Positive Inotropic Agents Pharmacology in Nursing
Definition <ul><li>Drugs that increase the force of myocardial contraction </li></ul><ul><li>Used to treat heart muscle fa...
Heart Failure <ul><li>The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metab...
What happens when the heart fails? <ul><li>Weakened heart is unable to pump blood in sufficient amounts </li></ul><ul><li>...
What happens when the heart fails? <ul><li>As renal perfusion decreases, renin is released by kidney </li></ul><ul><li>Vas...
Heart Failure: Causes <ul><li>Cardiac defect </li></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Valve ...
 
Treatment of Heart Failure <ul><li>Block the compensatory mechanisms </li></ul><ul><li>Treat underlying conditions </li></...
Cardiac Glycosides <ul><li>Originally obtained from  Digitalis  plant, foxglove </li></ul><ul><li>Digoxin is the prototype...
Cardiac Glycosides: Mechanism of Action <ul><li>Increase myocardial contractility </li></ul><ul><li>Change electrical cond...
Drug Effects: General Terms <ul><li>Inotropic </li></ul><ul><ul><li>Force or energy of muscular contractions </li></ul></u...
How Positive Inotropic Agents Work
Cardiac Glycosides: Drug Effects <ul><li>Positive inotropic effect </li></ul><ul><ul><li>Increase in force and velocity of...
Cardiac Glycosides: Drug Effects (cont’d) <ul><li>Increased stroke volume </li></ul><ul><li>Reduction in heart size during...
Cardiac Glycosides: Indications <ul><li>Heart failure </li></ul><ul><li>Supraventricular dysrhythmias </li></ul><ul><ul><l...
Heart Failure
Atrial Fibrillation/Flutter
Cardiac Glycosides: Adverse Effects <ul><li>Digoxin (Lanoxin) </li></ul><ul><ul><li>Very narrow therapeutic window </li></...
Digoxin:  Adverse Effects <ul><li>Cardiovascular </li></ul><ul><ul><li>Dysrhythmias, including bradycardia or tachycardia ...
Digoxin:  Adverse Effects (cont’d) <ul><li>Eye </li></ul><ul><ul><li>Colored vision (seeing green, yellow, purple), halo v...
Digoxin Toxicity <ul><li>digoxin immune Fab (Digibind) therapy </li></ul><ul><ul><li>Hyperkalemia (serum potassium greater...
Conditions That Are Predisposing to Digoxin Toxicity <ul><li>Hypokalemia </li></ul><ul><li>Use of cardiac pacemaker </li><...
Dosing Digoxin <ul><li>Adult Digitalizing Dose: </li></ul><ul><li>PO or IV : 1-1.5 mg/day  (4 doses) </li></ul><ul><li>Usu...
Phosphodiesterase Inhibitors <ul><li>Work by inhibiting the enzyme phosphodiesterase </li></ul><ul><li>Results in: </li></...
Phosphodiesterase Inhibitors: Indications <ul><li>Short-term management of heart failure </li></ul><ul><li>Given when pati...
Phosphodiesterase Inhibitors: Adverse Effects <ul><li>Inamrinone (Inocor) </li></ul><ul><ul><li>Thrombocytopenia, most wor...
Cardiostimulatory Drugs <ul><li>Enhance cardiac function by: </li></ul><ul><li>Increasing heart rate </li></ul><ul><li>Inc...
Beta-adrenoceptor agonists <ul><li>Sympathomimetic drugs that bind to beta receptors located in cardiac nodal tissue, cond...
Beta-Agonists Cardiac Effects <ul><li>Increase contractililty </li></ul><ul><li>Increase heart rate </li></ul><ul><li>Incr...
Beta Agonists Vascular & Other Effects <ul><li>Smooth muscle relaxation </li></ul><ul><li>Bronchodilatation </li></ul><ul>...
Beta-Agonist Drugs <ul><li>Epinephrine </li></ul><ul><li>Norepinephrine  (Levophed) </li></ul><ul><li>Dopamine </li></ul><...
Major Side Effects <ul><li>Arrhythmias </li></ul><ul><li>Increase myocardial demand for oxygen </li></ul><ul><li>Increase ...
B-type natriuretic peptide  <ul><li>New class </li></ul><ul><li>Nesiritide ( Natrecor) </li></ul><ul><li>Synthetic recombi...
Positive Inotropic Drugs: Nursing Implications <ul><li>Assess history, drug allergies, contraindications </li></ul><ul><li...
Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Assess clinical parameters (cont'd) </li></ul><ul><ul><li>...
Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Before giving any dose, count apical pulse for 1 full minu...
Positive Inotropic Drugs:   Nursing Implications (cont’d)   <ul><li>Hold dose and notify prescriber if patient experiences...
Positive Inotropic Drugs:  Nursing Implications (cont’d)   <ul><li>Check dosage forms carefully, and follow instructions f...
Positive Inotropic Drugs:  Nursing Implications (cont’d)   <ul><li>Inamrinone or Milrinone </li></ul><ul><ul><li>Use an in...
Positive Inotropic Drugs:  Nursing Implications (cont’d)  <ul><li>Monitor for therapeutic effects </li></ul><ul><ul><li>In...
Question <ul><li>When teaching the patient the signs and symptoms of cardiac glycoside toxicity, the nurse should alert th...
Question <ul><li>During assessment of a patient receiving Digoxin, which finding would indicate an increased possibility o...
Question <ul><li>When monitoring a patient who is receiving an IV infusion of Inocor, the nurse will look for which advers...
Question <ul><li>When administering the daily dose of digoxin 0.125mg PO to a patient with IDDM who is now in heart failur...
Case Scenario Heart Failure <ul><li>Mrs. Allen is a 76 year old female admitted with heart failure.  She has been started ...
Scenario con’t <ul><li>Weight gain of 2 lbs over past  5 days </li></ul><ul><li>Urine output =240 ml/8 hr shift </li></ul>
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Pharmacology positive-positive inotropicagentsfixed

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Pharmacology positive-positive inotropicagentsfixed

  1. 1. Positive Inotropic Agents Pharmacology in Nursing
  2. 2. Definition <ul><li>Drugs that increase the force of myocardial contraction </li></ul><ul><li>Used to treat heart muscle failure </li></ul><ul><li>Cardiac glycosides </li></ul><ul><ul><li>digoxin </li></ul></ul><ul><li>Phosphodiesterase inhibitors ( PDIs) </li></ul>
  3. 3. Heart Failure <ul><li>The heart is unable to pump blood in sufficient amounts from the ventricles to meet the body’s metabolic needs </li></ul><ul><li>Impairs heart’s ability to fill or eject properly </li></ul><ul><li>Symptoms depend on cardiac area affected </li></ul><ul><ul><li>Left ventricular failure </li></ul></ul><ul><ul><li>Right ventricular failure </li></ul></ul>
  4. 4. What happens when the heart fails? <ul><li>Weakened heart is unable to pump blood in sufficient amounts </li></ul><ul><li>Decrease in CO, decrease tissue perfusion </li></ul><ul><li>Compensatory mechanisms help to maintain CO and arterial blood pressure </li></ul><ul><li>Renin-angiotensin-aldosterone system activated as a compensatory mechanism </li></ul><ul><li>As cardiac output decreases, SNS releases catecholamines which increase HR, contractility & vasoconstriction </li></ul>
  5. 5. What happens when the heart fails? <ul><li>As renal perfusion decreases, renin is released by kidney </li></ul><ul><li>Vasoconstriction increases SVR, which increases afterload </li></ul><ul><li>End result, the failing heart must now work HARDER to pump blood </li></ul>
  6. 6. Heart Failure: Causes <ul><li>Cardiac defect </li></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Valve deficiency </li></ul></ul><ul><li>Defect outside the heart </li></ul><ul><ul><li>Coronary artery disease/Hypertension </li></ul></ul><ul><ul><li>Pulmonary hypertension </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><li>Supraventricular dysrhythmias </li></ul><ul><ul><li>Atrial fibrillation </li></ul></ul><ul><ul><li>Atrial flutter </li></ul></ul>
  7. 8. Treatment of Heart Failure <ul><li>Block the compensatory mechanisms </li></ul><ul><li>Treat underlying conditions </li></ul><ul><li>Goal is to decrease SVR, decrease volume, </li></ul><ul><li>Increase cardiac output </li></ul>
