NCLEX FARMACOLOGY CARDIOVASCULAR
Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value).
An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin).
Grapefruit inhibits enzyme CYP3A4. The drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects.
Calcium channel blocker (eg, nifedipine) use with grapefruit juice can cause severe hypotension; some statins (eg, simvastatin) may result in myopathy.
Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage.
Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged.
ACE inhibitors ("-prils") and angiotensin II receptor blockers (ARBs) ("-sartans") may potentiate hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Aldosterone promotes sodium retention and causes potassium excretion.
However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client with hyperkalemia (Option 2).
side efects Thiazide diuretics
Hypokalemia - manifests as muscle cramps (Option 3). Hyponatremia - manifests as altered mental status and seizures. Hyperuricemia - may precipitate or worsen gout attacks. Hyperglycemia - may require adjustment of diabetic medications.
Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5)
Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication (Option 2).
Clients at risk for developing orthostatic hypotension should be instructed to:
Take medications at bedtime, if approved by the health care provider. Rise slowly from a supine to standing position, in stages (especially in the morning). Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather). Maintain adequate hydration
Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed.
The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy.
Thrombolytic therapy aims.
Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium.
titrating
adjusting dose to maintain a particular level of the substance. (titulando)
antiplatelet agents
clopidogrel, ticagrelor, prasugrel, aspirin
erectile dysfunction drugs
sildenafil, tadalafil, vardenafil
Chlorthalidone (Hygroton)
thiazide diuretic
Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding (Option 3)
(Option 1) Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level.
(Option 1) Diltiazem is unlikely to convert atrial fibrillation to sinus rhythm. Antiarrhythmic medications such as amiodarone or ibutilide will be used for conversion of the rhythm.
(Option 2) Calcium channel blockers such as diltiazem may reduce blood pressure, but the nurse is not evaluating this client in atrial fibrillation for this outcome. In this case, diltiazem is being used for ventricular rate reduction.
A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 2-3) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote.
(Option 2) Fresh, frozen plasma is considered when major bleeding is occurring related to warfarin overdose, but this is typically after the vitamin K has been administered.
(Option 1) Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin)
(Option 2) Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect.
(Options 1 and 3) Medications that can cause stomach upset (eg, NSAIDs) should be taken with food.
(Option 2) Medications such as levothyroxine should be taken on an empty stomach in the morning. Acid-suppressing medications (eg, proton pump inhibitors, H2 blockers) should also be taken 30 minutes before the meal.
(Option 2) Active menstruation is not a contraindication for thrombolytic therapy. Research shows that the risk of increased menstrual bleeding due to thrombolytic administration is low and not life-threatening. Physiologic menstrual bleeding is also not a contraindication for anticoagulation therapy.
(Option 3) Chest pain is one of the inclusion criteria for thrombolytic therapy.
(Option 4) Basal insulin glargine (Lantus) is used for glucose control in diabetic clients. Insulin glargine has no peak and should be administered even if the current blood glucose level is within normal limits.
(Option 3) Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 gram). When the infusion is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion should be slowed or stopped and restarted at a slower rate after 30 minutes. Facial flushing in isolation is not indicative of an allergic or anaphylactic reaction, and the nurse can independently manage this side effect.
The nurse should not give an ARB to a pregnant client (Option 2). The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa)
(Option 4) Tiotropium is an inhaled anticholinergic drug that inhibits receptors in the smooth muscles of the airways. It is prescribed daily for the long-term management of bronchospasm in clients with chronic obstructive pulmonary disease.
(Option 4) Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss may be used with care in some clients.
(Option 5) Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin, heparin)
This client's history of heart failure is a contraindication to increased fluid intake due to potential fluid overload and increased workload on the heart (Option 1). The nurse should consult the health care provider before recommending a specific amount of fluid intake.
(Options 2 and 4) Exercise is important, but clients with heart failure may not exercise for long periods due to fatigue. Warm baths are not helpful for constipation.
Aims
(Proposito, objetivos)
milrinone
(Se usa en la insuficiencia cardíaca (falla cardíaca) terminal por corto tiempo, refractaria a otros inotrópicos (catecolaminérgicos),o en pacientes programados para trasplante de corazón. max x 35 hrs.)
(Option 2) The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension.
Educational objective: The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed.
(Option 3) Having no signs or symptom of stroke is a positive outcome in this client; however, it is not a specific outcome of diltiazem. Anticoagulants (eg, warfarin, dabigatran, rivaroxaban, apixaban) are used for this purpose.
Educational objective: The nurse should monitor for a reduction in ventricular rate in the client with atrial fibrillation who is receiving diltiazem, metoprolol, or digoxin. Anticoagulants are used to prevent embolic complications.
If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath).
If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide).
