cardiovascular medications

Must- knows about Cardiovascular Medications

By: Dave Manriquez RN.

MEDICATIONS AFFECTING BLOOD PRESSURE

(HYPERTENSION/ HYPOTENSION)

(2) Stroke volume (Preload) (1) Heart rateThree Elements:

Vital facts:BLOOD PRESSURE CONTROL

(3) Peripheral Resistance (Afterload)Renin- Angiotensin- Aldosterone System

HYPERTENSION:BRIEF PATHOPHYSIOLOGY

Trauma To Small Vessels

Overworked Heart

High Peripheral Resistance

Cardiac Death C.A.D. Eyes Brain Kidneys

Kidney Perfusion

Kidney: Renin

Liver: Angiotensinogen to Angiotensin I

A.C.E. in Lungs: Angiotensin I to Angiotensin II

Vasoconstriction Aldosterone release

BP Blood volume

Sodium

Hypothalamus:ADH

Risk Factors for Hypertension

High salt diet

Exposure to high frequency noise

High levels of psychological stress

Lack of rest

Genetic predisposition

Trivia TimeWhat is a white-coat

hypertension?

Hypertension

Trivia Time: ANSWER

Doctor- induced HPN. Nurses should take BP instead for 3x over a 2-3 week period before a dx is made (American

Heart Association)

Hypertension

Friendly Reminder: There is ________ for Hypertension.

The medications we are about to discuss

only control the symptoms.

NO CURE

HYPERTENSIONHypertension

A:

Common side-effects:

Major suffix:

Vital facts:

-pril

A-C-E-S

Accumulation of Potassium

C: Cough (may become persistent)

E: Edema (Angioedema)

ANGIOTENSIN- CONVERTING ENZYME (ACE) INHIBITORS

Common ACEs:

Captopril Enalapril

Quinapril

S: Severe Pancytopenia that may be fatal

Angioedema:


Reflex cardiac response:

Kidneys:

Skin:

Other key s/e:

Mild rash

Renal insufficiency

Reflex tachycardia

ACE INHIBITORS

Tip:

Best time to give drugs:

Vital facts:

1 hour ac or 2 hours pc

Among drugs affecting blood pressure, ACE inhibitors are the ones most affected if taken with food


Key teaching on therapy compliance: Take your ACEI even if feeling better.

Ineffective tissue perfusion (total body) r/t:

Possible priority NURSING diagnosis:

Changes in cardiac output

Vasodilation = venous dilationWhy?

Blood pools in peripheral veins

Decreased venous return

Decreased CO



ACE I to ACE II

Vasoconstriction Aldosterone

Deceased peripheral resistance Deceased blood volume

Trivia Time

What drug has been recently approved to treat Pulmonary

Hypertension?

ACE Inhibitors

Trivia Time: ANSWER

Bosentan (Traceleer) – Endothelin receptor

antagonist

ACE Inhibitors

ANGIOTENSIN II RECEPTOR BLOCKERS

Major Suffix: -sartan

Common “ARBs”:

Telmisartan Losartan

ANGIOTENSIN II RECEPTOR BLOCKERS

Vasoconstriction

ACE I to ACE II

Ang. II Receptors onBlood Vessels/ Adrenal Cortex

Aldosterone

Trivia Time

What could happen if ARBS are taken with Phenobarbital?

ARBS

Trivia Time: ANSWER

Decreased serum levels of ARBS

ARBS

CALCIUM CHANNEL BLOCKERS

Major Suffix: -dipine

Common Calcium Channel Blockers:

Amlodipine Nifedipine Felodipine ***Diltiazem ***Verapamil


Myosin Actin

Troponin Protein complex

ACTION POTENTIAL/ TRIGGER


Myosin Actin

Troponin Protein complex

Ca

= CONTRACTION

Actin-myosin Sliding Is Spoiled

Smooth Muscles Cardiac Muscle

Peripheral Resistance

Blood PressureCardiac Workload

Cardiac O2 Demand


(-) Chronotropic & Dromotropic Effect

Trivia TimeIs there any positive benefit

that comes with the (-) dromotropic effect of Ca

channel blockers?

Calcium Channel Blockers

Trivia Time: ANSWER

Yes. Prolonged repolarization equals increased myocardial

tissue perfusion

Calcium Channel Blockers

Essential vital signs to monitor:

Why?

Main indication:

Vital facts:


Angina

It not only BP but also cardiac workload

HR (Brady) and BP

Other uses for Calcium channel blockers: Anti-dysrhythmics

Risk for injury related to:


CNS effects

VasodilationWhy?

Blood pools in peripheral veins

Decreased venous return

Decreased CO

Decreased blood flow to the brain


Bradycardia

DIRECT ACTING VASODILATORS

Major Suffix: none Major consideration: Used only for SEVERE Hypertension

Common Vasodilators:

Diazoxide Hydralazine Minoxidil Nitroprusside Tolazoline

TIP: Sometimes, the action of the medication can be deduced/ obtained from its brand name.e.g.: Diazoxide (Hyperstat)

Hydralazine (Apresoline)

Nitroprusside (Nitropress)

Minoxidil (Loniten)

Enalapril (Vasotec)

Benazepril (Lotensin)

Diltiazem (Cardizem, Dilacor)

Nifedipine (Procardia XL)

Blood Vessel

D.A. Vasodilators

Blood Vessel


Smooth Muscle dilation

Peripheral Resistance

Blood PressureHeart misinterprets BP

Heart compensates: Tachycardia

Cardiac workload


Minoxidil:

Hydralazine:

Diazoxide:

Other actions:

Blocks Insulin = Increases glucose levels

Increases renal blood flow

Topical form: Tx for baldness


Other actions:

Nitroprusside: Thiocyanate metabolite: cyanide toxicity

Tolazoline: IV: Tx for Pulmonary HPN in Newborn


Consciousness:

Gait:

Color:

Symptoms of cyanide toxicity:

Pink

Ataxia

Decreased LOC

Vital signs: Depressed (HR,RR,BP)

Pupils: Dilated


Trivia Time

What effect does Nitroprusside have on the thyroid gland?

