Pharm exam 2

When is it indicated?

Indication: Hypertensive crisis, emergency situations (normally only administered to patients receiving intensive care) controlled hypotension during anesthesia, cardiogenic shock

Describe a major difference between JNC 7 and JNC 8 Guidelines.

JNC8: therapy should be started if BP is at or greater than 150/90 for patients older than 60 and 140/90 for patients younger than 60 and those who have chronic kidney disease JNC7: Based on normal prehypertension, stage 1 HTN and stage 2 HTN. SBP is more important r/t higher morbidity/mortality with HF stroke and renal failure

There are 4 broad classes of diuretics and each one has its own indications for use. Describe major concerns, advantages and indications as well as monitoring and teaching with agents such as Lasix,

Lasix (loop); most commonly used loop diuretic. Act on ascending limb of loop of henle to inhibit chloride and Na+ resorption. Increases renal prostaglandins resulting in dilation of vessels. Potent diuresis, causing decreased fluid volume and decrease BP/ vasc. resistance .Uses; PE, edema associated with HF, liver disease, nephrotic syndrome, ascites, HTN, edema, increase renal excretion in pts with hypercalcemia. HF resulting from diastolic dysfucntion. i.Advantages ii.Disadvantages: Dizziness, HA, tinnitus, blurred vision, NVD, Steven-Johnson (torsemide), agranulocytosis, thrombocytopenia, neutropenia, hypokalemia, hyperglycemia, hyperuricemia iii.Monitoring: DM pts monitor BG and watch for elevated levels iv.Teaching: Maintain proper nutritional and fluid status. Eat K+ rich foods.

Describe a major benefit associated with this class of drug.

Benefits: Ace inhibitors can stop the progression of left ventricular hypertrophy after MI, "ventricular remodeling" (cardioprotective) morbidity in pts w/ HF, they are drug of choice for pts with HF ACE has a protective effect on kidney by ¯ glomerular filtration pressure, for this reason they are one of the cardiovascular drugs of choice for diabetic patients. Ace also reduce proteinuria and are a standard therapy for diabetic neuropathy

Beta blockers are a class of antihypertensives rarely used as a primary/only agent in managing htn. Describe some other cardiac conditions that this class of agent might be used in.

Beta-blocker uses: Angina (exertional), dysrhythmias, HTN, MI. Common but not FDA approved uses: migraine HA, and tachycardia associated with stage fright

In what manner do they agree with regard to implementing therapy for Af/Amer's?

Both start with a thiazide diuretic or with a combo primarily African American's use calcium channel blockers alone or in combination with thiazide diuretics

Describe common side effects associated with CCB's. What other class of antihypertensives have this common side effect? Describe the primary nursing intervention associated with relief of this symptoms?

Common SE's associated with calcium channel blockers Abrupt withdrawal can precipitate rebound HTN and worsening tissue ischemia: educate patient not to stop taking abruptly Negative inotropic effects of CCB's ¯ cardiac contractility and S/S of HF: Monitor for SOB and Edema, weight should be measured daily Orthostasis/Syncope: Patient should change positions slowly Constipation: fluid and fiber Palpations, pronounced dizziness, nausea and dyspnea are adverse effects that should be reported immediately. ACE inhibitors can also cause rebound HTN with abrupt withdrawal Beta-blockers can also exacerbate HF because of drugs negative inotropic effects, and can also cause orthostasis/postural hypotension/syncope. Obs for edema/weight gain and implement orthostasis precautions

What nursing activities do you undergo in order to assure patient compliance/follow up with regard to medical therapy for hypertension.

Create an environment where the patient feels open to discussing concerns. Discuss options to relieve such as combo medications that allow lower dosages of the drug to be use as well as the option to change to another antihypertensive. Reinforce the fact that antihypertensive should never be stopped abruptly 2º to risk for hypertensive crisis/severe hypertensive rebound

Describe nursing assessment during therapy.

Assessment: Monitor CO HR ECG frequently Monitor for rebound HTN following discontinuation Monitor for cyanide toxicity (hypoxemia, tachycardia, altered LOC, almond smelling breath, seizures)

What nursing assessments are included with this agent?

Assessments for Digoxin: Frequent monitoring of serum electrolytes: low potassium and magnesium can cause toxicity (Assess before administration of dose) Monitor renal function: ¯ in renal function can cause toxicity Assess digoxin levels once it has been administered (narrow therapeutic range): 0.5-2 ng/mL Measure baseline weight before and during therapy Always measure apical PR for one full min, withhold and notify provider for PR <60, >100. Neuro assessment: hx of HA, fatigue, confusion, seizures, alertness, orientation to person/place/time/situation GI system: changes in appetite (decreased) or complaints of diarrhea, nausea, vomiting, Cardiac system: hx of irregularities or PR <60 or >100, baseline BP , heart sounds, abnormal ECG findings Visual disturbances: baseline vision and any changes: green, yellow, purple halo surrounding peripheral field of vision. Assess for drug interactions: b-blockers, CCBs, antidysrhythmic drugs

What assessment is always included for patients taking this class of medication.

