Myocardial infarction, commonly known as a heart attack, occurs when blood flow to the heart is blocked, injuring the heart muscle due to lack of oxygen. The main causes are blockages in the coronary arteries from plaque buildup. Symptoms can include chest pain, shortness of breath, nausea and more. Diagnosis involves electrocardiograms, blood tests for cardiac markers, and imaging tests. Treatment depends on whether the blockage is partial or complete, but may include medications, angioplasty, stents or bypass surgery to restore blood flow. Lifestyle changes and medications are then used to prevent future attacks.

1. Myocardial Infarction (MI)
Heart Attack
PRESENTED BY:
ANCHOS, MADELAINE G.
CAPISTRANO, CRYSTAL ROSE
DELOS REYES, MELISSA ASHLYN T.

2. Myocardial Infarction (MI)
▪ is the medical term for an event
commonly known as a heart attack
▪ It happens when blood stops flowing
properly to part of the heart and
the heart muscle is injured due to
not enough oxygen.
▪ Usually this is because one of
the coronary arteries that supplies
blood to the heart develops a
blockage due to an unstable buildup
of white blood cells, cholesterol and
fat.
▪ The event is called "acute" if it is
sudden and serious.

3. Myocardial Infarction (MI)
▪ A person having an acute myocardial
infarction usually has sudden chest pain
that is felt behind the breast bone and
sometimes travels to the left arm or the
left side of the neck.
▪ Additionally, the person may
have shortness of
breath, sweating, nausea, vomiting,
abnormal heartbeats, and anxiety.
▪ The anxiety is often described as a "sense
of impending doom."
▪ Women experience fewer of these
symptoms than men, but usually have
shortness of breath, weakness, a feeling
of indigestion, and fatigue.

4. Myocardial Infarction (MI)
▪ In many cases, in some estimates as high as 64 percent, the
person does not have chest pain or other symptoms.
▪ These are called “silent” myocardial infarctions. Important risk
factors are previous cardiovascular
disease, old age, tobacco
smoking, high blood levels of certain
lipids (low-density lipoprotein
cholesterol, triglycerides) and low
levels of high density lipoprotein
(HDL) cholesterol, diabetes, high
blood pressure, lack of physical
activity, obesity, chronic kidney
disease, excessive alcohol
consumption, the use of illicit drugs
(such as cocaine and
amphetamines), and chronic high
stress levels.

5. Myocardial Infarction (MI)
▪ The two main ways to determine if a person has had a myocardial
infarction are an electrocardiograms(ECGs) that trace the electrical signals
in the heart and testing the blood for substances associated with damage
to the heart muscle. Common blood tests are creatinekinase (CK-MB)
and troponin. ECG testing is used to differentiate between two types of
myocardial infarctions based on the shape of the tracing. When the ST
section of the tracing is higher than the baseline it is called an ST-
elevation myocardial infarction (STEMI) which usually requires more
aggressive treatment. Immediate treatments for a suspected myocardial
infarction include aspirin, which prevents further blood from clotting, and
sometimes nitroglycerin to treat chest pain and oxygen.
▪ STEMI is treated by restoring circulation to the heart, called reperfusion
therapy, and typical methods are angioplasty where the arteries are
pushed opened and thrombolysis where the blockage is removed using
medications.

6. Myocardial Infarction (MI)
▪ Non-ST elevation myocardial infarction (NSTEMI) may be
managed with medication, although angioplasty may be
required if the person is considered to be at high risk.
▪ People who have multiple blockages of their coronary
arteries, particularly if they also have diabetes, may also be
treated with bypass surgery (CABG).
▪ Ischemic heart disease, which includes myocardial
infarction, angina and heart failure when it happens after
myocardial infarction, was the leading cause of death for both
men and women worldwide in 2011.

7. LABORATORY WORKS :
Exercise Stress Test
▪ Determine the amount of stress that your heart can
manage:
▪ before developing either an abnormal rhythm
▪ or evidence of ischemia
A physician may recommend an exercise stress test for
various reasons:
▪ diagnose coronary artery disease
▪ diagnose a possible heart-related cause of symptoms
▪ To determine a safe level of exercise
▪ To check the effectiveness of procedures done
▪ To predict risk of dangerous heart-related conditions
such as a heart attack.
▪ effectiveness of medications to control angina and
ischemia.

8. Types of Stress Tests
▪ Dobutamine or Adenosine Stress Test:
▪ used in people who are unable to exercise.
▪ heart respond as if the person were exercising.
▪ no exercise is required.
▪ Stress echocardiogram:
▪ An echocardiogram (often called "echo") is a graphic outline of the
heart's movement.
▪ accurately visualize the motion of the heart's walls and pumping action
when the heart is stressed
▪ Nuclear stress test:
▪ determine which parts of the heart are healthy and function normally
and which are not.
▪ radioactive substance is injected into the patient.
▪ These pictures are done both at rest and after exercise.
▪ a less than normal amount of thallium will be seen in those areas of the
heart that have a decreased blood supply.

