Cardiovascular Medications

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Cardiovascular Medications

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Cardiovascular Medications

  1. 1. Must- knows about Cardiovascular Medications By: Dave Manriquez RN.
  2. 2. MEDICATIONS AFFECTING BLOOD PRESSURE (HYPERTENSION/ HYPOTENSION)
  3. 3. (2) Stroke volume (Preload) (1) Heart rate Three Elements: Vital facts: <ul><ul><li>BLOOD PRESSURE CONTROL </li></ul></ul>(3) Peripheral Resistance (Afterload) Renin- Angiotensin- Aldosterone System
  4. 4. HYPERTENSION: BRIEF PATHOPHYSIOLOGY Trauma To Small Vessels Overworked Heart High Peripheral Resistance Cardiac Death C.A.D. Eyes Brain Kidneys
  5. 5. 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
  6. 6. Risk Factors for Hypertension High salt diet Exposure to high frequency noise High levels of psychological stress Lack of rest Genetic predisposition
  7. 7. ? Trivia Time What is a white-coat hypertension? Hypertension
  8. 8. ? 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
  9. 9. Friendly Reminder: There is ________ for Hypertension. The medications we are about to discuss only control the symptoms. NO CURE HYPERTENSION Hypertension
  10. 10. 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 <ul><li>Common ACEs: </li></ul><ul><ul><li>Capto pril </li></ul></ul><ul><ul><li>Enala pril </li></ul></ul><ul><ul><li>Quina pril </li></ul></ul>S: Severe Pancytopenia that may be fatal
  11. 11. Angioedema: ANGIOTENSIN- CONVERTING ENZYME (ACE) INHIBITORS
  12. 12. Reflex cardiac response: Kidneys: Skin: Other key s/e: Mild rash Renal insufficiency Reflex tachycardia ACE INHIBITORS
  13. 13. 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.
  14. 14. 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
  15. 15. ANGIOTENSIN- CONVERTING ENZYME (ACE) INHIBITORS ACE I to ACE II Vasoconstriction Aldosterone Deceased peripheral resistance Deceased blood volume
  16. 16. ? Trivia Time What drug has been recently approved to treat Pulmonary Hypertension? ACE Inhibitors
  17. 17. ? Trivia Time: ANSWER Bosentan (Traceleer) – Endothelin receptor antagonist ACE Inhibitors
  18. 18. ANGIOTENSIN II RECEPTOR BLOCKERS Major Suffix: -sartan <ul><li>Common “ARBs”: </li></ul><ul><ul><li>Telmi sartan </li></ul></ul><ul><ul><li>Lo sartan </li></ul></ul>
  19. 19. ANGIOTENSIN II RECEPTOR BLOCKERS Vasoconstriction ACE I to ACE II Ang. II Receptors on Blood Vessels/ Adrenal Cortex Aldosterone
  20. 20. ? Trivia Time What could happen if ARBS are taken with Phenobarbital? ARBS
  21. 21. ? Trivia Time: ANSWER Decreased serum levels of ARBS ARBS
  22. 22. <ul><li>CALCIUM CHANNEL BLOCKERS </li></ul>Major Suffix: -dipine <ul><li>Common Calcium Channel Blockers: </li></ul><ul><ul><li>Amlo dipine </li></ul></ul><ul><ul><li>Nife dipine </li></ul></ul><ul><ul><li>Felo dipine </li></ul></ul><ul><ul><li>***Diltiazem </li></ul></ul><ul><ul><li>***Verapamil </li></ul></ul>
  23. 23. CALCIUM CHANNEL BLOCKERS Myosin Actin Troponin Protein complex
  24. 24. ACTION POTENTIAL/ TRIGGER
  25. 25. CALCIUM CHANNEL BLOCKERS Myosin Actin Troponin Protein complex Ca = CONTRACTION
  26. 26. Actin-myosin Sliding Is Spoiled Smooth Muscles Cardiac Muscle Peripheral Resistance Blood Pressure Cardiac Workload Cardiac O2 Demand CALCIUM CHANNEL BLOCKERS (-) Chronotropic & Dromotropic Effect
  27. 27. ? Trivia Time Is there any positive benefit that comes with the (-) dromotropic effect of Ca channel blockers? Calcium Channel Blockers
  28. 28. ? Trivia Time: ANSWER Yes. Prolonged repolarization equals increased myocardial tissue perfusion Calcium Channel Blockers
  29. 29. 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
  30. 30. 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