Assessments for b-blocker use: Assess BP and apical pulse rate immediately before each dose, don't administer if systolic is <90 mmHg or PR is < 60. Assess breath sounds before and after dose, weight and edema (S/S of HF) Negative inotropic effect can cause a worsening of HF, In this case a different class should be administered.

Describe dromo-chrono-ino tropic effects.

Dromo-chrono-inotropic effect: Positive inotropic effect: increases the force and velocity of myocardial contraction w/o change in o2 consumption by cellular sodium and calcium concentration. Negative chronotropic effect: reduces heart rate Negative dormotropoc effect: decreased atomicity at the SA node, decreased AV nodal conduction and reduced conductivity at the bundle of His and prolongation of the arterial and ventricular refractory periods

For any agent being used as an antidysrhythmic drug, what is a potential side effect of therapy?

Dysrhythmias

Describe the potential effect of this agent for the patient with a co-morbidity of T2DM.

Effect of b-blocker with co-morbidity of T2DM, teaching: Beta blockers can mask tachycardia associated with hypoglycemia and diabetic patients may not be able to tell when their BS falls too low. B-blockers may also cause both hypoglycemia and hyperglycemia by interacting with pancreatic nerve signals.

Describe a side effect of antihypertensive therapy that may cause discontinuance of medication.

Erectile dysfunction in males is the most common reason for nonadherence

How do the therapies differ?

For any form: Administer while patient is seated to avoid falls or injury from hypotension, hypotension can last up to 30mins. Contact provider is BP is < 90 systolic or has a PR <60 or >100.

ALL diuretics:

*** ALL diuretics: If patient is taking digitalis along with diuretics, monitor for dig toxicity. Change to standing position slowly due to possible ortho hypotension. Keep log of daily weight. IF NVD, notify provider because of potential for fluid/ electrolyte imbalance. Monitor for s/s hypokalemia (weakness, constipation, irregular pulse rate, lethargy. Notify prov if rapid heart rate or syncope. Monitor for metabolic alkalosis, drowsiness, lethargy, hypokalemia, tachycardia, hypotension, leg cramps, restlessness, decreased mental alertness.

There are 4 broad classes of diuretics and each one has its own indications for use. Describe major concerns, advantages and indications as well as monitoring and teaching with agents such as HCTZ,

HCTZ/ Thiazide diuretics; inhibit reabsorption of Na+, K+, Chloride. Action in distal convoluted tubule. Water, Na+ and chloride are excreted (K+ also to a lesser extent). Dilate arterioles by direct relaxation; lowered peripheral vascular resistance. Uses: HTN (most prescribed group of drugs for HTN), edematous state, idiopathic hypercalciuria, DI, HF caused by diastolic dysfunction, adjunct drug in tx of edema r/t HF, hepatic cirrhosis, corticosteroid or estrogen therapy. Advantages Disadvantages: Dizziness, HA, blurred vision, anorexia, NVD impotence, jaundice, leukopenia, urticaria, photosensitivity, hypokalemia, hyperglycemia, hyperuricemia, hypochloremic alkalosis. Monitoring: Creatinine (should not be used if creatinine clearance <30-50 mL/min. DM pts monitor BG and watch for elevated levels Teaching: Maintain proper nutritional and fluid status. Eat K+ rich foods. Excessive licorice consumption can lead to hypokalemia.

Lidocaine administration with alcohol involved liver disease

A client with a history of cirrhosis of the liver develops heart failure. When ventricular bigeminy develops, the provider orders lidocaine. What alterations in lidocaine dosages does the nurse anticipate? Lower because the drug is metabolized at a diminished rate. The client has heart failure, which causes liver congestion, further compromising liver function; therefore, less than the usual adult dose will be prescribed because the liver will not be able to break down lidocaine as effectively as necessary. A dose higher to compensate for the impaired liver function increases the concentration of lidocaine in the blood, leading to toxicity. Lidocaine is metabolized by the liver; other organs cannot assist in the process. This may be life threatening because the client cannot metabolize lidocaine at the required rate, and toxicity may result.

Hypertension is often described as 'the silent killer". Why is this true?

Hypertension is often described as a silent killer because it patients won't have any symptoms until s/s of end organ damage or other serious health complication occurs secondarily to the hypertension

IV therapy?

