Pharm Chps 22 - 29

amyloid blockers

drugs that prevent the formation of amyloids

analeptics

drugs that stimulate the central nervous system

xerostomia

dry mouth

cholinesterase

enzyme to inhibit the action of acetylcholine

catecholamines

epinephrine, norepinephrine, and dopamine, derived from tyrosamine

euphoria

exaggerated feeling of well-being

dyskinesia

excessive involuntary body movements

diaphoresis

excessive perspiration

grand mal seizure

generalized tonic-clonic seizure

Adverse effects of Beta blockers

- bradycardia - decreased cardiac output (decreased contractility) - decreased conduction - bronchoconstriction - hypoglycemia *Black box alert*- rebound cardiac excitability if abruptly d/c.

Therapeutic uses of Low-molecular weight heparin

- post op DVT prevention - treatment of established deep vein thrombosis (DVT) with or without pulmonary embolism (PE).

Prodrugs

A drug that is inactive in its administered form and must be metabolized to its active form in the body, generally by the liver, to be effective.

Nebivolol (Bystolic)

A newer beta blocker. Beta 1 selective (cardio-selective) beta blocker. *Used to treat* hypertension, investigational for heart failure. In addition to blocking beta 1 receptors, it also produces vasodilation, which results in a decrease in systemic vascular resistance (SVR).

Torsades de pointes

A type of ventricular tachycardia associated with long QT syndrome. A prolongation of the QT interval.

Angina pectoris

Chest pain that occurs when the heart's supply of blood carrying oxygen is insufficient to meet the demands of the heart.

The overall goal of antianginal drug therapy is to-

Increase blood flow to the ischemic myocardium, decrease myocardial oxygen demand, or both.

Positive dromotropic drugs

Increase the conduction of electrical impulses across the heart.

Positive inotropic drugs

Increase the force of myocardial contraction.

physical dependence

craving for drugs because of extended use, so the drugs have taken over the individual's life and have affected normal body functioning, discontinuation of use of the drug typically results in withdrawal symptoms

dystonia

weak, slow body movements caused by lack of muscle coordination or impaired muscle tone

Angiotensin II

A potent vasoconstrictor activated by renin; also triggers release of aldosterone.

Examples of anti-platelet drugs

Aspirin (acetylsalicylic acid) Clopidogrel (Plavix) Abciximab (ReoPro)

Drug interactions with thiazide diuretics

Digoxin Antihypertensives Lithium NSAIDs

Paroxysmal supraventricular tachycardia (PSVT)

Tachycardia of sudden onset and termination; initiated by a reentry loop in or around the AV node.

Arrhythmia

"No rhythm" Implies asystole, or no heartbeat at all.

Key point

(Page 360) Always assess for the presence of contraindications, cautions, and potential drug interactions before administering any of the antihypertensive drugs. Contraindications include a history of MI or chronic renal disease. Cautious use is recommended in patients with renal insufficiency or glaucoma. Drugs that interact with antihypertensive drugs include other antihypertensive drugs, anesthetics, and diuretics.

Adverse effects of Nitrates/Nitrites

(Usually diminish with use) Headache** Orthostatic hypotension Reflex tachycardia Dizziness/syncope

Laboratory monitoring with the use of Heparin (unfractionated)

*Activated partial thromboplastin time (PTT).* Normal value is 40 seconds. Therapeutic PTT for patients on heparin is *60-80 seconds*. Usually check PTT every 4-6 hours when therapy is initiated until therapeutic level is achieved.

Adverse effects and drug interactions with the use of Clopidogrel (Plavix)

*Adverse effects*- - bleeding - thrombotic thrombocytopenia purpura (TTPO) - bronchospasm - Stevens Johnson syndrome - black box warning: complex, has to do with how the medication is metabolized. *Drug interactions*- - other drugs that promote bleeding - proton pump inhibitors

Adverse effects and Interactions with the use of Dabigatran (Pradaxa)

*Adverse effects*- - bleeding (no antidote). - dyspepsia, gastritis type symptoms. - black box warning: increased chance of thrombotic events if drug is abruptly. discontinued. *Interactions*- - antiplatelet drugs - heparin - NSAIDs

Adverse effects and drug interactions with Ezetimibe (Zetia)

*Adverse effects*- - usually well tolerated. - some reports of myopathy, rhabdomyolysis, hepatitis, pancreatitis, and thrombocytopenia. *Drug interactions*- - Fibrates: increases the risk of myopathy + gallstones. - Bile acid sequestrants: absorption of ezetimibe is decreased when taken together. - Cyclosporine: when taken together, level of ezetimibe is increased.

Adverse effects and interactions for Quinidine (Quinidex)

*Adverse effects*- dizziness, diarrhea, cardiotoxicity, hepatic toxicity, thrombocytopenia, agranulocytosis. - Cinchonism: tinnitus, headache, nausea/vertigo, disturbed vision. *Interactions*- many interactions, digoxin (can displace digoxin and cause toxicity), grapefruit juice.

Adverse effects and interactions of the use of Calcium Channel Blockers

*Adverse effects*- orthostatic hypotension, constipation, peripheral edema, bradycardia, reflex tachycardia. *Interactions*- beta blockers, grapefruit juice, digoxin.

Anti-platelet drugs are primarily used to prevent __________ _________.

*Arterial* clots

Nursing implications for certain HMG-CoA Reductase Inhibitors

*Atorvastatin (Lipitor)*- better for renal patients. *Fluvastatin (Lescol)*- better for renal patients. Can decrease platelets and WBCs. *Pravastatin (Pravachol)*- fewer side effects. Can increase blood glucose levels. *Simvastatin (Zocor)*- can increase blood glucose levels. *Rosuvastatin (Crestor)*- biggest risk for rhabdomylosis (breakdown of muscle tissue): higher risk for myopathy for patients of Asian ancestry.

Class II Antidysrhythmics

*Beta blockers.* Decreases automaticity, slows velocity conduction, reduces contractility. Ex- propranolol, metoprolol, esmolol.

Adverse effects of Heparin (unfractionated)

*Bleeding* Heparin induced thrombocytopenia (HIT)- decreased platelets. Spinal/epidural hematoma (in patients undergoing spinal anesthesia). Hypersensitivity reactions.

Class IV Antidysrhythmics

*Calcium channel blockers*. Decrease AV node conduction. Ex- diltiazem, verapamil.

Adverse effects of Digoxin- Cardiac Glycoside

*Cardiac dysrhythmias- most serious side effect*. - AV block (atrio-ventricular) Must monitor potassium level. - normal range is 3.5 to 5.0 mEq/L. Non-cardiac side effects- - anorexia, nausea, vomiting, fatigue, headache. - visual disturbances- halo vision, blurred vision.

Types of angina

*Chronic stable angina*- A chronic narrowing usually caused by atherosclerosis: occurs with predictable stress of exertion; also called exertional angina — angina triggered by physical exercise, nicotine, caffeine; usually subsides within 15 minutes. *Unstable angina*- Acute, can be triggered by a rupture of a coronary artery; can end in an MI; pain may occur at rest. *Vasospastic angina (Prinzmetal)*- coronary artery vasospasm; can occur at rest and without a precipitating factor; also called *variant angina*.

Indications for anti-dysrhythmics

*Class Ia*- suppression of ventricular and supraventricular dysrhythmias. *Class Ib*- short-term use only for ventricular dysrhythmias. *Class Ic*- maintenance therapy of supraventricular dysrhythmias. *Class II*- dysrhythmias caused by excessive sympathetic stimulation. *Class III*- A-fib, a-flutter, life-threatening ventricular dysrhythmias. *Class IV*- ventricular rate control in patients with supraventricular tachy-dysrhythmias, a-fib, a-flutter.

Nursing implications for certain Bile Acid Sequestrants

*Colesevelam (Welchol)*- fewer GI adverse effects and interactions. Take with 4-8 ounces of fruit juice or water. *Cholestryramine (Questran)*- Phenylketonuria (PKU) issue. Take with meals.

Contraindications and adverse effects of Fondaparinux (Arixtra)

*Contraindications* - creatinine clearance below 30 mL/min. - body weight below 50 kg. *Adverse effects*- - bleeding (no antidote) - thrombocytopenia - *Black box warning*: potential spinal hematoma if the patient has an epidural catheter. Can interact with other medications that cause bleeding.

Contraindications and Interactions with the use of Low-molecular weight heparin

*Contraindications*- - allergy - cautious use in clients with heparin induced thrombocytopenia (HIT). - lumbar anesthesia. - major bleeding. *Interactions*- - anti-platelet drugs increase the chance of bleeding. - NSAIDs

Contraindications and adverse effects of Phosphodiesterase inhibitors-

*Contraindications*- allergy, aortic or pulmonary valve disease, diastolic dysfunction. *Adverse effects*- hypotension, angina, dizziness.

Contraindications and adverse effects of Angiotensin Receptor Blockers (ARBs)

*Contraindications*- drug allergy, pregnancy, lactation; use cautiously in older adults and in patients with renal dysfunction. *Adverse effects-* angioedema, fetal harm, renal failure, hyperkalemia, chest pain, fatigue, hypoglycemia, diarrhea, UTI, anemia, and weakness.

Indications and Contraindications for use of Beta blockers

*Indications*- exertional (exercise induced) angina (not used to treat acute angina). Also used to treat MI, hypertension, cardiac dysrhythmias, and essential tremor. *Contraindications*- acute heart failure, heart block. *Cautious use in patients with*- diabetes mellitus, heart failure, AV block.

S/S of Left-sided vs Right-sided Heart Failure

*Left-sided* = pulmonary edema, coughing, shortness of breath, and dyspnea. *Right-sided* = systemic venous congestion, pedal edema, jugular venous distention, ascites, and hepatic congestion.

EKG Waves/Intervals

*P wave*- atrial depolarization. *QRS wave*- ventricular depolarization. *T wave*- ventricular repolarization. *PR interval*- time between onset of the P wave and the onset of the QRS wave (lengthening this interval indicates a delay in conduction through the AV node). *QT interval*- time between the onset of the QRS complex and the completion of the T wave. *ST segment*- time between the end of QRS and the beginning of the T wave.

Antidote to heparin overdose

*Protamine sulfate*- effects are immediate. 1 mg of protamine will inactivate 100 units of heparin. Administered by slow IV injection.

Common Dysrhythmias— Categories

*Supraventricular*- originate above the ventricles in the SA or AV node or atria. *Ventricular*- originate below the AV node. *Ectopic*- outside the conduction system.

Alteplase (tPA, Activase)

*Tissue plasminogen activator* - activates plasmin which is an enzyme that digests clots. *Therapeutic uses*- - acute MI - acute ischemic stroke - acute massive PE (pulmonary embolism) - clotted central IV catheters Timing is crucial. Very short half-life, IV only. *Adverse effects*- BLEEDING! Dosing is based on reason for use.

Forms of lipids in the blood

*Triglycerides*- stored in adipose tissue, used as an energy source. *Cholesterol*- used to make steroid hormones, cell membranes, and bile acids.

Interactions with Gemifibrozil (Lopid)

*Warfarin*- gemifibrozil displaces warfarin from plasma albumin (thereby increasing anticoagulant effects); patients will be prone to bleeding. *Repaglinide (Prandin)*- hypoglycemia. *Sulfonylurea antidiabetic agents*- hypoglycemia. *Statins*- increase the chance of rhabdomyolysis.

Adverse effects of Niacin

- *Intense flushing of the face, neck, and ears* can occur in almost all patients receiving Niacin in pharmacologic doses. This reaction diminishes in several weeks and can be minimized by taking 325 mg of aspirin 30 minutes before each dose of Niacin. - Liver injury - Hyperglycemia - Gouty arthritis - GI upset - Increased uric acid levels

Adverse effects of HMG-CoA Reductase Inhibitors

- *Myopathy* (muscle pain): Risk is higher in patient with small frame, fraility, multi-system disease, renal disease, patients of Asian descent. - Liver injury - Cataracts - GI upset (abdominal pain, constipation, diarrhea, nausea) - Headache - Rash - Insomnia

Adverse effects of Bile Acid Sequestrants

- Devoid of systemic side effects because they are not absorbed from the GI tract. - Constipation - Nausea - Bloating/gas - Indigestion Administer with meals to decrease GI effect.