Direct-acting Vasodilators

Trivia Time: ANSWER

Decreased Iodide uptake equals

hypothyroidism

Direct-acting Vasodilators

ANTI- ORTHOSTATIC HYPOTENSION MEDICATION

Midodrine

Major consideration: Administer to MOBILE patients only to prevent severe hypertension.

Blood Vessel Anti- Hypotensives

Blood Vessel

ANTI- HYPOTENSION MEDICATION

When does this usually occur:

Essential vital sign to monitor:

Main indication:

Vital facts:

Orthostatic hypotension

Heart rate (Bradycardia)

Initial therapy


Vital facts:

Key instruction before taking a dose: Void

Why? To decrease problems of urinary retention

Discontinue drug if… Any signs of HPN occur (visual changes)


Trivia Time

What precaution safety precaution should you take with all

vasodilators?

Vasodilators

Trivia Time: ANSWER

Safety against falls due to lightheadedness and

dizziness

Vasodilators

A nurse is monitoring a client who is taking propanolol (Inderal). Which of the ff assessment data would indicate a potential serious complication associated with propanolol?

A. a baseline BP of 150/80 mm Hg followed by a BP of 138/72 mm Hg after two doses of the med

B. a baseline resting HR of 88 beats per minute followed by a resting HR of 72 beats per minute after two doses of the med

C. the development of audible expiratory wheezes

PRACTICE QUESTIONS

A home health care nurse is visiting an older client at home. Furosemide (Lasix) is prescribed for the client. The nurse teaches the client about the med. Which of the ff statements, if made by the client, indicates the need for further teaching?

A. “I will take my med every morning with breakfast”

B. “I will call my doctor if my ankles swell or my rings get tight”

C. “I need to drink lots of coffee and tea to keep myself healthy”

D. “I will sit up slowly before standing each morning”

PRACTICE QUESTIONS

A nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. The nurse understands that which of the ff are concerns related to the administration of this med?

A. hyperkalemia, hypoglycemia, penicillin allergy

B. hypouricemia, hyperkalemiaC. hypokalemia, hyperglycemia, sulfa allergyD. increased risk of osteoporosis

PRACTICE QUESTIONS

A nurse has admitted a client who has a diagnosis of syncope to a medical unit. The client is taking enalapril (Vasotec), atenolol (Tenormin), and aspirin daily. The client admits that the meds were prescribed by different physicians. The admitting physician wrote in the client’s order sheet, “Administer meds taken at home.” Which is most appropriate action for the nurse to take?

A. administer the meds as ordered by the physicianB. send the client’s meds bottles to the pharmacy for

identification and then administer the meds as ordered

C. call the physician, describes the meds, and request order clarification

PRACTICE QUESTIONS

A 66-year-old client complaining of not feeling well is seen in a clinic. The client is taking several meds for the control of heart disease and hypertension. These meds include atenolol (Tenormin), digoxin (Lanoxin), and chlorothiazide (Diuril). A tentative diagnosis of digoxin toxicity is made. Which of the ff assessment data would support this diagnosis?

A. chest pain, hypotension, and paresthesiaB. constipation, dry mouth, and sleep disorderC. double vision, loss of appetite, and nauseaD. dyspnea, edema, and palpitations

PRACTICE QUESTIONS

A client is being discharged with a prescription for propanolol hydrochloride (Inderal). In developing a med teaching plan, a nurse would include which of the ff instructions?

A. exercise will prevent orthostatic hypotension

B. hot baths and showers are advised to increase vasodilation

C. med should be taken on an empty stomach to enhance absorption

D. med should be withheld if the pulse rate drops below 60 beats per

PRACTICE QUESTIONS

CARDIOTONIC/ INOTROPIC AGENTS

(CONGESTIVE HEART FAILURE)

CONGESTIVE HEART FAILURE STARLING’S LAW OF THE

HEARTDegree of Cardiac muscle stretch

Force of contraction

Point of exhaustion/ Point of no return

Non- compliant heart/ CHF

Compromised Circulation

AfterloadPreload

CARDIAC GLYCOSIDES

(-) Chronotropic Effect

Possible Bradycardia

Adult: __ bpm Infant: __ bpm

Adult: 60 bpm Infant: 90 bpm

CARDIAC GLYCOSIDES

(+) Inotropic Effect

Cardiac output

Renal perfusion

Renin release

Blood volume

Urinary output

Vasoconstriction

CARDIAC GLYCOSIDES

(-) Dromotropic Effect

Possible heart block (AV block)

Is it safe for patients with liver dysfunction?

Therapeutic serum level:

Main indication:

Vital facts:

Congestive heart failure

0.5-2.0 ng/mL

Yes

How come? It is excreted unchanged in the urine

CARDIAC GLYCOSIDES

Vital facts:

Essential vital sign to monitor: Heart rate (Bradycardia )

Another main indication: Atrial dysrhythmias (A-flutter, A-fib

CARDIAC GLYCOSIDES

Ventricular dys. are C/I. To Digoxin.Note: Ventricular dys. …

If bradycardia persists, withhold the drugNotify the physician and document the event

Retake pulse after 1 hourIf there is bradycardia

Take apical pulse for one whole minute

What to do if client has bradycardia:CARDIAC GLYCOSIDES

On driving:

On abnormal weight gain/loss to report:

On missed doses:

Nursing teachings:

Don’t play catch up. Take as prescribed.