  8. 9. Cardiac Glycosides <ul><li>Originally obtained from Digitalis plant, foxglove </li></ul><ul><li>Digoxin is the prototype </li></ul><ul><li>Used in heart failure and to control ventricular response to atrial fibrillation or flutter </li></ul>
  9. 10. Cardiac Glycosides: Mechanism of Action <ul><li>Increase myocardial contractility </li></ul><ul><li>Change electrical conduction properties of the heart </li></ul><ul><ul><li>Decrease rate of electrical conduction </li></ul></ul><ul><ul><li>Prolong the refractory period </li></ul></ul><ul><ul><ul><li>Area between SA node and AV node </li></ul></ul></ul><ul><li>Result: reduced heart rate and improved cardiac </li></ul><ul><li>efficiency </li></ul>
  10. 11. Drug Effects: General Terms <ul><li>Inotropic </li></ul><ul><ul><li>Force or energy of muscular contractions </li></ul></ul><ul><li>Chronotropic </li></ul><ul><ul><li>Rate of the heartbeat </li></ul></ul><ul><li>Dromotropic </li></ul><ul><ul><li>The conduction of electrical impulses </li></ul></ul>
  11. 12. How Positive Inotropic Agents Work
  12. 13. Cardiac Glycosides: Drug Effects <ul><li>Positive inotropic effect </li></ul><ul><ul><li>Increase in force and velocity of myocardial contraction (without an increase in oxygen consumption) </li></ul></ul><ul><li>Negative chronotropic effect </li></ul><ul><ul><li>Reduced heart rate </li></ul></ul><ul><li>Negative dromotropic effect </li></ul><ul><ul><li>Decreases automaticity at SA node, decreases AV nodal conduction, and other effects </li></ul></ul>
  13. 14. Cardiac Glycosides: Drug Effects (cont’d) <ul><li>Increased stroke volume </li></ul><ul><li>Reduction in heart size during diastole </li></ul><ul><li>Decrease in venous BP and vein engorgement </li></ul><ul><li>Increase in coronary circulation </li></ul><ul><li>Promotion of diuresis due to improved blood circulation </li></ul><ul><li>Palliation of exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis </li></ul>
  14. 15. Cardiac Glycosides: Indications <ul><li>Heart failure </li></ul><ul><li>Supraventricular dysrhythmias </li></ul><ul><ul><li>Atrial fibrillation and atrial flutter </li></ul></ul>
  15. 16. Heart Failure
  16. 17. Atrial Fibrillation/Flutter
  17. 18. Cardiac Glycosides: Adverse Effects <ul><li>Digoxin (Lanoxin) </li></ul><ul><ul><li>Very narrow therapeutic window </li></ul></ul><ul><ul><li>Drug levels must be monitored </li></ul></ul><ul><ul><li>Low potassium levels increase its toxicity </li></ul></ul><ul><ul><li>Electrolyte levels must be monitored </li></ul></ul>
  18. 19. Digoxin: Adverse Effects <ul><li>Cardiovascular </li></ul><ul><ul><li>Dysrhythmias, including bradycardia or tachycardia </li></ul></ul><ul><li>CNS </li></ul><ul><ul><li>Headaches, fatigue, malaise, confusion, convulsions </li></ul></ul>
  19. 20. Digoxin: Adverse Effects (cont’d) <ul><li>Eye </li></ul><ul><ul><li>Colored vision (seeing green, yellow, purple), halo vision, flickering lights </li></ul></ul><ul><li>GI </li></ul><ul><ul><li>Anorexia, nausea, vomiting, diarrhea </li></ul></ul>
  20. 21. Digoxin Toxicity <ul><li>digoxin immune Fab (Digibind) therapy </li></ul><ul><ul><li>Hyperkalemia (serum potassium greater than 5 mEq/L) in a digitalis-toxic patient </li></ul></ul><ul><ul><li>Life-threatening cardiac dysrhythmias </li></ul></ul><ul><ul><li>Life-threatening digoxin overdose </li></ul></ul><ul><ul><li>Therapeutic drug level= 0.5 – 2 ng/ml </li></ul></ul>
  21. 22. Conditions That Are Predisposing to Digoxin Toxicity <ul><li>Hypokalemia </li></ul><ul><li>Use of cardiac pacemaker </li></ul><ul><li>Hepatic dysfunction </li></ul><ul><li>Hypercalcemia </li></ul><ul><li>Dysrhythmias </li></ul><ul><li>Hypothyroid, respiratory, or renal disease </li></ul><ul><li>Advanced age </li></ul>