  31. 31. <ul><li>DIRECT ACTING VASODILATORS </li></ul><ul><li>Major Suffix: none  </li></ul><ul><li>Major consideration : </li></ul>Used only for SEVERE Hypertension <ul><li>Common Vasodilators: </li></ul><ul><ul><li>Diazoxide </li></ul></ul><ul><ul><li>Hydralazine </li></ul></ul><ul><ul><li>Minoxidil </li></ul></ul><ul><ul><li>Nitroprusside </li></ul></ul><ul><ul><li>Tolazoline </li></ul></ul>
  32. 32. 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)
  33. 33. Blood Vessel D.A. Vasodilators Blood Vessel DIRECT ACTING VASODILATORS
  34. 34. Smooth Muscle dilation Peripheral Resistance Blood Pressure Heart misinterprets BP Heart compensates: Tachycardia Cardiac workload DIRECT ACTING VASODILATORS
  35. 35. Minoxidil: Hydralazine: Diazoxide: Other actions: Blocks Insulin = Increases glucose levels Increases renal blood flow Topical form: Tx for baldness DIRECT ACTING VASODILATORS
  36. 36. Other actions: Nitroprusside: Thiocyanate metabolite: cyanide toxicity Tolazoline: IV: Tx for Pulmonary HPN in Newborn DIRECT ACTING VASODILATORS
  37. 37. Consciousness: Gait: Color: Symptoms of cyanide toxicity: Pink Ataxia Decreased LOC Vital signs: Depressed (HR,RR,BP) Pupils: Dilated DIRECT ACTING VASODILATORS
  38. 38. ? Trivia Time What effect does Nitroprusside have on the thyroid gland? Direct-acting Vasodilators
  39. 39. ? Trivia Time: ANSWER Decreased Iodide uptake equals hypothyroidism Direct-acting Vasodilators
  40. 40. <ul><li>ANTI- ORTHOSTATIC HYPOTENSION MEDICATION </li></ul><ul><li>Midodrine </li></ul>Major consideration: Administer to MOBILE patients only to prevent severe hypertension.
  41. 41. Blood Vessel Anti- Hypotensives Blood Vessel ANTI- HYPOTENSION MEDICATION
  42. 42. When does this usually occur: Essential vital sign to monitor: Main indication: Vital facts: Orthostatic hypotension Heart rate (Bradycardia) Initial therapy ANTI- HYPOTENSION MEDICATION
  43. 43. 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
  44. 44. ? Trivia Time What precaution safety precaution should you take with all vasodilators? Vasodilators
  45. 45. ? Trivia Time: ANSWER Safety against falls due to lightheadedness and dizziness Vasodilators
  46. 46. 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 
  47. 47. 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 
  48. 48. 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 
  49. 49. 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 
  50. 50. 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 
  51. 51. 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 
  52. 52. CARDIOTONIC/ INOTROPIC AGENTS (CONGESTIVE HEART FAILURE)
  53. 53. 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
  54. 54. CARDIAC GLYCOSIDES (-) Chronotropic Effect Possible Bradycardia Adult: __ bpm Infant: __ bpm Adult: 60 bpm Infant: 90 bpm
  55. 55. CARDIAC GLYCOSIDES (+) Inotropic Effect Cardiac output Renal perfusion Renin release Blood volume Urinary output Vasoconstriction
  56. 56. CARDIAC GLYCOSIDES (-) Dromotropic Effect Possible heart block (AV block)
  57. 57. 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
  58. 58. 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. …
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. Nursing actions: Vision changes: Yellow halos around lights Cardiovascular changes: Bradycardia & Heart block Antidote: CARDIAC GLYCOSIDES Digoxin Immune Fab (Digibind/ Digifab) Route: Intravenous infusion
  63. 63. 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
  64. 64. PHOSPHODIESTERASE INHIBITORS Inhibition of the enzyme: Phosphodiesterase Cyclic Adenosine Mono-phosphate in myocardium Increased Calcium levels (+) Inotropic effect
  65. 65. 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
