Pharmacology Exam 2

Chp 26 Hemostasis - The stopping of a flow of blood - Coagulation is hemostasis that occurs because of the physiologic clotÝng of blood - Thrombus: Blood clot (stationary) - Embolus: thrombus that moves through blood vessels. Coagulation System - The Liver is responsible for the clotÝng cascade. o The liver activates prothrombin, then it turns into a thrombin, which then turn into fibrinogen and then becomes fibrin which forms a mesh that attracts the platelets and stop the bleeding. Fibrinolytic System - Initiates the breakdown of clots and serves to balance the clotÝng process - Fibrinolysis o mechanism by which formed thrombi are lysed (destroyed) to prevent excessive clot formation and blood vessel blockage Hemophilia - Rare genetic disorder - Lacks certain clotÝng factors. - Patients with hemophilia can bleed to death if coagulation factors are not given. Coagulation Modifier Drugs - Anticoagulants o Prevents clot formation o It does not dissolve clots and it doesn’t have any action on platelets - Antiplatelet drugs o Inhibit platelet aggregation (clumping together of platelets) o Prevent platelet plug  Ex: Aspirin - Thrombolytic drugs o Lyse (break down) existing clots Anticoagulants - Also known as antithrombotic - Can be used prophylactically to prevent clots - Does not help with a blood clot that is already formed - Prevent intravascular thrombosis by decreasing blood coagulability - Used prophylactically to prevent o Clot formation (thrombus) o An embolus (dislodged clot) Embolus - Thromboembolic events o Myocardial infarction (MI): embolus lodges in a coronary artery o Stroke: embolus obstructs a brain vessel o Pulmonary emboli: embolus in the pulmonary circulation o Deep vein thrombosis (DVT): embolus goes to a vein in the leg Anticoagulants Drugs (KNOW THIS) - Heparins-part 1 o Given prophylactically to prevent clots - Low-molecular- weight heparins (LMWH) o Enoxaparin (Lovenox)  A subcutaneous heparin given prophylactically to prevent clots.  This Is only given Sub q  No lab valued to be monitored. o Dalteparin (Fragmin) - Heparins- part 2 o Un-fractioned heparin (given IV only)  This is NOT prophylactic, this is for someone who has a thromboembolic event.  Patient usually get this on IV drip or a bolus o Must monitor PTT lab value when someone is on IV heparin. Warfarin (Coumadin) - Comes PO only - Mechanical heart valve - Most commonly prescribed oral anticoagulant - Careful monitoring of the prothrombin time/international normalized ratio (PT/INR) - A normal INR (without warfarin) is 1.0, but a therapeutic INR (with warfarin) ranges from 2 to 3.0, (3.0-3.5 mechanical valve) depending on the indication for use of the drug (e.g., atrial fibrillation, thromboprevention, prosthetic heart valve). - Many drug interactions - Dietary considerations: Green leafy vegetables (Don’t eat too much) Nursing Implications Warfarin (Coumadin) - May be started while the patient is still on heparin until PT/INR levels indicate adequate anticoagulation - Full therapeutic effect takes several days. - Monitor PT/INR regularly; keep follow-up appointments. - Antidote is vitamin K. Treatment: Toxic Effects of Warfarin (KNOW THIS) - - Discontinue the warfarin. May take 36 to 42 hours before the liver can resynthesize enough clotÝng factors to reverse the warfarin effects Vitamin K1 (phytonadione)-antidote to warfarin- can hasten the return to normal coagulation. High doses of vitamin K (10 mg) given IV will reverse the anticoagulation within 6 hours. Many herbal products have potential interactions; increased bleeding may occur o Capsicum pepper o Garlic o Ginger o Ginkgo o St. John’s wort o Feverfew Enoxaparin (Lovenox) - Prototypical LMWH - Greater afÏnity for factor Xa than for factor Iia - Higher degree of bioavailability and longer elimination half-life - Lab monitoring is not necessary. - Injectable form - Used for prophylaxis and treatment - Pre-filled syringes - Do not expel air bubble Nursing Implications for LWMH - Given subcutaneously in the abdomen - Rotate injection sites. - Protamine sulfate can be given as an antidote in case of excessive anticoagulation, but rarely Heparin - Natural anticoagulant obtained from the lungs or intestinal mucosa of pigs - 10 to 40,000 units/mL - DVT prophylaxis: 5000 units subcutaneously two or three times a day; does not need to be monitored when used for prophylaxis - When heparin is used therapeutically (for treatment), continuous IV infusion. o Measurement of aPTT (usually every 4-8 hours until therapeutic effects are seen) is necessary Nursing Implications for Heparin - IV doses are usually double checked with another nurse. - IV doses may be given by bolus or IV infusions. Anticoagulant effects are seen immediately. Laboratory values are done daily to monitor coagulation effects (aPTT). Protamine sulfate can be given as an antidote in case of excessive anticoagulation. Treatment: Toxic Effects of Heparin (Know This) - Symptoms: hematuria, melena (blood in the stool), petechiae, ecchymoses, and gum or mucous membrane bleeding - Stop drug immediately. - Intravenous (IV) protamine sulfate-The antidote to IV Heparin: 1 mg of protamine can reverse the effects of 100 units of heparin. Anticoagulants Indications - Used to prevent