IV therapy: IV therapy is used for BP control in hypertensive patients, for treatment of ischemic pain, HF, pulmonary edema associated with acute MI, and in hypertensive emergencies. Dosing for use in emergency situations only and requires close automatic monitoring of blood pressure and ECG, IV can lead to severe hypotension and shock. Only give IV solution through an infusion pump and as ordered. Administer using specific non-polyvinalchloride (non-PVC) plastic IV bags and tubing (this avoids absorption of the nitrate in bag/tubing, and the decomposition of nitrate in to cyanide when exposed to light. IV forms are stable for 96 hours after preparation. If solutions are not clear and are discolored, discard. solutions are not clear and are discolored, discard.

What is Adenosine? Describe a condition when this agent might be used. How is the drug given?

Adenosine is an unclassified antidysrhythmic, administered only IV because half life is < 10 seconds and only FAST PUSH because half life is < 10 seconds. 6 or 12 mg. Commonly causes asystole for a period of seconds. Used in conversion of Paroxymal supraventricular tachycardia to sinus rhythm, particularly useful when PSVT has failed to respond to verapamil or if pt has co-existing conditions like HF, hypotension, or left ventricular dysfunction that limit use of verapamil.

Lidocaine is typically encountered as a local anesthetic agent but it has uses as a cardiac medication as well. How do the doses and methods of delivery differ?

Lidocaine is a class 1b antidisrrhythmic. For cardiac IV administration is usually started with loading dose which is weight based. (1-1.5 mg/kg) followed my maintenance dose 1-3 mg.q 3-5 minutes Adjust rate according to cardiac response. Usually used no more than 24 hrs. Never administer lidocaine preparation that contains epinephrine usually in lidocaine used for local anesthesia severe hypertension or dysrhythmias can occur. Describe indications for the use of lidocaine as a cardiac agent Block sodium channels Accelerate repolarization Lidocaine is used for ventricular dysrhythmias only. Action: raises the ventricular fibrillation threshold How might other medical comorbidities effect use of lidocaine. · Contraindications: hypersensitive, severe SA or atrioventricular (AV) intraventricular block, or Stokes-Adams or Wolff-Parkinson-White syndrome. · Use cautiously in clients who have liver and kidney dysfunction and chronic respiratory disorders. Pregnancy category B Nursing considerations: drowsiness, altered mental status, paresthesia, seizures, severe hypertension or dysrhythmias can occur.Administer phenytoin for seizure activity. Significant adverse effects: twitching, convulsions, confusion, respiratory depression or arrest, hypotension, bradycardia, and dysrhythmia. Class Ib: phenytoin, lidocaine. Lidocaine has a narrow window

What major side effects may occur including possible warning signs.

Major Side Effects: Increased stroke volume, reduction in heart size during diastole, decrease in venous BP and vein engorgement, increase in coronary circulation, promotion of tissue perfusion and diuresis as result of improved circulation. Decrease in exertional and paroxymal nocturnal dyspnea, cough and cyanosis. Improved symptom control and exercise tolerance. Adverse effects: Bradycardia or tachycardia, hypotension headache, fatigue, confusion, convulsions, colored vision (green yellow or purple, halo vision) anorexia, nausea, vomiting, diarrhea. Warning signs of tox: Bradycardia, HA, dizziness, confusion, nausea, visual disturbances (blurry or yellow vision), ECG may indicate heart block, atrial tachycardia with block or ventricular dysrhythmias.

Describe major side effects for this class of agent

Major side effects Diazoxide: (many adverse effects rarely used in practice) Hydralazine: dizziness, HA, anxiety, tachycardia, edema, dyspnea, nausea, vomiting, diarrhea, hepatitis, systemic lupus erythematosus (SLE), vitamin B6 deficiency, and rash Minoxidil: T-wave electrocardiogram changes, pericardial effusion, tamponade, angina, breast tenderness, rash, thrombocytopenia. Sodium nitroprusside: Bradycardia, decreased platelet aggregation, rash, hypothyroidism, hypotension, methemoglobinemia and rarely cyanide toxicity.

Describe management of electrolytes with this agent.

Management of Electrolytes with Digoxin: Frequent monitoring of serum electrolytes because low potassium and magnesium can cause toxicity, assess before administration of dose

There are 4 broad classes of diuretics and each one has its own indications for use. Describe major concerns, advantages and indications as well as monitoring and teaching with agents such as Mannitol:

Mannitol; most used osmotic diuretic, works by pulling water into renal tubules and inhibiting tubular resorption of water and solutes, thus producing rapid diuresis. It increases glomerular filtration rate and renal plasma flow thus preventing kidney damage during renal failure. .Uses: Reduces cerebral edema assoc. w/ head trauma. Reduces intraocular pressure, RF i.Advantages ii.Disadvantages: Convulsions, thrombophlebitis, pulm congestion. iii.Monitoring: IV infusion only. Use of a filter is required. May crystalize when exposed to low temps. iv.Teaching: Maintain proper nutritional and fluid status. Eat K+ rich foods.