9. Holter monitoring
▪ continuous monitoring of
the electrical activity of a
patient's heart muscle
(electrocardiography) for
24 hours,
▪ special portable device
called a Holter monitor.

10. TROPONIN T AND I
▪ These isoforms are very
specific for cardiac injury
▪ Preferred markers for
detecting myocardial cell
injury
▪ Rise 2-6 hours after injury
Peak in 12-16 hours
Stay elevated for 5-14 days

11. Creatinine Kinase ( CK-MB)
▪ Creatinine Kinase is found in heart muscle (MB), skeletal muscle (MM), and brain
(BB)
▪ Increased in over 90% of myocardial infraction
▪ However, it can be increased in muscle trauma, physical exertion, post-op,
convulsions, and other conditions
▪ Time sequence after myocardial infarction
Begins to rise 4-6 hours
Peaks 24 hours
returns to normal in 2 days
▪ MB2 released from heart muscle and converted to MB1.
▪ A level of MB2 > or = 1 and a ratio of MB2/MB1 > 1.5 indicates myocardial injury

12. Myoglobin
▪ Damage to skeletal or cardiac muscle release myoglobin into
circulation
▪ Time sequence after infarction
Rises fast 2hours
Peaks at 6-8 hours
Returns to normal in 20-36 hours
▪ Have false positives with skeletal muscle injury and renal
failure

13. Renal Failure and Renal
Transplantation
▪ Diagnostic accuracy of serum markers of cardiac injury
are altered in patients with renal failure
▪ Cardiac troponins decreased diagnostic sensitivity and
specificity in patients receiving renal replacement
therapy
▪ Current data show levels of troponin I are unaltered while
levels of troponin T may be elevated

14. CBC
▪ CBC is indicated if anemia is suspected as
precipitant
▪ Leukocytosis may be observed within several hours
after myocardial injury and returns returns to levels
within the reference range within one week

15. Chemistry Profile
▪ Potassium and magnesium levels should be
monitored and corrected
▪ Creatinine levels must be considered before using
contrast dye for coronary angiography and
percutanous revascularization

16. C-reactive Protein (CRP)
▪ C- reactive protein is a marker of acute inflammation
▪ Patients without evidence of myocardial necrosis but with
elevated CRP are at increased risk of an event

17. Chest X-Ray
▪ Chest radiography may
provide clues to an alternative
diagnosis ( aortic dissection or
pneumothorax)
▪ Chest radiography also reveals
complications of myocardial
infarction such as heart failure
▪ Radiologic Findings
Chest X-Ray
▪ Normal
▪ Cardiomegaly
▪ Signs of CHF

18. Echocardiography
▪ Use 2-dimentional and M
mode echocardiography
when evaluating overall
ventricular function and
wall motion
abnormalities
▪ Echocardiography can
also identify
complications of MI ( eg.
Valvular or pericardial
effusion, VSD)

19. Electrocardiogram
▪ A normal ECG does not
exclude ACS
▪ High probability include ST
segment elevation in two
contiguous leads or presence
of q waves
▪ Intermediate probability ST
depression
▪ T wave inversions are less
specific

20. ANATOMY AND PHYSIOLOGY

21. PATHOPHYSIOLOGY

24. DRUG ANALYSIS
NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Propranolol
Hydrochloride
Through beta-
blocking action,
propranolol:
• prevents arterial
dilation and inhibits
renin secretion,
resulting in
decreased
blood pressure (in
hypertension and
pheochromocytoma)
and relief of
migraine headaches
• decreases heart
rate, which helps
resolve
Tachyarrhythmias
To manage
hypertension
E.R. TABLETS
Adults. Initial: 80 mg
daily, increased
gradually
up to 160 mg daily
Maximum: 640 mg
daily.
876 propranolol
hydrochloride
XL TABLETS
(INNOPRAN XL)
Adults. Initial: 80 mg
once daily at
bedtime,
increased, as
needed, to 120 mg
once
daily at bedtime.
CNS: Anxiety,
depression,
dizziness,
drowsiness,
fatigue, fever,
insomnia, lethargy,
nervousness,
weakness
CV: AV conduction
disorders, cold
limbs,
heart failure,
hypotension, sinus
bradycardia
EENT: Dry eyes,
laryngospasm, nasal
congestion,
pharyngitis
• Use propranolol
cautiously in
patients
with bronchospastic
lung disease
because
it may induce
asthmatic attack.
•Monitor blood
pressure, apical and
radial
pulses, fluid intake
and output, daily
weight, respiration,
and circulation in
extremities before
and during therapy.

25. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
• improves
myocardial
contractility, which
helps ease
symptoms of
hypertrophic
cardiomyopathy
• decreases
myocardial oxygen
demand,
which helps prevent
anginal pain and
death of myocardial
tissue. In addition,
peripheral beta-
adrenergic
blockade may play a
role in propranolol’s
ability to alleviate
tremor.
ORAL SOLUTION,
TABLETS
Adults. Initial: 40 mg
b.i.d., increased
gradually
to 120 to 240 mg
daily, as needed.
Maximum: 640 mg
daily.
Children. Initial: 0.5
to 1 mg/kg daily in
divided doses b.i.d.
to q.i.d., adjusted as
needed.
Maintenance: 2 to 4
mg/kg daily in
divided doses b.i.d.
To treat chronic
angina
E.R. TABLETS
Adults. Initial: 80 mg
daily, increased
every
GI: Abdominal pain,
constipation,
diarrhea,
nausea, vomiting
GU: Impotence,
peyronie’s disease,
sexual
dysfunction
HEME:
Agranulocytosis
MS: Muscle
weakness
RESP:
Bronchospasm,
dyspnea, respiratory
distress, wheezing
• Give I.V. injection
at no more than 1
mg/
minute.
WARNING Monitor
ECG continuously, as
ordered, when giving
I.V. injection. Have
emergency drugs
and equipment
available
in case of
hypotension or
cardiac arrest
• Protect injection
solution from light..
• Because drug’s
negative inotropic
effect
can depress cardiac
output, monitor
cardiac
output in patients

26. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
3 to 7 days, as
prescribed.
Maximum:
320 mg/day.
ORAL SOLUTION,
TABLETS
Adults. 80 to 320
mg daily in divided
doses
b.i.d., t.i.d., or q.i.d.
To treat
supraventricular
arrhythmias
and ventricular
tachycardia
ORAL SOLUTION,
TABLETS
Adults. 10 to 30 mg
t.i.d. or q.i.d.,
adjusted
as needed.
SKIN: Alopecia,
erythema
multiforme,
erythematous rash,
exfoliative
dermatitis,
psoriasiform rash,
Stevens-Johnson
syndrome,
toxic epidermal
necrolysis, urticaria
Other: Anaphylaxis,
flulike symptoms,
systemic
lupuslike reaction
with heart failure.,
particularly those
with severely
compromised
left ventricular
dysfunction.
• Be aware that
propranolol can
mask tachycardia
in hyperthyroidism
and that abrupt
withdrawal in
patients with
hyperthyroidism
or thyrotoxicosis can
cause thyroid
storm.

27. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
I.V. INJECTION
Adults. 1 to 3 mg at
a rate not to exceed
1 mg/min; repeated
after 2 min and
again
after 4 hr, if needed
Children. 0.01 to 0.1
mg/kg at a rate not
to
exceed 1 mg/min;
repeated every 6 to
8 hr,
as needed.
Maximum: 1
mg/dose.
To control tremor
ORAL SOLUTION,
TABLETS
Adults. Initial: 40 mg
b.i.d., adjusted as
needed and
prescribed.
Maximum: 320 mg
daily.
•Monitor diabetic
patient taking an
antidiabetic
because propranolol
can prolong
hypoglycemia or
promote
hyperglycemia.
It also can mask
signs of
hypoglycemia,
especially
tachycardia,
palpitations, and
tremor, but it
doesn’t suppress
diaphoresis
or hypertensive
response to
hypoglycemia.

28. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
To prevent
vascular migraine
headaches
E.R. TABLETS
Adults. Initial: 80 mg
daily, increased
gradually,
as needed.
Maximum: 240 mg
daily.
ORAL SOLUTION,
TABLETS
Adults. Initial: 20 mg
q.i.d., increased
gradually,
as needed.
Maximum: 240 mg
daily.
As adjunct to
treat hypertrophic
cardiomyopathy
ORAL SOLUTION,
TABLETS
Adults. 20 to 40 mg
t.i.d. or q.i.d.,
WARNING Be aware
that stopping drug
abruptly may cause
myocardial
ischemia,
MI, ventricular
arrhythmias, or
severe
hypertension,
especially in
patients with
cardiac disease. It
also m increased
intraocular pressure
to return. Dosage
should be reduced
gradually.
ay cause

29. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
adjusted
as needed.
As adjunct to
manage
pheochromocytoma
ORAL SOLUTION,
TABLETS
Adults. For operable
tumors, 20 mg t.i.d.
to
40 mg t.i.d. or q.i.d.
for 3 days before
surgery,
concurrently with an
alpha blocker.
For inoperable
tumors, 30 to 160
mg daily
in divided doses.
To prevent MI
ORAL SOLUTION,
TABLETS
Adults. 180 to 240
mg daily in divided
doses.

30. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Metoprolol Inhibits stimulation
of beta1-receptor
sites,
located mainly in
the heart, resulting
in
decreased cardiac
excitability, cardiac
output,
and myocardial
oxygen demand.
DOSAGE
ADJUSTMENT
Dosage increased or
decreased for
elderly patients,
depending on
sensitivity to
propranolol.
Route: P.O.
Onset: Unknown
Peak: 1–1.5hr*
Duration: Unknown
To manage
hypertension, alone
or with
other
antihypertensives
E.R. TABLETS
(METOPROLOL
SUCCINATE)
Adults. Initial: 25 to
100 mg daily,
adjusted weekly as
prescribed.
CNS: Anxiety,
confusion,
depression,
dizziness,
drowsiness, fatigue,
hallucinations,
headache,
insomnia, weakness
CV: Angina,
arrhythmias
(including AV
block and
• Use metoprolol
with extreme
caution in
patients with
bronchospastic
disease who
don’t respond to or
can’t tolerate other
antihypertensives.
Expect to give
smaller

31. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
These
effects help relieve
angina.Metoprolol
also
helps reduce blood
pressure by
decreasing
renal release of
renin.
Maximum: 400 mg
daily.
E.R. TABLETS
(METOPROLOL
TARTRATE)
Adults.Maintenance:
100 to 400 mg daily
to maintain blood
pressure control
after
therapeutic level has
been achieved with
immediate-release
tablets.
TABLETS
(METOPROLOL
TARTRATE)
Adults. Initial: 100
mg daily, adjusted
weekly
as prescribed.
Maximum: 450 mg
daily as
a single dose or in
divided doses.
bradycardia), chest
pain,
decreased HDL level
increased
triglyceride
levels, gangrene of
extremity, heart
failure,
hypertension,
orthostatic
hypotension
EENT: Nasal
congestion, rhinitis,
taste disturbance
GI: Constipation,
diarrhea, hepatitis,
nausea,
Vomiting
GU: Impotence
HEME: Leukopenia,
thrombocytopenia
doses more often to
avoid the higher
plasma
levels in longer
dosage intervals.
• Use cautiously in
patients with
hypertension
or angina who have
congestive heart
failure because beta
blockers such as
metoprolol can
further depress
myocardial
contractility,
worsening heart
failure.

32. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
To treat acute MI
or evolving acute MI
TABLETS
(METOPROLOL
TARTRATE), I.V.
INJECTION
(METOPROLOL
TARTRATE)
Adults. Initial: 5 mg
by I.V. bolus every
2 min for 3 doses
followed by 50 mg
P.O. for patients who
tolerate total I.V.
dose
(25 to 50 mg P.O. for
patients who can’t
tolerate
total I.V. dose) every
6 hr for 48 hr,
starting 15 min
after final I.V. dose;
after
48 hr, 100 mg b.i.d.
followed by
maintenance
Dosage.
MS: Arthralgia, back
pain, myalgia
RESP:
Bronchospasm,
dyspnea
SKIN: Diaphoresis,
photosensitivity,
rash, urticaria,
worsening of
psoriasis
• For patient with
acute MI who can’t
tolerate
initial dosage or who
delays treatment,
start with
maintenance
dosage, as
prescribed
and tolerated.
• Before starting
therapy for heart
failure,
expect to give a
diuretic, an ACE
inhibitor,
and digoxin to
stabilize patient
.
• If patient has
pheochromocytoma,
alpha
blocker therapy
should start first,
followed by
metoprolol to

33. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Maintenance: 100
mg P.O.
b.i.d. for at least 3
mo.
To treat angina
pectoris and chronic
stable angina
E.R. TABLETS
(METOPROLOL
SUCCINATE)
Adults. 100 mg
daily, increased
weekly as
prescribed.
Maximum: 400 mg
daily as a
single dose or in
divided doses.
E.R. TABLETS
(METOPROLOL
TARTRATE)
Adults. Initial: 100
mg daily, adjusted
weekly as
prescribed.Maximu
m: 450 mg daily.
prevent paradoxical
Increase
vasodilation in
skeletal muscle.
• Be aware that
metoprolol dosage
for heart failure is
highly
individualized.Monit
or patient for
evidence of
worsening heart
failure during
dosage increases. If
heart failure
worsens, expect to
increase diuretic
dosage and possibly
decrease metoprolol
dosage or
temporarily
discontinue drug, as
prescribed.
Metoprolol dosage
shouldn’t be
increased until

34. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
TABLETS
(METOPROLOL
TARTRATE)
Adults. Initial: 50 mg
b.i.d., adjusted
weekly
as prescribed.
Maximum: 450 mg
daily.
To treat stable,
symptomatic (New
York Heart
Association [NYHA]
Class II or III),
ischemic,
hypertensive, or
cardiomyopathic
heart failure
E.R. TABLETS
(METOPROLOL
SUCCINATE)
Adults. Initial: 25 mg
daily (NYHA Class
II) or 12.5 mg daily
(NYHA Class III or
more severe heart
failure)
worsening heart
failure has been
stabilized.
• If patient with
heart failure
develops
symptomatic
bradycardia, expect
to decrease the
metoprolol dosage.
WARNING If dosage
exceeds 400 mg
daily, monitor
patient for
bronchospasm and
dyspnea because
metoprolol
competitively
blocks beta2-
adrenergic receptors
in bronchial and
vascular smooth
muscles.
WARNING When
substituting
metoprolol for

35. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
for 2 wk. Then
dosage doubled
every 2 wk as
tolerated.
Maximum: 200 mg
daily.
Route : P.O.
P.O.(E.R.)
I.V.
Onset : 60 min
Unknown
Unknown
Peak : 1–2 hr
6–12 hr
20 min
Duration: Unknown
Unknown
Unknown
clonidine, expect to
gradually reduce
clonidine and
increase metoprolol
Dosage over several
days. Given together,
these drugs have
additive hypotensive
effects.
• Patients who take
metoprolol may be
at risk for AV block.
If AV block results
from depressed AV
node conduction,
prepare to give
appropriate drug, as
ordered, or assist
with insertion of
temporary
pacemaker.
• Check for signs of
poor glucose control
in patient with
diabetes mellitus.

36. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Metoprolol may
interfere with
therapeutic effects
of insulin and oral
antidiabetic drugs.
It also may mask
evidence of
hypoglycemia, such
as palpitations,
tachycardia, and
tremor.
•Monitor patient
with peripheral
vascular
disease for evidence
of arterial
insufficiency
(pain, pallor, and
coldness in affected
extremity)
Metoprolol can
precipitate or
aggravate peripheral
vascular disease.

37. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Nitroglycerin
(glyceryl trinitrate)
May interact with
nitrate receptors in
vascular
smooth-muscle cell
To prevent or
treat angina
E.R. BUCCAL
TABLETS
CNS: Agitation,
anxiety, dizziness,
headache,
insomnia,
WARNING Expect to
taper dosage over 1
to 2 weeks when
drug is discontinued;
stopping
abruptly can cause
myocardial
ischemia,
MI, ventricular
arrhythmias, or
severe hypertension,
especially in
patients
with cardiac
disease. Abrupt
withdrawal
also may cause
thyroid storm in a
patient
with
hyperthyroidism or
thyrotoxicosis.
• Use nitroglycerin
cautiously in elderly
patients, especially
those who are

38. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
membranes. This
interaction reduces
nitroglycerin to nitric
oxide, which
activates the
enzyme guanylate
cyclase, increasing
intracellular
formation of cGMP.
Increased cGMP
level may relax
vascular smooth
muscle by forcing
calcium
out of muscle cells,
causing
vasodilation. Venous
dilation decreases
venous return to
the heart, reducing
left ventricular
enddiastolic
pressure and
pulmonary artery
wedge pressure.
Adults. 1 mg every 5
hr while awake.
E.R. CAPSULES
Adults. 2.5, 6.5, or 9
mg every 12 hr.
Frequency of doses
increased to every 8
hr
based on patient’s
response.
E.R. TABLETS
Adults. 2.6 or 6.5
mg every 12 hr.
Frequency of doses
increased to every 8
hr based on pat
S.L. TABLETS
Adults. 0.3 to 0.6
mg, repeated every
5 min.
Maximum: 3 tabs in
15 min or 10 mg
daily.
ient’s response.
restlessness,
syncope,
Weakness
CV: Arrhythmias
(including
tachycardia),
edema, hypotension,
orthostatic
hypotension,
Palpitations
EENT: Blurred vision,
burning or tingling
in mouth (buccal,
S.L. forms), dry
mouth
GI: Abdominal pain,
diarrhea,
indigestion,
nausea, vomiting
GU: Dysuria,
impotence, urinary
frequency
volume depleted or
taking several
medications,
because of the
increased risk of
hypotension and
falls. Hypotension
may be
accompanied by
angina and
paradoxical
slowing of the heart
rate. Notify
prescriber if these
occur, and provide
appropriate
treatment, as
ordered.
• Plan a
nitroglycerin-free
period of about
10 hours each day,
as prescribed, to
maintain
therapeutic effects
and avoid tolerance.

39. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Arterial dilation
decreases
systemic vascular
resistance, systolic
arterial
pressure, and mean
arterial pressure.
Thus,
nitroglycerin reduces
preload and
afterload,
Decreasing
myocardial workload
and oxygen
demand. It also
dilates coronary
arteries,
increasing blood
flow to ischemic
myocardial tissue.
TRANSDERMAL
OINTMENT
Adults. 1" to 2" (15
to 30 mg) every 8 hr.
Frequency of doses
increased to every 6
hr
if angina occurs
between
doses.Maximum:
5" (75
mg)/application.
TRANSDERMAL
PATCH
Adults. 0.1 to 0.8
mg/hr, worn 12 to
14 hr.
TRANSLINGUAL
SPRAY Adults. For
treatment, 1 or 2
metered doses
(0.4 or 0.8 mg) onto
or under tongue,
repeated every 5
min as needed. For
prevention,
HEME:
Methemoglobinemia
MS: Arthralgia
RESP: Bronchitis,
pneumonia
SKIN: Contact
dermatitis
(transdermal
forms), flushing of
face and neck, rash
• Place E.R. buccal
tablets in buccal
pouch
with patient in
sitting or lying
position.
• Don’t break or
crush E.R. tablets or
capsules. Have
patient swallow
them whole
with a full glass of
water.
• Place S.L. tablet
under patient’s
tongue
and make sure it
dissolves
completely.
• Be sure to remove
cotton from S.L.
tablet container to
allow quick access
to drug.

40. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Route: P.O. *
P.O.†
I.V.
S.L.
Trans-
dermal‡
Trans-
dermal§
Trans-
lingual
Onset: 3 min
20–45 min
1–2 min
1–3 min
In 30 min
In 30 min
2 to 4 min
Peak: Unknown
Duration:5 hr
8–12 hr
3–5 min
30–60 min
4–8 hr
8–24 hr
30–60 min
1 or 2 metered
doses (0.4 or
0.8 mg) onto or
under tongue 5 to
10 minutes
before activities that
could lead to acute
attack.
To prevent or
treat angina, to
manage
hypertension or
heart failure
I.V. INFUSION
Adults. 5 mcg/min,
increased by 5
mcg/min
every 3 to 5 min to
20 mcg/min, as
prescribed,
and then by 10 to
20 mcg/min
every 3 to 5 min
until desired effect
occurs.
•When applying
transdermal
ointment,
apply correct
amount on dose-
measuring paper.
Then place paper on
hairless area of body
and spread in a thin,
even layer over an
area at least 2
inches by 3 inches.
Don’t place on cuts
or irritated areas.
Wash your hands
after application.
Rotate sites. Store
at room
temperature.

41. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Heparin calcium
Heparin sodium
Binds with
antithrombin III,
enhancing
antithrombin III’s
inactivation of the
coagulation
enzymes thrombin
(factor IIa) and
factors Xa and XIa.
At low doses,
heparin inhibits
factor Xa and
prevents conversion
of prothrombin to
thrombin. Thrombin
is needed for
conversion of
fibrinogen to fibrin;
without fibrin, clots
can’t form. At high
doses, heparin
inactivates
thrombin, preventing
fibrin formation and
existing clot
extension.
To prevent and
treat deep vein
thrombosis and
pulmonary
embolism, to treat
peripheral arterial
embolism, and to
Prevent
thromboembolism
before and after
cardioversion of
chronic atrial
fibrillation
I.V. INFUSION OR
INJECTION
Adults. Loading: 35
to 70 units/kg or
5,000 units by
injection. Then
20,000 to
40,000 units
infused over 24 hr.
Children. Loading:
50 units/kg by
injection.
CNS: Chills,
dizziness, fever,
headache,
peripheral
neuropathy
CV: Chest pain,
thrombosis
EENT: Epistaxis,
gingival bleeding,
rhinitis
GI: Abdominal
distention and pain,
hematemesis,
melena, nausea,
vomiting
GU: Hematuria,
hypermenorrhea
HEME: Easy bruising,
excessive bleeding
from wounds,
thrombocytopenia
• Use heparin
cautiously in
alcoholics;
menstruating
women; patients
over age 60,
especially women;
and patients with
Mild hepatic or renal
disease or a history
of allergies, asthma,
or GI ulcer.
WARNING Be aware
that the new
standard
for manufacturing
heparin in the U.S.
has decreased its
I.V. potency by about
10%. When using
this route,
determine if the
heparin has been
manufactured under
the new standard by

42. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Then 100 units/kg
infused every 4 hr or
20,000 units/m2
infused over 24 hr.
I.V. INJECTION
Adults. Initial:
10,000 units.
Maintenance:
5,000 to 10,000
units every 4 to 6 hr.
Children. Initial: 50
units/kg.
Maintenance:
100 units/kg/dose
every 4 hr.
I.V. OR
SUBCUTANEOUS
INJECTION
Adults. Loading:
5,000 units I.V. Then
10,000 to 20,000
units
subcutaneously.
Maintenance: 8,000
to 10,000 units
subcutaneously
every 8 hr or 15,000
MS: Back pain,
myalgia,
osteoporosis
RESP: Dyspnea,
wheezing
SKIN: Alopecia,
cyanosis, petechiae,
pruritus,
Urticaria
Other: Anaphylaxis;
injection site
hematoma,
irritation, pain,
redness, and
ulceration
looking for the letter
“N” in the lot
number or after the
expiration date (or, if
made by Hospira,
the number “82” or
higher at the start of
the lot number). If
giving such heparin,
be aware that
more drug may be
required than in the
past to achieve
desired level of
anticoagulation
in some patients.
The change in
potency also may
require more
frequent or
intensive APTT or
ACT monitoring.
Change in potency
doesn’t appear
problematic
using subcutaneous
route.

43. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
to 20,000 units
subcutaneously
every 12 hr.
To diagnose and
treat disseminated
intravascular
coagulation (DIC)
I.V. INFUSION OR
INJECTION
Adults. 50 to 100
units/kg every 4 hr.
Drug
may be discontinued
if no improvement
occurs in 4 to 8 hr.
Children. 25 to 50
units/kg every 4 hr.
Drug may be
discontinued if no
improvement
occurs in 4 to 8 hr.
To prevent
postoperative
thromboembolism
WARNING Give
heparin only by
subcutaneous
or I.V. route; I.M. use
causes
hematoma,
irritation, and pain
• Avoid injecting any
drugs by I.M. route
during heparin
therapy, to decrease
risk of bleeding and
hematoma.
WARNING Don’t use
heparin sodium
injection
as a catheter-lock
flush because fatal
errors have occurred
in children when
1-ml heparin sodium
injection vials were
confused with 1-ml
catheter-lock flush
vials. Always

44. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
SUBCUTANEOUS
INJECTION
Adults. 5,000 units
2 hr before surgery
and
then 5,000 units
every 8 to 12 hr for
7 days
or until patient is
fully ambulatory.
To prevent clots
in patients
undergoing
open-heart and
vascular surgery
I.V. INFUSION OR
INJECTION
Adults. 300 units/kg
for procedures that
last less than 60
min; 400 units/kg
for procedures
that last longer than
60 min. Minimum:
150 units/kg.
examine vial labels
closely to ensure
correct product is
being used.
• Administer
subcutaneous
heparin into anterior
abdominal wall,
above the iliac
crest, and 5 cm (20)
or more away from
the umbilicus. To
minimize
subcutaneous
tissue trauma, lift
adipose tissue away
from deep tissues;
don’t aspirate for
blood before
injecting drug; don’t
move needle while
injecting drug; and
don’t massage
injection site before
or after injection.

45. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Children. 300
units/kg for
procedures that
last less than 60
min. Then dosage
based
on coagulation test
results. Minimum:
150 units/kg.
To maintain
heparin lock
patency
I.V. INJECTION
Adults. 10 to 100
units/ml heparin
flush solution
(enough to fill
device) after each
use of device.
DOSAGE
ADJUSTMENT
Increased dosage
may be needed if
patient needs
aggressive
anticoagulation
You can apply gentle
pressure to the site
after withdrawing
needle.
• Alternate injection
sites, and watch for
signs of bleeding
and hematoma.
• To prepare
heparin for
continuous infusion,
invert container at
least six times to
prevent drug from
pooling. Anticipate
slight discoloration
of prepared solution;
this doesn’t indicate
a change in potency.
• During continuous
I.V. therapy, expect
to obtain APTT after
8 hours of therapy.
Use the arm

46. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
to treat or prevent
life-threatening
thromboses, if
heparin will be given
I.V., and if heparin
has been
manufactured
under the new
standard
implemented in
October, 2009. (The
letter “N” appears in
the lot number or
after the expiration
date on heparin
products made
under the new
standard. An
exception is Hospira,
which identifies its
new-standard
products using a
lot number starting
with “82” or higher.)
Route: I.V.
SubQ
opposite the
infusion site.
• For intermittent
I.V. therapy, expect
to adjust dose based
on coagulation test
results performed
30 minutes earlier
Therapeutic range is
typically 1.5 to 2.5
times the control.
• Bleeding is major
adverse effect of
heparin therapy.
Take safety
precautions to
prevent bleeding,
such as having
patient use a
softbristled
toothbrush and an
electric razor.
Bleeding may occur
at any site and also
may indicate an

47. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Aspirin
(acetylsalicylic acid,
ASA)
Blocks the activity of
cyclooxygenase, the
enzyme needed for
prostaglandin
synthesis.
Prostaglandins,
important mediators
in the
inflammatory
response, cause
local vasodilation
with swelling and
pain.With blocking
of cyclooxygenase
and inhibition of
Onset: Immediate
20–60 min
Peak: Minutes
Unknown
Duration: Unknown
Unknown
To relieve mild
pain or fever
CHEWABLE
TABLETS, CHEWING
GUM,
CONTROLLEDRELEA
SE
TABLETS, ENTERIC-
COATED TABLETS,
SOLUTION, TABLETS,
TIMED-RELEASE
TABLETS,
SUPPOSITORIES
Adults and
adolescents. 325 to
CNS: Confusion, CNS
depression
EENT: Hearing loss,
tinnitus
GI: Diarrhea, GI
bleeding, heartburn,
hepatotoxicity,
nausea, stomach
pain, vomiting
HEME: Decreased
blood iron level,
leukopenia,
underlying problem,
such as GI or urinary
tract bleeding. Other
sites of bleeding
that could be fatal
and require
immediate attention
includes adrenal,
ovarian, and
retroperitoneal
hemorrhage.
• Don’t crush timed-
release or controlled
release Aspirin
tablets unless
directed.
• Ask about
tinnitus. This
reaction usually
occurs when blood
aspirin level reaches
or exceeds
maximum for
therapeutic effect.

48. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
prostaglandins,
inflammatory
symptoms
subside. Pain is also
relieved because
prostaglandins play
a role in pain
transmission
from the periphery
to the spinal cord.
Aspirin inhibits
platelet aggregation
by interfering with
production of
thromboxane
A2, a substance that
stimulates platelet
aggregation. Aspirin
acts on the
heatregulating
center in the
hypothalamus and
causes peripheral
vasodilation,
diaphoresis, and
heat loss.
650 mg
every 4 hr, p.r.n., or
500 mg every 3 hr,
p.r.n., or 1,000 mg
every 6 hr, p.r.n.
Children ages 2 to
14. 10 to 15
mg/kg/dose
every 4 hr, p.r.n., up
to 80 mg/kg daily.
To relieve mild to
moderate pain from
inflammation, as in
rheumatoid arthritis
and osteoarthritis
CHEWABLE
TABLETS, CHEWING
GUM,
CONTROLLEDRELEA
SE
TABLETS, ENTERIC-
COATED TABLETS,
SOLUTION, TABLETS,
TIMED-RELEASE
TABLETS,
SUPPOSITORIES
prolonged bleeding
time, shortened
life span of RBCs,
thrombocytopenia
SKIN: Ecchymosis,
rash, urticaria
Other: Angioedema,
Reye’s syndrome,
salicylism
(dizziness, tinnitus,
difficulty hearing,
vomiting, diarrhea,
confusion, CNS
depression,
diaphoresis,
headache,
hyperventilation,
and lassitude) with
regular use
of large doses

49. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
Adults and
adolescents. 3.2 to
6 g daily in divided
doses. Maximum: 6
g daily.
Children. 10 to 15
mg/kg daily, up to
80 mg/
kg daily, in divided
doses every 4 to 6
hr.
To treat juvenile
rheumatoid arthritis
CHEWABLE
TABLETS, CHEWING
GUM,
CONTROLLEDRELEA
SE TABLETS,
ENTERIC-COATED
TABLETS, SOLUTION,
TABLETS, TIMED-
RELEASE TABLETS,
SUPPOSITORIES
Children. 60 to 110
mg/kg daily in
divided doses every
6 to 8 hr.

50. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
To treat acute
rheumatic fever
CHEWABLE
TABLETS, CHEWING
GUM,
CONTROLLEDRELEA
SE
TABLETS, ENTERIC-
COATED TABLETS,
SOLUTION, TABLETS,
TIMED-RELEASE
TABLETS,
SUPPOSITORIES
Adults and
adolescents. 5 to 8 g
daily in divided
doses.
Children. Initial: 100
mg/kg daily in
divided
doses for first 2 wk.
Maintenance: 75
mg/ kg/day in
divided doses for
next 4 to 6 wk.
To reduce the risk

51. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
of recurrent
transient ischemic
attacks or stroke in
men CHEWABLE
TABLETS, CHEWING
GUM,
CONTROLLEDRELEA
SE TABLETS,
ENTERIC-COATED
TABLETS, SOLUTION,
TABLETS, TIMED-
RELEASE TABLETS,
SUPPOSITORIES
Adults. 650 mg b.i.d.
or 325 mg q.i.d.
To reduce the
severity of or
prevent acute MI
CHEWABLE
TABLETS, CHEWING
GUM,
CONTROLLEDRELEA
SE TABLETS,
ENTERIC-COATED
TABLETS, SOLUTION,
TABLETS, TIMED-

52. NAME OF DRUG ACTION INDICATOR ADVERSE
REACTION
NURSING
RESPONSIBILITY
-RELEASE TABLETS,
SUPPOSITORIES
Adults. Initial: 160 to
162.5 mg (half of a
325-mg tablet or
two 80- or 81-mg
tablets) as soon as
MI is suspected.
Maintenance:
160 to 162.5 mg
daily for 30 days.
To reduce risk of
MI in patients with
previous MI or
unstable angina
CHEWABLE
TABLETS, CHEWING
GUM,
CONTROLLEDRELEA
SE TABLETS,
ENTERIC-COATED
TABLETS, SOLUTION,
TABLETS, TIMED-
RELEASE TABLETS,
SUPPOSITORIES
Adults. 325 mg
daily.

53. NURSING CARE PLAN (Actual)

54. NURSING CARE PLAN (Potential)

55. DISCHARGE PLAN
▪ M