sloughing.
- Monitor intake and output ratios and daily weights. Appraise for peripheral edema, and auscultate lungs for rales/crackles throughout therapy.
- Before administering initial loading dose, make up one's mind whether patient has taken whatever digoxin in the preceding 2–3 wk.
Lab Examination Considerations:
Evaluate serum electrolyte levels (especially potassium, magnesium, and calcium) and renal and hepatic function periodically during therapy. Notify health care professional before giving dose if patient is hypokalemic. Hypokalemia, hypomagnesemia, or hypercalcemia may make the patient more susceptible to digitalis toxicity. Pedi:Neonates may have falsely elevated serum digoxin concentrations due to a naturally occurring substance chemically similar to digoxin.
Toxicity Overdose:
Therapeutic serum digoxin levels range from 0.5–ii ng/mL. Serum levels may be drawn half-dozen–8 hr later a dose is administered; normally drawn immediately before the adjacent dose. Geri:Older adults are at increased risk for toxic effects of digoxin (on Beers list) due to age-related decreased renal clearance; may exist even when serum creatinine levels are normal. Digoxin requirements in older adult may change and a formerly therapeutic dose can go toxic.
- Detect for signs and symptoms of toxicity. In adults and older children, first symptoms of toxicity usually include abdominal pain, anorexia, nausea, airsickness, visual disturbances, bradycardia, and other arrhythmias. In infants and small children, first signs of overdose are usually cardiac arrhythmias. If these appear, withhold drug and notify health care professional immediately.
- If signs of toxicity occur and are not severe, discontinuation of digoxin may exist all that is required.
- Correct electrolyte abnormalities, thyroid dysfunction, and concomitant medications. Administer potassium to maintain serum potassium betwixt iv.0 and 5.five mmol/L. Monitor ECG for evidence of potassium toxicity (peaked T waves).
- Handling of life-threatening arrhythmias may include administration of digoxin allowed Fab (Digibind) , which binds to the digitalis glycoside molecule in the blood and is excreted by the kidneys.
Potential Diagnoses
- Decreased cardiac output (Indications)
- Scarce knowledge, related to medication regimen (Patient/Family/Didactics)
Implementation
- Do non confuse Lanoxin (digoxin) with levothyroxine or naloxone.
- High Warning: Digoxin has a narrow therapeutic range. Medication errors associated with digoxin include miscalculation of pediatric doses and insufficient monitoring of digoxin levels. Take second practitioner independently cheque original society and dose calculations.
-
For rapid digitalization, initial dose is college than maintenance dose; 50% of total digitalizing dose is given initially. Administer remainder of dose in 25% increments at 4–8 hr intervals.
- When changing from parenteral to oral dose forms, dose adjustments may be necessary because of pharmacokinetic variations in pct of digoxin absorbed: 100 mcg (0.one mg) digoxin injection = 125 mcg (0.125 mg) tablet or 125 mcg (0.125 mg) of elixir.
- POAdminister oral preparations consistently with regard to meals. Tablets can be crushed and administered with food or fluids if patient has difficulty swallowing. Utilise calibrated measuring device for elixir; calibrated dropper is non authentic for doses of less than 0.two mL or 10 mcg.
- IMAdminister deep into gluteal muscle and massage well to reduce painful local reactions. Do non administer more two mL of digoxin in each IM site. IM administration is not more often than not recommended.
4 Administration
- IV Push: Diluent: May be administered undiluted. May likewise dilute one mL of digoxin in 4 mL of sterile h2o for injection, D5W, or 0.9% NaCl. Less diluent will cause precipitation. Utilise diluted solution immediately.
- Charge per unit:Administer over at least v min.
- Y-Site Compatibility:
- acyclovir
- alemtuzumab
- alfentanil
- MORE...
