Question

Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54 . The appropriate nursing intervention is to: A. Record the pulse rate and administer the medication B. Administer the medication and monitor the heart rate C. Withhold the medication and notify the doctor D. Withhold the medication until the heart rate increases

Short answer

Answer: The appropriate nursing intervention is to withhold the medication and notify the doctor, as the apical pulse rate is below the threshold of 60 beats per minute.

Step-by-step solution

Know the medication's function and possible side effects

Lanoxin (digoxin) is a medication used to treat certain heart conditions, such as heart failure and atrial fibrillation. One of its side effects is bradycardia (low heart rate).

Understand the normal and significant apical pulse rates

A normal adult resting heart rate falls between 60 and 100 beats per minute. In the case of Lanoxin administration, withholding the medication is usually considered if the heart rate drops below 60 beats per minute. This threshold may be different for special cases, such as athletes or elderly patients, as per doctor's instructions.

Compare the observed apical pulse rate with the known threshold

In this exercise, the nurse finds the apical pulse rate to be 54, which is below the general threshold of 60 beats per minute. Hence, this indicates that there might be a risk of bradycardia due to the medication.

Decide the appropriate nursing intervention

Since the apical pulse rate is below the threshold of 60 beats per minute, the appropriate nursing intervention would be to withhold the medication and notify the doctor, as they will be able to assess whether or not it is safe to continue the treatment. Therefore, the correct answer is Option C.

Key concepts

Nursing Interventions

Nursing interventions are crucial actions that nurses take to improve the health and well-being of patients. When it comes to administering medications like Lanoxin (digoxin), nurses must be vigilant. In the context of digoxin, if the apical pulse rate falls below a certain threshold (usually 60 bpm), the nurse should consider withholding the medication. This proactive step prevents complications like severe bradycardia. Always remember, a key part of nursing interventions is effective communication. After withholding the medication, it's essential to notify the doctor to determine the next steps. This collaboration ensures patient safety and optimal treatment outcomes.
Furthermore, interventions are part of a holistic approach. The nurse should monitor for other symptoms or changes in the patient's condition. This can involve reassessing vital signs or reviewing the patient's current medications to check for interactions.

• Withhold medication if the heart rate is low.
• Communicate promptly with the healthcare provider.
• Continuously monitor the patient's overall condition.

Medication Management

Managing medications effectively is a vital competency in nursing practice. This involves knowing about the medications being administered, understanding their effects, and recognizing when they might pose risks to the patient. Lanoxin (digoxin) is a medication used for heart conditions that requires careful heart rate monitoring because of the risk of causing bradycardia.
To ensure medication management is done correctly, nurses should:

• Understand the therapeutic effects and side effects of each medication.
• Assess patient history including current medications to avoid interactions.
• Educate the patient on the medication's purpose and any signs or symptoms to watch for.

Effective medication management ensures that patients benefit from their treatments with minimal risks.
It also involves documenting all administered medications accurately, noting any adverse effects, and making adjustments as needed under the guidance of a healthcare provider.

Cardiac Assessment

A thorough cardiac assessment is essential before administering medications such as Lanoxin (digoxin) that affect heart function. This process involves evaluating the heart's rate and rhythm, particularly through the apical pulse, which is taken at the apex of the heart.
A normal adult resting heart rate is between 60 and 100 bpm. If the rate is below 60 bpm, it may indicate bradycardia, especially in patients taking digoxin. The assessment aims to detect any potential complications early. Nurses should:

• Precisely measure the apical pulse for a full minute to ensure accuracy.
• Recognize signs of abnormal heart rhythms that could indicate adverse reactions.
• Communicate findings accurately to the healthcare team for further evaluation.

The accurate assessment also helps in identifying other issues like fluid overload or heart failure symptoms.
This allows healthcare providers to adjust treatment plans effectively.

Patient Safety Protocols

Patient safety protocols are a set of procedures aimed at ensuring the well-being and safety of patients. In the case of medications like digoxin, protocols include verifying the heart rate before administration, knowing the medication dosage, and understanding potential side effects. These protocols help in preventing medication errors.
To maintain patient safety, nurses should:

• Always follow the five rights of medication administration: the right patient, drug, dose, route, and time.
• Encourage patient involvement by explaining the medication and its potential side effects.
• Document every action taken to maintain a clear, accurate patient record.

By implementing these safety measures, nurses can help prevent adverse medication reactions and complications.
Patient safety relies heavily on diligence, ongoing education, and the application of best practices within nursing care.