Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant’s heart rate is 120 beats/minute. Based on this, what action should the PN take?
A.
Administer the medication and alert the charge nurse
B.
Hold the medication and document cardiac assessment
C.
Administer the medication and document the heart rate
D.
Hold the medication and recheck the heart rate in 1 hour
The Correct Answer and Explanation is:
The correct answer is B. Hold the medication and document cardiac assessment.
Explanation
When administering digoxin, particularly in pediatric patients, it is crucial to consider specific guidelines regarding heart rates. Digoxin is a cardiac glycoside used to treat heart failure and certain arrhythmias, and it has a narrow therapeutic window. In infants, the acceptable heart rate range for administering digoxin is typically between 90 to 160 beats per minute. However, it is essential to assess the patient’s overall clinical status and follow facility protocols.
In this scenario, the infant’s heart rate is 120 beats/minute, which initially appears to be within the acceptable range. However, the action to hold the medication is warranted for several reasons:
- Assessment of Trends: A single heart rate reading may not accurately reflect the infant’s condition. If there are underlying issues such as tachycardia, bradycardia, or other arrhythmias that might not be evident, further assessment is necessary.
- Infant Response: Infants can have varying physiological responses to medications, especially digoxin. Holding the medication allows for additional monitoring to ensure the infant does not exhibit any signs of distress or adverse effects.
- Safety Protocols: The PN should adhere to facility protocols, which may require rechecking the heart rate after a specific period or conducting a more comprehensive assessment before administering medications that impact cardiac function.
- Documentation: Documenting the cardiac assessment is vital for continuity of care. It provides a clear record of the infant’s heart rate and the decision-making process behind withholding the medication.
Overall, by choosing to hold the medication and document the assessment, the PN prioritizes patient safety and ensures that a thorough evaluation is conducted before any potential risks associated with administering digoxin are taken. This approach aligns with best practices in pediatric nursing and medication administration.