3 lbs/ day or more

Avoid due to CNS s/e (Drowsiness)

On vision changes: These may normally exist within the 1st 3 days of therapy

CARDIAC GLYCOSIDES

Early possible toxicity Sx:

Therapeutic serum level:

Essential Electrolyte:

Nursing actions:

K & Mg (Hypo) & Ca (Hyper)

0.5-2.0 ng/mL

Anorexia & Excessive vomiting

CARDIAC GLYCOSIDES

Nursing actions:

Vision changes: Yellow halos around lights

Cardiovascular changes: Bradycardia & Heart block

Antidote:

CARDIAC GLYCOSIDES

Digoxin Immune Fab (Digibind/ Digifab)

Route: Intravenous infusion

Why?

Potential vital sign to measure:

Major suffix:

Vital facts:

PHOSPHODIESTERASE INHIBITORS (2nd-line CHF Treatment Option)

-rinone

Heart rate– Pulse deficits

***High risk for fatal ventricular dysrhythmias

PHOSPHODIESTERASE INHIBITORS

Inhibition of the enzyme: Phosphodiesterase

Cyclic Adenosine Mono-phosphate in myocardium

Increased Calcium levels

(+) Inotropic effect

PHOSPHODIESTERASE INHIBITORS

Inhibition of the enzyme: Phosphodiesterase

Cyclic Adenosine Mono-phosphate in myocardium

Increased Calcium levels Prolonged SNS stimulation

Rebound vasodilation

Hypotension

Tachycardia

Ventricular Arrhythmia

(+) Inotropic effect

Heart perfusion

Chest pain -- MI

Vital facts:


Key nursing precaution to institute:Possible bleeding precautionsWhy?

Thrombocytopenia is a possible S/E

Recommended duration of use:Short-term only

On drug administration:

On drug integrity:

On the injection site:

Nursing teachings:


Burning sensation

Protect from light

Monitor HR and BP

Dosage may be decreased if A/E occur

Inamrinone (Inocor)

Milrinone (Primacor)

A client has a serum potassium of 3 mEq/L and is complaining of anorexia. A physician orders a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the ff is the therapeutic serum level (range) for digoxin?

A. 0.5 to 2 ng/mLB. 1.2 to 2.8 ng/mLC. 3 ng/mLD. 3.5 ng/mL

PRACTICE QUESTIONS

A client is admitted to a medical unit with nausea and bradycardia. The family hands a nurse a small white envelope labeled “heart pill.” The envelope is sent to pharmacy and reveals digoxin (Lanoxin). A family member states, “That doctor doesn’t know how to take care of my family.” The most therapeutic response by the nurse would be

A. “You are concerned your loved one receives the best care”

B. “You’re right! I’ve never seen a doctor put pills in an envelope”

C. “I think you’re wrong. That physician has been in practice over 30 years”

D. “Don’t worry about this. I’ll take care of everything”

PRACTICE QUESTIONS

A nurse is caring for a client receiving dopamine (Intropin). Which of the ff potential nursing diagnoses is appropriate for this client?

A. increased cardiac outputB. excess fluid volumeC. impaired tissue perfusionD. disturbed sensory perception

PRACTICE QUESTIONS

A client with congestive heart failure is on a 1-g sodium diet. A nurse understands that which med prescribed for the client promotes sodium excretion while conserving potassium?

A. spironolactone (Aldactone)B. furosemide (Lasix)C. ethacrynic acid (Edecrin)D. hydrochlorothiazide (HydroDIURIL)

PRACTICE QUESTIONS

A client has developed paroxysmal nocturnal dyspnea. Which of the ff med does a nurse anticipate will be prescribed by the physician?

A. lidocaine (Xylocaine)B. propranolol (Inderal)C. bumetanide (Bumex)D. Streptokinase (Streptase)

PRACTICE QUESTIONS

A client is being treated for acute congestive heart failure with intravenously administered bumetanide (Bumex). The v/s are as follows: BP 100/60; pulse 96 beats per minute; and respirations 24 beats per minute. After the initial dose, which of the ff is the priority assessment?

A. monitoring BPB. monitoring potassium levelC. monitoring urine outputD. monitoring weight loss

PRACTICE QUESTIONS

A client with a diagnosis of congestive heart failure is seen in a clinic. The client is being treated with a variety of meds, including digoxin (Lanoxin) and furosemide (Lasix). Which of the ff assessment findings would lead the nurse to suspect that the client is hypokalemic?

A. diarrheaB. intermittent intestinal colicC. muscle weakness and leg crampsD. tingling of fingers and toes

PRACTICE QUESTIONS

ANTIARRHYTHMIC AGENTS

Class IA Antiarrhythmics

Class IB Antiarrhythmics

Class IC Antiarrhythmics

Class II Antiarrhythmics

Class III Antiarrhythmics

Class IV Antiarrhythmics

Other Antiarrhythmics

SA Node: ___ bpm

AV node

AV bundle/Bundle of His: ___ bpm

Right/Left Bundle Braches

Purkinje Fibers: ___bpm

CONDUCTION SYSTEM OF THE HEART

60-100

40-60

20-40

HEART AUTOMATICITY SODIUM-POTASSIUM

PUMPStimulation (Automaticity)

Na gates open: Na enters cell; Potassium leaves the cell

Action Potential: Depolarization

Calcium Release

Na gates begin to close: repolarization

Na-K pump: Na-out & K- in. Cell is now repolarized

Electrolyte disturbances Hypoxia Structural

Damage

Acidosis/

Azotemia

Arrhythmia

Decreased Cardiac Output

Decreased Tissue Perfusion

BRIEF PATHOPHYSIOLOGY: ARRHYTHMIA

Trivia TimeWhat did the cardiac

arrhythmia suppression trials in the early 1990s reveal?

