Pharmaceutical patient care plan
Done by / Fatimah Al-Shehri ,Pharm.D
SOAP Formula:
Items
S
O
HF
DM
AF
Dyslipidemi
a
HTN
-Shortness of breath.
-High heartbeat.
-Dyspnea on exertion.
-Fatigue.
Usually no
symptoms
Palpitation.
Uncontrolled
heart beat .
No symptoms
Headache.
Confusion.
-RR= 22, CK-MB 0.8 IU/L
High blood
sugar
(Glucose 139
Irregular rhythm
P= 100-150
ECG:
AF with rapid
Wt 103 kg,
overweight.
BP= 150/95
-pitting edema bilaterally.
-Skin color is pale and
diaphoretic.
–JVD, CO2 27 mEq/L.
-Chest X-ray Shows
evidence of congestive
failure with cardiomegaly
-EF was estimated at 15 %
to 20 %
-BNP 1200 pg/Ml.
mg/dL)
Ventricular
HbA1c 7.2%
High blood
pressure
response rate of
140.
INR 2.8
-Rosiglitazon
The patient started on
carvedilol
Abnormal lipid
profile.
4 mg po once
-Warfarin 7.5 mg
po once daily.
daily.
-Digoxin 0.125 mg
-Metformine
po once daily.
-Pravastatin 10 mg
-Lisinopril 2.5
po once daily.
mg po once
daily.
850 mg po
A
TID
-Glyburide
2.5 mg po
BID
The overall assessment : the patient has diagnosed with diabetes with new-onset
congestive heart failure with rapid ventricular response. Considering his medical problems,
treatment goals are: The main treatment goals in the hospitalized patient with heart
failure are to restore euvolemia and to minimize adverse events(stabilization of the
patient ) so the American society of heart failure recommended the following treatment
goals for patient admitted to the hospital with acute heart Failure:
1-improvement of symptoms especially (congestion,shortness of breath ,dysnea,and low
output symptoms ).
2-Optimize volume status(decrease edema ).
3-Restore normal oxygenation.
4-Identify and address the precipitating factors .
5-Optimize chronic oral therapy .
6-Minimize the side effects .
the medications that are indicated in the long-term management of this patient’s heart
failure are usually : Common in-hospital treatments include intravenous diuretics,
vasodilators, and inotropic agents. But In the long term management of heart Failure
strategies differ according to whether or not the patient has significant systolic
dysfunction, but in general for any patient with heart Failure after stabilization according
to the guidelines we use :
-ACEI or ARBs.
-BB.(not in the acute HF).
-And if the patient is overloaded(edema) we add :
ACEI+BB+Loop diuretics.
The drugs, doses, schedules, and duration for the management of this patient? For
management of his heart Failure - we use ACEI (e.g:Captopril 6.25mg/day as a starring
dose, and the target dose is :50mg TID.
-BB and the best in this case is:
-Carvedilol :3.125mg/day as a staring dose then increase toward the target dose which
is :25mg BID. Because the patient has hypertension and heart failure so we prefer
carvedilol as BB coz it has Alpha activity (it means that will help to reduce the
hypertension due to it's activity on alpha receptors inducing dilatation ) .
From diuretics : we use loop diuretics , Furosemide:20-40mg/day as a stating dose and
a maximum dose is 600mg/day .
ACEI+BB should be used long life ,but diuretics only if the patient is edematous ,and
once the patient is improved no need to use it .
The most common precipitants for HF hospitalization are:
- noncompliance with medications or dietary restrictions.
- uncontrolled hypertension, ischemia, arrhythmias.
-exacerbation of chronic obstructive pulmonary disease with or without pneumonia.
-Other contributors include noncardiac conditions such as renal dysfunction, diabetes
mellitus, anemia, and the side effects of medications (nonsteroidal anti-inflammatory
drugs, calcium-channel blockers, and thiazolidinediones).
So the patient has DM we should monitor his blood glucose to insure that the DM is
controlled .The patient also has AF and he's on warfarin ,and digoxin ,we should monitor
the digoxin level routinely to make sure that the level is in the theraputic window .
The patient also on furosemide and the most common side effect is electrolyte imbalance
so we should monitor the hypokalemia which is a major cause of digoxin toxicity .
Rosiglitasone (that is used for DM ) can cause fluid retention and peripheral edema. As a
result, it may precipitate congestive heart failure (which worsens with fluid overload in
those at risk)so it's better to use another anti diabetic or to decrease the dose of
rosiglitasone.
Thiazolidinediones, including pioglitazone and rosiglitazone, cause or exacerbate
congestive heart failure in some patients.
(After initiation of these drugs, as well as after dose increases, observe patients carefully
for signs and symptoms of heart failure (including excessive, rapid weight gain; dyspnea;
and/or edema); if these signs or symptoms develop, the heart failure should be managed
according to the current standards of care; furthermore, discontinuation or dose reduction
of these drugs must be considered. These drugs are not recommended for patients with
symptomatic heart failure; initiation of these drugs in patients with established NYHA
class III or IV heart failure is contraindicated).
Metformin:
Patients with CHF requiring pharmacologic management, in particular those with
unstable or acute CHF who are at risk for hypoperfusion and hypoxemia, are at an
increased risk for lactic acidosis; the risk for lactic acidosis increases with the degree of
renal dysfunction and the patient’s age,so we should take this in our consideration .
The plan:
-Stabilization of the patient,and restoration of heart functions and elimination of exx
fluid.
-Monitoring of INR, digoxin level and electrolytes to prevent any adverse effects that
could happened from diuretic therapy and other medications.
-Monitoring of potassium level.
-Monitor the patient's blood pressure because it wasn’t controlled.
-Monitoring of liver function tests because the patient is on pravastatin which may
cause hepatotoxicity and rhabdopmyolysis.
-Changing the ant diabetic rosiglitazone or decrease its dose until the patient is
stabilized and monitoring the lactic acidosis because the patient is on metformin .