  66. 66. 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
  67. 67. 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)
  68. 68. 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 
  69. 69. 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 
  70. 70. 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 
  71. 71. 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 
  72. 72. 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 
  73. 73. 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 
  74. 74. 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 
  75. 75. ANTIARRHYTHMIC AGENTS <ul><li>Class I A Antiarrhythmics </li></ul><ul><li>Class I B Antiarrhythmics </li></ul><ul><li>Class I C Antiarrhythmics </li></ul><ul><li>Class II Antiarrhythmics </li></ul><ul><li>Class III Antiarrhythmics </li></ul><ul><li>Class IV Antiarrhythmics </li></ul><ul><li>Other Antiarrhythmics </li></ul>
  76. 76. SA Node: ___ bpm AV node AV bundle/Bundle of His: ___ bpm Right/Left Bundle Braches Purkinje Fibers: ___bpm <ul><ul><li>CONDUCTION SYSTEM OF THE HEART </li></ul></ul>60-100 40-60 20-40
  77. 77. 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
  78. 78. Electrolyte disturbances Hypoxia Structural Damage Acidosis/ Azotemia Arrhythmia Decreased Cardiac Output Decreased Tissue Perfusion BRIEF PATHOPHYSIOLOGY: ARRHYTHMIA
  79. 79. ? Trivia Time What did the cardiac arrhythmia suppression trials in the early 1990s reveal? Anti-arrhythmics
  80. 80. ? Trivia Time: ANSWER Non life-threatening dys. Plus meds = 2-3x greater risk of death Anti-arrhythmics
  81. 81. Fact about anti-arrythmics: Major suffix: Vital facts: <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>-caine, -cain- All of them are pro-arrhythmics <ul><ul><li>Pro cain amide (Pronestyl) </li></ul></ul><ul><ul><li>*Quinidine (Cardioquin) </li></ul></ul><ul><ul><li>*Lido caine (Xylocaine) </li></ul></ul><ul><ul><li>Fle cain ide (Tambocor) </li></ul></ul>1
  82. 82. 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
  83. 83. *Quinidine: Procainamide (Pronestyl): Disopyramide (Norpace): Usual indications: Ventricular arrhythmias Ventricular arrhythmias Atrial arrhythmias <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>*Lidocaine: Ventricular arrythmias, esp. PVC All others: Usually for ventricular arrhhythmias
  84. 84. ? Trivia Time What equipment should be available when a patient is taking anti-dysrhythmics? <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  85. 85. ? Trivia Time: ANSWER ECG Monitor <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  86. 86. On cardiovascular C/I: Nursing teachings; Bradycardia, Heart block and CHF Essential assessment: ECG readings (Heart rhythm) <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  87. 87. ? Trivia Time What diet should be considered to enhance Quinidine excretion? <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  88. 88. ? Trivia Time: ANSWER Acid- Ash Diet <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  89. 89. On Quinidine + Digoxin: On Quinidine excretion: Nursing teachings; Urine must be acidic Decreased Digoxin excretion <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  90. 90. Food interaction: Procainamide frequency: Nursing teachings; RTC – alarm clock on hand Best taken on an empty stomach <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  91. 91. ? Trivia Time What should a patient taking Disopyridamole avoid exposing himself to? <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  92. 92. ? Trivia Time: ANSWER Sunlight <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  93. 93. Rationale: What to avoid when taking disopyramide: Nursing teachings; Sunlight Due to photosensitivity <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>