Anti-arrhythmics

Trivia Time: ANSWERNon life-threatening dys. Plus meds = 2-3x greater risk of

death

Anti-arrhythmics

Fact about anti-arrythmics:

Major suffix:

Vital facts:

CLASS I ANTI-ARRHYTHMICS

-caine, -cain-

All of them are pro-arrhythmics

Procainamide (Pronestyl)*Quinidine (Cardioquin) *Lidocaine (Xylocaine) Flecainide (Tambocor)

HEART AUTOMATICITY SODIUM-POTASSIUM

PUMPStimulation (Automaticity)

Na gates are opened. SUPPOSEDLY: Na enters cell; Potassium leaves the cell

Lesser Action Potentials are generated: Lesser depolarization

But CLASS I AA BLOCK the Na gates. No Sodium is able to enter.

(-) Chronotropic and (-) Dromotropic effect, BP

*Quinidine:

Procainamide (Pronestyl):

Disopyramide (Norpace):

Usual indications:

Ventricular arrhythmias

Ventricular arrhythmias

Atrial arrhythmias


*Lidocaine:Ventricular arrythmias, esp. PVC

All others:Usually for ventricular arrhhythmias

Trivia TimeWhat equipment should be available when a patient is taking anti-dysrhythmics?


Trivia Time: ANSWER

ECG Monitor


On cardiovascular C/I:

Nursing teachings;

Bradycardia, Heart block and CHF

Essential assessment:ECG readings (Heart rhythm)


Trivia Time

What diet should be considered to enhance Quinidine excretion?


Trivia Time: ANSWER

Acid- Ash Diet


On Quinidine + Digoxin:

On Quinidine excretion:

Nursing teachings;

Urine must be acidic

Decreased Digoxin excretion


Food interaction:

Procainamide frequency:

Nursing teachings;

RTC – alarm clock on hand

Best taken on an empty stomach


Trivia Time

What should a patient taking Disopyridamole avoid exposing

himself to?


Trivia Time: ANSWER

Sunlight


Rationale:

What to avoid when taking disopyramide:

Nursing teachings;

Sunlight

Due to photosensitivity



CNS effects

Membrane-stabilizing effectsWhy?

Action potential is affected

Tingling:

LOC:

Tremors:

Disturbed sensory perception r/t


Circumoral paresthesia

Drowsiness with slurred speech

May lead to convulsions

Why?

Key nursing assessment:

Major suffix:

Vital facts:CLASS II ANTIARRHYTHMICS

-olol

Be alert for wheezing sounds

Bronchospasm is a potential side-effect

Vital facts:

CLASS II ANTIARRHYTHMICS

Key vital sign to measure before administration: Heart rate

Do not give if: Heart rate is below 60 bpm

Acebutolol (Sectral)

Propranolol (Inderal) Esmolol

(Brevibloc)

Stimulation (Automaticity)


Action Potential: Depolarization

Calcium Release

Na gates begin to close: repolarization

Beta Blockers DELAY Na-K pump: Na-out & K- in. CELL REPOLARIZATION IS ALSO DELAYED.

CLASS II ANTIARRHYTHMICS

Why?

When should it be used?

Major suffix:

Vital facts:

CLASS III ANTIARRHYTHMICS

-tilide

For life-threatening cases only

Due to its fatal toxic reactions

Dofetilide (Tikosyn) Ibutilide (Corverf) *Amiodarone (Cordarone) Bretylium (Generic only) Sotalol (Betapace AF)


Stimulation (Automaticity)


Class III AAs DELAY the outflow of Potassium from the cell. Hence, the action Potential is prolonged.

Prolonged Action Potential: Depolarization

Fatal effects of Amiodarone:

Vital facts:

Liver toxicity

Ocular abnormalities

Serious arrythmias


Vital facts:

Sotalol: Maintains normal sinus rhythm

When is it used? After cardioverison of atrial arrythmias


Other classification of these drugs:

What do they stand for?

Mnemonic:

Vital facts:

CLASS IV ANTIARRHYTHMICS

Very Nice Drugs

Verapamil, Nifedipine and Diltiazem

Calcium Channel blockers

Vital facts:


Priority nursing diagnosis: Risk for injury

Why? V.N.D. causes systemic vasodilation Hypotension

Diltiazem (Cardizem) For P.A.T.

Verapamil (Calan/ Covera) For P.A.T. & A-Flutter/ A-Fib

Trivia Time

What AD is specifically indicated for Wolff-Parkinson-White

Syndrome?


Trivia Time: ANSWER

Adenosine (Adenocard)


Atrial Tachycardia

SA Node stimulation

AV Node/ AV Bundle blocks off

excess impulses

Normal Ventricular Rhythm

Very Rapid Ventricular Rhythm

Abnormal passageway from SA Node to the Ventricles

Normal Heart W-P-W-Syn.

BRIEF PATHOPHYSIOLOGY: WOLFF- PARKINSON- WHITE

SYNDROME

A client is being treted with procainamide hydrochloride (Pronestyl) for a cardiac dysrhythmia. Following IV administration of the med, the client complains of dizziness. What intervention should the nurse do first?

A. administer ordered nitroglycerin tabletsB. auscultate the client’s apical pulse and

obtain a blood pressureC. measure the heart rate on the rhythm

stripD. obtain a 12-lead ECG immediately

PRACTICE QUESTIONS

LIPID LOWERING AGENTS (CORONARY ARTERY DISEASE)

THE ROLE OF CHOLESTEROL

Steroids/ sex hormones

*Cell membrane formation

*Bile acid production

With the help of

Enzyme: Hydroxymethylglutaryl- coenzyme A (HMG CoA) Reductase

Regulates cholesterol synthesis

CHOLESTEROL: WHO’S GOOD or BAD?