  22. 23. Dosing Digoxin <ul><li>Adult Digitalizing Dose: </li></ul><ul><li>PO or IV : 1-1.5 mg/day (4 doses) </li></ul><ul><li>Usual maintenance dose 0.125 mg- 0.5 mg day </li></ul>
  23. 24. Phosphodiesterase Inhibitors <ul><li>Work by inhibiting the enzyme phosphodiesterase </li></ul><ul><li>Results in: </li></ul><ul><ul><li>Positive inotropic response </li></ul></ul><ul><ul><li>Vasodilation </li></ul></ul><ul><li>Two drugs (inodilators) </li></ul><ul><ul><li>Inamrinone (Inocor) and milrinone (Primacor) </li></ul></ul>
  24. 25. Phosphodiesterase Inhibitors: Indications <ul><li>Short-term management of heart failure </li></ul><ul><li>Given when patient has not responded to treatment with digoxin, diuretics, and/or vasodilators </li></ul><ul><li>Often given as weekly 6-hour infusions </li></ul><ul><ul><li>Improved quality of life </li></ul></ul><ul><ul><li>Decreased readmissions for heart failure episodes </li></ul></ul>
  25. 26. Phosphodiesterase Inhibitors: Adverse Effects <ul><li>Inamrinone (Inocor) </li></ul><ul><ul><li>Thrombocytopenia, most worrisome </li></ul></ul><ul><ul><li>Dysrhythmia, nausea, hypotension </li></ul></ul><ul><ul><li>Elevated liver enzymes with long-term use </li></ul></ul><ul><li>Milrinone (Primacor) </li></ul><ul><ul><li>Dysrhythmia, mainly ventricular </li></ul></ul><ul><ul><li>Hypotension, angina, hypokalemia, tremor, thrombocytopenia </li></ul></ul>
  26. 27. Cardiostimulatory Drugs <ul><li>Enhance cardiac function by: </li></ul><ul><li>Increasing heart rate </li></ul><ul><li>Increasing myocardial contractility </li></ul><ul><li>Positive Inotrop </li></ul>
  27. 28. Beta-adrenoceptor agonists <ul><li>Sympathomimetic drugs that bind to beta receptors located in cardiac nodal tissue, conducting tissue </li></ul><ul><li>Beta-1 & beta-2 adrenoceptor activation stimulates heart rate & contractility </li></ul><ul><li>Net effect: Increase in cardiac output </li></ul><ul><li>Used to treat heart failure, cardiogenic and circulatory shock </li></ul>
  28. 29. Beta-Agonists Cardiac Effects <ul><li>Increase contractililty </li></ul><ul><li>Increase heart rate </li></ul><ul><li>Increase conduction velocity </li></ul>
  29. 30. Beta Agonists Vascular & Other Effects <ul><li>Smooth muscle relaxation </li></ul><ul><li>Bronchodilatation </li></ul><ul><li>Hepatic glycogenolysis </li></ul><ul><li>Pancreatic release of glucagon </li></ul><ul><li>Renin release by kidney </li></ul>
  30. 31. Beta-Agonist Drugs <ul><li>Epinephrine </li></ul><ul><li>Norepinephrine (Levophed) </li></ul><ul><li>Dopamine </li></ul><ul><li>Dobutamine </li></ul><ul><li>Isoproterenol </li></ul>
  31. 32. Major Side Effects <ul><li>Arrhythmias </li></ul><ul><li>Increase myocardial demand for oxygen </li></ul><ul><li>Increase in heart rate </li></ul><ul><li>Can precipitate angina </li></ul>
  32. 33. B-type natriuretic peptide <ul><li>New class </li></ul><ul><li>Nesiritide ( Natrecor) </li></ul><ul><li>Synthetic recombinant version of B-type natriuretic peptide </li></ul><ul><li>Vasodilating effects on arteries and veins </li></ul><ul><li>Used in ICU setting as last alternative </li></ul>
  33. 34. Positive Inotropic Drugs: Nursing Implications <ul><li>Assess history, drug allergies, contraindications </li></ul><ul><li>Assess clinical parameters, including: </li></ul><ul><ul><li>BP </li></ul></ul><ul><ul><li>Apical pulse for 1 full minute </li></ul></ul><ul><ul><li>Heart sounds, breath sounds </li></ul></ul>
  34. 35. Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Assess clinical parameters (cont'd) </li></ul><ul><ul><li>Weight, I&O measures </li></ul></ul><ul><ul><li>EKG </li></ul></ul><ul><ul><li>Serum labs: potassium, sodium, magnesium, calcium, renal and liver function studies </li></ul></ul>
  35. 36. Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Before giving any dose, count apical pulse for 1 full minute </li></ul><ul><li>For apical pulse less than 60 or greater than 120 beats/minute </li></ul><ul><ul><li>Hold dose </li></ul></ul><ul><ul><li>Notify prescriber </li></ul></ul>
