A deadly drug interaction has been going around for several years now. This drug interaction is called Digoxin toxicity, and it is caused by an interaction between two drugs.
Digoxin is a drug used to treat heart conditions like heart failure. When a person with heart failure receives Digoxin, they will need to have vitamin K in their system in order for the body to process it.
When a person receives too much Digoxin in their system, it can cause problems with how the body processes vitamin K. This can then lead to low blood circulation and urine that looks grayish-colored.
The problem is that nurses are being trained to look for signs of these symptoms, but they are not being taught how to identify them in people who have received Digoxin. This makes it hard to detect the problem before it gets worse.
Heart sounds
A digoxin-sensitive nurse should always assess the client’s heart sounds. Digoxin can cause abnormal heartbeats called arrhythmias.
Arrhythmias can be transient, or momentary changes in rhythm, or permanent. Transient arrhythmias may or may not require treatment, while permanent arrhythmias always require treatment.
Transient arrhythmias are usually not dangerous, but should be documented. Permanent arrhythmias are always a concern as they could be life-threatening.
The nurse should listen for the following sounds: beating together (syncope), faint beats (slow pulse), irregular beats (arrhythmia), and absence of any heart sounds (death). All of these should be documented.
Lung function
As mentioned before, digoxin can cause decreased lung function. If the nurse suspects that the client has digoxin toxicity, they should assess their lung function.
This is done by assessing how well the client can breathe, how many breaths they take per minute, how much air they breathe in per breath, and how strong their breathing is.
Breathing tests include the six-minute walk test, the timed step test, and the breathless rate test. The six-minute walk test assesses whether a person can walk a certain distance in six minutes without stopping to breathe hard.
A normal person can do this test without difficulty, indicating good pulmonary function. A person with poor pulmonary function would have difficulty doing the test due to shortness of breath (dyspnea).
The timed step test is similar to the six-minute walk test, but does not measure the distance walked.
Nutritional status
Malnourished patients are at higher risk for digoxin toxicity due to decreased glucose metabolism. Patients with diabetes and those receiving starvation therapy or fasting are also at higher risk.
Monitoring a patient’s weight and intake is an important part of nursing care. Tracking these over time can help identify changes that may require medical attention.
Monitoring dietary intake can help detect nutritional deficiencies, which can be caused by medications such as digoxin. By monitoring nutritional status, nurses can identify complications that may be caused by malnutrition.
Pre-diabetic patients may also be at an increased risk for developing digitalis toxicity due to reduced glucose metabolism. Checking blood glucose levels and offering appropriate intervention as needed is important in these cases.
Digoxin level
In cases where the nurse suspects that the client has digoxin toxicity, he or she should also assess for a digoxin level.
Digoxin levels can be taken from a blood sample or urine sample. A blood sample is more reliable, however, as urine samples can be affected by other substances in the body.
A low level of digoxin in the body does not mean that the symptoms are not due to digoxin toxicity. It is important to note that there is no “normal” level of digoxin in the body, as it varies from person to person.
A doctor should evaluate your symptoms and check your level of fatigue, heart rate, and rhythm to determine if you have digoxin toxicity or an unrelated issue.
History of digoxin use
If the patient has been on a medication that could potentially cause potassium levels to drop, such as digoxin, ask about when they last took the drug and if they have been taking it regularly.
If the patient has not been taking their medication as prescribed, further assessment for hypokalemia is necessary. If the patient has discontinued their medication or has not taken it regularly, administer additional potassium unless contraindicated.
If the patient reports no change in medication or dosage, continue monitoring for any other signs or symptoms of hypokalemia. If symptoms are present, further assess whether medical therapy can be done to counteract them.
Digoxin is a drug used to treat cardiac arrhythmias such as atrial fibrillation. It can take several weeks for the body to eliminate it, so checking past drug screens may be helpful in determining if the client is still eliminating it (Mayo Clinic 2018).
Toxicity symptoms
Digoxin toxicity can occur when someone ingests digoxin. This can be from someone eating plant parts with the toxin in it, as a prescription overdose, or theft.
Symptoms can take several hours to develop after ingestion. The sooner the nurse assesses for these symptoms, the sooner they can be addressed.
Digoxin toxicity symptoms include nausea or vomiting, diarrhea, abdominal pain or discomfort, altered bowel habits, and bleeding in the digestive tract.
General malaise or feeling unwell is also a symptom of digoxin toxicity. The individual may also have muscle pain or weakness and changes in heart rate or rhythm. Changes in mental status such as confusion or reduced alertness may also be noticed.
The last two symptoms are important as they relate to nursing assessments. The individual may not be feeling well so asking questions related to their health is important.
Clinical findings for digoxin toxicity
Digoxin can cause a variety of clinical findings, some of which are listed below. While these findings are not exclusive to digoxin toxicity, the presence of some or many of them should raise suspicion for digoxin toxicity.
Parasympathetic nervous system stimulation: These include vomiting, diarrhea, decreased appetite, and increased salivation. Although these findings may also be present in other medical conditions, the presence of all of them together with other symptoms may point toward digoxin toxicity.
Cardiovascular changes: These include a slow heart rate (bradycardia), low blood pressure (hypotension), and heart failure symptoms such as shortness of breath (dyspnea) when lying down and swelling (edema) in the legs and/or hands.
Nerve-related changes: These include altered mental status such as confusion or disorientation, muscle weakness or paralysis, and abnormal urination such as difficulty emptying the bladder (incontinence). All of these can be due to nerve damage from digoxin.
Laboratory tests for digoxin toxicity
In addition to assessing the patient directly, the nurse should also assess the results of laboratory tests. Several tests can determine whether or not a patient has digoxin in their system and how much is in their system.
These tests include a serum digoxin assay, urine toxicology screen, and plasma quantitative plasma assay. A doctor may order any of these tests depending on the symptoms and/or cause of concern.
The serum digoxin assay is a simple test that can be done in a doctor’s office or hospital laboratory. It checks the level of digoxin in the blood by using a radioassay technique. This test is very accurate and does not have any false negatives or positives.
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