HDL LDL

HDL cholesterol:

LDL cholesterol:

Total cholesterol:

Normal values:

< 240 mg/ dL

130-170 mg/dL

40-70 mg/ dL

Triglycerides: < 200 mg/dL

CHOLESTEROL

Best time to give other drugs:

Ideal time of administration:

Major Prefix:

Vital facts:

BILE ACID SEQUESTRANTS

Choles- ; Coles-

Bed time and alone

1 hour a.c. or 4-6 hours p.c.

Vital facts:


Cholestyramine (Questran):

Mix with liquids

Tablet form is taken whole

*Colestipol (Colestid):

Colesevelam (Welchol)

Upto 6x/day

4x/day

1-2x/day

Cholestyramine + carbonated beverage:

Colestipol + carbonated beverage:

Cholestyramine:

Vital facts:


Also ideal for pruritus r/t biliary obstruction

OK

Not OK

Can tablets be chewed or crushed? No.

BILE ACID SEQUESTRANTSFat intake

Bile acids are released to emulsify fats

Liver attempts to form bile

Where does it obtain cholesterol?

Reduced serum cholesterol (LDL)

Increased GOOD cholesterol (HDL)

THIS IS BLOCKED

Obtains cholesterol from bloodstream

Vitamin deficiency:

Stool characteristics:

How it affects nutrition?

Adverse effects:


Impaired fat absorption

Steatorrhea

ADEK deficiency

Bowel patterns: Constipation

Type of malnutrition: Fat malnutrition

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Best time to administer drug:

Major suffix:

Vital facts:

HMG- CoA REDUCTASE INHIBITORS (STATINS)

-statin

BedtimeOphthalmic side-effect: Bilateral cataract

Why? Cholesterol is needed for normal cell membrane synthesis

HMG – COA Reductase Inhibition

Cell needs another source for cholesterol synthesis

Obtains cholesterol from bloodstream

Reduced serum cholesterol (LDL)

Increased GOOD cholesterol (HDL)

HMG- CoA REDUCTASE INHIBITORS

Vital facts:HMG- CoA REDUCTASE INHIBITORS

(STATINS)

Before therapy:Ensure diet/ exercise was done for 3-6 mos.

What’s the reason?To make sure that statins are really needed.

Trivia TimeStatins have a very marked

first-pass effect. What does this tell you about its adverse

effects?

Statins

Trivia Time: ANSWER

Highly liver toxic

Statins

Why?

Renal side-effect:

Vital facts:

Acute tubular necrosis = Acute renal failure

Statins cause Rhabdomyolysis myoglobinuria


*Atorvastatin (Lipitor) Simvastatin (Zocor)

Lovastatin (Mevacor) Pravastatin (Pravachol)

GIT S/E:

Vital facts:

Constipation or diarrhea


Onset of sudden bilateral leg cramps:Due to Rhabdomyolysis

Essential lab value measurement:CPK

Pravastatin (Pravachol)

Lovastatin (Mevacor)

Atorvastatin (Lipitor):

Statins: Their good and bad sides

Severe liver toxicity

Rhabdomyolysis but lesser liver toxic

The only statin with outcome data shown to prevent1st MI possibility

Fluvastatin (Lescol): Cross- hypersensitivity to fungal by-products

HMG- CoA REDUCTASE INHIBITORS

Trivia Time

When are the peak effects of statins seen?

Statins

Trivia Time: ANSWER2-4 weeks

Statins

Peak action is at:

Onset of action is at:

Major suffix:

Vital facts:FIBRATES

-fibrate, -fibroFour days (Fibrates= Four)

Four weeksBest time to give drug: Bedtime

Clofibrate (Atromid)

Fenofibrate (Tricor)

Gemfibrozil (Lopid)

Niacin (Nissan)

They ACT @ the LIVER to:

Used for severely elevated serum cholesterol levels only.

FIBRATES GO STRAIGHT TO THE POINT

FIBRATES

Decrease LDL/Triglyceride Production Increase HDL Production

When are these drugs usually recommended?

Vital facts:

FIBRATES

Key assessment when giving Clofibrate:Watch for bleeding (anti-platelet)Key lab value to assess when giving Niacin:Uric acid (Hyperuricemia)

Gemfibrozil (Lopid) + Statins:

Vital facts:

FIBRATES

Increased Rhabdomyolysis risk

ANTI-ANGINAL AGENTS

Angina

Unstable angina

Stable angina

Substance P

Act directly on blood vessels: Vasodilation

Peripheral veins

Blood pools

Venous return

Preload

Peripheral arteries

Coronary arteries

Cardiac workload

NITRATES


Peripheral veins

Peripheral arteries

Coronary arteries

Resistance

Afterload

Cardiac workload

NITRATES


Peripheral veins

Peripheral arteries

Coronary arteries

Cardiac blood flow/

O2

NITRATES


Peripheral veins

Blood pools

Venous return

Preload

Peripheral arteries

Coronary arteries

Resistance

Afterload

Cardiac blood flow/

O2

Cardiac workload

NITRATES

Priority nursing action after administration:

Uncomfortable side-effect:

Major suffix/ prefix:

Vital facts:

NITRATES

-nitrate, Nitro-

Headache

Provide safety

Why? Due to orthostatic hypotension--Sit for a few minutes

Vital facts:

NITRATES

Side-rail guidelines: Upper side rails “Understandable”

Lower side rails: Look for a doctor’s order

On discontinuation: Taper for 4-6 wks – to prevent possible MI as an A/E

Mode of administration:

Onset:

Amyl Nitrate

Sample medications:

NITRATES

Within 30 seconds

Capsule is waved under the nose

Sample medications:

NITRATES

Nitroglycerin

Onset: Within 3-5 minutes

Isosorbide mononitrate/ dinitrate

For phophylactic use only. Effects may last up to 4 hours

Maximum shelf-life:

Storage temperature:

Container:

Nitroglycerin guidelines: SublingualNITRATES

Dark and covered

Room temperature (avoid extremes)

Three (3) months

CHULOU H. PENALES, RN

NITRATES

Nitroglycerin guidelines: Sublingual

Sign of potency: Fizzles under the tongue

Route: Sublingual or buccal

Frequency: 1 tablet every 5 minutes for a maximum of 3 doses

Common side-effect: Headache and hypotension

Ideal Site:

Alternative route:

NITRATES

Topical- Patch application

Hairless skin area

No. of patch-free hours/day: 8-12 hours (to prevent tolerance)

Chest/back, upper thigh/arm

Nitroglycerin guidelines: Patch

NITRATES

What not to do if the patch peels off: Cutting/removing it

What to do if it peels off: Secure it w/ a adhesive tape

Nursing skin care: Rotate patch sites

Nitroglycerin guidelines: Patch

Trivia Time

Why are nitrates C/I with severe anemia and head

trauma?

