A patient with congestive heart failure and pulmonary edema is experiencing chest pain.
The patient has been prescribed morphine sulfate IV 4 mg every 5-30 minutes as needed until chest pain subsides.
The last dose of 4 mg was administered 15 minutes ago, and the patient is still complaining of chest pain and showing signs of increased respiratory effort.
The nurse observes a heart rate of 82 beats per minute, a respiratory rate of 18 breaths per minute, and a blood pressure of 135/88 mm Hg. What should the nurse do next?

Choice A rationale:

Propylthiouracil (PTU) is a thionamide medication that inhibits the synthesis of thyroid hormones. It is the preferred drug for presurgical treatment of Graves' disease because it effectively lowers thyroid hormone levels and reduces the risk of thyroid storm, a life-threatening complication that can occur during or after surgery.

PTU acts by blocking the enzyme thyroid peroxidase, which is essential for the production of thyroid hormones. It also inhibits the conversion of thyroxine (T4) to triiodothyronine (T3), the more active form of thyroid hormone. This results in a decrease in circulating levels of both T4 and T3, leading to a reduction in the symptoms of hyperthyroidism.

PTU is typically started at a dose of 100-300 mg daily, divided into two or three doses. The dose is then adjusted based on the patient's response and thyroid hormone levels. The goal of treatment is to achieve a euthyroid state, which means that the thyroid hormone levels are within the normal range.

PTU is generally well-tolerated, but it can cause some side effects, including skin rash, itching, nausea, vomiting, abdominal pain, joint pain, and hair loss. In rare cases, it can also cause serious side effects, such as liver damage and agranulocytosis (a decrease in white blood cells).

Choice B rationale:

Liotrix (Thyrolar) is a combination of synthetic T4 and T3 hormones. It is not used for presurgical treatment of Graves' disease because it can worsen the symptoms of hyperthyroidism.

Choice C rationale:

Propranolol (Inderal) is a beta-blocker medication that can be used to control the symptoms of hyperthyroidism, such as tachycardia, tremor, and anxiety. However, it does not lower thyroid hormone levels and is not used for presurgical treatment of Graves' disease.

Choice D rationale:

Levothyroxine sodium (Synthroid) is a synthetic T4 hormone. It is used to treat hypothyroidism, but it is not used for presurgical treatment of Graves' disease.

Choice A rationale:

Hypertension is not a primary contraindication for mannitol use. While it's important to monitor blood pressure during mannitol administration, it's not the most concerning factor in this scenario.

Mannitol can even be used cautiously in hypertensive patients with conditions like intracranial hypertension or acute renal failure, where its benefits may outweigh the potential risks of exacerbating hypertension.

Choice B rationale:

Mannitol is actually indicated for the treatment of increased intracranial pressure (ICP). It works by drawing fluid from the brain tissues into the bloodstream, thereby reducing pressure within the skull.

Therefore, a patient with ICP would not be a concern for mannitol administration; rather, they would be a potential candidate for its use.

Choice D rationale:

While fluid volume overload can be a concern with mannitol use, it's typically managed with careful monitoring and fluid restriction.

The more significant concern in this scenario is congestive heart failure (CHF).

Choice C rationale:

Mannitol is contraindicated in patients with congestive heart failure (CHF). Here's why:

Increased Circulating Volume: Mannitol is an osmotic diuretic, meaning it draws fluid from the tissues into the bloodstream, increasing circulating blood volume. This can overload the already compromised heart in CHF patients, leading to worsening heart failure and pulmonary edema.

Elevated Blood Pressure: Mannitol can also cause a transient increase in blood pressure due to its osmotic effects. This can further strain the heart and worsen CHF symptoms.

Renal Impairment: CHF patients often have impaired renal function, which can reduce their ability to excrete mannitol effectively. This can lead to fluid retention and electrolyte imbalances, further complicating CHF management.

In summary, administering mannitol to a patient with CHF could potentially lead to:

Exacerbation of heart failure symptoms Pulmonary edema

Worsening renal function Electrolyte imbalances Increased risk of mortality

Therefore, it's crucial to avoid mannitol use in patients with CHF and to closely monitor fluid status and electrolytes in those who must receive it for other indications.