Case Study: Male Patient on Lithium, Enalapril, Insulin and Furosemide (Nursing)

00:00 Mr. Smith has been diagnosed with bipolar disorder, hypertension, diabetes, and is newly diagnosed with CHF. Okay, so he's got 4 diagnoses right off the bat. He takes lithium, enalapril, and insulin daily. He will now begin taking furosemide. Okay, now that is too much for your brain to keep straight. So here's what I would recommend when you see a question like this. First of all, we don't have any age of Mr. Smith, we just look at him as an adult male. Right? He has 4 diagnoses; bipolar, hypertension, diabetes, and now we're adding CHF as a new diagnosis. Okay, so we've got straight in our mind, we know bipolar disorder is a mood disorder. Hypertension means elevated blood pressure. Diabetes, I'm going to be worried about maintaining normal blood sugars. And CHF is a fluid volume overload risk and I'll be most concerned about pulmonary edema. So now let's look at the medications he takes. Lithium, well that's for the bipolar disorder. Enalapril is for the hypertension, it helps lower his blood pressure. And insulin is for the diabetes. Now we're going to add a 4th medication, right? We're going to add furosemide, which is a loop diuretic.

01:17 So you should already be thinking through we're adding 1 more medication to this patient who's pretty complex. What impact is furosemide going to have? So let's think about the most important concepts to educate Mr. Smith about the impact of furosemide with his current medications because as a nurse my job is to keep him safe and patient education is our responsibility and we've just got to do a better job then printing things off and handing it to the patient as they walk out the door. So let's take a look at each one of those medications and the possible impact with furosemide. So first of all lithium. Lithium and furosemide puts the patient at increased risk for lithium toxicity. Well, why is that? Well, remember, low sodium for any reason, a low serum sodium, puts the patient who is taking lithium at increased risk for lithium toxicity. Furosemide's job is to get rid of those extra electrolyte so the water will follow. So furosemide puts you at an increased risk for low sodium. That's why lithium plus furosemide puts them at an increased risk for lithium toxicity. So make sure Mr. Smith is aware what the signs and symptoms are of lithium toxicity. Now I want to encourage you don't ever assume just because a patient has been on the medication that they fully understand it. It's hard to process all these information and all the things that are coming at a patient when they're being discharged. So make sure you just ask a thoughtful, polite, and respectful questions about their understanding so you can make sure they are safe taking this new medication. Now look at the next medication, enalapril. Enalapril is given to lower blood pressure. Now if I give furosemide, that also has a potential to lower blood pressure. Right? Because you're getting rid of volume and you'll have a lower blood pressure.

03:05 So this puts them at an increased risk for hypotension. Well I'm really worried about things like orthostatic hypotension. Right? Going from lying to sitting or sitting to standing too quickly. So I want to make sure that he knows to be very careful to take his time doing that so he doesn't risk falling no matter what age he is. Let him know that he may sometimes feel dizzy if he is getting up from a seated position and that's normal, he just needs to be cautious. Now what about the last one, insulin plus furosemide. Well, insulin is given to control blood sugar but furosemide has that potential to raise blood sugar. So someone on insulin who's taking furosemide is at an increased risk for hyperglycemia. So you just want to let the patient know if he notices that his blood sugars are kind of rising, he needs to contact the healthcare provider for followup.

03:57 Now the use of furosemide can cause electrolyte imbalances of potassium, calcium, sodium, and magnesium. So what particular imbalance is most concerning with lithium? Let's see what you remember. Right. Remember we just talked about furosemide can lower sodium and a low sodium leads to less lithium excretion because the body will hang on to both sodium and lithium and that's what increases the risk of lithium toxicity. So what are the signs and symptoms of lithium toxicity that Mr. Smith would need to follow up immediately? Well, the signs and symptoms of lithium toxicity progress from GI distress and tremors and muscle weakness to certainly see more CNS symptoms like drowsiness, seizures, agitation, slurred speech, and a significant drop in his blood pressure.

04:52 So we want to make sure that Mr. Smith is very aware what the signs and symptoms are of lithium toxicity and they'll progress from GI distress up to those CNS symptoms like drowsiness, seizures, agitation, changes in his speech, and even a drop in blood pressure.