Nitrates

Trivia Time: ANSWER

Severe anemia- worsened with low C.O.Head trauma- worsened with vasodilation

Nitrates

A home health care nurse is visiting a client with elevated triglycerides and a serum cholesterol of 398 mg/dL. The client is taking cholestyramine resin (Questran). Which of the ff statements, if made by the client, indicates the need for further education?

A. “Constipation and bloating might be a problem”

B. “I’ll continue to watch my diet and reduce my fats”

C. “I’ll continue my nicotinic acid from the healthy food store”

D. “Walking a mile each day will help the whole process”

PRACTICE QUESTIONS

A home health nurse instructs a client about the use of a nitrate patch. The nurse tells the client which of the ff that will prevent client tolerance to nitrates?

A. do not remove the patchesB. have a 12-hour “no nitrate” timeC. have a 24-hour “no nitrate” timeD. keep nitrate on 24 hours, the off 24 hours

PRACTICE QUESTIONS

A client arrives in the ER after complaining of unrelieved chest pain for 2 days. The pain has subsided slightly but never disappeared. When the nurse approaches the client with a 0.4-mg nitroglycerin sublingual tablet the client states, “I don’t need that. My dad takes that for his heart. There’s nothing wrong with my heart.” The nurse interprets that the client is exhibiting which type of reaction?

A. obsessive-compulsiveB. denialC. phobicD. anger

PRACTICE QUESTIONS

MEDICATIONS AFFECTING BLOOD COAGULATION

Vessel injury

Vasospasm

PLATELET aggregation: PLUG

Blood contacts exposed collagen

Hageman Fx Activation (XII- XIIa)

Intrinsic pathway: clotting Fxs

BLOOD COAGULATION: INTRINSIC PATHWAY


Prothrombin- Thrombin

Fibrinogen – Fibrin threads: basis of the clot by trapping RBCs

Clot/ Thrombus Formation


BLOOD COAGULATION:EXTRINSIC PATHWAYVessel injury

Blood leaks out of vessel

Injured vessel cells release Tissue Thromboplastin

Extrinsic Pathway:Clotting Fxs activation


CLOT RESOLUTION

Serum Plasminogen

Converting Factor/s

Plasma/ Fibrinolysin

Dissolves clot

Lungs Uterus

Hemophilia

Liver Disease

Bone Marrow Disorders

Vessel wall injuryBlood Stasis

Hypercoagulability of Blood

Virchow’s Triad

Possible Hemorrhage

Blood disorders

ANTIPLATELETS

Major Suffix: none Common Antiplatelets:

Anti-platelets

Aspirin Abciximab (ReoPro) Anagrelide (Agrylin) Clopidogrel (Plavix)

ANTIPLATELETS

Major Suffix: none Common Antiplatelets:

Anti-platelets

Dipyridamole (Persantine) Eptifibatide (Integrelin) Ticlopidine (Ticlid) Tirofiban (Aggrastat)

Anti-platelets: Indications

Thromboembolism

Myocardial infarction/ Stroke

Pulmonary embolism

Valvular disorders

Anyone at risk for pathologic clotting

Dipyridamole (Persantine):

Cilostazol (Pletal):

Actions:

ANTIPLATELETS

Ideal for intermittent claudication

Also for pharamcologic stress tests

Most of them are used as___ Adjuncts to anti-coagulants

Trivia Time

What makes Anagrelide different from most Anti-platelets?

Anti-platelets

Trivia Time: ANSWER

It acts directly on the bone marrow to reduce platelet

production

Anti-platelets

Parenteral Anticoagulant:

Oral Anticoagulant:

Major suffix:

Vital facts:

ANTICOAGULANTS

-parin, -farin

Warfarin (Coumadin)

Heparin and Anti-thrombin (IV route)

Vital facts:

ANTICOAGULANTS

Useful antidote Mnemonic:

In Heaven, there is Peace,

In War there is Kill

Trivia TimeWhen do you expect vitamin K or Phytonadione to reverse

the effects of warfarin?

Anti-coagulants

Trivia Time: ANSWERIV: 6-8 hours

Parenteral: 12-48 hrs Vitamin K doesn’t act on warfarin

but on the liver itself

Anti-coagulants

Vital facts:ANTICOAGULANTS

Mild forms of heparin:Enoxaparin (Lovenox)Dalteparin (Fragmin)

What makes these medications mild?They only inhibit CF Xa and IIa. They do not however greatly affect PT or clotting times

Trivia Time

What advantage does Enoxaparin have over

Heparin?

ANTICOAGULANTS

Trivia Time: ANSWER

No need to monitor periodic APTT levels.