Classes of Anticoagulants

- Heparins - Selective factor Xa inhibitor - Coumadins - Direct thrombin inhibitors

Summary of the inotropic, chronotropic, dromotropic, and other effects produced by digoxin-

- Positive inotropic effect: increased contraction. - Negative chronotropic effect: reduced heart rate. - Negative dromotropic effect: decreased conduction. - Increase in stroke volume. - Reduction in heart size during diastole. - Decrease in venous blood pressure and vein engorgement. - Increase in coronary circulation. - Promotion of tissue perfusion and diuresis as a result of improved blood circulation. - Decrease in exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis. - Improved symptom control, quality of life, and exercise tolerance, but no apparent reduction in mortality.

Three main therapeutic objectives of antianginal drugs-

1) Minimize the frequency of attacks and decrease the duration and intensity of the anginal pain. 2) Improve the patient's functional capacity with as few adverse effects as possible. 3) Prevent or delay the worst possible outcome: myocardial infarction.

Categories of Antihypertensives

1. Adrenergics (many sub classes) 2. Angiotensin-converting enzyme inhibitors 3. Angiotensin II blockers 4. Direct renin inhibitors 5. Aldosterone antagonists 6. Calcium channel blockers 7. Direct acting vasodilators 8. Diuretics

Potential nursing diagnoses for a patient taking a diuretic

1. Decreased cardiac output r/t drug effects and adverse effects of diuretics (e.g., fluid and electrolyte loss). 2. Deficient fluid volume related to drug effects and adverse effects or diuretics. 3. Risk for injury related to postural hypotension and dizziness.

Five classes of Antilipemic drugs

1. Hydrooxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors 2. Bile acid sequestrants 3. B vitamin Niacin 4. Fibric acid derivatives 5. Cholesterol absorption inhibitors

Possibly nursing diagnoses for a patient with hypertension

1. Ineffective peripheral tissue perfusion r/t the impact of the hypertensive disease process and/or possible severe hypotensive adverse effects associated with antihypertensive drug therapy. 2. Sexual dysfunction r/t adverse effects of some antihypertensive drugs. 3. Constipation r/t adverse effects of some antihypertensive drugs. 4. Noncompliance with drug therapy r/t lack of familiarity with or acceptance of the disease process. 5. Risk for injury r/t possible antihypertensive drug-induced orthostatic hypotension with dizziness and syncope.

Dobutamine

A beta 1-selective adrenergic drug. Through stimulation of the beta 1 receptors on heart muscle (myocardium), it increases cardiac output by increase contractility (positive inotropy), which increases the stroke volume. Used in the short term management of acute heart failure. I.V. only. Dose is titrated to achieve therapeutic effects; up to 40 mcg/kg/min. Side effects: - tachycardia - palpitations/fluttering - infiltration Must be on continuous monitoring!

Patient teaching for Nitroglycerin

1. Keep a journal of angina attacks and triggers. 2. Never crush or chew extended release tablets. 3. How to store sublingual (SL) Nitroglycerin- keep in its original amber-colored glass container with metal lid to avoid loss of potency from exposure to heat, light, moisture, and cotton filler. 4. After taking SL nitro, patient should feel a burning or stinging sensation, if not then the drug has lost its potency. 5. Avoid alcohol and hot conditions. 6. Include nitro free periods. 7. Always keep a fresh supply (drug is potent for 3-6 months).

Embolus

A blood clot that moves through blood vessels.

Action potential

A rapid change in membrane potential, brought on by a rapid change in membrane permeability (cell depolarization and repolarization).

B-type natriuretic peptide (BNP) is-

A substance secreted from the ventricles of the heart in response to changes in pressure that occur when heart failure develops. The level of BNP in the blood increases when heart failure symptoms worsen. Acts as a natural diuretic.

Nesiritide (Natrecor)

A synthetic B-type natriuretic hormone that has vasodilating effects on both arteries and veins. Vasodilation + diuresis. Used in ICU settings only. Do not mix with other medications! IV bolus, then continuous drip. Side effects- - significant *hypotension*. - angina, palpitations - headache, dizziness Patients must be monitored at all times!

Which statement by the patient reflects the need for *additional* patient education about the calcium channel blocker diltiazem (Cardizem)? A. "I can take this drug to stop an attack of angina." B. "I understand that food and antacids alter the absorption of this oral drug." C. "When the long-acting forms are taken, the drug cannot be crushed." D. "This drug may cause my blood pressure to drop, so I need to be careful when getting up."

A. "I can take this drug to stop an attack of angina."

An older adult patient has been discharged following treatment for a mild case of heart failure. He will be taking a loop diuretic. Which instruction(s) from the nurse are appropriate? (Select all that apply) A. "Take the diuretic at the same time each morning." B. "Take the diuretic only if you notice swelling in your feet." C. "Be sure to stand up slowly because the medicine may make you feel dizzy if you stand up quickly." D. "Drink at least 8 glasses of water each day." E. "Here is a list of foods that are high in potassium; you need to avoid these." F. "Please call your doctor immediately if you notice muscle weakness or increased dizziness."

A. "Take the diuretic at the same time each morning." C. "Be sure to stand up slowly because the medicine may make you feel dizzy if you stand up quickly." F. "Please call your doctor immediately if you notice muscle weakness or increased dizziness."

A beta 1 blocker is prescribed for a patient with heart failure and hypertension. Which adverse effects, if present, may indicate a serious problem is developing while the patient is taking this medication? (Select all that apply) A. Edema B. Nightmares C. Shortness of breath D. Nervousness E. Constipation

A. Edema C. Shortness of breath

The nurse is reviewing drug interactions with a male patient who has a prescription for isosorbide dinitrate (Isordil) as treatment for angina symptoms. Which substances listed below could potentially result in a drug interaction? (Select all that apply) A. A glass of wine B. Thyroid replacement hormone C. Tadalafil (Cialis), an erectile dysfunction drug. D. Metformin (Glucophage), an antidiabetic drug. E. Carvedilol (Coreg), a beta blocker.

A. A glass of wine C. Tadalafil (Cialis), an erectile dysfunction drug. E. Carvedilol (Coreg), a beta blocker.

What assessment finding in a patient with heart failure receiving furosemide would indicate an improvement in fluid volume status? A. Absence of crackles on auscultation of lungs. B. Complaints of proximal nocturnal dyspnea. C. Bounding radial pulse. D. Decrease in hematocrit.

A. Absence of crackles on auscultation of lungs.

When giving antihypertensive drugs, the nurse will consider giving the first dose at bedtime for which class of drugs? A. Alpha blockers such as doxazosin. B. Diuretics such as furosemide. C. ACE inhibitors such as captopril. D. Vasodilators such as hydralazine.

A. Alpha blockers such as doxazosin.

When caring for a patient who is taking digoxin, the nurse will monitor for which signs and symptoms of toxicity? (Select all that apply) A. Anorexia B. Diarrhea C. Visual changes D. Nausea and vomiting E. Headache F. Bradycardia

A. Anorexia C. Visual changes D. Nausea and vomiting E. Headache F. Bradycardia

A patient is at risk for a stroke. Which drug is recommended to prevent platelet aggregation for stroke prevention by the American Stroke Society? A. Aspirin B. Warfarin sodium (Coumadin) C. Heparin D. Alteplase (Activase)

A. Aspirin

The nurse is reviewing the use of anticoagulants. Anticoagulant therapy is appropriate for which conditions? (Select all that apply) A. Atrial fibrillation B. Thrombocytopenia C. Myocardial infarction D. Presence of mechanical heart valve E. Aneurysm F. Leukemia

A. Atrial fibrillation C. Myocardial infarction D. Presence of mechanical heart valve

During his morning walk, a man begins to experience chest pain. He sits down and takes one nitroglycerin sublingual tablet. After 5 minutes, the chest pain is worsening. What action would be the priority in this situation? A. Call 911 (emergency medical services) B. Take another nitroglycerin tablet. C. Take two more nitroglycerin tablets at the same time. D. Sit quietly to wait for the pain to subside.

A. Call 911 (emergency medical services)

The nurse would identify which of the following as the most serious side effect of milrinone (Primacor)- A. Cardiac dysrhythmias B. Hypotension C. Heart failure D. Liver toxicity

A. Cardiac dysrhythmias

The nurse is reviewing dosage forms of nitroglycerin (Nitrostat). This drug can be given by which routes? (Select all that apply) A. Continuous intravenous drip B. Intravenous bolus C. Sublingual spray D. Oral dosage forms E. Topical ointment F. Rectal suppository

A. Continuous intravenous drip C. Sublingual spray D. Oral dosage forms E. Topical ointment

When administering Niacin, the nurse needs to monitor for which adverse effect? A. Cutaneous flushing B. Muscle pain C. Headache D. Constipation

A. Cutaneous flushing

When monitoring laboratory test results for patients receiving loop diuretics, the nurse knows to look for- A. Decreased serum levels of potassium. B. Increased serum levels of calcium. C. Decreased serum levels of glucose's D. Increased serum levels of sodium.

A. Decreased serum levels of potassium.

When monitoring a patient who is receiving an intravenous infusion of nesiritide (Natrecor), the nurse will look for which adverse effect? A. Dysrhythmias B. Proteinuria C. Hyperglycemia D. Hypertension

A. Dysrhythmias

Adverse effects of nesiritide (Natrecor) include which of the following? (Select all that apply) A. Hypotension B. Cardiac dysrhythmias C. Insomnia D. Headache E. Abdominal pain F. Photosensitivity

A. Hypotension B. Cardiac dysrhythmias C. Insomnia D. Headache E. Abdominal pain

The nurse is assessing a patient who has a new prescription for vorapaxar (Zontivity). Which of these conditions are considered contraindications to the use of vorapaxar? (Select all that apply) A. Impaired renal function B. Impaired liver function C. History of myocardial infarction D. Peripheral artery disease E. History of stroke

A. Impaired renal function B. Impaired liver function E. History of stroke

In reviewing the history of a newly admitted cardiac patient, the nurse knows that the patient would have a contraindication to antilipemic therapy of which condition is present? A. Liver disease B. Renal disease C. Coronary artery disease D. Diabetes mellitus

A. Liver disease

The greatest volume of diuresis is produced by which class of diuretics? A. Loop B. Thiazide C. Osmotic D. Potassium sparing

A. Loop

Which statement regarding digoxin therapy and potassium levels is correct? A. Low potassium levels increase the chance of digoxin toxicity. B. High potassium levels increase the chance of digoxin toxicity. C. Digoxin reduces the excretion of potassium in the kidneys. D. Digoxin promotes the excretion of potassium in the kidneys.

A. Low potassium levels increase the chance of digoxin toxicity.

When teaching a patient about diuretic therapy, which would the nurse indicate as the best time of day to take these medications? A. Morning B. Midday C. Bedtime D. The time of day does not matter

A. Morning

The nurse is administering an intravenous infusion of a Phosphodiesterase inhibitor to a patient who has heart failure. The nurse will evaluate the patient for which therapeutic effects? (Select all that apply) A. Positive inotropic effects B. Vasodilation C. Decreased heart rate D. Increased blood pressure E. Positive chronotropic effects

A. Positive inotropic effects B. Vasodilation E. Positive chronotropic effects

The nurse would recognize which of the following symptoms as descriptive of a side effects of nitrates? A. Reflex tachycardia B. Hypertension C. Nausea D. Cough

A. Reflex tachycardia

A patient is being treated for a hypertensive emergency. The nurse expects which drug to be used? A. Sodium nitroprusside B. Losartan C. Captopril D. Prazosin

A. Sodium nitroprusside

The nurse will instruct the patient taking antilipemic drugs about which dietary measures? (Select all that apply) A. Taking supplements of fat-soluble vitamins B. Taking supplements of B vitamins C. Increasing fluid intake D. Choosing foods that are lower in cholesterol and saturated fats E. Increasing the intake of raw vegetables, fruit, and bran.

A. Taking supplements of fat-soluble vitamins C. Increasing fluid intake D. Choosing foods that are lower in cholesterol and saturated fats E. Increasing the intake of raw vegetables, fruit, and bran.

Which of the following describes a rationale for the administration of nitroglycerin by the sublingual route? A. The first pass effect is avoided. B. Side effects are lessened. C. Patients can self-administer. D. It can be used in patients with swallowing problems.

A. The first pass effect is avoided.

Patients who are taking beta blockers for angina need to be taught which information? A. These drugs are for long-term prevention of angina episodes. B. These drugs must be taken as soon as angina pain occurs. C. These drugs will be discontinued if dizziness is experienced. D. These drugs need to be carried with the patient at all times in case angina occurs.

