Assessment and Evaluation of Patients Receiving Cardiac Glycosides
强心甙类药使用患者的护理评估与评价
A. Assessment
Assess for contraindications or cautions: Known allergies to any digitalis product to avoid hypersensitivity reactions; impaired kidney function, which could alter the excretion of the drug; ventricular tachycardia or fibrillation, which require treatment with other life-saving drugs; heart block, sick sinus syndrome, or IHSS, which could be exacerbated by the drug; acute MI, which could lead to increased muscle damage and infarction; electrolyte abnormalities (increased calcium, decreased potassium, or decreased magnesium), which could alter the action potential and drug effects; and current status of pregnancy or lactation to evaluate benefits versus potential risk to the fetus when using the drug.
Perform a physical assessment to establish baseline status before beginning therapy, determine the effectiveness of therapy, and evaluate for any potential adverse effects.
进行体检评估，确立治疗前基线状况，确定治疗效果，评价有无任何可能的不良效应。
Obtain the patient’s weight, noting any recent increases or decreases, to determine the patient’s fluid status.
获取患者体重，注意任何最新的增加或减少，以确定患者的液体状况。
Assess cardiac status closely, including pulse and blood pressure, to identify changes requiring a change in dosage of the drug or the presence of adverse effects, and auscultate heart sounds, noting any evidence of abnormal sounds, to identify conduction problems.
密切评估心功能状态，包括脉搏和血压，确认需要调整药剂量或存在不良效应的任何变化；听诊心音，注意任何异常声音证据，以确认心脏传导问题。
Inspect the skin and mucous membranes for color, and check nail beds and capillary refill for evidence of perfusion.
检查皮肤和粘膜的颜色，检查甲床和毛细管充盈，以发现有无灌注证据。
Monitor affect, orientation, and reflexes to evaluate CNS effects of the drug.
监测情感、定向力和反射，评价药物的CNS效应。
Assess the patient’s respiratory rate and auscultate lungs for evidence of adventitious breath sounds to monitor for evidence of left-sided HF.
评估患者呼吸率，听诊肺音，评估有无附加音证据，监测有无左侧HF证据。
Examine the abdomen for distention; auscultate bowel sounds to evaluate GI motility.
检查有无腹胀；听诊肠鸣音，评价GI能动性。
Assess voiding patterns and urinary output to provide a gross indication of renal function.
评估排便形态和尿排量，提供肾功能指征。
Obtain a baseline ECG to identify rate and rhythm and evaluate for possible changes.
获取基线ECG，确认心率和心律，评价有无可能的变化。
Monitor the results of laboratory tests, including serum electrolyte levels and renal function tests, to determine the need for possible dose adjustment.
监护实验室试验结果，包括血清电解质水平和肾功能试验，确定是否需要调整剂量。
The patient will receive the best therapeutic effect from the drug therapy.
患者将获得药物的疗法的最佳治疗效果。
The patient will have limited adverse effects to the drug therapy.
患者会有有限的药物疗法不良效应。
The patient will have an understanding of the drug therapy, adverse effects to anticipate, and measures to relieve discomfort and improve safety.
患者将了解药物疗法，预期的不良效应，及缓解不适提高安全性的措施。
B. Evaluation 评价
Monitor patient response to the drug (improvement in signs and symptoms of HF, resolution of atrial arrhythmias, serum digoxin level of 0.5–2 ng/mL).
监测患者对药物反应（HF症状体征、房性心律不齐 的改善、血清地高辛水平0.5 – 2 ng/mL）
Monitor for adverse effects (vision changes, arrhythmias, HF, headache, dizziness, drowsiness, GI upset, nausea).
监测有无不良效应（视觉变化、心律不齐、FH、头痛、头晕、嗜睡、GI不适、恶心）。
Monitor the effectiveness of comfort measures and compliance with the regimen.
监测舒适措施效果和治疗方案依从性。
Evaluate the effectiveness of the teaching plan (patient can name drug, dosage, proper administration, adverse effects to watch for, specific measures to avoid them, and the importance of continued follow-up).
评价宣教计划效果（患者能说出药名、剂量、适当的给药方式、需要留意的不良效应、具体的避免措施、继续随访的重要性）。
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Cardiac Glycosides -- Nursing Considerations
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1. Which is the most appropriate action for the nurse to take before administering digoxin?
A. Monitor potassium level.
B. Assess blood pressure.
C. Evaluate urinary output.
D. Avoid giving with thiazide diuretic. 2. Jason James is taking ß blockers, all of the following should be included in his assessment except:
A. Pulmonary function tests.
B. Baseline ECG.
C. Glucose level.
D. Blood pressure.
奥医教育“在线自测”题库 ISPN/RN复习练习、效果检验一站完成。
答案 Answer 1. A. Rationale: Monitoring potassium is especially important because hypokalemia potentiates digoxin toxicity. Digoxin exhibits its therapeutic and toxic effects by poisoning the sodium-potassium ATPase. The subsequent increase in intracellular sodium leads to increased intracellular calcium by decreasing calcium expulsion through the sodium-calcium, cation exchanger. Blood pressure and urinary output are incorrect because these data reflect overall CV status but are not specific for digoxin. 2. A. Rationale: Unless the client has a history of pulmonary disease and pulmonary function tests are indicated, there is no need to include this in the routine assessment of the client taking ß blockers. Beta-blockers, as a class of drugs, are primarily used to treat cardiovascular diseases and other conditions.
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