  94. 94. Possible priority NURSING diagnosis: CNS effects Membrane-stabilizing effects Why? Action potential is affected Tingling: LOC: Tremors: Disturbed sensory perception r/t <ul><ul><li>CLASS I ANTI-ARRHYTHMICS </li></ul></ul>Circumoral paresthesia Drowsiness with slurred speech May lead to convulsions
  95. 95. Why? Key nursing assessment: Major suffix: Vital facts: CLASS II ANTIARRHYTHMICS -olol Be alert for wheezing sounds Bronchospasm is a potential side-effect 2
  96. 96. Vital facts: CLASS II ANTIARRHYTHMICS Key vital sign to measure before administration: Heart rate Do not give if: Heart rate is below 60 bpm <ul><ul><li>Acebut olol (Sectral) </li></ul></ul><ul><ul><li>Propran olol (Inderal) </li></ul></ul><ul><ul><li>Esm olol (Brevibloc) </li></ul></ul>
  97. 97. 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
  98. 98. 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 <ul><ul><li>Dofe tilide (Tikosyn) </li></ul></ul><ul><ul><li>Ibu tilide (Corverf) </li></ul></ul><ul><ul><li>*Amiodarone (Cordarone) </li></ul></ul><ul><ul><li>Bretylium (Generic only) </li></ul></ul><ul><ul><li>Sotalol (Betapace AF) </li></ul></ul>3
  99. 99. 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
  100. 100. Fatal effects of Amiodarone: Vital facts: Liver toxicity Ocular abnormalities Serious arrythmias CLASS III ANTIARRHYTHMICS
  101. 101. Vital facts: Sotalol: Maintains normal sinus rhythm When is it used? After cardioverison of atrial arrythmias CLASS III ANTIARRHYTHMICS
  102. 102. 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
  103. 103. 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
  104. 104. ? Trivia Time What AD is specifically indicated for Wolff-Parkinson-White Syndrome? CLASS IV ANTIARRHYTHMICS
  105. 105. ? Trivia Time: ANSWER Adenosine (Adenocard) CLASS IV ANTIARRHYTHMICS
  106. 107. 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
  107. 108. 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 
  108. 109. LIPID LOWERING AGENTS (CORONARY ARTERY DISEASE)
  109. 110. 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
  110. 111. CHOLESTEROL: WHO’S GOOD or BAD? HDL LDL
  111. 112. HDL cholesterol: LDL cholesterol: Total cholesterol: Normal values: < 240 mg/ dL 130-170 mg/dL 40-70 mg/ dL Triglycerides: < 200 mg/dL CHOLESTEROL
  112. 113. Best time to give other drugs: Ideal time of administration: Major Prefix: Vital facts: <ul><ul><li>BILE ACID SEQUESTRANTS </li></ul></ul>Choles- ; Coles- Bed time and alone 1 hour a.c. or 4-6 hours p.c.
  113. 114. Vital facts: <ul><ul><li>BILE ACID SEQUESTRANTS </li></ul></ul>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
  114. 115. Cholestyramine + carbonated beverage: Colestipol + carbonated beverage: Cholestyramine: Vital facts: <ul><ul><li>BILE ACID SEQUESTRANTS </li></ul></ul>Also ideal for pruritus r/t biliary obstruction OK Not OK Can tablets be chewed or crushed? No.
  115. 116. 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
  116. 117. Vitamin deficiency: Stool characteristics: How it affects nutrition? Adverse effects: <ul><ul><li>BILE ACID SEQUESTRANTS </li></ul></ul>Impaired fat absorption Steatorrhea ADEK deficiency Bowel patterns: Constipation Type of malnutrition: Fat malnutrition
  117. 118. Best time to administer drug: Major suffix: Vital facts: <ul><ul><li>HMG- CoA REDUCTASE INHIBITORS (STATINS) </li></ul></ul>-statin Bedtime Ophthalmic side-effect: Bilateral cataract Why? Cholesterol is needed for normal cell membrane synthesis
  118. 119. 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
  119. 120. Vital facts: <ul><ul><li>HMG- CoA REDUCTASE INHIBITORS (STATINS) </li></ul></ul>Before therapy: Ensure diet/ exercise was done for 3-6 mos. What’s the reason? To make sure that statins are really needed.