A. These drugs are for long-term prevention of angina episodes.

A patient taking a statin calls the office to report an increase in muscle pain. Which information takes priority as the nurse communications with the patient? A. This could be the sign of a serious side effect, stop taking the medication immediately. B. You should take a dose of ibuprofen for the next few days. C. This is an expected occurrence; continue the dose as prescribed. D. Did you pull a muscle or injure yourself?

A. This could be the sign of a serious side effect, stop taking the medication immediately.

Which are indications for the use of diuretics? (Select all that apply) A. To increase urine output. B. To reduce uric acid levels. C. To treat hypertension. D. To treat open-angle glaucoma. E. To treat edema associated with heart failure.

A. To increase urine output. C. To treat hypertension. D. To treat open-angle glaucoma. E. To treat edema associated with heart failure.

The nurse is preparing to administer a newly ordered statin drug to a patient and is reviewing the patient's list of current medications. Which medications may cause an interaction with the statin drug? (Select all that apply) A. Warfarin (Coumadin) B. Metformin (Glucophage) C. Erythromycin (Erythrocin) D. Cyclosporine (Gengraf) E. Gemfibrozil (Lopid)

A. Warfarin (Coumadin) C. Erythromycin (Erythrocin) D. Cyclosporine (Gengraf) E. Gemfibrozil (Lopid)

A patient who has heart failure will be started on an oral ACE inhibitor. While monitoring the patient's response to this drug therapy, which laboratory tests would be a priority? (Select all that apply) A. White blood cell count B. Platelet count C. Serum potassium level D. Serum magnesium level E. Creatinine level F. Blood urea nitrogen (BUN)

A. White blood cell count C. Serum potassium level E. Creatinine level F. Blood urea nitrogen (BUN)

Contraindications to the use of Heparin (unfractionated)

Allergy Uncontrolled bleeding. Decreased platelets. Avoid both during and immediately after eye surgery, brain surgery, or spinal cord surgery. Lumbar puncture.

acetylcholine

ACh; chemical neurotransmitter in the parasympathetic nervous system

Contraindications to the use of Calcium channel blockers

Allergy Acute MI Second- or third-degree AV block Hypotension

Dysrhythmia

Abnormal heart rhythm. Any deviation from the normal rhythm of the heart. Involves changes to either automaticity or conductivity.

Mechanism of action of Nitrates/Nitrites

Acts directly on vascular smooth muscle. Dilates veins and arteries (primarily veins) which will reduce preload. Can also directly dilate coronary arteries.

Direct Renin Inhibitor

Acts on renin to inhibit the conversion of angiotensin to angiotensin I. Example drug- Aliskiren

Administration of Adenosine (Adenocard)

Administer 6mg by rapid bolus (over 1-2 seconds). If after 1-2 minutes PSVT isn't eliminated, give 12 mg (rapid bolus). If needed, give one more dose of 12 mg. (Think 6-12-12)

Interactions with Nitrates/Nitrites

Alcohol Anti-hypertensives Erectile dysfunction drugs

Prolongs survival of heart failure patients by blocking aldosterone receptors and preventing heart remodeling, heart and vascular fibrosis, baroreceptor dysfunction, and dysrhythmias, in addition to mild reduction in blood volume by increasing excretion of water and sodium with conservation of potassium.

Aldosterone receptor antagonist (Eplerenone)

Indications for use of Nitrates/Nitrites

All forms of angina (stable, unstable, vasospastic). Long-acting forms are used for prophylaxis (prevention) Rapid-acting forms are used to treat acute angina attacks.

Contraindications to the use of Warfarin (Coumadin)

Allergy Thrombocytopenia Patients undergoing lumbar puncture, spinal anesthesia. Eye, brain, or spinal cord injury. Any bleeding disorder — should be closely monitored. Pregnancy.

Contraindications to the use of Bile Acid Sequestrants

Allergy. Biliary or bowel obstruction. *Phenylketonuria (PKU)*- an inherited disease. Increases the amount of phenylanine (building blocks of proteins) in the blood. If not treated, can lead to intellectual disability and health problems.

Contraindications to the use of Nitrates/Nitrites

Allergy. Hypotension. Increased intracranial pressure (ICP). Patients using erectile dysfunction medications. Anemia. Closed-angle glaucoma.

Potassium-sparing diuretics

Also referred to as aldosterone-inhibiting diuretics because they block the aldosterone receptors. Can cause two potentially therapeutic responses: - modest increase in urine production. - produce a substantial decrease in potassium excretion. Rarely used alone for diuresis.

Nursing implications

Always take BP and heart rate before giving any antihypertensive (parameters are usually set by the prescriber, HR should be > 60 and BP > 100 systolic. Always monitor for side effects. Monitor lab values.

Heart failure

An abnormal condition in which the heart cannot pump enough blood to keep up with the body's demand. It is often the result of myocardial infarction, ischemic heart disease, or cardiomyopathy. Risk factors- obesity, coronary artery disease (CAD), diabetes mellitus (DM), hypertension (HTN).

Angina

An imbalance of oxygen supply and demand.

Therapeutic effects of antihypertensives

An improvement in blood pressure and in the disease process. A return to a normal baseline level of blood pressure with improved energy levels and decreased signs and symptoms of hypertension, such as less edema, improved breath sounds, no abnormal heart sounds, capillary refill in less than 5 seconds, and less shortness of breath.

Medications to treat heart failure

Angiotensin converting Enzyme (ACE) inhibitors. Angiotensin II receptor blockers (ARBs). Beta-blockers. Diuretics. Direct-acting vasodilators. Aldosterone antagonists. B-type natriuretic peptide. Phosphodiesterase inhibitors. Cardiac glycoside.

Decrease aldosterone production resulting in vasodilation and mild reduction in blood volume by increasing excretion of water and sodium with conservation of potassium, do not cause cough and do not prevent heart remodeling.

Angiotensin receptor blockers (ARBs) (valsartan)

Increase level of kinins and decrease aldosterone production resulting in vasodilation, some prevention of heart remodeling, and mild reduction in blood volume by increasing excretion of water and sodium with conservation of potassium.

Angiotensin-converting enzyme (ACE) inhibitors (Captopril)

Examples of HMG-CoA Reductase Inhibitors

Atorvastatin (Lipitor) Fluvastatin (Lescol) Lovastatin (Mevacor) Pravastatin (Pravachol) Simvastatin (Zocor) Rosuvastatin (Crestor) Pitavastatin (Livalo)

Abciximab (ReoPro)

Anti-platelet drug. Inhibits the final step of platelet aggregation (GP IIb/IIIa inhibitor). *Therapeutic uses-* - short term to prevent ischemic events in patients with acute coronary syndrome and those undergoing percutaneous coronary intervention; usually given with aspirin (ASA) and heparin. IV only, draw up and administer through a filter. Expensive ($1200/dose). Other examples of GP IIb/IIIa inhibitors: eptifibatide (Integrilin), tirofiban (Aggrastat).

Clopidogrel (Plavix)

Anti-platelet drug. Adenosine diphosphate (ADP) inhibitor. *MOA*- blocks specific receptors on platelets, therefore preventing aggregation. *Therapeutic uses*- - prevent blockage of *coronary artery stents* - reduce thrombotic events *Dosing*- available in 75 mg tablets taken once daily.

Drug interactions with Heparin (unfractionated)

Anti-platelet medications; oral anticoagulants. Nitroglycerin Cephalosporins, penicillins

Aspirin (acetylsalicylic acid)

Anti-platelet. Suppresses platelet aggregation by causing irreversible inhibition of cyclooxygenase (an enzyme required for the synthesis of thromboxane A2, which causes platelet aggregation). *Forms-* enteric coated, buffered, rectal, chewable. *ASA poisoning*- - medical emergency - can cause respiratory depression

Rivaroxaban (Xarelto)

Anticoagulant. Direct Factor Xa Inhibitor. *Therapeutic uses*- - prevention of DVT following hip/knee surgery. - prevention of stroke in patients with a-fib. - treatment of DVT or PE. - to decrease risk of recurrent DVT or PE. Administered P.O. Avoid use with other anticoagulants. Cautious use with liver/renal patients. Unsafe to use during pregnancy. Dose depends on reason for use.

Dabigatran (Pradaxa)

Anticoagulant. Direct thrombin inhibitor. *Therapeutic uses*- prevention of strokes and thrombosis in patients with nonvalvular atrial fibrillation. *Dosing*- - 150 mg BID for a-fib (P.O.) - reduced for patients with renal dysfunction (75 mg BID).

Heparin (unfractionated)

Anticoagulant. Rapid-acting, very short half-life. Inactivates thrombin and factor Xa. Turns off the coagulation pathway and prevents clots from forming. Does not readily cross membranes (why it can't be administered orally). Does not cross the placenta or breast milk. Parenteral only. IV bolus then continuous infusion, or given SQ.

Low-molecular weight heparin

Anticoagulant. Heparin preparations composed of molecules that are shorter than those in unfractionated heparin. Two available preparations: - Enoxoparin (Lovenox) - Dalteparin (Fragmin) Preferentially inactivates factor Xa. Do not need to monitor PTT. Expensive.

Fondaparinux (Arixtra)

Anticoagulant. Selective inhibitor of factor Xa. Approved for- - preventing deep vein thrombosis (DVT) following surgery. - acute PE/DVT (in conjunction with warfarin). Administer SubQ. Administered using a fixed dosage, does not require laboratory monitoring. Cautious use with renal impairment.

Warfarin (Coumadin)

Anticoagulant. Vitamin K antagonist (inhibits the enzyme needed to convert vitamin K to the active form). -> Inhibits vitamin K-dependent clotting factors. P.O. dosing; highly protein bound. Long half-life, effects are not immediate. Many, many drug interactions. Cautious use with patients with liver dysfunction.

Categories of coagulation modifiers

Anticoagulants Anti-platelet drugs Thrombolytic drugs Anti-fibrinolytic drugs

Interactions with the use of Aspirin (acetylsalicylic acid)

Anticoagulants Glucocorticoids Alcohol NSAIDs ACE inhibitors, ARBs.

Direct thrombin inhibitors

Anticoagulants. Direct inhibits thrombin (thrombin is an enzyme that causes clot formations). Examples: Argatroban, Dabigatran (Pradaxa).

Hemostasis

Any process that stops bleeding

Class III- Amiodarone (Cordarone)

Approved for long-term therapy of recurrent ventricular fibrillation and ventricular tachycardia, atrial fibrillation. Delays repolarization and prolongs the action potential. QRS widening, prolongation of QT and PR intervals. Many, many interactions. - avoid grapefruit juice, can increase levels of amiodarone. - digoxin, quinidine, Coumadin.

Dosing of Digoxin- Cardiac Glycoside

Available in 3 formulations- *Tablets*- 0.125 and 0.25 mg. *Pediatric elixir*- 0.05 mg/mL. *Solution for injection*- 0.01 and 0.25 mg/mL. Normal adult dosage is 0.75 - 1.5 mg/day.

Preparations of Niacin

Available under several trade names and generically. Available in immediate release, timed release, controlled release, sustained release, and extended release. Available as capsules and tablets.

During teaching of a patient who will be taking warfarin sodium (Coumadin) at home, which statement by the nurse is correct regarding over-the-counter drug use? A. "Choose nonsteriodal antiinflammatory drugs as needed for pain." B. "Aspirin products may result in increased bleeding." C. "Vitamin E therapy is recommended to improve the effect of warfarin." D. "Mineral oil is the laxative of choice while taking anticoagulants."

B. "Aspirin products may result in increased bleeding."

Which statement needs to be included when the nurse provides patient education for a patient with heart failure who is taking daily doses of spironolactone (Aldactone)? A. "Be sure to eat foods that are high in potassium." B. "Avoid foods that are high in potassium." C. "Avoid grapefruit juice while taking this medication." D. "A low-fiber diet will help prevent adverse effects of this medication."

B. "Avoid foods that are high in potassium."

A nurse is instructing a patient on dietary considerations while taking spironolactone (Aldactone). Which of the following statements made by the patient indicates that further teaching is necessary? A. "I should not eat foods high in potassium while taking this medication." B. "I should use a salt substitute instead of regular salt." C. "I should call my nurse practitioner if I have significant adverse effects from my medications." D. "I should not take large amounts of potassium chloride supplements."