Beta blockers lower heart rate by blocking the action of beta receptors that increase heart rate and contractility. The nurse should assess blood pressure and heart rate prior to administration (Option 3).
ACE inhibitors increase serum potassium by decreasing urinary potassium excretion. The nurse should assess blood pressure and serum potassium levels prior to administration (Option 5).
Clopidogrel (Plavix)
Antiplatelet
Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL).
Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness (Option 5). Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold the medication and notify the health care provider (Option 4).
Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor)
Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option 3).
The client has sinus bradycardia, which can be caused by:
Drugs (eg, beta blockers, calcium channel blockers, digoxin). Consider withholding beta blockers if systolic blood pressure <100 mm Hg or heart rate <60 and notify the provider. Vagal stimulation (eg, carotid sinus massage, Valsalva maneuver). Diseases (eg, hypothyroidism, myocardial infarction, increased intracranial pressure)
Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible lung damage (Option 4).
Educational objective: Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias. Pulmonary toxicity is a life-threatening complication that may cause symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients taking amiodarone with signs of pulmonary toxicity require immediate follow-up.
(Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication. (Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth.
Educational objective: Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly.
The nurse should question the prescription for furosemide (Lasix), a potent loop diuretic, before administering the medication. The client has a significant decrease in systolic blood pressure (50 mm Hg), a negative fluid balance of 2000 mL for 24 hours, hypernatremia (normal sodium, 135-145 mg/dL [135-145 mmol/L]), and a potassium level that is trending downward. These parameters indicate hypotonic dehydration, which is often caused by diuretic use. If the diuretic were administered, the fluid volume deficit would increase further.
Educational objective: Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy.
(Option 5) Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension.
Educational objective: Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure.
Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis.
Educational objective: Residual paresthesia and motor weakness for several hours are expected findings after regional anesthesia. Anticoagulants are not given while an epidural catheter is in place.
(Option 4) Uncontrolled blood pressure of >180 mm Hg systolic or >110 mm Hg diastolic is a relative contraindication for thrombolytic therapy. This client's blood pressure (170/92 mm Hg) is elevated but not uncontrolled, which does not rule out this therapy.
Educational objective: The candidate for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the health care provider if the client has history of arteriovenous malformation, which is an absolute contraindication to the use of thrombolytics.
Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L).
Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment.
Signs and symptoms of digoxin toxicity include the following:
Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms (Option 2). Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion). Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness Cardiac arrhythmias - most dangerous
This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication.
Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) (Option 1).
Parent teaching for administration of digoxin includes the following
Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child. Administer oral liquid in the side and back of the mouth. Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication (Option 4). If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule. If more than 2 doses are missed, notify the HCP. If the child vomits, do not give a second dose. (Option 1). Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP (Option 2). Give water or brush the client's teeth after administration to remove the sweetened liquid
Drugs commonly associated with orthostatic hypotension include:
Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) (Option 3). Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) (Option 4). Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide). Vasodilator medications (eg, nitroglycerine, hydralazine). Narcotics (eg, morphine)
NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth.
Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead.
During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension)
The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem), beta blockers (ie, metoprolol), and digoxin.
Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of a stroke, venous thrombosis, or pulmonary embolism.
Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. An increase in vitamin K could decrease the effectiveness of warfarin, placing the client at increased risk of blood clot formation; a decrease could increase the effectiveness of warfarin, placing the client at increased risk for bleeding.
Absolute contraindications to thrombolytics
Prior intracranial hemorrhage Structural cerebrovascular lesion (eg, arteriovenous malformation, aneurysm). Ischemic stroke within 3 months (except within 3 hr). Suspected aortic dissection. Active bleeding or bleeding diathesis. Significant head trauma within 3 months.
Major side effects of angiotensin-converting enzyme (ACE) inhibitors include:
Symptomatic hypotension. Intractable cough. Hyperkalemia. Angioedema (allergic reaction involving edema of the face and airways). Temporary increase in serum creatinine.
Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina.
The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4)
Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances can be harmful to the kidney and often cause kidney damage. .
The client should immediately report any signs of muscle aches or weakness to the HCP. These could be early signs of rhabdomyolysis, which can be fatal
Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot.
The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming.
Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line.
The home health nurse should perform the following: Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting (Option 4). Evaluate medication effectiveness and possible side effects. Monitor the central line insertion site for infection. Change the central line dressing as prescribed (Option 3). Monitor daily weight (Option 1). Monitor blood pressure for possible hypotension (Option 2). Implement safety precautions as hypotension increases the client's risk of falling
Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn.
The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation.
Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) are prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. Most of the cholesterol in the body is synthesized by the liver during the fasting state, at night.
Trials have found greater reductions in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day.
Other manifestations of digoxin toxicity that clients should report include:
Visual symptoms (eg, alterations in color vision, scotomas, blindness) (Option 1). Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms (Option 3). Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion).