clot formation in certain setÝngs in which clot is more likely to form o MI o Unstable angina o Atrial fibrillation  Blood get stagnant in the atria and can become clots o Indwelling devices, such as mechanical heart valves o Major orthopedic surgery Anticoagulants Contraindications - Any acute bleeding process or high risk such an occurrence - Warfarin is contraindicated in pregnancy - LMWHs are contraindicated in patients with an indwelling epidural catheter risk of epidural hematoma. Anticoagulants: Adverse Effects - Bleeding o Risk increases with increased dosages. o May be localized or systemic - May also cause: o Heparin-induced thrombocytopenia (HIT)-like DIC o Nausea, vomiting, abdominal cramps, thrombocytopenia, others Anticoagulant: Heparin Anticoagulant: Warfarin LMWH: Enoxaparin - PO only - No lab monitoring required Indications - Given SQ prophylactically - Prevent clots in Angina, MI, CVA (ischemic), DVT, Mechanical valves Unfractionated Heparin (IV) - As a bolus than infusion via pump for Nursing Implications therapeutic use (when patient already - Monitor PT/INR has a clot). - Normal: 0.9-1.0 secs - Normal PTT is 30-40 seconds, when - Therapeutic 2-3 sec for all conditions on heparin drip we want PTT to be except MVR (3.0-3.5) 1.5-2 times the normal. - Antagonistic drug: Vitamin K 10mg - Nursing Implications - Monitor for bleeding - Not for use in pregnancy - Monitor PTT 4-8 hours while on drip. - Antagonistic drug: Protamine Sulfate - Side effects: Bleeding Antiplatelet Drugs - Works on platelets - No labs to monitor - Decrease platelets aggregation or platelet adhesion - Decrease clotÝng - Drugs o Aspirin o Clopidogrel (Plavix) - Aspirin o 81 mg or 325mg o Contraindicated for flulike symptoms in children and teenagers  Reye’s syndrome - Clopidogrel (Plavix) o Widely used in addition to aspirin, most common. o Oral Use o Many drug interaction  Any anticoagulation  Anything GI Thrombolytic Drugs - Drugs that break down, or lyse, preformed clots - Ase is the sufÏx for these drugs. - There are criteria’s before a person can take these drugs and they must be met. - Mechanism of Action o Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction - Indications o Acute MI o Arterial thrombolysis o DVT o Occlusion of shunts or catheters o Pulmonary embolus o Acute ischemic stroke - Adverse effects o Bleeding Chapter 27 Liproproteins - Low-density lipoprotein (LDL) o Bad cholesterol o Get LDL lower  We want people LDL to be below 70 for patients with heart disease and diabetes etc. - High-density lipoprotein (HDL) o Responsible for “recycling” of cholesterol o Also known as “good cholesterol” o Get HDL higher Vitamin B3 and Statin drugs are needed to treat Statins (Know THIS) - First-line drug therapy for hypercholesterolemia - Treatment of types IIa and IIb hyperlipidemias o Reduces LDL levels by up to 50% o Increases HDL levels by 2% to 15% o Reduces triglycerides by 10% to 30% - Recommended to take at night time Adverse effects on Statin (KNOW THIS) - Monitor liver with liver function test because drug is metabolized in the liver. - Biggest side effect is mayalsia and muscle pain - Myopathy (muscle pain), possibly leading to the serious condition rhabdomyolysis (muscle break down) - Rhabdomyolysis o Breakdown of muscle protein o Myoglobinuria: urinary elimination of the muscle protein myoglobin o Can lead to acute renal failure and even death o When recognized reasonably early, rhabdomyolysis is usually reversible with discontinuation of the statin drug. o Instruct patients to immediately report any signs of toxicity, including muscle soreness or changes in urine color. Niacin (Nicotinic Acid) - Vitamin B3 - Lipid-lowering properties require much higher doses than when used as a vitamin. - Used with the statin drugs - Mechanism of Action o Thought to increase activity of lipase, which breaks down lipids o Reduces the metabolism or catabolism of cholesterol and triglycerides - Indications o Effective in lowering triglyceride, total serum cholesterol, and LDL levels o Increases HDL levels - Adverse effects o Flushing (caused by histamine release)  Small dose aspirin or NSAIDS 30 minutes before Niacin may help cutaneous flushing o Pruritus’ (itchy) Herbal Product: Garlic, flax and Omega 3 Statin Drugs Indications: Lower LDL, Increase HDL, 1st line for LDL lowering. Nursing Implications: Check Livre function test. Medicine is metabolized in the liver Side effects: Myalgia, which can lead to rhabdomyolysis Niacin B3 (b12) Indications: Primarily to increase HDL, lower trig, commonly used with statin. Nursing Implications: Take with snack QHS or baby ASA to reduce flushing and itching. Titrate dose Side Effects: Flushing, palpitation Anaphylaxis: Severe Allergic Reactions - Release of excessive amounts of histamine can lead to: o Constriction of smooth muscle, especially in the stomach and lungs o Increase in body secretions o Vasodilatation and increased capillary permeability, movement of fluid out of the blood vessels and into the tissues, and drop in blood pressure and edema Histamine - Major inflammatory mediator in allergic disorders o Allergic rhinitis (hay fever and mold, dust allergies) o Angioedema o Urticaria (itching) Antihistamine - H1 antagonists (also called H1 blockers) o