B. "I should use a salt substitute instead of regular salt."

A 68-year-old male patient has been taking the nitrate isosorbide dinitrate (Isordil) for 2 years for angina. He recently has been experiencing erectile dysfunction and wants a prescription for sildenafil (Viagra). Which response would the nurse most likely hear from the prescriber? A. "He will have to be switched to isosorbide mononitrate if he wants to take sildenafil." B. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists." C. "I'll write a prescription, but if he uses it, he needs to stop taking the isosorbide for one dose." D. "These drugs are compatible with each other, so I'll write a prescription."

B. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists."

A 46-year-old man started antihypertensive drug therapy 3 months earlier and is in the office for a follow-up visit. While the nurse is taking his blood pressure, he informs the nurse that he has had some problems with sexual intercourse. Which is the most appropriate response by the nurse? A. "Not to worry. Eventually, tolerance will develop." B. "The physician can work with you on changing the dose and/or drugs." C. "Sexual dysfunction happens with this therapy, and you will learn to accept it." D. "This is an unusual occurrence, but it is important to stay on your medications."

B. "The physician can work with you on changing the dose and/or drugs."

The nurse is teaching a patient about self-administration of enoxaparin (Lovenox). Which statement will be included in this teaching session? A. "We will teach a family member how to give this drug in your arm." B. "This drug is given in the folds of your abdomen, but at least 2 inches away from your navel." C. "This drug needs to be taken at the same time everyday with a full glass of water." D. "Be sure to massage the injection site thoroughly after giving the drug."

B. "This drug is given in the folds of your abdomen, but at least 2 inches away from your navel."

A patient is currently taking a statin. The nurse considers that the patient may have a higher risk for developing rhabdomyolysis when also taking which product? A. NSAIDs B. A fibric acid derivative C. Orange juice D. Fat-soluble vitamins

B. A fibric acid derivative

A patient has a new prescription for an ACE inhibitor. During a review of the patient's list of current medications, which would cause concern for a possible interaction with this new prescription? (Select all that apply) A. A benzodiazepine taken as needed for allergies. B. A potassium supplement taken daily. C. An oral anticoagulant taken daily. D. An opioid used for occasional severe pain. E. An NSAID taken as needed for headaches.

B. A potassium supplement taken daily. E. An NSAID taken as needed for headaches.

A nurse administering Niacin would implement which action to help to reduce adverse effects? A. Give the medication with grapefruit juice. B. Administer a small dose or aspirin or an NSAID 30 minutes before the Niacin dose. C. Administer the medication on an empty stomach. D. Have the patient increase dietary fiber intake.

B. Administer a small dose or aspirin or an NSAID 30 minutes before the Niacin dose.

A patient is starting warfarin (Coumadin) therapy as part of treatment for atrial fibrillation. The nurse will follow which principles of warfarin therapy? (Select all that apply) A. Teach proper subcutaneous administration. B. Administer the oral dose at the same time every day. C. Assess carefully for excessive bruising or unusual bleeding. D. Monitor laboratory results for a target INR of 2 to 3. E. Monitor laboratory results for a therapeutic aPTT value of 1.5 to 2.5 the control value.

B. Administer the oral dose at the same time every day. C. Assess carefully for excessive bruising or unusual bleeding. D. Monitor laboratory results for a target INR of 2 to 3.

The nurse is administering cholestyramine (Questran), a bile acid sequestrant. Which nursing intervention(s) is appropriate? (Select all that apply) A. Administering the drug on an empty stomach. B. Administering the drug with meals. C. Instructing the patient to follow a low-fiber diet while taking this drug. D. Instructing the patient to take a fiber supplement while taking this drug. E. Increasing fluid intake. F. Not administering this drug at the same time as other drugs.

B. Administering the drug with meals. D. Instructing the patient to take a fiber supplement while taking this drug. E. Increasing fluid intake. F. Not administering this drug at the same time as other drugs.

A patient with coronary artery spasms will be most effectively treated with which type of antianginal medication? A. Beta blockers B. Calcium channel blockers C. Nitrates D. Nitrites

B. Calcium channel blockers

When teaching the patient about the signs and symptoms of cardiac glycoside toxicity, the nurse should alert the patient to watch for- A. Visual changes such as photophobia. B. Flickering lights or halos around lights. C. Dizziness when standing up. D. Increased urine output.

B. Flickering lights or halos around lights.

A patient has received a double dose of heparin during surgery and is bleeding through the incision site. While the surgeons are working to stop the bleeding at the incision site, the nurse will prepare to take what action at this time? A. Give IV vitamin K as an antidote. B. Give IV protamine sulfate as an antidote. C. Call the blood bank for an immediate platelet infusion. D. Obtain an order for packed red blood cells.

B. Give IV protamine sulfate as an antidote.

The nurse is preparing a patient's morning medications and, upon reviewing the list of drugs, notes that the patient is to receive heparin 5000 units and enoxaparin (Lovenox), both subcutaneously. What is the nurse's priority action at this time? A. Administer the drugs in separate sites. B. Hold the drugs and clarify the order with the prescriber. C. Administer the enoxaparin and hold the heparin. D. Check the patient's aPTT.

B. Hold the drugs and clarify the order with the prescriber.

The nursing is administering antihypertensive drugs to older adult patients. The nurse knows which adverse effect is of most concern for these patients? A. Dry mouth B. Hypotension C. Restlessness D. Constipation

B. Hypotension

During thrombolytic therapy, the nurse monitors for bleeding. Which symptoms may indicate a serious bleeding problem? (Select all that apply) A. Hypertension B. Hypotension C. Decreased level of consciousness D. Increased pulse rate E. Restlessness

B. Hypotension C. Decreased level of consciousness D. Increased pulse rate E. Restlessness

A patient with type 2 diabetes mellitus has developed hypertension. What is the blood pressure goal for this patient? A. Less than 110/80 mmHg. B. Less than 130/80 mmHg. C. Less that 130/84 mmHg. D. Less that 140/90 mmHg.

B. Less than 130/80 mmHg.

A patient is taking an aminoglycoside antibiotic for pneumonia, and will also be taking the loop diuretic furosemide (Lasix) due to fluid overload. The nurse will monitor carefully for which potential effect from the interaction of these two drugs? A. Nephrotoxicity B. Ototoxicity C. Pulmonary fibrosis D. Hepatotoxicity

B. Ototoxicity

A patient is taking a beta blocker as part of the treatment plan for heart failure. The nurse knows that the purpose of the beta blocker for this patient is to- A. Increase urine output. B. Prevent stimulation of the heart by catecholamines. C. Increase the contractility of the heart muscle. D. Cause peripheral vasodilation.

B. Prevent stimulation of the heart by catecholamines.

A patient has a new order for daily doses of spironolactone (Aldactone). Which condition, if present, may be a contraindication to this drug therapy? (Select all that apply) A. Heart failure B. Renal failure C. Diabetes mellitus D. Deep vein thrombosis E. Hyperkalemia

B. Renal failure E. Hyperkalemia

When infusing milrinone (Primacor), the nurse will keep which considerations in mind? A. The patient must be monitored for hyperkalemia. B. The patient's cardiac status must be monitored closely. C. The drug may cause reddish discoloration of the extremities. D. Hypertension is the primary effect seen with excessive doses.

B. The patient's cardiac status must be monitored closely.

Which statement is true regarding enoxaparin (Lovenox) and dalteparin (Fragmin)? A. Their method of action is to interrupt vitamin K-dependent clotting factors. B. They do not require clotting time monitoring. C. They are administered deep IM. D. They have thrombolytic properties.

B. They do not require clotting time monitoring.

The nurse is assessing a patient who has been taking quinidine and asks about adverse effects. An adverse effect associated with the use of this drug includes: A. Muscle pain B. Tinnitus C. Chest pain D. Excessive thirst

B. Tinnitus

A patient has been taking simvastatin (Zocor) for 6 months. Today he received a call that he needs to come to the office for a "laboratory check". The nurse expects which laboratory studies to be ordered at this time? (Select all that apply) A. PT/INR B. Total cholesterol C. Triglyceride D. Liver function studies E. Complete blood count F. HDL and LDL levels

B. Total cholesterol C. Triglyceride D. Liver function studies F. HDL and LDL levels

A patient with a rapid, irregular heart rhythm is being treated in the emergency department with adenosine. During administration of this drug, the nurse will be prepared to monitor the patient for which effect? A. Nausea and vomiting B. Transitory asystole C. Muscle tetany D. Hypertension

B. Transitory asystole

Verapamil (Calan, Isotopin)

Blocks calcium channels in the heart and blood vessels. The following occurs- - vasodilation - increased coronary artery perfusion *Indicated for* hypertension, angina, cardiac dysrhythmias. Administered P.O. or IV, extensive first pass through the liver. *Adverse effects:* edema, constipation, bradycardia, flushing, decreased conduction, headache. *Interactions:* beta blockers, grapefruit juice, digoxin.

Nursing implications for Furosemide (Lasix)

Best on empty stomach, but can take with food if GI upset occurs. Give as early in the day as possible. If given P.O., should urinate within 60 min. If given IV, should urinate within 5-10 minutes. Assess for dehydration, vital signs, urine output, weight, monitor electrolytes, blood glucose levels. Do not exceed 4mg/min for IV bolus. *Black box alert*- large amounts can lead to profound diuresis with water and electrolyte loss.

Slow the heart rate and can reduce the force of contraction if dose is not carefully titrated.

Beta-Adrenergic receptor blockers (beta-blockers) (Metoprolol)

Mechanism of action of Bile Acid Sequestrants

Bile acids are normally reabsorbed and reused. Bile Acid Sequestrants prevent this reabsorption and accelerates their excretion (in the stool). An increase in excretion demands an increased synthesis of bile acids. Bile acids require cholesterol for synthesis, so the liver converts more cholesterol into bile acids which decreases the amount of cholesterol in the blood.

Adverse effects of Abciximab (ReoPro)

Bleeding Bradycardia Thrombocytopenia Interacts with other drugs that can increase the chance of bleeding.

Adverse effects of Rivaroxaban (Xarelto)

Bleeding Extremity pain, muscle spasms. *Black box warning*- Risk for hematoma with epidural/spinal anesthesia. Increased chance of thrombotic events if drug is abruptly.

Adverse effects of Low-molecular weight heparin

Bleeding Thrombocytopenia *Black box warning*- avoid in patients undergoing lumbar puncture or spinal anesthesia.

Calcium Channel Blockers

Block calcium channels in blood vessels (vascular smooth muscles), which causes vasodilation in arterioles (little to no effect in veins). *Therapeutic uses:* hypertension, angina, cardiac dysrhythmias.

Aldosterone Antagonist

Block receptors of aldosterone. Example drug- Eplerenon

Angiotensin Receptor Blockers (ARBs)

Block the *actions* of angiotensin II (ACE inhibitors block the *production* of angiotensin II). Effects are much like those of ACE inhibitors, but do not increase bradykinin (thus less incidence of a cough). *Therapeutic uses:* hypertension, heart failure, diabetic neuropathy, stroke prevention, prevent mortality following MI.

Interactions with Beta blockers

Calcium channel blockers Insulin Oral anti-diabetic meds Diuretics Other anti-hypertensives

Cultural implications

Both thiazide-type diuretics and calcium channel blockers (CCBs) are recommended as first-line therapy for management of HTN in black patients. Asian patients receiving a CCB have been reported as achieving the highest rates of control of HTN. ARBs and ACEIs appear to have tolerability and/or adherence advantages. Asian patients have increased risk of occurrence of serious side effects with diuretic use.

The most common adverse effects of adrenergic drugs are-

Bradycardia with reflex tachycardia. Postural and postexercise hypotension. Dry mouth Drowsiness, dizziness. Depression Edema Constipation Sexual dysfunction Other- headache, sleep disturbances, nausea, rash, and palpitations.

Nonsustained ventricular tachycardia (NSVT)

Brief period of ventricular tachycardia.

A 46-year-old man has been taking clonidine for 5 months. For the past 2 months, his blood pressure has been normal. During this office visit, he tells the nurse that he would like to stop taking the drug. What is the nurse's best response? A. "I'm sure the doctor will the stop it — your blood pressure is normal now." B. "Your doctor will probably have you stop taking the drug for a month, and then we'll see how you do." C. "This drug should not be stopped suddenly; let's talk to your doctor." D. "It's likely that you can stop the drug if you exercise and avoid salty foods."