- amikacin
- aminocaproic acid
- aminophylline
- amphotericin B lipid complex
- anidulafungin
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- arsenic trioxide
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- atracurium
- atropine
- azathioprine
- azithromycin
- aztreonam
- benztropine
- bivalirudin
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- calcium chloride
- calcium gluconate
- cangrelor
- carboplatin
- carmustine
- cefazolin
- cefotaxime
- cefotetan
- cefoxitin
- ceftaroline
- ceftazidime
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorpromazine
- ciprofloxacin
- cisatracurium
- cisplatin
- clindamycin
- cyanocobalamin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- dactinomycin
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- daunorubicin
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- diltiazem
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- dobutamine
- docetaxel
- dopamine
- doxorubicin liposome
- doxycycline
- enalaprilat
- ephedrine
- epinephrine
- epirubicin
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- eptifibatide
- ertapenem
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fenoldopam
- fentanyl
- fludarabine
- fluorouracil
- folic acid
- fosfomycin
- fosphenytoin
- furosemide
- ganciclovir
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- heparin
- hetastarch
- hydrocortisone sodium succinate
- hydromorphone
- ifosfamide
- imipenem/cilastatin
- indomethacin
- irinotecan
- isoproterenol
- ketamine
- ketorolac
- labetalol
- leucovorin calcium
- levofloxacin
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- meperidine
- meropenem
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- methohexital
- methotrexate
- methylprednisolone sodium succinate
- metoclopramide
- metoprolol
- midazolam
- milrinone
- mitomycin
- morphine
- moxifloxacin
- multivitamins
- mycophenolate
- nafcillin
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- norepinephrine
- octreotide
- ondansetron
- oxacillin
- oxaliplatin
- oxytocin
- palonosetron
- pamidronate
- pancuronium
- pantoprazole
- papaverine
- pemetrexed
- penicillin Thousand
- pentobarbital
- phenobarbital
- phentolamine
- phenylephrine
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- potassium acetate
- potassium chloride
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- pyridoxine
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- tirofiban
- tobramycin
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- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- vitamin B complex with C
- voriconazole
- zoledronic acid
- Y-Site Incompatibility:
- amiodarone
- amphotericin B deoxycholate
- amphotericin B liposome
- More than...
- caspofungin
- dantrolene
- diazepam
- diazoxide
- doxorubicin
- foscarnet
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- minocycline
- mitoxantrone
- paclitaxel
- pentamidine
- phenytoin
- propofol
- quinupristin/dalfopristin
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Patient/Family unit Teaching
- Instruct patient to accept medication as directed, at same time each day. Teach parents or caregivers of infants and children how to accurately measure medication. Take missed doses within 12 hr of scheduled dose or omit. Do not double doses. Consult health care professional if doses for 2 or more days are missed. Do not discontinue medication without consulting health care professional.
- Teach patient to have pulse and to contact health care professional before taking medication if pulse charge per unit is <60 or >100.
- Pedi: Teach parents or caregivers that changes in centre rate, especially bradycardia, are amid the first signs of digoxin toxicity in infants and children. Instruct parents or caregivers in upmost heart rate assessment and ask them to notify health care professional if heart rate is exterior of range fix by wellness intendance professional before administering the side by side scheduled dose.
- Review signs and symptoms of digitalis toxicity with patient and family. Suggest patient to notify health care professional immediately if these or symptoms of HF occur. Inform patient that these symptoms may exist mistaken for those of colds or flu.
- Instruct patient to go along digoxin tablets in their original container and not to mix in pill boxes with other medications; may look like to and may be mistaken for other medications.
- Suggest patient that sharing of this medication tin can be dangerous.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products beingness taken and to consult health care professional before taking other Rx, OTC, or herbal products, particularly St. John's wort. Advise patient to avert taking antacids or antidiarrheals within 2 hour of digoxin.
- Advise patient to notify health intendance professional person of this medication regimen before treatment.
- Patients taking digoxin should deport identification describing disease process and medication regimen at all times.
- Geri:Review autumn prevention strategies with older adults and their families.
- Advise female person patient to notify health care professional person if pregnancy is planned or suspected, may increment risk for depression nascency weight or preterm nascence. Monitor neonates for signs and symptoms of digoxin toxicity (airsickness, cardiac arrhythmias).
- Emphasize the importance of routine follow-upwardly exams to make up one's mind effectiveness and to monitor for toxicity.
Evaluation/Desired Outcomes
- Decrease in severity of HF.
- Increment in cardiac output.
- Subtract in ventricular response in atrial tachyarrhythmias.
- Termination of paroxysmal atrial tachycardia.
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