Examples: chlorpheniramine, fexofenadine (Allegra), loratadine (Claritin), cetirizine (Zyrtec), diphenhydramine (Benadryl) - Antihistamines have several properties o Antihistaminic o Anticholinergic o Sedative Antihistamine effects - Cardiovascular (small blood vessels) o Histamine effects  Dilation and increased permeability (allowing substances to leak into tissues) o Antihistamine effects  Reduce dilation of blood vessels  Reduce increased permeability of blood vessels - Smooth muscle (on exocrine glands) o Histamine effects  Stimulate salivary, gastric, lacrimal, and bronchial secretions o Antihistamine effects  Reduce salivary, gastric, lacrimal, and bronchial secretions Antihistamine: Indications - Management of: o Nasal allergies o Seasonal or perennial allergic rhinitis (hay fever) o Allergic reactions o Motion sickness o Parkinson’s disease o Sleep disorders o Sneezing, runny nose Antihistamines: Contraindications - Known drug allergy - Narrow-angle glaucoma - Cardiac disease, hypertension - Kidney disease - Bronchial asthma, chronic obstructive pulmonary disease (COPD) - Sole drug therapy during acute asthmatic attacks Albuterol or epinephrine Benign prostatic hyperplasia (BPH) Antihistamines: Adverse Effects - Anticholinergic (drying) effects: most common o Dry mouth o DifÏculty urinating o Constipation o Changes in vision - Drowsiness o Mild drowsiness to deep sleep Non-sedating: (KNOW THIS) - loratadine, cetirizine, and fexofenadine Nursing Implications (KNOW THIS) - Contraindicated in the presence of acute asthma attacks and lower respiratory diseases, such as pneumonia o We want to expectorate the mucus, not dry it up. - Best tolerated when taken with meals; reduces GI upset Decongestants: Types - Adrenergics o Largest group o Sympathomimetics - Anticholinergics o Less commonly used o Parasympatholytics - Corticosteroids o Topical, intranasal steroids Topical Nasal Decongestants - Steroids decrease inflammation in the nasal passage way. - We don’t have to worry about systemic affects when it is administered through nasal passageway. - Steroids end in (ide or one) Mechanism of Action - Constrict small blood vessels that supply upper respiratory tract structures - As a result, these tissues shrink, and nasal secretions in the swollen mucous membranes are better able to drain. Contraindications (KNOW THIS) - Drug allergy - Narrow-angle glaucoma - Uncontrolled cardiovascular disease, hypertension - Diabetes and hyperthyroidism - History of cerebrovascular accident or transient ischemic attacks - Long-standing asthma - BPH - Diabetes Nursing Implications (KNOW THIS) - Patients should avoid caffeine and caffeine-containing products. - Patients should report a fever, cough, or other symptoms lasting longer than 1 week. Two types of Cough - Productive cough: congested; removes excessive secretions - Nonproductive cough: dry cough Coughing - Most of the time, coughing is beneficial. o Removes excessive secretions o Removes potentially harmful foreign substances - In some situations, coughing can be harmful, such as after hernia repair surgery. Antitussives (KNOW THIS) - Drugs used to stop or reduce coughing - Opioid and nonopioid - Used only for nonproductive coughs! - May be used in cases when coughing is harmful Antitussives: Mechanism of Action - Nonopioids o Dextromethorphan: works in the same way o Not an opioid o No analgesic properties o No CNS depression o Benzonatate o Suppress the cough reflex by numbing the stretch receptors in the respiratory tract and prevent reflex stimulation of the medullary cough center Antitussives: Contraindications - Drug allergy - Opioid dependency - Respiratory depression Expectorants (KNOW THIS ) - Drugs that aid in the expectoration (removal) of mucus - Reduce the viscosity of secretions - Disintegrate and thin secretions - Example: guaifenesin o Expectorants such as guaifenesin aid in the expectoration (i.e., coughing up and spitÝng out) of excessive mucus that has accumulated in the respiratory tract by breaking down and thinning out the secretions. Expectorants: Nursing Implications (KNOW THIS) - Expectorants should be used with caution in older adults and patients with asthma or respiratory insufÏciency. - Patients taking expectorants should receive more fluids, if permitted, to help loosen and liquefy secretions. Chapter 37 Diseases of the Lower Respiratory Tract - Chronic obstructive pulmonary disease (COPD) o Asthma (persistent and present most of the time despite treatment) o Emphysema o Chronic bronchitis Bronchial Asthma - Recurrent and reversible shortness of breath - Occurs when the airways of the lungs become narrow as a result of: o Bronchospasms o Inflammation of the bronchial mucosa o Edema of the bronchial mucosa o Production of viscous mucus o Wheezing Asthma - Four categories o Intrinsic (occurring in patients with no history of allergies) o Extrinsic (occurring in patients exposed to a known allergen) o Exercise induced  Occurs when exercising, patient may use inhaler prior to working out. o Drug induced - Status asthmaticus (KNOW THIS) o Prolonged asthma attack that does not respond to typical drug therapy o May last several minutes to hours o Medical emergency - Chronic Bronchitis o Continuous inflammation and