  120. 121. ? Trivia Time Statins have a very marked first-pass effect. What does this tell you about its adverse effects? Statins
  121. 122. ? Trivia Time: ANSWER Highly liver toxic Statins
  122. 123. Why? Renal side-effect: Vital facts: Acute tubular necrosis = Acute renal failure Statins cause Rhabdomyolysis  myoglobinuria <ul><ul><li>HMG- CoA REDUCTASE INHIBITORS (STATINS) </li></ul></ul><ul><ul><li>*Atorvastatin ( Lipi tor) </li></ul></ul><ul><ul><li>Simvastatin (Zo cor ) </li></ul></ul><ul><ul><li>Lovastatin (Meva cor ) </li></ul></ul><ul><ul><li>Pravastatin (Prava chol ) </li></ul></ul>
  123. 124. GIT S/E: Vital facts: Constipation or diarrhea <ul><ul><li>HMG- CoA REDUCTASE INHIBITORS (STATINS) </li></ul></ul>Onset of sudden bilateral leg cramps: Due to Rhabdomyolysis Essential lab value measurement: CPK
  124. 125. 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
  125. 126. ? Trivia Time When are the peak effects of statins seen? Statins
  126. 127. ? Trivia Time: ANSWER 2-4 weeks Statins
  127. 128. Peak action is at: Onset of action is at: Major suffix: Vital facts: <ul><ul><li>FIBRATES </li></ul></ul>-fibrate, -fibro F our days ( F ibrates= F our) F our weeks Best time to give drug: Bedtime <ul><ul><li>Clo fibrate (Atromid) </li></ul></ul><ul><ul><li>Feno fibrate (Tri cor ) </li></ul></ul><ul><ul><li>Gem fibro zil ( Lopid ) </li></ul></ul><ul><ul><li>Niacin (Nissan) </li></ul></ul>
  128. 129. 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?
  129. 130. Vital facts: <ul><ul><li>FIBRATES </li></ul></ul>Key assessment when giving Clofibrate: Watch for bleeding (anti-platelet) Key lab value to assess when giving Niacin: Uric acid (Hyperuricemia)
  130. 131. Gemfibrozil (Lopid) + Statins: Vital facts: <ul><ul><li>FIBRATES </li></ul></ul>Increased Rhabdomyolysis risk
  131. 132. ANTI-ANGINAL AGENTS
  132. 133. Angina Unstable angina Stable angina Substance P
  133. 134. Act directly on blood vessels: Vasodilation Peripheral veins Blood pools Venous return Preload Peripheral arteries Coronary arteries Cardiac workload NITRATES
  134. 135. Act directly on blood vessels: Vasodilation Peripheral veins Peripheral arteries Coronary arteries Resistance Afterload Cardiac workload NITRATES
  135. 136. Act directly on blood vessels: Vasodilation Peripheral veins Peripheral arteries Coronary arteries Cardiac blood flow/ O2 NITRATES
  136. 137. 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
  137. 138. Priority nursing action after administration: Uncomfortable side-effect: Major suffix/ prefix: Vital facts: <ul><ul><li>NITRATES </li></ul></ul>-nitrate, Nitro- Headache Provide safety Why? Due to orthostatic hypotension--Sit for a few minutes
  138. 139. Vital facts: <ul><ul><li>NITRATES </li></ul></ul>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
  139. 140. Mode of administration: Onset: Amyl Nitrate Sample medications: <ul><ul><li>NITRATES </li></ul></ul>Within 30 seconds Capsule is waved under the nose
  140. 141. Sample medications: <ul><ul><li>NITRATES </li></ul></ul>Nitroglycerin Onset: Within 3-5 minutes Isosorbide mononitrate/ dinitrate For phophylactic use only. Effects may last up to 4 hours
  141. 142. Maximum shelf-life: Storage temperature: Container: Nitroglycerin guidelines: Sublingual <ul><ul><li>NITRATES </li></ul></ul>Dark and covered Room temperature (avoid extremes) Three (3) months CHULOU H. PENALES, RN
  142. 143. <ul><ul><li>NITRATES </li></ul></ul>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
  143. 144. Ideal Site: Alternative route: <ul><ul><li>NITRATES </li></ul></ul>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
