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Cardiac/Vascular CirculationCardiac/Vascular Circulation
Brenda Rowe, RN, MN, JDBrenda Rowe, RN, MN, JD
Georgia Baptist College of Nursing Georgia Baptist College of Nursing
of Mercer Universityof Mercer University
C.O. = Stroke Vol. X Heart C.O. = Stroke Vol. X Heart RateRate
Preload - passive stretching force Preload - passive stretching force exerted on ventricle muscleexerted on ventricle muscle
Contractility - force of the squeezing Contractility - force of the squeezing that the ventricle is able to achievethat the ventricle is able to achieve
Afterload - amount of pressure the Afterload - amount of pressure the ventricle muscle must overcome to ejectventricle muscle must overcome to eject
Contraction - dependent upon Contraction - dependent upon conduction systemconduction system
Cardiac Effects of DigoxinCardiac Effects of Digoxin
Positive inotropin effect: strengthens Positive inotropin effect: strengthens the force of contractionthe force of contraction
Negative dromotropin effect: Negative dromotropin effect: decreases conductiondecreases conduction
Negative chronotropin effect: Negative chronotropin effect: decreases heart ratedecreases heart rate
Improve renal perfusionImprove renal perfusion
DigoxinDigoxin* CHF, atrial fib* CHF, atrial fib
* digitalization* digitalization
* toxic effects - N&V, diarrhea, * toxic effects - N&V, diarrhea, green/yellow vision, double green/yellow vision, double vision, headache, dizziness, vision, headache, dizziness, fatigue, weaknessfatigue, weakness
* monitor effectiveness* monitor effectiveness
* watch for hypokalemia* watch for hypokalemia
* education* education
* antidote - digoxin immune * antidote - digoxin immune FABFAB
Nursing InterventionsNursing Interventions
Monitor HR - apical for 1 minuteMonitor HR - apical for 1 minute Monitor Dig level - 0.5-2.0 ng/mlMonitor Dig level - 0.5-2.0 ng/ml Monitor K, Calcium, Mag - increase in Monitor K, Calcium, Mag - increase in
calcium or decrease in K or Mag will calcium or decrease in K or Mag will potentiate the effect of Digoxinpotentiate the effect of Digoxin
Other Cardiac GlycosidesOther Cardiac Glycosides
inamrinone (Inocor) & milrinone inamrinone (Inocor) & milrinone (Primacor): increase force of (Primacor): increase force of contraction and produce a contraction and produce a vasodilatory effect which increases vasodilatory effect which increases cardiac outputcardiac output
Used for short term management of Used for short term management of CHFCHF
Critical Thinking ExerciseCritical Thinking Exercise
A patient with CHFA patient with CHF Is on Digoxin, Lasix, and potassium Is on Digoxin, Lasix, and potassium
supplementsupplement What is the desired therapeutic effect?What is the desired therapeutic effect? Why should hypokalemia be prevented?Why should hypokalemia be prevented? What blood work should be monitored?What blood work should be monitored?
NitroglycerinNitroglycerin
Relaxes vascular smooth muscles & Relaxes vascular smooth muscles & dilates arterial & venous vessels thus dilates arterial & venous vessels thus reducing afterload & myocardial reducing afterload & myocardial consumptionconsumption
Acute angina: sublingual, transmucosal, Acute angina: sublingual, transmucosal, or translingual sprayor translingual spray
Prophylactic for angina: above & topical Prophylactic for angina: above & topical & oral SR& oral SR
IV: used to treat primarily hypertensionIV: used to treat primarily hypertension
Tolerance & Adverse EffectsTolerance & Adverse Effects
Tolerance may developTolerance may develop Less likely in sublingual & Less likely in sublingual &
translingual spraytranslingual spray Most common adverse effects: Most common adverse effects:
headache, can have hypotension, headache, can have hypotension, tachycardia, syncopetachycardia, syncope
Anginal EpisodeAnginal Episode
Have a person lie downHave a person lie down Give nitroglycerin tabs x 3, if needed, Give nitroglycerin tabs x 3, if needed,
5 minutes apart5 minutes apart If no relief – call 911If no relief – call 911
EducationEducation
Smoking causes vasoconstriction Smoking causes vasoconstriction which may cause anginawhich may cause angina
Sublingual: keep in original bottle Sublingual: keep in original bottle with tight capwith tight cap
Transdermal: nonhairy area but Transdermal: nonhairy area but avoid distal parts of extremities, avoid distal parts of extremities, remove patch for 10-12 hoursremove patch for 10-12 hours
Education (cont.)Education (cont.)