low-grade infection of the bronchi o Excessive secretion of mucus and certain pathologic changes in the bronchial structure o Often occurs as a result of prolonged exposure to bronchial irritants - Emphysema o No longer used as a term but is included into COPD o Air spaces enlarge as a result of the destruction of alveolar walls. o Caused by the effect of proteolytic enzymes released from leukocytes in response to alveolar inflammation o The surface area where gas exchange takes place is reduced. o Effective respiration is impaired. o Alveoli is dead (bleb), they have decreased or no breath sounds Pharmacologic Overview - Bronchodilators o These drugs relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process. o Three classes: beta-adrenergic agonists, anticholinergics, and xanthine derivatives - Short-acting beta agonist (SABA) inhalers o Albuterol (Ventolin, ProAir)- quick acting and used for acute asthma o Levalbuterol (Xopenex) o Pirbuterol (Maxair) o Terbutaline (Brethine) o Metaproterenol (Alupent) - Long-acting beta agonist (LABA) inhalers o Arformoterol (Brovana) o Formoterol (Foradil, Perforomist) o Salmeterol (Serevent)- maintaince only -1 puff Bronchodilators: Beta-Adrenergic Agonists - Used during acute phase of asthmatic attacks - Quickly reduce airway constriction and restore normal airflow - Agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system o Sympathomimetics o Warn patient that they may feel palpitations but it will go away. - Three Types o Nonselective adrenergics  Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors  Example: epinephrine (EpiPen)- status asthmaticus o Nonselective beta-adrenergics  Stimulate both beta1 and beta2 receptors  Beta1 receptor is in the heart  Example: metaproterenol o Selective beta2 drugs  Stimulate only beta2 receptors (in the lungs)  Example: albuterol o Mechanisms of Action  Dilates bronchioles and increase airflow o Indications  Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases  Used in treatment and prevention of acute attacks  Used in hypotension and shock o Contraindications  Known drug allergy  Cardiac dysrhythmias  uncontrolled hypertension  High risk of stroke (because of the vasoconstrictive drug action) Beta-Adrenergic Agonists: Albuterol (Proventil) (KNOW THIS) - Short-acting beta2-specific bronchodilating beta agonist - Most commonly used drug in this class - Must not be used too frequently - Oral and inhalational use - Inhalational dosage forms include metered-dose inhalers (MDIs) as well as solutions for inhalation. Beta-Adrenergic Agonists: Salmeterol (Serevent) (KNOW THIS) - Long-acting beta2 agonist bronchodilator - Never to be used for acute treatment - Used for the maintenance treatment of asthma and COPD and is used in conjunction with an inhaled corticosteroid Salmeterol should never be given more than twice daily nor should the maximum daily dose (one puff twice daily) be exceeded. Anticholinergics: Mechanism of Action (KNOW THIS) - Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways. - Anticholinergics bind to the ACh receptors, preventing ACh from binding. - Result: bronchoconstriction is prevented, airways dilate - Ipratropium (Atrovent) is most commonly used - Indirectly cause airway relaxation and dilation - Help reduce secretions in COPD patients - Indications o prevention of the bronchospasm associated with chronic bronchitis or emphysema; not for the management of acute symptoms Xanthine Derivatives (KNOW THIS) - Commonly given as a PO drug - Narrow therapeutic index so labs must be drawn - Therapeutic range for theophylline blood level is 10 to 20 mcg/mL - Aminophylline o Given IV form and is used for Status asthmaticus that don’t respond to albuterol - Must be on telemetry because has a lot of tachycardia - Avoid Caffeine Nonbronchodilating Respiratory Drugs (KNOW THIS) - Leukotriene receptor antagonists (montelukast, zafirlukast, and zileuton) o Montelukast (Singulair) - Prophylaxis and long-term treatment and prevention of asthma in adults and children 12 years of age and older - Not meant for management of acute asthmatic attacks - Montelukast is also approved for treatment of allergic rhinitis - Improvement with their use is typically seen in about 1 week. Corticosteroids (Glucocorticoids) - Anti-inflammatory properties - Used for chronic asthma - Do not relieve symptoms of acute asthma attacks - May be administered IV - Oral or inhaled forms o Inhaled forms reduce systemic effects. - May take several weeks before full effects are seen - Have patient rinse there mouth after using it so they won’t get thrush - Never abruptly stop oral steroids Inhaled Corticosteroids: Indications - Primary treatment of bronchospastic disorders to control the inflammatory responses that are believed to be the cause of these disorders - Persistent asthma - Often used concurrently with the beta-adrenergic agonists - Systemic corticosteroids are generally used only to treat acute exacerbations, or severe asthma. - IV corticosteroids: acute exacerbation of asthma or other COPD - Contraindications o Patients whose sputum tests positive for Candida organisms o Patients with systemic fungal infection Inhalers: Patient Education - Provide demonstration and return demonstration. - Ensure that the