  36. 37. Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Hold dose and notify prescriber if patient experiences signs/symptoms of toxicity </li></ul><ul><ul><li>Anorexia, nausea, vomiting, diarrhea </li></ul></ul><ul><ul><li>Visual disturbances (blurred vision, seeing green or yellow halos around objects) </li></ul></ul>
  37. 38. Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Check dosage forms carefully, and follow instructions for giving </li></ul><ul><li>Avoid giving digoxin with high-fiber foods (fiber binds with digitalis) </li></ul><ul><li>Patients should report immediately a weight gain of 2 or more pounds in 1 day or 5 or more pounds in 1 week </li></ul>
  38. 39. Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Inamrinone or Milrinone </li></ul><ul><ul><li>Use an infusion pump </li></ul></ul><ul><ul><li>Monitor I&O, heart rate, BP, daily weights, respirations, etc. </li></ul></ul><ul><li>IV Inamrinone </li></ul><ul><ul><li>Do not mix with dextrose </li></ul></ul><ul><ul><li>Solution color is true yellow </li></ul></ul>
  39. 40. Positive Inotropic Drugs: Nursing Implications (cont’d) <ul><li>Monitor for therapeutic effects </li></ul><ul><ul><li>Increased urinary output </li></ul></ul><ul><ul><li>Decreased edema, shortness of breath, dyspnea, crackles, fatigue </li></ul></ul><ul><ul><li>Resolving of paroxysmal nocturnal dyspnea </li></ul></ul><ul><ul><li>Improved peripheral pulses, skin color, temperature </li></ul></ul><ul><li>Monitor for adverse effects </li></ul>
  40. 41. Question <ul><li>When teaching the patient the signs and symptoms of cardiac glycoside toxicity, the nurse should alert the patient to watch for; </li></ul><ul><ul><li>A. Visual changes such as photophobia </li></ul></ul><ul><ul><li>B. Flickering lights or halos around lights </li></ul></ul><ul><ul><li>C. dizziness when standing up </li></ul></ul><ul><ul><li>D. Increased urine output </li></ul></ul>
  41. 42. Question <ul><li>During assessment of a patient receiving Digoxin, which finding would indicate an increased possibility of toxicity? </li></ul><ul><ul><li>A. Apical rate of 62 </li></ul></ul><ul><ul><li>B. Digoxin level of 1.5 ng/ml </li></ul></ul><ul><ul><li>C. Serum potassium level of 2 mEq/L </li></ul></ul><ul><ul><li>D. Serum potassium level of 4.8 mEq/L </li></ul></ul>
  42. 43. Question <ul><li>When monitoring a patient who is receiving an IV infusion of Inocor, the nurse will look for which adverse effect? </li></ul><ul><ul><li>A. Thrombocytopenia </li></ul></ul><ul><ul><li>B. Proteinuria </li></ul></ul><ul><ul><li>C. Anemia </li></ul></ul><ul><ul><li>D. Decreased BUN/Creatinine levels </li></ul></ul>
  43. 44. Question <ul><li>When administering the daily dose of digoxin 0.125mg PO to a patient with IDDM who is now in heart failure, it is most important for the nurse to: </li></ul><ul><ul><li>A. Give medication with a class of orange juice. </li></ul></ul><ul><ul><li>B. Monitor the patient for dysrhythmias. </li></ul></ul><ul><ul><li>C. Administer it 1 hour before the morning dose of insulin. </li></ul></ul><ul><ul><li>D. Withhold dose if the apical heart rate is less then 80 beats per minute. </li></ul></ul>
  44. 45. Case Scenario Heart Failure <ul><li>Mrs. Allen is a 76 year old female admitted with heart failure. She has been started on Digoxin 0.125 mg po. Your initial assessment of this patient revealed the following: </li></ul><ul><li>AAOx1 </li></ul><ul><li>Vitals: P 110, RR 33, BP 110/56 SAO2 92% </li></ul><ul><li>+2 pedal edema </li></ul><ul><li>Bilateral basilar crackles, SOB on minimal exertion </li></ul>
  45. 46. Scenario con’t <ul><li>Weight gain of 2 lbs over past 5 days </li></ul><ul><li>Urine output =240 ml/8 hr shift </li></ul>

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