Increase absorption with broken skin, Increase absorption with broken skin, increase with exercise, increase increase with exercise, increase temperature (avoid sauna)temperature (avoid sauna)
Ointment: choose a different Ointment: choose a different application site, use tissue to remove application site, use tissue to remove any old ointment, do not massage or any old ointment, do not massage or rub in ointmentrub in ointment
AntiarrhythmicsAntiarrhythmics
* see after MI, cardiac * see after MI, cardiac surgery, CAD, electrolyte surgery, CAD, electrolyte imbalance, thyroid diseaseimbalance, thyroid disease
* abnormality with initiation * abnormality with initiation of impulse or in impulse of impulse or in impulse conduction or bothconduction or both
* should be monitored, most * should be monitored, most meds given IV, monitor AP meds given IV, monitor AP (rate & rhythm)(rate & rhythm)
Antiarrhythmic AgentsAntiarrhythmic AgentsQuinidine (Cardioquin)Quinidine (Cardioquin) – class – class 1A depresses Phase 0 in 1A depresses Phase 0 in depolarizationdepolarization
* depresses cardiac function, * depresses cardiac function, however inhibits vagal action however inhibits vagal action so may have sinus so may have sinus tachycardiatachycardia
* has high incidence of * has high incidence of adverse effects with most adverse effects with most common being GIcommon being GI
* monitor renal & liver * monitor renal & liver functionfunction
LidocaineLidocaine
Lidocaine (Xylocaine)Lidocaine (Xylocaine) - Class 1B - Class 1B depresses phase 0 but not as much depresses phase 0 but not as much as Quinidineas Quinidine
brief action so less chance of brief action so less chance of cumulative drug toxicity, make sure cumulative drug toxicity, make sure you have correct type of Lidocaine, you have correct type of Lidocaine, tx ventricular arrhythmiastx ventricular arrhythmias
give IVgive IV
Antiarrhythmic Agents Antiarrhythmic Agents (cont.)(cont.)
Flecainide (Tambocor)Flecainide (Tambocor) - Class - Class 1C markedly depresses phase 1C markedly depresses phase 0, tx PAF or flutter & 0, tx PAF or flutter & ventricular arrhymias, ventricular arrhymias, suppress conduction, many suppress conduction, many adverse effectsadverse effects
Propranolol (Inderal)Propranolol (Inderal) - Class II - Class II depresses phase 4 depresses phase 4 depolarization, beta depolarization, beta adrenergic blocking agent, tx adrenergic blocking agent, tx arrhythmias secondary to dig arrhythmias secondary to dig toxicity, also used to tx toxicity, also used to tx hypertension, angina & MIhypertension, angina & MI
amiodarone (Cordarone)amiodarone (Cordarone)
Amiodarone (Cordarone)Amiodarone (Cordarone) - Class III - Class III prolongs phase III repolarizationprolongs phase III repolarization
increases refractory period, increases increases refractory period, increases myocardial contractility, vasodilatory myocardial contractility, vasodilatory actionaction
used to prophylaxis and therapy of vent used to prophylaxis and therapy of vent fibfib
keep pt supine - most common AE is keep pt supine - most common AE is orthostatic hypotensionorthostatic hypotension
Verapamil HCL (Calan)Verapamil HCL (Calan) Class IV depresses phase 4 depolarization Class IV depresses phase 4 depolarization
& lengthens phase 1 & 2 of repolarization& lengthens phase 1 & 2 of repolarization calcium channel blocker, decrease calcium channel blocker, decrease
myocardial contraction, decrease SA node myocardial contraction, decrease SA node impulse, decrease conduction, also causes impulse, decrease conduction, also causes CA dilatation & peripheral vasodilatationCA dilatation & peripheral vasodilatation
also used to tx anginaalso used to tx angina watch for bradycardia & hypotensionwatch for bradycardia & hypotension AE - most common is constipationAE - most common is constipation IV solution must be protected from lightIV solution must be protected from light Administer slowly – greater than 2 minutesAdminister slowly – greater than 2 minutes
Potassium-Removing ResinsPotassium-Removing Resins
Sodium polystyrene sulfonate Sodium polystyrene sulfonate (Kayexalate)(Kayexalate)
oral or enemaoral or enema AE - hypokalemiaAE - hypokalemia
AntihyperlipidemicsAntihyperlipidemics
DefinitionDefinition HDL/LDLHDL/LDL
StatinsStatins
lovastatin (Mevacor)lovastatin (Mevacor) Blocks synthesis of cholesterol in Blocks synthesis of cholesterol in
liverliver Decrease LDL, increase HDLDecrease LDL, increase HDL
Bile acid sequestrantsBile acid sequestrants
cholestyramine (Questran)cholestyramine (Questran) Lower LDL levelsLower LDL levels Binds bile acids in intestineBinds bile acids in intestine
New drugsNew drugs
How actions differHow actions differ
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