  144. 145. <ul><ul><li>NITRATES </li></ul></ul>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
  145. 146. ? Trivia Time Why are nitrates C/I with severe anemia and head trauma? Nitrates
  146. 147. ? Trivia Time: ANSWER Severe anemia- worsened with low C.O. Head trauma- worsened with vasodilation Nitrates
  147. 148. 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 
  148. 149. 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 
  149. 150. 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 
  150. 151. MEDICATIONS AFFECTING BLOOD COAGULATION
  151. 152. Vessel injury Vasospasm PLATELET aggregation: PLUG Blood contacts exposed collagen Hageman Fx Activation (XII- XIIa) Intrinsic pathway: clotting Fxs BLOOD COAGULATION: INTRINSIC PATHWAY
  152. 153. Intrinsic pathway: clotting Fxs Prothrombin- Thrombin Fibrinogen – Fibrin threads: basis of the clot by trapping RBCs Clot/ Thrombus Formation BLOOD COAGULATION: INTRINSIC PATHWAY
  153. 154. BLOOD COAGULATION: INTRINSIC PATHWAY
  154. 155. 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
  155. 156. CLOT RESOLUTION Serum Plasminogen Converting Factor/s Plasma/ Fibrinolysin Dissolves clot Lungs Uterus
  156. 157. Hemophilia Liver Disease Bone Marrow Disorders Vessel wall injury Blood Stasis Hypercoagulability of Blood Virchow’s Triad Possible Hemorrhage Blood disorders
  157. 158. <ul><li>ANTIPLATELETS </li></ul><ul><li>Major Suffix: none  </li></ul><ul><li>Common Antiplatelets: </li></ul>Anti-platelets <ul><ul><li>Aspirin </li></ul></ul><ul><ul><li>Abciximab (ReoPro) </li></ul></ul><ul><ul><li>Anagrelide ( Ag rylin) </li></ul></ul><ul><ul><li>Clopidogrel ( Pla vix) </li></ul></ul>
  158. 159. <ul><li>ANTIPLATELETS </li></ul><ul><li>Major Suffix: none  </li></ul><ul><li>Common Antiplatelets: </li></ul>Anti-platelets <ul><ul><li>Dipyridamole (Persantine) </li></ul></ul><ul><ul><li>Eptifibatide (Integrelin) </li></ul></ul><ul><ul><li>Ticlopidine (Ticlid) </li></ul></ul><ul><ul><li>Tirofiban (Aggrastat) </li></ul></ul>
  159. 160. Anti-platelets: Indications Thromboembolism Myocardial infarction/ Stroke Pulmonary embolism Valvular disorders Anyone at risk for pathologic clotting
  160. 161. 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
  161. 162. ? Trivia Time What makes Anagrelide different from most Anti-platelets? Anti-platelets
  162. 163. ? Trivia Time: ANSWER It acts directly on the bone marrow to reduce platelet production Anti-platelets
  163. 164. Parenteral Anticoagulant: Oral Anticoagulant: Major suffix: Vital facts: <ul><ul><li>ANTICOAGULANTS </li></ul></ul>-parin, -farin Warfarin (Coumadin) Heparin and Anti-thrombin (IV route)
  164. 165. Vital facts: <ul><ul><li>ANTICOAGULANTS </li></ul></ul>Useful antidote Mnemonic: In H eaven, there is P eace, In W ar there is K ill
  165. 166. ? Trivia Time When do you expect vitamin K or Phytonadione to reverse the effects of warfarin? Anti-coagulants
  166. 167. ? 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
  167. 168. Vital facts: <ul><ul><li>ANTICOAGULANTS </li></ul></ul>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
  168. 169. ? Trivia Time What advantage does Enoxaparin have over Heparin? <ul><ul><li>ANTICOAGULANTS </li></ul></ul>
  169. 170. ? Trivia Time: ANSWER No need to monitor periodic APTT levels. <ul><ul><li>ANTICOAGULANTS </li></ul></ul>
  170. 171. 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
  171. 172. Teratogenicity: Home use: Duration of use: Comparison: <ul><ul><li>ANTICOAGULANTS </li></ul></ul>Short-term Usually in hospitals only H ope:  Long-term For home use also W rong:  Heparin Warfarin
  172. 173. <ul><ul><li>ANTICOAGULANTS </li></ul></ul>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