ANTICOAGULANTS

Vessel injury

Vasospasm

Platelet aggregation: PLUG

Blood contacts exposed collagen

Hageman Fx Activation (XII- XIIa)


Prothrombin- Thrombin

Fibrinogen – Fibrin threads: basis of the clot by trapping RBCs


ANTICOAGULANTS

Warfarin

Heparin

Teratogenicity:

Home use:

Duration of use:

Comparison:ANTICOAGULANTS

Short-term

Usually in hospitals only

Hope:

Long-term

For home use also

Wrong:

Heparin Warfarin

ANTICOAGULANTS

Onset of action: 5-15 minutes

Lab value to monitor: APTT

Therapeutic values: 1.5-3x the APTT

3 days & lasts 4-5 days

PT & INR

1.5-2.5x PT levels

Comparison: Heparin Warfarin

APTT:

INR (High-dose Warfarin therapy):

INR (Standard Warfarin therapy):

Normal values:

2-3

3-4.5

20-36 seconds

PT: 8-11 seconds

Clotting time: 8-15 minutes

ANTICOAGULANTS

Diet (Warfarin):

Sports:

Razor and toothbrush:

Nursing teachings: Bleeding precautions

Electric, Soft Bristled

Avoid contact sports

What your diet was before should be as is.

ANTICOAGULANTS

Trivia TimeWhat should you

remember regarding possible drug-drug

interactions with warfarin?

Anti-coagulants

Trivia Time: ANSWERWarfarin has so many D-D

interactions. Avoid adding/removing usual meds w/o first consulting the

doctor

Anti-coagulants

Nursing teachings: Bleeding precautions

Bleeding Signs:Dark stools, dark urine, Petechiae

Alarming sign: Decreased LOC--Intracerebral hemorrhage

Injections: Apply pressure for 5-15 minutes and do not massage the site

ANTICOAGULANTS

Warfarin may cause alopecia

Lepirudin is used for Heparin Allergy

Yellow-orange urine discoloration occurs with Heparin therapy.

Vinegar added to the urine above will give me an idea of the seriousness of the side-effect

Enoxaparin acts by blocking factors Xa and IIa

With Enoxaparin, I do have to tell my client to have periodic APTT evaluation.

Warfarin

ANTICOAGULANTSTrue or false:

Plus: thromboembolic tendencies

Lepirudin acts by inhibiting thrombin

Heparin- induced thrombocytopenia

Heparin administration

Pre-existing heparin allergy

Heparin and Lepirudin

Trivia Time

What challenge does DIC pose to the

nurse?

Anti-coagulants

Trivia Time: ANSWERTreating a patient who is bleeding

to death with an anticoagulant

Anti-coagulants

Why?

Best given within:

Major suffix:

Vital facts:

THROMBOLYTICS

-plase, -kinase

4-6 hours within the onset of MI/ Stroke

It takes 4-6 hours before the blocked area is infarcted

Antidote: Aminocaproic acid (Amicar)

C/I: Major surgery within the past… 2 months

High BP and liver disease

Trivia Time

What is the number one requirement for thrombolytics to

take effect?

Thrombolytics

Trivia Time: ANSWER

Presence of Plasminogen in the

blood

Thrombolytics

THROMBOLYTICS

Activates Serum Plasminogen to Plasmin

Plasmin dissolves the fibrin threads in a clot to

dissolve a clot

THROMBOLYTICS

Alteplase (Activase)

Steptokinase (Streptase)

Urokinase (Abbokinase)

Ideal drug for sepsis-induced clotting:

What may potentiate its effects?

Major suffix:

Vital facts:

HEMORRHEOLOGIC AGENT

None

Caffeine & Theophylline

Drotrecogin alfa(Xigris)

Doses per day:

Priority teaching:

Route:

Pentoxyfilline (Trental):HEMORRHEOLOGIC AGENT

Oral Sustained release form

Do nut crush or chew the tablet

3 doses per day


Effects are apparent: After 2-3 weeks

Action:

- Reduces Platelets & Fibrinogen - Reduces blood viscosity increased blood flow esp. to hands & feet

Indications:

DM leg ulcers, strokes, high-altitude sickness, sickle cell disease

If the next dose is still far away:

For missed doses:When to notify doc:


Chest pain & very rapid HR (A/E)

Take the missed doseIf the next dose is near:Just take the next dose instead

Nursing teaching: Do not double up doses for a missed dose

Decreases platelet aggregation

Decreases fibrinogen concentration

Decrease blood clot formation

Possible S/E for Unknown reasons

Intermittent claudication

HEMORRRHEOLOGIC AGENT

Coagulation factor VIIa:

Indication:

Anti-hemophilic factor

Medications:ANTI-HEMOPHILIC AGENTS

Factor VIII

Classic hemophilia A

Preformed clotting factors

Indication:Hemophilia A or B

Drug category of Anti-hemophilics:

Indication:

Factor IX complex

Medications:ANTI-HEMOPHILIC AGENTS

Factor IX plus Vit K dependent CF

Christmas disease

D

General nursing care: Same with blood transfusion interventions

Aprotinin (Trasylol) common S/E:

Priority precaution:

Main action:

Vital facts:

SYSTEMIC HEMOSTATIC AGENTS

Plasminogen/ Plasmin inhibition

Watch for excessive clotting

Cardiac arrhythmias

Indication: CABGs

Priority precaution:

Main indication:

Aminocaproic acid:SYSTEMIC HEMOSTATIC AGENTS

Hemophilia, Post-op bleeding

Watch for excessive clotting

Instructions for intake:

Take 10 tablets now then RTC thereafter

Other indications: Angioedema

Clot dissolution changes

Drowsiness… Psychotic states

Affects blood flow to brain

Affects GIT mucosa

Clots Build up in muscles

GIT Hypermotility Muscle pain

SYSTEMIC HEMOSTATIC AGENTS: SIDE EFFECTS

A nurse provides discharge instructions to a post-op client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching?

A. “I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated”

B. “I will be certain to limit my alcohol consumption”

C. “I will take my pills every day at the same time”

D. “I have already called my family to pick up a Medic-Alert bracelet”

PRACTICE QUESTIONS

A nurse is caring for a client receiving a heparin IV infusion. The nurse anticipates that which lab study will be prescribed to monitor the therapeutic effect of heparin?