C. "This drug should not be stopped suddenly; let's talk to your doctor."

Given the nurse's knowledge of the side effects of alpha blockers, which instruction should the nurse provide to the patient with a new order for an alpha blocker to treat hypertension? A. Drink plenty of fluids. B. Wear sunscreen outside. C. Change positions slowly. D. Increase intake of potassium-rich foods.

C. Change positions slowly.

A patient with heart failure will be starting the beta blocker metoprolol (Lopressor). The nurse will monitor for which expected cardiovascular effects? (Select all that apply) A. Increased heart rate B. Increased myocardial contractility C. Delayed AV node conduction D. Reduced heart rate E. Decreased myocardial automaticity.

C. Delayed AV node conduction D. Reduced heart rate E. Decreased myocardial automaticity.

When a patient is being taught about the potential adverse effects of an ACE inhibitor, which of these effects should the nurse mention as possibly occurring when this drug is taken to treat hypertension? A. Diarrhea B. Nausea C. Dry, nonproductive cough D. Sedation

C. Dry, nonproductive cough

HMG-CoA Reductase Inhibitors are best taken in the- A. Morning B. Afternoon C. Evening

C. Evening Endogenous cholesterol is produced by the liver in the evening. All are dosed once daily.

The nurse will teach a patient who will be taking nitroglycerin (Nitrostat) about which common adverse effect of this drug? A. Blurred vision B. Dizziness C. Headache D. Weakness

C. Headache

A man is taking an oral hypoglycemic for management of his type 2 diabetes mellitus begins taking hydrochlorothiazide. The nurse should monitor for which of the following serum laboratory changes? A. Hypocalcemia B. Hypercalcemia C. Hyperglycemia D. Hypernatremia

C. Hyperglycemia

As part of treatment for early heart failure, a patient is started on an angiotensin-converting enzyme (ACE) inhibitor. The nurse will monitor the patient's laboratory work for which potential effect? A. Agranulocytosis B. Proteinuria C. Hyperkalemia D. Hypoglycemia

C. Hyperkalemia

The nurse is obtaining a drug history on the patient being treated for hypertension. The prescriber has chosen the angiotensin receptor blocker losartan (Avapro) to treat the patient's hypertension. Which drug on the patient's current drug list would most concern the nurse? A. Furosemide B. Albuterol C. Ibuprofen D. Augmentin

C. Ibuprofen (An NSAID)

When administering subcutaneous heparin, the nurse will remember to perform which action? A. Use the same sites for injection to reduce trauma. B. Use a 1-inch needle for subcutaneous injections. C. Inject the medication without aspirating for blood return. D. Massage the site after the injection to increase absorption.

C. Inject the medication without aspirating for blood return.

A nurse with adequate knowledge about the administration of intravenous Nitroglycerin will recognize that which statement is correct? A. The intravenous form is given by IV push injection. B. Because the intravenous forms are short-lived, the dosing must be every 2 hours. C. Intravenous Nitroglycerin must be protected from exposure to light through use of special tubing. D. Intravenous nitroglycerin can be given via gravity drip infusions.

C. Intravenous Nitroglycerin must be protected from exposure to light through use of special tubing.

Which point will the nurse emphasize to a patient who is taking an Antilipemic medication in the "statin" class? A. The drug needs to be taken on an empty stomach. B. A low-fat diet is not necessary while taking these medications. C. It is important to report muscle pain immediately. D. Improved cholesterol levels will be evident within 2 weeks.

C. It is important to report muscle pain immediately.

A patient is being assessed before a newly ordered Antilipemic medication is given. Which condition would be a potential contraindication? A. Diabetes insipidus B. Pulmonary fibrosis C. Liver cirrhosis D. Myocardial infarction

C. Liver cirrhosis

A patient is receiving instructions regarding warfarin therapy and asks the nurse about what medications she can take for headaches. The nurse will tell her to avoid which type of medication? A. Opioids B. Acetaminophen (Tylenol) C. NSAIDS D. There are no restrictions while taking warfarin.

C. NSAIDS

When assessing a patient who has been taking amiodarone for 6 months, the nurse monitors for which potential adverse effect? A. Hyperglycemia B. Dysphagia C. Photophobia D. Urticaria

C. Photophobia

A patient is receiving dabigatran (Pradaxa), 150 mg twice daily, as part of treatment for atrial fibrillation. Which condition, if present, would be concern if the patient were to receive this dose? A. Asthma B. Elevated liver enzymes C. Renal impairment D. History of myocardial infarction

C. Renal impairment

During assessment of a patient who is receiving digoxin, the nurse monitors for findings that wound indicate an increased possibility of toxicity, such as: A. Apical pulse rate of 62 beats/min. B. Digoxin level of 1.5 ng/mL. C. Serum potassium level of 2.0 mEq/L. D. Serum calcium level of 9.9 mEq/L.

C. Serum potassium level of 2.0 mEq/L.

When the nurse is checking the laboratory data for a patient taking spironolactone (Aldactone), which result would be a potential concern? A. Serum sodium level of 140 mEq/L. B. Serum calcium level of 10.2 mg/dL. C. Serum potassium level of 5.8 mEq/L. D. Serum magnesium level of 2.0 mg/dL.

C. Serum potassium level of 5.8 mEq/L.

What is the purpose of antianginal drug therapy? A. To increase myocardial oxygen demand. B. To increase blood flow to peripheral arteries. C. To increase blood flow to ischemic cardiac muscle. D. To decrease blood flow to ischemic cardiac muscle.

C. To increase blood flow to ischemic cardiac muscle.

A patient has a new prescription for transdermal Nitroglycerin patches. The nurse teaches the patient that these patches are most appropriately used for which reason? A. To relieve exertional angina. B. To prevent palpitations. C. To prevent the occurrence of angina. D. To stop an episode of angina.

C. To prevent the occurrence of angina.

Calcium channel blockers

Can increase supply and decrease demand. Blocks calcium channels in vascular smooth muscle (primarily arterioles); resulting in arterial dilation and decreased peripheral resistance (decrease in afterload). Used to treat chronic stable and vasospastic (variant) angina.

Examples of Angiotensin-Converting Enzyme (ACE) Inhibitors

Captopril Enalapril Fosinopril Lisinopril Moexipril Ramipril

Types of diuretic drugs

Carbonic anhydrase inhibitors Loop (high-ceiling) diuretics Osmotic diuretics Potassium-sparing diuretics Thiazide-like diuretics

Increases force of heart contraction, decreases heart rate, reduces vasoconstriction, and increases urine production.

Cardiac glycoside (Digoxin)

Direct-acting vasodilators

Cause direct vasodilation of peripheral arteries and veins. Example drugs- Hydralazine, Sodium nitroprusside, Minoxidil.

Sodium Nitroprusside (Nipride)

Causes arterial and venous dilation. Administered via IV only; effect begins immediately. *Adverse effects:* reflex tachycardia, excessive hypotension, cyanide poisoning (delirium, hallucinations). *Black box alert*: should only be mixed with D5W. Fresh solutions may appear faint brown in color; solutions that are deeply colored should be discarded. Protect from light when administering. Max rate of 10 mcg/kg/min (max rate can only be for 10 min. Do not mix with other drugs.

Hydralazine (Apresoline)

Causes selective dilation of arterioles, has little or no effect on veins. Occurs from direct action on vascular smooth muscle. Metabolism occurs by acetylation and is highly variable among patients. *Used to treat:* essential hypertension, hypertensive crisis, heart failure. *Adverse effects:* lupus-like syndrome (fever, joint pain, rash), reflex tachycardia, fluid retention, neutropenia, hemoglobin. Available P.O. and IV (IV reserves for treating hypertensive crisis).

Clonidine (Catapres)

Centrally acting alpha 2 receptor agonist. Highly lipid soluble. *Approved for* hypertension (HTN), severe pain, and ADHD. Off-label or investigational uses: migraine prevention, opioid withdrawal, Tourette's. *Adverse effects:* dry mouth, constipation, nightmares, sedation, rebound hypertension (if abruptly d/c), sexual dysfunction. Usually administer twice a day (BID); available as a transdermal patch. *Safety measures:* take 2nd dose at bedtime, monitor blood pressure, change positions slowly; use hard candy, gum, and increase fluid intake.

Nursing implications for Digoxin

Check apical heart rate before administering (needs to be > 60/min). Check dose carefully. Check for interactions.

Nursing implications for Quinidine (Quinidex)

Check apical pulse and BP before administering. Monitor for EKG changes. Monitor liver enzymes first 4-8 weeks. Administer with food to avoid GI upset. Avoid grapefruit juice. Teach patient to report ringing in the ears.

Thrombolytic drugs (fibrinolytic drugs)

Clot busters- *breaks down formed clots.* Activates the conversion of plasminogen to plasmin, which breaks down (lyses) the thrombus. Can be venous or arterial. Includes- Alteplase (tPA, Activase), tenecteplase (TNKase), reteplase (Retevase)

Nursing Considerations for Anti-dysrhythmics

Complete a thorough nursing assessment. - EKG, heart sounds, BP, edema, capillary refill, JVD, activity tolerance, baseline labs (CBC, LFTs, BMP, thyroid studies, liver labs, renal labs), medication profile, urinary output, chest pain, LOC. Nursing diagnoses- - risk for injury, decreased cardiac output, risk for falls, decreased cardiac tissue perfusion. Consider special considerations for administering these meds. - telemetry monitoring, blood pressure monitoring, apical pulse. Ask yourself- - is the cardiac rhythm normal? - is cardiac output maintained? - are adverse effects absent or minimized?

IV administration of Osmotic diuretics

Concentrations range from 5-25%. Dosing is complex. Infusion rate should be set to achieve an hourly urine output of 30 to 50 mL/hr. Observe for crystals prior to use; if noted, warm to re-dissolve crystals, then cool to body temperature to administer. Use a filtered needle to withdraw mannitol from the vial. Use an in-line filter when administering to prevent any crystals from entering the circulation.

Fibric Acid Derivatives (Fibrates)

Considered third-line drugs for managing lipid disorders. Primarily affects triglycerides (most effective drugs for this); also raises HDL. *Examples*- Gemifibrozil (Lopid), Fenofibrate (Tricor)

A patient received IV furosemide 80 mg for symptoms of severe heart failure. The nurse recognizes that administering the drug slowly by IV push reduces the likelihood of which of the following adverse effects of drug therapy? A. Hyponatremia B. Hypokalemia C. Fluid volume deficit D. Ototoxicity

D. Ototoxicity

Which drug is most often used for deep vein thrombosis prevention after major orthopedic surgery, even after the patient has gone home? A. Antiplatelet drugs, such as aspirin. B. Adenosine diphosphate (ADP) inhibitors, such as clopidogrel (Plavix) C. Anticoagulants, such as warfarin sodium (Coumadin) D. Low-molecular weight heparins, such as enoxaparin (Lovenox)

D. Low-molecular weight heparins, such as enoxaparin (Lovenox)

When monitoring a patient for hypokalemia related to diuretic use, the nurse looks for which possible symptoms? A. Nausea, vomiting, anorexia B. Diarrhea and abdominal pain C. Orthostatic hypotension D. Muscle weakness and lethargy

D. Muscle weakness and lethargy

The nurse is reviewing the medications that have been ordered for a patient whom a loop diuretic has just been prescribed. The loop diuretic may have a possible interaction with which of the following? A. Vitamin D B. Warfarin C. Penicillins D. NSAIDs

D. NSAIDs

Aliskiren (Rasilez, Tekturna)

Direct Renin Inhibitor. Approved only for hypertension. Route- P.O., avoid high fat foods/meals. *Adverse effects-* angioedema, cough, diarrhea, hyperkalemia. *Black box alert*- fetal injury/harm.

A patient with diabetes has a new prescription for a thiazide diuretic. Which statement will the nurse include when teaching the patient about the thiazide drug? A. "There is nothing for you to be concerned about when you are taking the thiazide diuretic." B. "Be sure to avoid foods that are high in potassium." C. "You need to take the thiazide at night to avoid interactions with the diabetes medication." D. "Monitor your blood glucose level closely, because the thiazide diuretic may cause the levels to increase."

D. "Monitor your blood glucose level closely, because the thiazide diuretic may cause the levels to increase."

While assessing a patient with angina who is to start beta blocker therapy, the nurse is aware that the presence of which condition may be a problem if these drugs are used? A. Hypertension B. Essential tremors C. Exertional angina D. Asthma

D. Asthma

Patients taking cholestyramine (Questran) may experience which adverse effects? A. Blurred vision and photophobia B. Drowsiness and difficult concentrating C. Diarrhea and abdominal cramps D. Belching and bloating

D. Belching and bloating

Before giving oral digoxin (Lanoxin), the nurse discovers that the patient's radial pulse is 52 beats/min. What will be the nurse's next action? A. Give the dose. B. Delay the dose until later. C. Hold the dose and notify the physician. D. Check the apical pulse for 1 minute.