  173. 174. 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 <ul><ul><li>ANTICOAGULANTS </li></ul></ul>
  174. 175. 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. <ul><ul><li>ANTICOAGULANTS </li></ul></ul>
  175. 176. ? Trivia Time What should you remember regarding possible drug-drug interactions with warfarin? Anti-coagulants
  176. 177. ? Trivia Time: ANSWER Warfarin has so many D-D interactions. Avoid adding/removing usual meds w/o first consulting the doctor Anti-coagulants
  177. 178. 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 <ul><ul><li>ANTICOAGULANTS </li></ul></ul>
  178. 179. <ul><li>Warfarin may cause alopecia </li></ul><ul><li>Lepirudin is used for Heparin Allergy </li></ul><ul><li>Yellow-orange urine discoloration occurs with Heparin therapy. </li></ul><ul><li>Vinegar added to the urine above will give me an idea of the seriousness of the side-effect </li></ul><ul><li>Enoxaparin acts by blocking factors Xa and II a </li></ul><ul><li>With Enoxaparin, I do have to tell my client to have periodic APTT evaluation. </li></ul>   Warfarin    <ul><ul><li>ANTICOAGULANTS </li></ul></ul>True or false:
  179. 180. Plus: thromboembolic tendencies Lepirudin acts by inhibiting thrombin Heparin- induced thrombocytopenia Heparin administration Pre-existing heparin allergy Heparin and Lepirudin
  180. 181. ? Trivia Time What challenge does DIC pose to the nurse? Anti-coagulants
  181. 182. ? Trivia Time: ANSWER Treating a patient who is bleeding to death with an anticoagulant Anti-coagulants
  182. 183. Why? Best given within: Major suffix: Vital facts: <ul><ul><li>THROMBOLYTICS </li></ul></ul>-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
  183. 184. ? Trivia Time What is the number one requirement for thrombolytics to take effect? Thrombolytics
  184. 185. ? Trivia Time: ANSWER Presence of Plasminogen in the blood Thrombolytics
  185. 186. THROMBOLYTICS Activates Serum Plasminogen to Plasmin Plasmin dissolves the fibrin threads in a clot to dissolve a clot
  186. 187. THROMBOLYTICS <ul><ul><li>Alte plase (Activase) </li></ul></ul><ul><ul><li>Stepto kinase (Streptase) </li></ul></ul><ul><ul><li>Uro kinase (Abbokinase) </li></ul></ul>
  187. 188. Ideal drug for sepsis-induced clotting: What may potentiate its effects? Major suffix: Vital facts: <ul><ul><li>HEMORRHEOLOGIC AGENT </li></ul></ul>None  Caffeine & Theophylline Drotrecogin alfa(Xigris)
  188. 189. Doses per day: Priority teaching: Route: Pentoxyfilline (Trental): <ul><ul><li>HEMORRHEOLOGIC AGENT </li></ul></ul>Oral  Sustained release form Do nut crush or chew the tablet 3 doses per day
  189. 190. Pentoxyfilline (Trental): <ul><ul><li>HEMORRHEOLOGIC AGENT </li></ul></ul>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
  190. 191. If the next dose is still far away: For missed doses: When to notify doc: Pentoxyfilline (Trental): <ul><ul><li>HEMORRHEOLOGIC AGENT </li></ul></ul>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
  191. 192. Decreases platelet aggregation Decreases fibrinogen concentration Decrease blood clot formation Possible S/E for Unknown reasons Intermittent claudication HEMORRRHEOLOGIC AGENT
  192. 193. Coagulation factor VIIa: Indication: Anti-hemophilic factor Medications: <ul><ul><li>ANTI-HEMOPHILIC AGENTS </li></ul></ul>Factor VIII Classic hemophilia A Preformed clotting factors Indication: Hemophilia A or B
  193. 194. Drug category of Anti-hemophilics: Indication: Factor IX complex Medications: <ul><ul><li>ANTI-HEMOPHILIC AGENTS </li></ul></ul>Factor IX plus Vit K dependent CF Christmas disease D General nursing care: Same with blood transfusion interventions
