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Cardiovascular Medications
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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:
ANGIOTENSIN- CONVERTING ENZYME (ACE) INHIBITORS
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
ANGIOTENSIN- CONVERTING ENZYME (ACE) INHIBITORS
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
ANGIOTENSIN- CONVERTING ENZYME (ACE) INHIBITORS
ANGIOTENSIN- CONVERTING ENZYME (ACE) INHIBITORS
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
CALCIUM CHANNEL BLOCKERS
Myosin Actin
Troponin Protein complex
ACTION POTENTIAL/ TRIGGER
CALCIUM CHANNEL BLOCKERS
Myosin Actin
Troponin Protein complex
Ca
= CONTRACTION
Actin-myosin Sliding Is Spoiled
Smooth Muscles Cardiac Muscle
Peripheral Resistance
Blood PressureCardiac Workload
Cardiac O2 Demand
CALCIUM CHANNEL BLOCKERS
(-) 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:
CALCIUM CHANNEL BLOCKERS
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:
Possible priority NURSING diagnosis:
CNS effects
VasodilationWhy?
Blood pools in peripheral veins
Decreased venous return
Decreased CO
Decreased blood flow to the brain
CALCIUM CHANNEL BLOCKERS
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
DIRECT ACTING VASODILATORS
Smooth Muscle dilation
Peripheral Resistance
Blood PressureHeart misinterprets BP
Heart compensates: Tachycardia
Cardiac workload
DIRECT ACTING VASODILATORS
Minoxidil:
Hydralazine:
Diazoxide:
Other actions:
Blocks Insulin = Increases glucose levels
Increases renal blood flow
Topical form: Tx for baldness
DIRECT ACTING VASODILATORS
Other actions:
Nitroprusside: Thiocyanate metabolite: cyanide toxicity
Tolazoline: IV: Tx for Pulmonary HPN in Newborn
DIRECT ACTING VASODILATORS
Consciousness:
Gait:
Color:
Symptoms of cyanide toxicity:
Pink
Ataxia
Decreased LOC
Vital signs: Depressed (HR,RR,BP)
Pupils: Dilated
DIRECT ACTING VASODILATORS
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
ANTI- HYPOTENSION MEDICATION
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)
ANTI- HYPOTENSION MEDICATION
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:
PHOSPHODIESTERASE INHIBITORS (2nd-line CHF Treatment Option)
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:
PHOSPHODIESTERASE INHIBITORS (2nd-line CHF Treatment Option)
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
CLASS I ANTI-ARRHYTHMICS
*Lidocaine:Ventricular arrythmias, esp. PVC
All others:Usually for ventricular arrhhythmias
Trivia TimeWhat equipment should be available when a patient is taking anti-dysrhythmics?
CLASS I ANTI-ARRHYTHMICS
Trivia Time: ANSWER
ECG Monitor
CLASS I ANTI-ARRHYTHMICS
On cardiovascular C/I:
Nursing teachings;
Bradycardia, Heart block and CHF
Essential assessment:ECG readings (Heart rhythm)
CLASS I ANTI-ARRHYTHMICS
Trivia Time
What diet should be considered to enhance Quinidine excretion?
CLASS I ANTI-ARRHYTHMICS
Trivia Time: ANSWER
Acid- Ash Diet
CLASS I ANTI-ARRHYTHMICS
On Quinidine + Digoxin:
On Quinidine excretion:
Nursing teachings;
Urine must be acidic
Decreased Digoxin excretion
CLASS I ANTI-ARRHYTHMICS
Food interaction:
Procainamide frequency:
Nursing teachings;
RTC – alarm clock on hand
Best taken on an empty stomach
CLASS I ANTI-ARRHYTHMICS
Trivia Time
What should a patient taking Disopyridamole avoid exposing
himself to?
CLASS I ANTI-ARRHYTHMICS
Trivia Time: ANSWER
Sunlight
CLASS I ANTI-ARRHYTHMICS
Rationale:
What to avoid when taking disopyramide:
Nursing teachings;
Sunlight
Due to photosensitivity
CLASS I ANTI-ARRHYTHMICS
Possible priority NURSING diagnosis:
CNS effects
Membrane-stabilizing effectsWhy?
Action potential is affected
Tingling:
LOC:
Tremors:
Disturbed sensory perception r/t
CLASS I ANTI-ARRHYTHMICS
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)
Na gates open: Na enters cell; Potassium leaves the cell
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)
CLASS III ANTIARRHYTHMICS
Stimulation (Automaticity)
Na gates open: Na enters cell; Potassium leaves the cell
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
CLASS III ANTIARRHYTHMICS
Vital facts:
Sotalol: Maintains normal sinus rhythm
When is it used? After cardioverison of atrial arrythmias
CLASS III ANTIARRHYTHMICS
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:
CLASS IV ANTIARRHYTHMICS
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?
CLASS IV ANTIARRHYTHMICS
Trivia Time: ANSWER
Adenosine (Adenocard)
CLASS IV ANTIARRHYTHMICS
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:
BILE ACID SEQUESTRANTS
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:
BILE ACID SEQUESTRANTS
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:
BILE ACID SEQUESTRANTS
Impaired fat absorption
Steatorrhea
ADEK deficiency
Bowel patterns: Constipation
Type of malnutrition: Fat malnutrition
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
HMG- CoA REDUCTASE INHIBITORS (STATINS)
*Atorvastatin (Lipitor) Simvastatin (Zocor)
Lovastatin (Mevacor) Pravastatin (Pravachol)
GIT S/E:
Vital facts:
Constipation or diarrhea
HMG- CoA REDUCTASE INHIBITORS (STATINS)
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
Act directly on blood vessels: Vasodilation
Peripheral veins
Peripheral arteries
Coronary arteries
Resistance
Afterload
Cardiac workload
NITRATES
Act directly on blood vessels: Vasodilation
Peripheral veins
Peripheral arteries
Coronary arteries
Cardiac blood flow/
O2
NITRATES
Act directly on blood vessels: Vasodilation
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
Intrinsic pathway: clotting Fxs
Prothrombin- Thrombin
Fibrinogen – Fibrin threads: basis of the clot by trapping RBCs
Clot/ Thrombus Formation
BLOOD COAGULATION: INTRINSIC PATHWAY
BLOOD COAGULATION: INTRINSIC PATHWAY
BLOOD COAGULATION:EXTRINSIC PATHWAYVessel injury
Blood leaks out of vessel
Injured vessel cells release Tissue Thromboplastin
Extrinsic Pathway:Clotting Fxs activation
Clot/ Thrombus Formation
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)
Intrinsic pathway: clotting Fxs
Prothrombin- Thrombin
Fibrinogen – Fibrin threads: basis of the clot by trapping RBCs
Clot/ Thrombus Formation
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
Pentoxyfilline (Trental):HEMORRHEOLOGIC AGENT
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:
Pentoxyfilline (Trental):HEMORRHEOLOGIC AGENT
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)
FOLIC ACID DERIVATIVES AND VITAMIN B12
Sample medications: Vitamin B12 Derivatives
Vital facts:
FOLIC ACID DERIVATIVES AND VITAMIN B12
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”
FOLIC ACID DERIVATIVES AND VITAMIN B12
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.
TOXIC METALS & THEIR ANTIDOTES
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
TOXIC METALS & THEIR ANTIDOTES
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!!!