Cardiovascular Medications

Must- knows about Cardiovascular Medications By: Dave Manriquez RN.

MEDICATIONS AFFECTING BLOOD PRESSURE (HYPERTENSION/ HYPOTENSION)

(2) Stroke volume (Preload) (1) Heart rate Three 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 Time What 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 HYPERTENSION Hypertension

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:
Capto pril
Enala pril
Quina pril
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 dilation Why? 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”:
Telmi sartan
Lo sartan

ANGIOTENSIN II RECEPTOR BLOCKERS Vasoconstriction ACE I to ACE II Ang. II Receptors on Blood 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:
Amlo dipine
Nife dipine
Felo dipine
***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 Pressure Cardiac Workload Cardiac O2 Demand CALCIUM CHANNEL BLOCKERS (-) Chronotropic & Dromotropic Effect

? Trivia Time Is 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 Vasodilation Why? 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 Pressure Heart 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, hyperkalemia C. hypokalemia, hyperglycemia, sulfa allergy D. 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 physician B. 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 paresthesia B. constipation, dry mouth, and sleep disorder C. double vision, loss of appetite, and nausea D. 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 HEART Degree of Cardiac muscle stretch Force of contraction Point of exhaustion/ Point of no return Non- compliant heart/ CHF Compromised Circulation Afterload Preload

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 drug Notify the physician and document the event Retake pulse after 1 hour If 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 1 st 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 precautions Why? 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 Inam rinone (Inocor) Mil rinone (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/mL B. 1.2 to 2.8 ng/mL C. 3 ng/mL D. 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 output B. excess fluid volume C. impaired tissue perfusion D. 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 BP B. monitoring potassium level C. monitoring urine output D. 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. diarrhea B. intermittent intestinal colic C. muscle weakness and leg cramps D. tingling of fingers and toes PRACTICE QUESTIONS 

ANTIARRHYTHMIC AGENTS
Class I A Antiarrhythmics
Class I B Antiarrhythmics
Class I C 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 PUMP Stimulation (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 Time What did the cardiac arrhythmia suppression trials in the early 1990s reveal? Anti-arrhythmics

? Trivia Time: ANSWER Non 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
Pro cain amide (Pronestyl)
*Quinidine (Cardioquin)
*Lido caine (Xylocaine)
Fle cain ide (Tambocor)
1

HEART AUTOMATICITY SODIUM-POTASSIUM PUMP Stimulation (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 Time What 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

Possible priority NURSING diagnosis: CNS effects Membrane-stabilizing effects Why? 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 2

Vital facts: CLASS II ANTIARRHYTHMICS Key vital sign to measure before administration: Heart rate Do not give if: Heart rate is below 60 bpm
Acebut olol (Sectral)
Propran olol (Inderal)
Esm olol (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
Dofe tilide (Tikosyn)
Ibu tilide (Corverf)
*Amiodarone (Cordarone)
Bretylium (Generic only)
Sotalol (Betapace AF)
3

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 V ery N ice D rugs Verapamil, Nifedipine and Diltiazem Calcium Channel blockers 4

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 tablets B. auscultate the client’s apical pulse and obtain a blood pressure C. measure the heart rate on the rhythm strip D. 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:
Choles tyramine (Questran): Mix with liquids Tablet form is taken whole * Coles tipol (Colestid): Coles evelam (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 SEQUESTRANTS Fat 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

Best time to administer drug: Major suffix: Vital facts:
HMG- CoA REDUCTASE INHIBITORS (STATINS)
-statin Bedtime Ophthalmic 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:
Before therapy: Ensure diet/ exercise was done for 3-6 mos. What’s the reason? To make sure that statins are really needed.

? Trivia Time Statins 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 ( Lipi tor)
Simvastatin (Zo cor )
Lovastatin (Meva cor )
Pravastatin (Prava chol )

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 prevent1 st 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: ANSWER 2-4 weeks Statins

Peak action is at: Onset of action is at: Major suffix: Vital facts:
FIBRATES
-fibrate, -fibro F our days ( F ibrates= F our) F our weeks Best time to give drug: Bedtime
Clo fibrate (Atromid)
Feno fibrate (Tri cor )
Gem fibro zil ( 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: U pper side rails “ U nderstandable” L ower side rails: L ook 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: Sublingual
NITRATES
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 patches B. have a 12-hour “no nitrate” time C. have a 24-hour “no nitrate” time D. 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-compulsive B. denial C. phobic D. 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 PATHWAY Vessel 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 injury Blood Stasis Hypercoagulability of Blood Virchow’s Triad Possible Hemorrhage Blood disorders

ANTIPLATELETS
Common Antiplatelets:
Anti-platelets
Aspirin
Abciximab (ReoPro)
Anagrelide ( Ag rylin)
Clopidogrel ( Pla vix)

ANTIPLATELETS
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 H eaven, there is P eace, In W ar there is K ill

? Trivia Time When do you expect vitamin K or Phytonadione to reverse the effects of warfarin? Anti-coagulants

? Trivia Time: ANSWER IV: 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 H ope:  Long-term For home use also W rong:  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 Time What should you remember regarding possible drug-drug interactions with warfarin? Anti-coagulants

? Trivia Time: ANSWER Warfarin 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 II a
With Enoxaparin, I do have to tell my client to have periodic APTT evaluation.
   Warfarin   
ANTICOAGULANTS
True 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: ANSWER Treating 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
Alte plase (Activase)
Stepto kinase (Streptase)
Uro kinase (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):
Oral  Sustained release form Do nut crush or chew the tablet 3 doses per day

Pentoxyfilline (Trental):
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):
Chest pain & very rapid HR (A/E) Take the missed dose If 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 time B. activated partial thromboplastin time C. hematocrit D. 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 available B. monitor for renal failure C. monitor for signs of bleeding D. 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
E poetin alfa
Darbo poetin 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 Time If 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 week Darbopoetin: 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. 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 Lecture Thank you so much for your attention!!!

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Cardiovascular Medications

by Jay-D Man on Sep 25, 2009

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Cardiovascular Medications — Presentation Transcript