patient knows the correct time intervals for inhalers. - Provide a spacer if the patient has difÏculty coordinating breathing with inhaler activation. - Ensure that the patient knows how to keep track of the number of doses in the inhaler device. Asthma Drugs SABA (Albuterol) LABA (Salmeterol ) Indications: Indications: Acute maintenanc attacks, not e only. 1 maintenance puff BID . Nurse Implications: CAD, uncontrolled HTN, arrythmias. Side effects: Tremor, nervousness, palpitations. Anticholinergi c (Ipratropium) Add on for maintenance only. Dries up secretions. Xanthine Derivatives PO (Theophylline) -Narrow therapeutic window. Normal levels 10-20 mcg/ml IV (Aminophylline ) Indicated for status asthmaticus when all else fails (Epi, IV steroids) Nsg Imp: LTRA’s (Montelukast ) -maintenance only. PO, works within a week. Indications: allergic rhinitis and asthma. Corticosteroid s (inhaled) SufÏx: one/ide Maintenance, commonly added to LABA. Nursing Imp: Rinse mouth, use bronchodilato r first. SE: candida, sore throat. IV steroids/PO: wean them Monitor cardiac SE: arrythmias off, do not stop abruptly, can cause hyperglycemia . Chapter 22 Blood Pressure - Blood pressure (BP) = CO × SVR o CO = cardiac output (4-8 L/min) o SVR = systemic vascular resistance - Hypertension = high BP - Hypertension is currently one of the most common disease states. - Hypertension is major risk factor for coronary artery disease (CAD), cardiovascular disease (CVD). Four stages based on BP measurements 1. Normal 2. Prehypertension 3. Stage 1 hypertension 4. Stage 2 hypertension According to the JNC 8, therapy should be started if BP is at or greater than150/90 for patients older than 60 years and 140/90 for patients younger than 60 and those who have chronic kidney disease or diabetes. Classification of Blood Pressure - Hypertension can also be defined by its cause. - Unknown cause o Essential, idiopathic, or primary hypertension 90% of cases o Hypertension happens because of genetics - Known cause Secondary hypertension o 10% of cases Pharmacology Overview - Drug therapy for hypertension must be individualized. - Seven main categories of drugs to treat hypertension o Diuretics o o o o o o Adrenergic drugs Vasodilators Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Direct renin inhibitors Adrenergic Drugs: Five Subcategories - Adrenergic neuron blockers (central and peripheral) - Alpha2 receptor agonists (central) - Alpha1 receptor blockers (peripheral) - Beta receptor blockers (peripheral) - Combination alpha1 and beta receptor blockers (peripheral) Centrally Acting Adrenergic Drugs - Clonidine and methyldopa o SAFE TO USE IN PRGENANCY - Stimulate alpha2-adrenergic receptors, thus reducing renin activity in the kidneys, which lowers blood pressure. Peripherally Acting Alpha1 Blockers - When alpha1-adrenergic receptors are blocked, BP is decreased. - Dilate arteries and veins - Alpha1 blockers also increase urinary flow rates and decrease outflow obstruction by preventing smooth muscle contractions in the bladder neck and urethra. - Use: benign prostatic hyperplasia (BPH) Beta Blocker - Propranolol, metoprolol, and atenolol (ends in LOL) o Reduction of the heart rate through beta1 receptor blockade o Cause reduced secretion of renin o Long-term use causes reduced peripheral vascular resistance. o Reduces Catecholamines o We use betablockers after an MI o Do not stop abruptly because it can cause rebound hypertension Angiotensin-Converting Enzyme (ACE) Inhibitors (ends in PRIL) - Large group of safe and effective drugs o Currently are 10 ACE inhibitors - Often used as first-line drugs for HF and hypertension - May be combined with a thiazide diuretic or CCB - ACE: converts angiotensin I (AI) (formed through the action of renin) to angiotensin II (AII). It decreases the pressure in the kidney…It has nothing to do with the heart. Induce aldosterone secretion, aldosterone absorbs sodium and water so the patient can urinate it out. Effects of ACE Inhibitors - Cardiovascular and renal - BP: reduce BP by decreasing SVR - HF o Prevent sodium and water resorption by inhibiting aldosterone secretion o Diuresis: decreases blood volume and return to the heart o Decreases preload, or the left ventricular - Use to protect the kidneys in someone that is a diabetic (Renal protective effects) o Standard therapy for diabetic patients to prevent the progression of diabetic nephropathy ACE inhibitor: Indications - Hypertension - HF (either alone or in combination with diuretics or other drugs) - Slow progression of left ventricular hypertrophy after myocardial infarction (MI) (cardioprotective) - Renal protective effects in patients with diabetes Side effects - Dry, nonproductive cough, which reverses when therapy is stopped - Angioedema: rare but potentially fatal Angiotensin II Receptor Blockers- ARBS (ends in ARTANS) - Also referred to as angiotensin II blockers o Like a cousin to ACE inhibitors - Well tolerated - Do not cause a dry cough that is common with ACE inhibitors - Can give chest pain ARBS Mechanism of Action - ARBs affect primarily vascular smooth muscle and the adrenal gland. - Blocks the secretions of aldosterone ARBS Indications - Hypertension - Adjunctive drugs for the treatment of HF May be used alone or with