D. Check the apical pulse for 1 minute.

The nurse is monitoring a patient who is receiving anti-thrombolytic therapy in the emergency department because of a possible MI. Which adverse effect would be of the greatest concern at this time? A. Dizziness B. Blood pressure of 130/98 mmHg C. Slight bloody oozing from the IV insertion site D. Irregular heart rhythm

D. Irregular heart rhythm

For a patient using transdermal nitroglycerin patches, the nurse knows that the prescriber will order which procedure for preventing tolerance? A. Leave the old patch on for 2 hours while applying a new patch. B. Apply a new patch every other day. C. Leave the patch off for 24 hours once a week. D. Remove the patch at night for 8 hours and then apply a new patch in the morning.

D. Remove the patch at night for 8 hours and then apply a new patch in the morning.

The nurse is administering lidocaine and considers which condition, if present in the patient, a caution for the use of this drug? A. Tachycardia B. Hypertension C. Ventricular dysrhythmias D. Renal dysfunction

D. Renal dysfunction

The nurse is assessing a patient who will be starting antihypertensive therapy with an ACE inhibitor. Which condition, if present in the patient, would be a reason for cautious use? A. Asthma B. Rheumatoid arthritis C. Hyperthyroidism D. Renal insufficiency

D. Renal insufficiency

A patient in her eighth month of pregnancy has preeclampsia. Her blood pressure is 210/100 mmHg this morning. This type of hypertension is classified as which of the following? A. Primary B. Idiopathic C. Essential D. Secondary

D. Secondary

A patient with angina has been given a prescription for a calcium channel blocker. The nurse knows that this class of drugs is used to treat which type of angina? A. Effort B. Unstable C. Crescendo D. Vasospastic

D. Vasospastic

The nurse is assessing a patient who is receiving a milrinone infusion and checks the patient's cardiac rhythm on the heart monitor. What adverse cardiac effect is most likely to occur in a patient who is receiving intravenous milrinone? A. Tachycardia B. Bradycardia C. Atrial fibrillation D. Ventricular dysrhythmia

D. Ventricular dysrhythmia

The nurse would recognize that a rise in human B-type natriuretic peptide (BNP) would indicate which of the following? A. Increases in myocardial damage. B. Decreased renal perfusion. C. Increases in sodium retention: D. Worsening of heart failure.

D. Worsening of heart failure.

Beta blockers

Decrease oxygen demand. Beta blockers used to treat angina- propranolol, atenolol, metoprolol, nadolol. *Mechanism of action*- - block beta 1 receptors in the heart; heart is in diastole longer which increases perfusion. - decreases sympathetic nervous stimulation and reduces the workload of the heart.

Nifedipine (Procardia)

Differs from verapamil and diltiazem in that it does not produce blockade of calcium channels in the heart, only in the periphery (therefore it is not used for dysrhythmias). Causes vasodilation by blocking calcium channels in the peripheral arterioles. Activates the baroreceptor reflex (reflex tachycardia)- can combine with a beta blocker to prevent it. Used for angina and hypertension. Adverse effects are similar to verapamil and diltiazem, except it causes *reflex tachycardia* instead of bradycardia or heart block.

Drug interactions with Loop diuretics

Digoxin Ototoxic drugs Lithium Antihypertensives Non-steroidal anti-inflammatory drugs (NSAIDs)

Interactions with Calcium channel blockers

Digoxin Beta blockers Grapefruit juice

Calcium channel blockers used to treat Angina

Diltiazem (Cardizem) Verapamil (Calan) Nifedipine (Procardia) Amlodipine (Norvasc) Nicarpidine (Cardene SR)

The hypotensive activity of diuretics is due to-

Direct arterial dilation, which decreases peripheral vascular resistance. Reduce extracellular fluid volume, plasma volume, and cardiac output, which may account for the decrease in blood pressure.

Managing overdose and toxicity of Digoxin- Cardiac Glycoside

Discontinue drug. Monitor for EKG changes. Determine labs. - MUST KNOW POTASSIUM LEVEL. - monitor digoxin level. GI support. Give potassium (oral or IV). Administer digoxin immune Fab (Digibind). - expensive. - administer through a filter. - dose is based on the amount to be neutralized. - can cause electrolyte imbalances, EKG changes, hypotension, low cardiac output.

Drugs interactions for Digoxin- Cardiac Glycoside

Diuretics ACE inhibitors/ARBs Adrenergics (Sympathomimetics) Quinidine Verapamil Non-drug interaction- Bran

What would you teach the patient regarding side effects?

Dizziness - safety- driving, changing positions, hot conditions.

Nursing implications for osmotic diuretics

Do not give/combine with any other medications. Osmotic diuretics need their own line. Monitor intake and output. Weigh patient. Check skin turgor and electrolyte levels. Assess LOC.

Contraindications for use of adrenergic antihypertensives

Drug allergy Acute heart failure Concurrent use of monoamine oxidase inhibitors (MAOIs) Peptic ulcer Severe liver or kidney disease Asthma (with use of any non-selective beta blockers)

Contraindications to the use of Angiotensin-Converting Enzyme (ACE) Inhibitors

Drug allergy Patients with a high baseline potassium level. Lactating women Children Patients with bilateral renal artery stenosis.

Contraindications to the use of HMG-CoA Reductase Inhibitors

Drug allergy. Pregnancy- risk category X (risk to fetus outweighs any benefit to mom). Liver disease.

Niacin

Drug of choice for lowering triglyceride levels in patients at risk for pancreatitis. Also used to treat elevated LDLs and low HDL. Can be used alone or in combination with other lipid-lowering drugs. Also used as a vitamin- B3 (the doses used as a vitamin are much lower than those used to treat increased cholesterol).

Anti-fibrinolytics (hemostatic drugs)

Drugs that *cause the blood to clot.* Prevents the lysis or breakdown of fibrin (fibrin is like a glue that keeps clots "stuck" to the vessel wall). Used to prevent excessive bleeding. *Contraindications*- allergy, disseminated intravascular coagulation (DIC). *Adverse effects*- rare but could cause a thrombotic event (acute cerebrovascular thrombosis, acute MI), hypotension, N/V/D. *Interactions*- estrogen, oral contraceptives. *Examples*- - aminocaproic acid (Amicar) - desmopressin (DDAVP) - tranexamic acid (TA, Lysteda)

Diuretics

Drugs that accelerate the rate of urine formation via a variety of mechanisms. The result is the removal of sodium and water from the body.

Adverse effects of Angiotensin-Converting Enzyme (ACE) Inhibitors

Dry cough Taste impairment Rash Angioedema Hyperkalemia Agranulocytosis

All anti-dysrhythmics can cause ____________.

Dysrhythmias

Premature ventricular contraction (PVC)

Ectopic ventricular beats that occur before the next expected beat.

Nursing implications for Spironolactone (Aldactone)

Elderly are more susceptible to hyperkalemia. Monitor patient's weight, monitor for dehydration and electrolyte imbalances. Therapeutic effects take a few days to develop.

What will you assess prior to giving a diuretic?

Electrolytes (potassium) BUN, creatinine Urine output Blood pressure Weight If diabetic- glucose. If being treated for heart failure- breath sounds.

Ventricular fibrillation

Extremely rapid, chaotic ventricular depolarization. Causes the ventricles to quiver and cease contacting. Cardiac output rapidly decreases. Aka *cardiac arrest*

Gemifibrozil (Lopid)

Fibric acid derivative. Used to treat high triglycerides. Increases the synthesis of lipoprotein lipase which accelerates the clearance of very low density lipoproteins (VLDL) which ultimately lowers triglycerides. Available in 600 mg tablets; usually give 30 minutes before AM and PM meals.

Advantages of using Dabigatran (Pradaxa) over Warfarin (Coumadin)

Fixed dosage. No lab monitoring. Decreased chance of bleeding. Fewer interactions. More rapid onset.

Examples of loop diuretics

Furosemide Ethacrynic acid Torsemide Bumetanide

Adverse effects of Aspirin (acetylsalicylic acid)

GI bleeding Hemorrhagic stroke Renal impairment *Toxic effects-* ototoxicity, tachycardia, headache, hyperventilation.

Adverse effects of Loop diuretics

GI upset. Dizziness, headache, rash. May cause blood dyscrasias. Hyponatremia, hypochloremia, and dehydration. - dehydration can lead to thrombus formation. Hypotension. Hypokalemia (muscle weakness, lethargy, muscle cramps, N/V). Ototoxicity (ear). Hyperglycemia, Hyperuricemia. **Not given during pregnancy

Adverse effects of Gemifibrozil (Lopid)

Gallstones Myopathy Liver disease Prolonged prothrombin time (can lead to bleeding). GI upset.

Hydrooxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors

Generic names all end in -statin. *Most effective* drugs for lowering LDL and total cholesterol, in some patients it can also raise HDL and lower triglycerides. *Mechanism of action*- HMG-CoA reductase is required for cholesterol synthesis, when this enzyme is blocked, cholesterol synthesis decreases. Inhibition of cholesterol synthesis in the liver increases the number of LDL receptors, as a result hepatocytes (liver cells) are better able to remove LDL from the blood and blood levels are decreased. *Used for*- hyperlipidemia (high cholesterol)

Sotalol (Betapace)

Has class II and III properties. Must know creatinine clearance before starting therapy.

Adverse effects of Warfarin (Coumadin)

Hemorrhage Fetal hemorrhage (not to be used during pregnancy or breastfeeding). GI upset. *Black box warning-* bleeding

Secondary hypertension

High blood pressure caused by another disease such as renal, pulmonary, endocrine, or vascular disease. May also result from the use of certain medications.

Essential hypertension

High blood pressure with no known cause. 90% of cases are this type. Also called primary or idiopathic hypertension.

Effective when kidney function is impaired, reduce blood volume, can cause hypokalemia and increase the risk of digitalis toxicity when both are prescribed.

High-ceiling (loop) diuretics (Furosemide, bumetanide)

Examples of Thiazide and Thiazide-like Diuretics

Hydrochlorothiazide Metolazone

___________________ is the most common cause of digoxin toxicity.

Hypokalemia

Adverse effects of Calcium channel blockers

Hypotension. Headache, dizziness. Bradycardia, reflex tachycardia. Flushing. Edema. Constipation.

Argatroban

IV anticoagulant. Directly inhibits thrombin. *Indicated for* prophylaxis and treatment of thrombosis in patients with HIT (heparin induced thrombocytopenia).

Nitro-Bid IV

IV formulation. Use glass bottle and special tubing (comes with medication). Titrate the dose to desired response (initially 5 mcg/min). Continuous infusion, always on the pump.

How do you evaluate for the effectiveness of drugs for heart failure?

Increased urinary output. Decreased dyspnea and crackles. Decreased edema. Weight. How they feel- activity, fatigue. Improvement in peripheral pulse, skin color, and skin temperature.

Positive chronotropic drugs

Increases the heart rate

Tranexamic acid (TA, Lysteda)

Inhibits plasmin (plasmin dissolves clots). *FDA approved uses*- menorrhagia, hemophilia for hemorrhage and prophylactically for tooth extraction. *Non FDA uses*- post-op hemorrhage, GI bleeding, postpartum hemorrhage. *Adverse effects*- dizziness, thromboembolic events, headache, GI upset. Available IV, P.O. Reduce dose for renal patients. Patient should be advised to avoid hormonal contraceptives while taking the oral form of this drug.

Indications for the use of Aspirin (acetylsalicylic acid)

Ischemic stroke. Transient ischemic strokes (TIAs). Chronic stable and acute angina. Coronary stenting. Acute MI, previous MI, preventing a MI. Rheumatoid arthritis. Rheumatic Fever Colon cancer prevention.

Maximum diuresis produced by thiazides is considerably ________ than that produced by the loops.

Less

Thiazide and Thiazide-like Diuretics

Like the loop diuretics, thiazides increase renal excretion of water, sodium (Na), potassium (K), and chloride (Cl). Thiazides also cause direct relaxation of arterioles, which reduces peripheral vascular resistance (afterload). Decreased preload and afterload are beneficial hemodynamic effects. Elevates levels of uric acid and glucose. Thiazides are less effective than loops when renal function is decreased.