A. prothrombin timeB. activated partial thromboplastin timeC. hematocritD. hemoglobin

PRACTICE QUESTIONS

A client is diagnosed with acute myocardial infarction and is receiving tissue plasminogen activator (t-PA). Which of the ff is a priority nursing intervention?

A. have heparin sodium availableB. monitor for renal failureC. monitor for signs of bleedingD. monitor for psychosocial status

PRACTICE QUESTIONS

MEDICATIONS USED TO

TREAT ANEMIA

RBC lives up to 120 days

RBC maturation under ideal conditions

Bone marrow produces immature RBC

Erythropoietin from kidneys

RBC formation

Old RBC gets lysed in spleen, liver, bone marrow

Folic acid:

Vitamin B12:

Iron:Hemoglobin formation

Supporting structure & RBC resiliency

Supporting structure & RBC resiliency

Essential amino acids:Basic structure

Carbohydrates:Basic structure

RBC formation

- Folic acid deficiency

- Vitamin B12 deficiency

Megaloblastic anemia

Iron Deficiency Anemia

Anemia

Trivia Time

What cells in the body are affected most by high Iron

levels?

Anemia

Trivia Time: ANSWER

Neurons

Anemia

Action:

Route of administration:

Major suffix:

Vital facts:

ERYTHROPOIETIN

-poetin alfa

SQ/IV

Stimulates production of RBCs in the bone marrow

Essential vital sign to monitor: Blood pressure

Why? This drug may cause HPN due to increased RBCs

Hence, C/I to this drug would be…: Uncontrolled HPN

Epoetin alfa

Darbopoetin alfa (Aranesp)

Renal failure

Dialysis patients

Erythropoietin: Indications

Can it be given for acute BV loss:No

Can it be given to someone with a normal kidney?No (-) feedback mechanism causes anemia Sx to worsen

Trivia TimeIf Epoetin has a half-life of 4-13 hours while Darbopoietin alfa

has a half-life of 21 hours, how frequent should they be given?

Erythropoietin

Trivia Time: ANSWER

Epoetin: 2-3x per weekDarbopoetin: 1x per week

Erythropoietin

Essential lab value to monitor:

Can you give it with other drug solutions?

Nursing actions:ERYTHROPOIETIN

No.

Hematocrit

Possible Precautions during therapy: Seizure precautions

If patient doesn’t respond within 8 weeks:

Nursing actions:ERYTHROPOIETIN

Re-evaluate the cause of anemia

Iron levels normalize in…

Improvements occur in…

Major prefix:

Vital facts:

IRON PREPARATIONS

Ferrous-, Iron-

2-3 weeks

6-10 months

Vital facts:

IRON PREPARATIONS

Oral Iron Preparations:Ferrous- (e.g. Ferrous Sulfate)

Parenteral Iron Preparations: Iron- (e.g. Iron Dextran)

Route of Parenteral IM Fe:Z-track method – gluteal area

Ferrous Sulfate (Feosol)

Ferrous Fumarate (Feostal)

Iron Dextran (InFeD)

IRON PREPARATIONS

Bowel pattern s/e:

Best taken…

Guidelines with oral administration:

Vital facts:

IRON PREPARATIONS

Take with anything acidic

1 hour ac or 2 hours pc

Possible constipation w/ some nausea

Take liquid forms thru a straw

Milk:Eggs:

Orange juice:

Foods to avoid taking with Iron:

Froccino Oreo (Coffee):

Vitamin C:

Green tea:

IRON PREPARATIONS

Vital facts:IRON PREPARATIONS

Stool color: Black/Green and tarry but (-) blood

Possible complications: GIT ulcerations

Priority nursing assessment before initiating therapy:

Ensure that IDA does exist

Essential function of folic acid:

Main indication:

Major suffix:

Vital facts:

FOLIC ACID DERIVATIVES AND VITAMIN B12

-cobalamin (vitamin b12)

Megaloblastic anemias

Cell growth & RBC formation

Essential function of Vit B12:

Same+ myelin sheath maintenance

Hydroxycobalamin (Hydro- Crysti 12)

Cyanocobalamin (Crystamine):

Also available as an intranasal form (Nascobal)


Sample medications: Vitamin B12 Derivatives

Vital facts:


Usual route of administration: SQ

Vit B12 injection schedule for pernicious anemia:

IM for 5-10 days then once a month forever

Leucovorin (Wellcovorin):

Folic acid (Folvite):Sample medications: Folic Acid Derivatives

Most commonly prescribed

Given per orem for “Leucovorin rescue”


Methotrexate

Chemotheraputic destructive effects

Cancer cells

LEUCOVORIN

Healthy cells

LEUCOVORIN RESCUE

Toxic Metals and their Antidotes

Priority intervention:

Route:

Iron:

Element

Hemochromatosis

IM,SQ or IV

Provide safety due to vision changes as s/e

TOXIC METALS & THEIR ANTIDOTES

Deferoxamine (Desferal)

Condition Antidote

Lead: Plumbism

Route: IM/IV

Priority nursing assessment:

Make sure kidney & liver functions are ok. Hepato-renal toxicity are likely s/e.


Calcium Disodium Edetate (EDTA)

Element Condition Antidote

Duration of therapy:

Route:

Arsenic, Gold and Mercury:

IM

7 days

Essential vital signs to monitor:

Ideal diet: Alkaline ash diet

Why? To increase excretion


Dimercaprol (BAL in oil)

HR & BP (S/E: Cardiotoxicity)

Another key nursing action: Push fluids

Element Condition Antidote

End of LectureThank you so much for your attention!!!

cardiovascular medications

Health & Medicine

calcium channel

coa reductase

clotting fxs

na gates open

ff assessment

na enters

folic acid

therapeutic