other drugs such as diuretics Calcium Channel Blockers: Mechanism of Action - Primary use: HTN and angina - Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction - Work similarly to beta blockers - Results in: o Decreased peripheral smooth muscle tone o Decreased SVR o Decreased BP CCB Indications (KNOW THIS) - Angina - Hypertension: amlodipine (Norvasc) - Dysrhythmias - Migraine headaches - Raynaud’s disease - Prevent the cerebral artery spasms after subarachnoid hemorrhage: nimodipine - We do not use CCB for post MI patients Side effects - Constipation Diuretics (ends in ide) - First-line antihypertensives in the JNC 8 guidelines for the treatment of hypertension - Decrease plasma and extracellular fluid volumes - Results o Decreased preload o Decreased CO o Decreased total peripheral resistance - Overall effect o Decreased workload of the heart and decreased BP - Thiazide diuretics are the most commonly used diuretics for hypertension. o We must monitor potassium but it don’t always waste it. - Vasodilators o Nitroprusside (Nitropress)  Relaxes arteries  High hypertension - Vasodilators Indications o Treatment of hypertension o May be used in combination with other drugs o Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies.  Used in the intensive care setÝng for severe hypertensive emergencies; titrated to effect by IV infusion  Contraindications: known hypersensitivity to the drug, severe HF, and known inadequate cerebral perfusion (especially during neurosurgical procedures) o Loop Diuretics is potassium wasting Nursing Implications - Blood pressure should be taken on a daily basis and not PRN. - Patient should not be in hot shower, hot weather for long time, heat causes vasodilation can cause syncope episodes. ACE Inhibitors and Laboratory Values - ACE inhibitors can cause renal impairment, which can be identified with serum creatinine. - ACE inhibitors can also cause hyperkalemia, so potassium levels need to be monitored. Central Alpha Methyldopa (Aldomet) SAFE FOR PREGNANCY -Alpha Blockers (osin) Indications: HTN, BPH Nsg: Fall precautions SE: Orthostatic hypotension Tamsulosin (Flomax): Specific for BPH, does NOT decrease BP ACE inhibitors (PRIL) Ind: HTN, HF, Renal protectant for Diabetic patients. ARBs (Sartan) Beta Blockers (LOL) B1, B2 Ind: HTN Nsg Imp: Monitor K+, ACE inhibitors can increase K. monitor for hyperkalemia . SE: Chest pain Ind: HTN, post MI- (reduces the workload of heart), Angina, Migraines, Reynaud Phenomon, Tachyarrythmias. SE: Dry cough (class effect) Nsg Imp: None, well tolerated Does not cause cough or hyperkalemia. Nsg Imp: check pulse, monitor blood sugar Do not stop abruptly, can lead to rebound HTN SE: Bradycardia, Impotence (dose Ca+ Channel blockers (CCB’s) Ind: Similar to Beta Blocker, no indication for post MI. HTN, Angina, Tachyarrythmias, Raynaud’s Disease. Nsg: Monitor BP SE: Constipation Diuretics Loop Diuretics (Furosemide) Lasix Ind: Primarily for HF Nsg: K+ wasting. Monitor K levels. Typically K supplements are given. SE: Dizziness, hypokalemia Thiazides: Hydrochlorothiazide (HCTZ) Nsg: Monitor K+ Amlodipine (most common SE: Dizziness related), can influence blood sugar CCB) PO only. If someone has asthma, they should not be on beta blocker K+ sparing diuretics: Spirolactone (Aldactone) Ind: HTN, Acne NSG: Avoid food high in K+ SE: Dizziness Mannitol: This diuretic is indicated for elevated ICP. Patients with head injuries. Nitroprusside: Potent Vasodilator Ind: HTN emergencies IV only, administered in ICU and patient must be on telemetry, Chapter 23 Angina Pectoris (Chest Pain) - When the supply of oxygen and nutrients in the blood is insufÏcient to meet the demands of the heart, the heart muscle “aches.” - Angina is not ischemia, there is no tissue death, we are trying to prevent that. We administer nitrate which vasodilate the arteries of brain. Ischemia - Ischemia o Poor blood supply to an organ - Ischemic heart disease o Poor blood supply to the heart muscle o Atherosclerosis o Coronary artery disease - Myocardial infarction (MI) o Necrosis, or death, of cardiac tissue  There is no coming back from tissue death. o Disabling or fatal Drugs for Angina - Nitrates or nitrites o Nitroglycerin is most common o Potent vasodilator - Beta blockers Calcium channel blockers (CCBs) We want to treat angina before the person develops an MI. Available forms o Sublingual* o Chewable tablets o Oral capsules/tablets o Intravenous (IV) solutions* o Transdermal patches*  Used prophylactically o Ointments o Translingual sprays* Nitrates Mechanism of Action - Cause vasodilation because of relaxation of smooth muscles - Potent dilating effect on coronary arteries o Can make low blood pressure - Result: oxygen to ischemic myocardial tissue - Used for prevention and treatment of angina Nitrates: Contraindications - Severe anemia - Closed-angle glaucoma - Hypotension - Severe head injury - Use of the erectile dysfunction drugs sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) o Phosphodiesterase inhibitors (erectile dysfunction medications) are potent vasodilators and therefore nitrates are contraindicated when the patient is taking this classification of medications. ED drugs are vasodilators and patients can become more hypotensive. Nitrates: Adverse effects - Headaches o Usually diminish in intensity and frequency with continued use - Reflex tachycardia - Postural hypotension - Skin irritation with topical application - If patient has patch, tolerance may develop, therefore we take out the patch and give break. Remove patch at bedtime for about 8 hours. - With sublingual nitroglycerin, the medication should be taken at the first sign of chest pain and not be delayed until the pain is severe. The patient should sit or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes after one dose, the patient (or family member) should call 911 immediately. Nitrates - Nitroglycerin o Large first-pass effect with oral forms o Used for symptomatic treatment of ischemic heart conditions (angina) o IV form used for BP control in perioperative hypertension, treatment of heart failure (HF), ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies Beta blockers - Mainstay in the treatment of several cardiovascular diseases o Angina o MI o Hypertension o Dysrhythmias - It is used Post MI because o Beta blockers block the harmful effects of catecholamines, thus improving survival after an MI. o Decrease heart rate, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart o Decrease myocardial contractility, helping to conserve energy or decrease demand - If patient suffer from MI he will go home with aspirin, low dose beta blockers, statin drug and/or nitroglycerin. Contraindications - Caution: bronchial asthma because any level of blockade of beta2 receptors can promote bronchoconstriction - Diabetes mellitus: can mask hypoglycemia-induced tachycardia Slowing the heart rate in patients with ischemic heart disease reduces myocardial oxygen demand and allows the coronary arteries time to fill with oxygen- and nutrient-rich blood. Beta blockers also block the irritating effects of circulating catecholamines on the heart. Calcium Channel Blockers - Indicated for Angina, but not post MI - Contraindications o Acute MI - Side effects: o Constipation Nursing Implications - Patient should report o Blurred vision o Persistent headache o Dry mouth o Edema o Fainting episodes o Weight gain of 2 lb in 1 day or 5 lb in 1 week o Pulse rate less than 60 beats/min o Dyspnea Nursing Implication for Nitroglycerin - Instruct patients in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain. - Instruct patients never to chew or swallow the sublingual form. - Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent. - Instruct patients to keep a fresh supply of sublingual medication on hand; potency is lost in about 3 months after the bottle has been opened. - Nitroglycerin loses its potency when exposed to light Drugs for Angina Nitroglycerin Ind: HTN, Angina Nsg Imp: Multiple forms IV, Sublingual, check BP, give q5 minute x 3. Does not effect the HR, only BP Tolerance with patch… remove if it during bed time for 6-8 hours. IV form needs to use filter SL given q5 min X 3 SE:Headaches, Hypotension Beta Blocker Calcium channel blocker (CCB) Ind: Angina, HTN, MI, Cardiac - Indicated for Angina, but not post MI dysrhythmias - It used for POST MI - Contraindications o Acute MI - Beta blockers block the harmful effects of catecholamines, - Side effects: improving survival o Constipation after an MI. - Decrease myocardial contractility, helping to conserve energy or decrease demand - Helps lower heart rate Chapter 24 Heart failure - Echocardiogram looks at the mechanical part of the heart. - EKG looks at the electrical part of the heart. - Ejection fraction is the percentage of how much blood the left ventricle pumps out with each contraction. o An ejection fraction of 60% means 60% of the total amount of blood in the left ventricle is pushed out with each heartbeat. o Normal ejection fraction is 55-60% o 30-40% means heart failure. - Symptoms depend on the cardiac area affected o Common symptoms: dyspnea, fatigue, fluid retention and/or pulmonary edema o “Left-sided” heart failure (HF): pulmonary edema, coughing, shortness of breath, and dyspnea (Respiratory system) o “Right-sided” HF: systemic venous congestion, pedal edema, jugular venous distension, ascites, and hepatic congestion Heart failure Causes - Myocardial infarction (MI) - Coronary artery disease - Cardiomyopathy - Valvular insufÏciency - Atrial fibrillation - Infection - Ischemia - Pulmonary hypertension - Systemic hypertension - Hypervolemia - Congenital abnormalities - Anemia - Thyroid disease - Infection - Diabetes Drug Therapy for Heart Failure - Positive inotropic drugs o Increase the force of myocardial contraction…helps the heart pump harder - Positive chronotropic drugs o Increase heart rate - Positive dromotropic drugs o Accelerate cardiac conduction STUDY OUT Inotropic: pos/neg CONTRACTILITY Chronotropic: pos/neg HEART RATE HF: Positive Inotrope> Digoxin MI: Negative Inotrope> Beta blocker HF: Pos Chronotropic>Atropine (increases heart rate) Neg Chronotropic> Beta blocker, CCB (decrease HR) Beta blocker: Negative inotrope, Negative chronotrope Digoxin: Positive inotrope, Negative chronotrope Drug Therapy for Heart failure - Positive inotropic drugs - Phosphodiesterase inhibitors - Cardiac glycosides - Sinoatrial modulators - Angiotensin receptor-neprilysin inhibitors - Angiotensin-converting enzyme (ACE) inhibitors - Angiotensin receptor blockers (ARBs) - Beta blockers - Diuretics Early treatments for HF - Focus on reducing effects of the renin-angiotensin-aldosterone system and the sympathetic nervous system - ACE inhibitors (lisinopril, enalapril, captopril, and others) - ARBs (valsartan, candesartan, losartan, and others) - Loop diuretics (furosemide) are used to reduce the symptoms of HF secondary to fluid overload. - Aldosterone inhibitors (spironolactone, eplerenone) are added as the HF progresses. - Only after these drugs are used is digoxin added. - Dobutamine: positive inotropic drug-IV (KNOW THIS) o Given to increase blood pressure for patients who are in shock o An increased heart rate is a side effect B-Type Natriuretic Peptides - Nesiritide (Natrecor) (KNOW THIS) o Used for major heart failure, decompensated HF when nothing else is workinhGGIVEN IV ONLY and in ICU o Synthetic version of human B-type natriuretic peptide o Vasodilating effects on both arteries and veins o Effects of nesiritide  Diuresis (urinary fluid loss)  Natriuresis (urinary sodium loss)  Vasodilation  Indirect increase in cardiac output and suppression of neurohormonal systems such as the renin-angiotensin system Cardiac Glycosides - Digoxin - Comes IV and PO - No longer used as first-line treatment - Used to slow down heart rate - Positive inotropic effect o Increased force and velocity of myocardial contraction (without an increase in oxygen consumption) - Negative chronotropic effect o Reduced heart rate - Before we give digoxin we must check apical heart rate for one minute…if it is less than 60 we hold the drug. Digoxin Adverse effects - Very narrow therapeutic window - Drug levels must be monitored. o 0.5 to 2 ng/mL - Low potassium levels increase its toxicity. - Electrolyte levels must be monitored. - Eyes: colored vision (seeing green, yellow, purple), halo vision, flickering lights - Gastrointestinal: anorexia, nausea, vomiting, diarrhea Digoxin Toxicity - Digoxin immune Fab (Digibind) therapy o Hyperkalemia (serum potassium greater than 5 mEq/L) in a digitalis-toxic patient o Life-threatening cardiac dysrhythmias o Life-threatening digoxin overdose Nursing Implications - Assess history, drug allergies, and contraindications. - Assess clinical parameters, including: o BP o Apical pulse for 1 full minute o Heart sounds, breath sounds o Weight, input, and output measures  Patients should immediately report a weight gain of 2 lb or more in 1 day or 5 lb or more in 1 week. o Electrocardiogram o Serum labs: potassium, sodium, magnesium, calcium, renal, and liver function studies o Hold dose and notify prescriber if the patient experiences signs or symptoms of toxicity.  Anorexia, nausea, vomiting, diarrhea  Visual disturbances (blurred vision, seeing green or yellow halos around objects) - Digoxin Ind: HF, Tachyarrhythmia Iv and PO Nsg Imp: Get levels 0.5-2 Low K+ level can potentiate dig toxicity. - High fiber decreases absorption - Check apical pulse for one full minute. - Hold for HR less than 60 SE: S/S of toxicity: nausea, vomiting, visual disturbances Tox: Dig immune fab. Positive Inotrope Negative Chronotrope Nesiritide Used for acute decompensated HF IV/only in ICU on a pump Chapter 25 Antidysrhythmic - Dysrhythmia o Any deviation from the normal rhythm of the heart - Arrhythmia o “No rhythm” which implies asystole - Terms dysrhythmia and arrhythmia are used interchangeably with the term arrhythmia being most commonly used. - Antidysrhythmic o Used for the treatment and prevention of disturbances in cardiac rhythm - ALL antidysrhythmic can cause dysrhythmia Aspects of Action Potential - SA node, AV node, and His-Purkinje cells all possess the property of automaticity. - SA node is the natural pacemaker of the heart. - SA node has an intrinsic rate of 60 to 100 bpm. - AV node has an intrinsic rate of 40 to 60 bpm. - Ventricular Purkinje fibers have an intrinsic rate of 40 or fewer beats per minute. Electrocardiography - ECG or EKG - P wave o Atrial - PR interval - QRS complex o Ventricular - ST segment - T wave Any heart rate above 150 is considered supraventricular (SVT)-above the ventricles With a-fibrillation we worry about clots forming Vaughan Williams Classification: Mechanism of Action and Indication - Amiodarone and Lidocaine o Number 1 drug used for ventricular arrhythmias o Increase APD o Prolong repolarization in Phase 3 o Used for dysrhythmias that are difÏcult to treat  Life-threatening ventricular tachycardia or fibrillation, atrial fibrillation or flutter that is resistant to other drug Adenosine - Must push this drug rapidly - The half-life of adenosine is very fast—only 10 seconds— - Asystole only lasts for a few seconds. - The nurse should continue to monitor the patient for therapeutic and adverse effects of the medication. Antidysarrthmia Ventricular Arrythmia Amiodarone and Lidocaine (not the lidocaine used in anesthesia) Lidocaine only IV (toxicity>seizures) Amiodarone is used more frequently because patient can go home to PO SVT HR above 150 Beta Blockers. Calcium Channel Blockers Adenosine: short half life Rapid IV push Can cause brief asystole MI in ICU Morphine Oxygen Nitroglycerine Anticoagulant Antidysrhythmic K+ 5.5 Captopril Furosemide Spirolactone Mannitol