The most potent diuretics are the-

Loop diuretics Follows by mannitol (osmotic diuretic), metolazone (a thiazide-like diuretic), the thiazides, and the potassium-sparing diuretics.

Potent diuretics that act along the ascending limb of the loop of Henle; furosemide is an example.

Loop diuretics.

Examples of Angiotensin Receptor Blockers (ARBs)

Losartan Candesartan Irbesartan Olmesartan Valsartan

Combination products available

Lovastatin/Niacin (Advicor) Simvastatin/Niacin (Simcor) Simvastatin/Ezetimibe (Vytorin) Pravastatin/Aspirin (Pravigard PAC) Atorvastatin/Amlodipine (Caduet) Simvastatin/Sitagliptin (Juvisync)

Therapeutic uses/Indications for the use of Heparin (unfractionated)

Low dose therapy: post op DVT prevention. Pulmonary embolism. Evolving stroke. Preferred anticoagulant during pregnancy. Disseminated intermittent claudication (DIC). Acute myocardial infarction. Open heart surgery. Renal dialysis.

Nitrates/Nitrites

Mainstay for angina therapy because they can increase supply and decrease demand. Many formations are available. Includes- - Nitroglycerin - Isosorbide dinitrate - Isosorbide mononitrate

Patient teaching

Maintain proper nutritional intake and fluid volume and eat potassium-rich foods (except when contraindicated). Change positions slowly. Forcing of fluids may be needed (if not contraindicated) to prevent dehydration and minimize constipation. Advise patient to keep a daily journal with weight, how they feel, dosage, and important info. Educate the patient about s/s of hypokalemia. Emphasize the importance of being cautious with heat. Patients with diabetes who are also taking thiazide and/or loop diuretics should closely monitor blood glucose levels.

Black box warning for Angiotensin-Converting Enzyme (ACE) Inhibitors

May cause fetal malformation if taken in the 2rd or 3rd trimester of pregnancy.

Interactions with Bile Acid Sequestrants

May decrease the absorption of orally administered medications. Bile Acid Sequestrants should be taken 1 hour before or 4 hours after other medications. Can decrease the absorption of fat-soluble vitamins (A, D, E, K).

Ranolazine (Ranexa)

Mechanism of action is unknown. Decreases oxygen demand and decreases anginal pain. Used only to treat chronic angina. Can widen the QT interval which can lead to a fatal dysrhythmia. Interacts with many medications; also with grapefruit juice. Adverse effects: dizziness, headache, constipation, dry mouth, increased blood pressure (hypertension).

Class I Antidysrhythmics

Membrane-stabilizing drugs; fast sodium channel blockers. *Class Ia*- sodium channel blockers. Slows impulse conduction and stabilizes membranes. Ex- quinidine, procainamide, disopyramide. *Class Ib*- slows immobilize conduction. Blocks fast sodium channels. Ex- lidocaine, phenytoin. *Class Ic*- slows impulse conduction. Ex- flecainide, propafenone.

Phosphodiesterase inhibitors

Milrinone (Primacor) Mechanism of action- - inhibits the action of phosphodiesterase, which increases the concentration of cAMP (cyclic adenosine monophosphate). - cAMP causes: increase in calcium = a positive inotropic response (increase in the force of contraction) and vasodilation. Available only in injectable form. Primarily used in the ICU setting for the short-term management of acute heart failure.

Adenosine (Adenocard)

Miscellaneous Anti-dysrhythmic. Approved only for terminating paroxysmal supraventricular tachycardia (PSVT) by decreasing automaticity of the AV node. Prolongs PR interval (delays conduction). Extremely short half-life, administered IV bolus only (as fast as possible). Common *adverse effects*- bradycardia, dyspnea, hypotension; can cause heart block and a brief period of asystole.

Ezetimibe (Zetia)

Miscellaneous Antilipemic drug- Cholesterol absorption inhibitor. Results in a reduction of cholesterol, lipoproteins, and triglycerides. May be used alone or in combination with statins. Used as an adjunct to dietary modifications. Usual dose is 10 mg/day.

Lab monitoring during the use of Warfarin (Coumadin)

Monitor *prothrombin time (PT) and international normalized ratio (INR)*. Dosage varies widely among patients and is based on INR.

Furosemide (Lasix)

Most commonly used loop diuretic. Has all the therapeutic and adverse effects of the loop diuretics listed in previous cards ⬆️. *Indications for use*: management of pulmonary edema and the edema associated with heart failure, liver disease, nephrotic syndrome, HTN (usually caused by heart failure), and ascites. Available P.O., IV.

Loop diuretics

Most effective diuretics available. Very potent. Have renal, cardiovascular, and metabolic effects. Act on the loop of Henle. Blocks the reabsorption of sodium (Na) and chloride (Cl), by doing so it prevents the reabsorption of water, thereby promoting the excretion of both. Available IV, IM, and P.O. *Indications for use:* edema of hepatic, renal, respiratory, or cardiovascular nature. hypertension.

S/S of hypokalemia

Muscle weakness Confusion Lethargy Anorexia Nausea Changes in the ECG.

Storage of Dabigatran (Pradaxa)

Must be stored in the manufacturer supplied bottle. Do not expose to moisture. Use within 30 days.

Interactions for use of Angiotensin-Converting Enzyme (ACE) Inhibitors

NSAIDs, other anti-hypertensives, diuretics, lithium, drugs that raise potassium levels, ETOH.

Monitoring digoxin levels-

Narrow therapeutic levels- - 0.5 to 2 mg/mL. - 0.5 to 0.8 mg/mL (heart failure patients do best at this level).

Isosorbide dinitrate (Isordil)

Nitrate Available in sub-lingual and oral formulations. 5 mg (sublingual), 80 mg P.O. bid or tid. *Patient teaching*- - do not abruptly stop. - sublingual form should be taken at the first sign of an angina attack. - take P.O. formulations on an empty stomach. - change positions slowly. - store drug in a cool, dry place.

Isosorbide mononitrate (Imdur)

Nitrate. Oral formulation only. Sustained release- designed to release a drug at a predetermined rate in order to maintain a constant drug concentration for a specific period of time with minimum side effects. 60-240 mg/day.

Three main classes of drugs used to treat angina pectoris

Nitrates/Nitrites Beta blockers Calcium channel blockers

Propranolol (Inderal)

Non-selective beta blocker. Can decrease BP by blocking renin release from the kidney, and reducing heart rate (which decreases O2 demand on the heart). Highly lipid soluble. *Adverse effects*: bradycardia, AV heart block, heart failure, rebound cardiac excitation, bronchoconstriction, inhibition of glycogenolysis. *Cautious use with* diabetics, respiratory patients, and heart failure patients. *Interactions:* calcium channel blockers, insulin. *Black box warning*- taper slowly to avoid rebound cardiac excitation.

Bile Acid Sequestrants

Now considered second line agents for reducing cholesterol. Widely used as adjuncts to the statins. *Used for*- - high cholesterol (hyperlipidemia). - pruritus (itching) associated with partial biliary obstruction. - off label use: diarrhea r/t excessive bile acids. *Three available agents*- - Colesevelam (Welchol) - Cholestryramine (Questran) - Colestipol (Colestid)

Cardiac Glycosides

One of the oldest groups of cardiac drugs. Have beneficial effects in the failing heart, and also help control the ventricular response to atrial fibrillation. No longer used as first-line drugs. Digoxin is the only cardiac glycoside currently available in the U.S.

Minoxidil

Only used for patients with severe hypertension that is unresponsive to safer drugs, causes more intense vasodilation, but also has more severe side effects. *Adverse effects:* tachycardia, Na and H2O retention, hypertrichosis (hair growth), and rarely pericardial effusion. *Black box alert*- pericarditis. Cardiac tamponade. PO and topical formulations.

Mannitol (Osmitrol)

Osmotic Diuretic. Must be given IV. Can increase the risk of lithium toxicity. *Therapeutic uses-* - prophylaxis of renal failure. - reduction of increased intracranial pressure. - reduction of intraocular pressure. *Adverse effects-* - heart failure - fluid and electrolyte imbalance - edema/pulmonary edema

Drugs that induce diuresis by increasing the osmotic pressure of the glomerular filtrate, which results in rapid diuresis; mannitol is an example.

Osmotic diuretics.

Drug interactions with Angiotensin Receptor Blockers (ARBs)

Other anti-hypertensives Picture (page 351)

Interactions with HMG-CoA Reductase Inhibitors

Other lipid lowering drugs can increase the risk of myopathy. Drugs that inhibit CYP3A3 (an enzyme system)- can raise the level of the statins (increases the risk of liver injury and myopathy). - Erythromycin - Ketoconazole, Itraconozole - HIV protease inhibitors - Amiodarone - Cyclosporine Coumadin (warfarin) Grapefruit juice.

Normal regulation of blood pressure and corresponding medications (picture)

Page 343

Adrenergic drugs: Drug interactions (picture)

Page 347

Antianginal drugs: therapeutic effects (picture)

Page 364

Common adverse effects of Anticoagulants (picture)

Page 416

Contraindications to the use of Aspirin (acetylsalicylic acid)

Peptic ulcer disease Bleeding disorders Allergy Extreme caution during pregnancy. *Do not give to children with chicken pox or flu*!! Can cause Reye's syndrome.

Doxazosin (Cardura, Cardura XL)

Peripherally acting alpha 1 receptor antagonist (blocker). Used for hypertension. *Adverse effects:* orthostatic hypotension, reflex tachycardia, first dose effect, nasal congestion, sexual dysfunction. P.O. only (immediate or extended release). Other anti-hypertensives can intensify hypotensive effects. Educate patients that when the drug is released from the extended-release form, the matrix of the capsule is expelled in the stool.

Carvedilol (Coreg)

Peripherally acting dual alpha 1 and beta receptor blocker. Dilates arterioles and veins, blocks beta 1's on the kidney and heart. *Used to treat* mild to moderate heart failure, hypertension, and angina. *Adverse effects:* mild. Similar to those of both alpha and beta blockers. Give with food. Full effects take 2-3 weeks. Contraindications: drug allergy, cardiogenic shock, severe bradycardia or heart failure, bronchospastic conditions such as asthma, and various cardiac problems involving the conduction system.

Substances that promote coagulation include-

Platelets von Willebrand factor Activated clotting factors Tissue thromboplastin

Mechanism of Action of Digoxin- Cardiac Glycoside

Positive inotropic effect (increase in myocardial contractility). Inhibits an enzyme called sodium-potassium adenosine triphosphatase (Na, L-ATPase). Hemodynamic benefit in heart failure. - Can increase cardiac output. — decreased sympathetic tone. —increased urine production. — decreased renin release. Electrical effects on the heart. - enhanced vagal effects on the heart. — negative chronotropic effect (decreased heart rate). — negative dromotropic effect (decreased conduction). — decreased automaticity of the SA node.

Class III Antidysrhythmics

Potassium channel blockers. Delays repolarization. Ex- amiodorane, ibutilide, sotalol, dofetilide, dronedarone.

Spironolactone (Aldactone)

Potassium-sparing diuretic. Blocks the action of aldosterone in the distal nephron, and therefore blocks the resorption of sodium and water. *Therapeutic uses- * - hypertension, edema - heart failure - primary hyperaldosteronism - acne (in women) - PMS, polycystic ovarian syndrome. *Adverse effects- * - *black box warning*: chronic use has shown to produce tumors in animal studies. - hyperkalemia - gynecomastia, amenorrhea, irregular menses, postmenopausal bleeding. - endocrine effects

Triamterene (Dyrenium)

Potassium-sparing diuretic. Directly inhibits the exchange process of sodium (Na) and potassium (K) in the distal tubule. Acts quicker than spironolactone (because it inhibits ion exchange directly). Used to treat hypertension, edema. *Adverse effects*: hyperkalemia, n/v, leg cramps, dizziness. Agranulocytosis and thrombocytopenia are rare, but may occur. *Black box warning:* hyperkalemia

Slightly reduces blood volume by causing loss of sodium and water with conservation of potassium; used to counteract potassium loss from other diuretics.

Potassium-sparing diuretics (Triameterene, Spironolactone)

Diuretics that result in the diuresis of sodium and water and the retention of potassium; spironolactone is an example.

Potassium-sparing diuretics.

Dosage and administration of Heparin (unfractionated)

Prescribed in units (not mL). Routes of administration- intermittent IV, continuous IV, subQ.