  194. 195. 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
  195. 196. 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
  196. 197. 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
  197. 198. 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 
  198. 199. 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 
  199. 200. 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 
  200. 201. MEDICATIONS USED TO TREAT ANEMIA
  201. 202. 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
  202. 203. 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
  203. 204. - Folic acid deficiency - Vitamin B12 deficiency Megaloblastic anemia Iron Deficiency Anemia Anemia
  204. 205. ? Trivia Time What cells in the body are affected most by high Iron levels? Anemia
  205. 206. ? Trivia Time: ANSWER Neurons Anemia
  206. 207. 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 <ul><ul><li>E poetin alfa </li></ul></ul><ul><ul><li>Darbo poetin alfa (Aranesp) </li></ul></ul>
  207. 208. 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
  208. 209. ? 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
  209. 210. ? Trivia Time: ANSWER Epoetin: 2-3x per week Darbopoetin: 1x per week Erythropoietin
  210. 211. Essential lab value to monitor: Can you give it with other drug solutions? Nursing actions: ERYTHROPOIETIN No. Hematocrit Possible Precautions during therapy: Seizure precautions
  211. 212. If patient doesn’t respond within 8 weeks: Nursing actions: ERYTHROPOIETIN Re-evaluate the cause of anemia
  212. 213. Iron levels normalize in… Improvements occur in… Major prefix: Vital facts: IRON PREPARATIONS Ferrous-, Iron- 2-3 weeks 6-10 months
  213. 214. 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
  214. 215. <ul><ul><li>Ferrous Sulfate (Feosol) </li></ul></ul><ul><ul><li>Ferrous Fumarate (Feostal) </li></ul></ul><ul><ul><li>Iron Dextran (InFeD) </li></ul></ul>IRON PREPARATIONS
  215. 216. 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
  216. 217. Milk: Eggs: Orange juice: Foods to avoid taking with Iron:    Froccino Oreo (Coffee):  Vitamin C:  Green tea:  IRON PREPARATIONS
  217. 218. 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
  218. 219. Essential function of folic acid: Main indication: Major suffix: Vital facts: <ul><ul><li>FOLIC ACID DERIVATIVES AND VITAMIN B12 </li></ul></ul>-cobalamin (vitamin b12) Megaloblastic anemias Cell growth & RBC formation Essential function of Vit B12: Same+ myelin sheath maintenance
  219. 220. Hydroxycobalamin (Hydro- Crysti 12) Cyanocobalamin (Crystamine): Also available as an intranasal form (Nascobal) <ul><ul><li>FOLIC ACID DERIVATIVES AND VITAMIN B12 </li></ul></ul>Sample medications: Vitamin B12 Derivatives
  220. 221. Vital facts: <ul><ul><li>FOLIC ACID DERIVATIVES AND VITAMIN B12 </li></ul></ul>Usual route of administration: SQ Vit B12 injection schedule for pernicious anemia: IM for 5-10 days then once a month forever
  221. 222. Leucovorin (Wellcovorin): Folic acid (Folvite): Sample medications: Folic Acid Derivatives Most commonly prescribed Given per orem for “Leucovorin rescue” <ul><ul><li>FOLIC ACID DERIVATIVES AND VITAMIN B12 </li></ul></ul>
  222. 223. Methotrexate Chemotheraputic destructive effects Cancer cells LEUCOVORIN Healthy cells LEUCOVORIN RESCUE
  223. 224. Toxic Metals and their Antidotes
  224. 225. 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
  225. 226. 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
  226. 227. 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
  227. 228. End of Lecture Thank you so much for your attention!!!
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