Therapeutic uses of Warfarin (Coumadin)

Prevention of venous thrombosis and pulmonary embolism. Prevention of thromboembolism in patients with prosthetic heart valves/atrial fibrillation. Prevention of recurrent myocardial infarction (MI), transient ischemic attack (TIA), pulmonary embolism (PE), and deep vein thrombosis (DVT).

Osmotic diuretics

Produces osmotic pressure that inhibits the passive reabsorption of water, this increases urine flow. The degree of diuresis is directly related to the concentration of mannitol in the filtrate; the more mannitol present, the greater the diuresis.

Class II- Beta blockers

Propranolol (Inderal) Used to treat dysrhythmias caused by *excessive sympathetic stimulation of the heart.* Non- selective beta blocker: blocks sympathetic stimulation of the heart. *Prolonged PR interval* (because of decreased conduction through the AV node). Generally well tolerated; can cause heart failure, AV block, bronchoconstriction. 3 other beta blockers used to treat dysrhythmias: acebutolol (Sectral), esmolol (Brevibloc), sotalol (Betapace).

Substances that inhibit coagulation include-

Prostacyclin Antithrombin II Proteins C and S

____________ _____________ is the antidote to overdose with Low-molecular weight heparin.

Protamine sulfate

Nitroglycerin

Prototypical nitrate. Has many trade names. Traditionally been the most important drug used in the symptomatic treatment of ischemic heart conditions such as angina. High first pass effect when taken orally.

Adverse effects of Amiodarone (Cordarone)

Pulmonary toxicity, cardio-toxicity, thyroid dysfunction, liver toxicity, optic neuritis, photosensitivity. (Think lungs, liver, thyroid, heart, eyes, skin) *Black box*- give loading doses in a hospital setting, can cause fatal toxicities (lung, liver)

restless leg syndrome

RLS; condition of unknown cause marked by intolerable creeping sensation in lower legs causing irresistible urge to move legs

Atrial flutter

Rapid and regular atrial rhythm; caused by an intra-atrial reentry mechanism. Looks like a saw tooth or picket fence appearance on EKG strip.

Angiotensin-Converting Enzyme (ACE) Inhibitors

Reduces levels of angiotensin II (a vasoconstrictor) and increases levels of bradykinin (a potent vasodilator). *Therapeutic uses:* hypertension, heart failure, nephropathy, high risk cardiovascular patients. All are P.O. (enalapril is the only one available in IV form). Many combination products are available.

Lab values to monitor

Renal labs- BUN (5-25 mg/dL) and creatinine (0.5-1.2 mg/dL). Liver enzymes. WBC (5-10,000/mm3)

Patient education for Digoxin

Report any GI issues or visual disturbances to the physician. Take Digoxin 1 hour before (if) eating bran. Weigh everyday.

Sustained ventricular tachycardia

Same as above, but lasts longer.

Diltiazem (Cardizem)

Same effects as verapamil. First pass effect. Similar adverse effects, except less chance of constipation. *Interactions:* digoxin, grapefruit juice. *Indications:* hypertension, angina, anti-dysrhythmia.

Eplerenon (Inspra)

Selective aldosterone blocker (antagonist). Used for hypertension and heart failure. Well tolerated. Hyperkalemia is the greatest risk. Interacts with drugs that can raise potassium levels, erythromycin, protease inhibitors, verapamil, azole antifungals, lithium, NSAIDs.

Metoprolol (Lopressor, Toprol)

Selective beta 1 blocker (cardio-selective). *Adverse effects:* bradycardia, reduced cardiac output, AV heart block, heart failure., lethargy, fatigue Safer for respiratory and diabetic patients. *Black box warning-* rebound cardiac excitation when abruptly d/c.

Ticlopidine (Ticlid)

Similar to Clopidogrel (Plavix), but with greater adverse effects. *Black box warning*- can cause life threatening hematological adverse reactions.

Class Ia- Procainamide (Procan)

Similar to Quinidine in actions and uses. Prolonged treatment can cause a systemic lupus erythematosus-like syndrome. Can cause cardio-toxicity, QT prolongation. Several *black box alerts*- blood dyscrasias or bone marrow suppression is just one of them. CBC is check frequently. Many, many interactions: alcohol, licorice.

Diuretics are classified according to their-

Sites of action within the nephron. Their chemical structure. Their diuretic potency.

Examples of Potassium-sparing diuretics

Spironolactone Triamterene Amiloride

Class Ia- Quinidine (Quinidex)

Strong anticholinergic properties. Widens QRS interval complex, *prolongs QT interval*- by slowing repolarization of the ventricles. Principle indication is the *long-term suppression* of dysrhythmias- atrial fibrillation/atrial flutter. Usual route is P.O., brands are not interchange. Also available IV. Therapeutic quinidine level- 4-8 mcg/mL.

Nitrostat

Sublingual. 0.3 - 0.5 mg prn. Rapid onset, short duration. Used to treat an acute anginal attack, or right before an activity that can cause an attack.

Atrial fibrillation

Supraventricular dysrhythmia. Disorganized atrial activity without discrete atrial contraction. Incompletely pumps blood into the ventricles. Predisposes patient to stroke because the blood tends to stagnate in the incompletely emptied atria and is more likely to clot. Absence of a P wave on EKG strip.

Stimulate cardiac sympathetic receptors causing an increase in the contractility of the heart but can cause tachycardia; only given IV with close monitoring.

Sympathomimetic drugs (Dobutamine)

Patient education for sublingual nitroglycerin (nitrostat)

Take as soon as the pain begins. If the pain is not relieved in 5 minutes, call 911. Can take a second tablet in 5 minutes, and a 3rd tablet in 5 minutes. Leave the tablet under the tongue until it dissolves. Should be stored at room temperature, away from light and moisture-free.

Patient teaching

Take meds exactly as prescribed, never abruptly withdrawal (rebound hypertension). Compliance is key to effective management of hypertension. Stress safety precautions. Wear a medical alert bracelet. Teach how to take blood pressure before taking a BP med. Change positions slowly. Schedule periodic eye exams. Just because you feel good, does not mean you can stop taking the meds. Discuss side effects with provider (sexual dysfunction).

Thrombus

Technical term for a blood clot

Automaticity

The ability to initiate an action potential through self-excitation.

Resting membrane potential

The difference in electronegative charge. Exists in all cardiac cells.

Blood pressure is determined by-

The product of cardiac output (4 to 8 L/min) x systemic vascular resistance (SVR). *Cardiac output* is the amount of blood that is ejected from the left ventricle. *SVR* is the resistance to blood flow that is determined by the diameter of the blood vessel and the vascular musculature.

Effective refractory period (ERP)

The time during which a cell is unable to respond to excitation and initiate a new action potential.

Class III- Dofetilide (Tikosyn)

Therapy must be initiated in the hospital. Continuous EKG monitoring for 3 days. Can cause serious toxicity, including Torsades de Pointes. Contraindicated for patients with severe renal impairment. Avoid grapefruit juice.

Hydrochlorothiazide

Thiazide diuretic. Blocks the reabsorption of sodium and chloride in the early segments of the distal convoluted tubule. Its ability to produce diuresis is dependent upon adequate kidney function. *Therapeutic uses:* hypertension, edema, diabetes insipidus. *Adverse effects-* - hyponatremia, hypochloremia, dehydration. - hypokalemia - not used during pregnancy. - gout - hyperglycemia

Reduce blood volume, can cause hypokalemia and increase the risk of digitalis toxicity when both are prescribed, not effective when kidney function is impaired.

Thiazide diuretics (Hydrochlorothiazide)

Diuretics that act on the distal convoluted tubule, where they inhibit sodium and water resorption; hydrochlorothiazide (HCTZ) is an example.

Thiazides

Nitro-Bid (Nitropaste)

Topical ointment. Measure with paper applicator. Apply to a hairless area of the body, cover with plastic wrap, and do *not* rub it in. Avoid touching with your hands.

Nitro-dur

Transdermal patch. Apply to a non-hairy part of the skin (chest, back, or abdomen). Remove patch before defibrillation. Gradually discontinue. Do not cut the patch. Remove the old patch entirely before applying the new patch. Remove at night for 8-12 hours for a nitrate free period.

Nitrolingual

Translingual spray. Do not inhale! One spray = one sublingual nitro.

Diuretic drugs increase the production of _________.

Urine (Two major uses: treatment of hypertension, decreasing edematous fluid).

Tolerance can develop rapidly to Nitrates/Nitrites (esp with high dose therapy), to avoid tolerance:

Use lowest effective dose. Long-acting formulations need an 8-hour nitrate free period. Can be reversed by withholding nitrates for a short period.

Class Ib- Lidocaine (Xyloxaine)

Used *short-term* only for ventricular dysrhythmias. IV only (large first pass effect); bolus followed by continuous infusion. Can cause drowsiness, confusion, paresthesias; toxic doses cause seizures and bronchospasm, respiratory arrest. Interactions- phenytoin, amiodarone, quinidine, procainamide, verapamil, beta blockers.

Nursing implications for Hydrochlorothiazide

Used in combination with many other drugs. Avoid use when creatinine clearance is less than 10 mL/min.

Class Ic- Flecainide (Tambocor)

Used mainly for *maintenance therapy* of supraventricular dysrhythmias (*a-fib*). Prolongs the PR interval and widens QRS complex (delays conduction). - has a negative inotropic effect. *Adverse effects*- dizziness, blurred vision, heart failure, metallic taste. *Black box*- increased risk for v-tach and v-fib for clients receiving Flecainide for a-fib or a-flutter.

Anticoagulants

Used to *prevent* the formation of clot by inhibiting certain clotting factors; primary use is the prevention of *venous* thromboembolism (VTE). Drugs in this class share the same mechanism of action; they enhance the activity of antithrombin, a protein that inactivates two major clotting factors: thrombin and factor Xa.

Nursing implications for Lidocaine (Xyloxaine)

Usually administered no more than 24 hours. Decreased dose for patients with liver disease. Monitor pump closely. Watch for toxicity.

Examples of Calcium Channel Blockers

Verapamil Nifedipine Diltiazem Other: amlodipine, felodipine, nicarpidine

Class IV- Calcium Channel Blockers

Verapamil (Calan), Diltiazem (Cardizem). Used to slow ventricular rate in patients with a-fib or a-flutter. Prolonged PR interval (delays conduction from SA to AV node). Can cause bradycardia, AV block, heart failure. *Interactions*- digoxin (can cause dig toxicity), beta blockers (have same effect on heart, can intensify these effects: bradycardia, AV block), avoid grapefruit juice.

______________ ______________ is the antidote for Warfarin (Coumadin).

Vitamin K

Nursing implications for Amiodarone (Cordarone)

Wear sunscreen Take with food if GI upset occurs Call provider if vision changes occur

cataplexy

a condition characterized by sudden muscular weakness and hypotonia caused by anger, fear, or surprise

convulsion

abnormal motor movements, such as the jerking movement of a grand mal seizure

sympatholytic agent

adrenergic blocking agent that blocks the action of the sympathetic nervous system

sympathomimetic agent

adrenergic or adrenergic-acting agent that acts to stimulate or mimic the sympathetic nervous system

blood-brain barrier

capillary walls of the brain, which can act to prevent potentially harmful substances from moving out of the bloodstream and entering the meninges in the brain or cerebral spinal fluid

parasympatholytic agent

cholinergic agent that blocks the action of the parasympathetic nervous system

tolerance

decreased response to a medication after prolonged use

neurohormones

hormones found in portions of the nervous system, such as the catecholamines

anesthesia

loss of sensation, either of the entire body or of certain body areas

hypnotic

medication used to induce or maintain sleep

sedative

medication used to reduce the desire for physical activity and produce a calming effect

anorexiant

medication used to suppress appetite

focal seizure

partial seizure; seizure with limited spread in the brain, usually affecting a single muscle group

clonic

pertaining to alternating contracting and relaxing of muscles

tonic

pertaining to muscular tension or contraction

absence seizure

petit mal seizure; loss of consciousness for a short period of time caused by seizure activity

spasticity

phenomenon in which uncoordinated movements are caused by CNS overstimulation

generalized seizure

seizure with loss of consciousness

adrenergic agonist

sympathomimetic agonist; agent that stimulates the action of the sympathetic nervous system or mimics the action of the sympathetic nervous system

narcolepsy

syndrome characterized by sudden sleep attacks, cataplexy, and visual/auditory hallucinations at the onset of sleep