What is Nipride?

Nitride/sodium nitroprusside: Antihypertensive/vasodilator causes decreased platelet aggregation

How long to administer IV nitro for hypertensive emergency

Nitroglycerin IV for hypertensive emergency special indications: Onset: 2-5 min Duration: 5-10 min Sodium nitroprusside IV for hypertensive emergency special indications: Onset: Immediate Duration: 1-2 min

What specific teaching is included for oral therapy?

Oral therapy: oral forms to be taken with meals and with at least 6 oz of water, acetaminophen may be given for a nitro induced HA. Sublingual tablets are used for acute onset chest pain, or for prevention of chest pain when patients are in situations likely to provoke pain. Store sublingual tablets in their original amber, glass, container because exposure to air, light, plastic, cotton filler and moisture can inactivate them. Advise pt to place under tongue and not to swallow until completely dissolved.

Describe the parameters for administration.

Parameters: Titrate to effect by infusion. Protect bag and tubing from light to decrease formation of cyanide ions. Thiosulfate mat be co-administered to decrease toxicity, Dilute with D5W 50/250-1000 mL,

Describe the reversal protocol for toxicity

Reversal protocol for toxicity: Treatment for toxicity depends of severity of symptoms, with holding dose may be sufficient for minor toxicity Significant toxicity: Digoxin immune Fab is an antibody that recognizes dig as an antigen and forms an antigen-antibody complex, inactivating the complex. This therapy is indicated only for the following: Hyperkalemia (>5 mEq/L) in a pt with dig tox, life threating cardiac dysrhythmias sustained v-tach or v-fib, severe bradycardia or heart block that is unresponsive to atropine or pacing. Life-threatening dig overdose > 10 mg in adults of > 4 mg in kids Administration: Given paternally over 30 mins, sometimes as IV bolus if cardiac arrest is immanent. All vials should be refrigerated, stable for 4 hours after being mixed. 1 vial binds 0.5 ng of digoxin. Closely monitor CO, apical pr, rhythm, ECG, and serum potassium levels

Describe side effects associated with ACE inhibitors. Include serious and less serious phenomena.

Side Effects: Dry cough, non-productive, (reversible with discontinuation) May have orthostatic hypotension with first dose Hyperkalemia (monitor potassium regularly, esp w/ potassium sparing diuretics) Loss of taste Angioedema (can progress to anaphylaxis) Renal impairment. In patients with HF who's renal function depends on rennin-angiotensin-aldosterone system, treatment with ACE may cause acute renal failure. CNS effects: fatigue, dizziness, mood changes, HA's

There are 4 broad classes of diuretics and each one has its own indications for use. Describe major concerns, advantages and indications as well as monitoring and teaching with agents such as , Spironolactone,

Spironolactone/ Aldactone (potassium sparing OR aldosterone inhibiting diuretics); work in collecting ducts and distal convoluted tubules. Interfere with Na+, K+; competitively bind to aldosterone receptors, prevent K+ from being pumped into tubule thus preventing its secretion. Promote excretion of Na+ & H2O .Uses: Hyperaldosteronism, HTN, reversing K+ loss, certain cases of HF/ remodeling prevention i.Advantages ii.Disadvantages: Dizziness, HA, cramps, NVD, urinary frequency, weakness, hyperkalemia, gynecomastia, amenorrhea, irregular menses, postmenopausal bleeding. iii.Monitoring: Maintain proper nutritional and fluid status. Monitor for hyperkalemia. iv.Teaching: Interacts with lithium, ACE inhibitors, K+ supplements, NSAIDs

What kind of teaching do you include?

Teach: Avoid abrupt withdrawal of drug. Daily weights should be recorded at same time of day, same scale etc. Report gain of > 2 lbs in 24 H or 5 lbs/week. Dangle feet at side of bed before standing. Report dizziness fatigue/lethargy, wheezing or dyspnea to provider. Monitor BS closely for T2DM, MORE?

What type of teaching do you always include when teaching patients with this condition?

Teaching: Never double up on doses or miss a dose (risk for hypertensive crisis) Monitor daily weight (report gain of 2 lbs in 24 h or >5 lbs in one week) Educate for risk of orthostatic hypotension Weight reduction to BMI 18.5-24, DASH diet, sodium reduction, physical activity for 30+ mins most days, moderate alcohol consumption, smoking cessation Risk for depression with medication BP journal Take medication with meals

What vital patient teaching is included when this drug is being used

Teaching: Tell patient that this treatment re-boots heats, don't say that it stops heart, you will feel terrible for 10 seconds but wont last long.

How about transdermal nitro? What teaching is included for this formulation? What safety teaching is included for transdermal patch? Paste?

Transdermal Nitro patch: Allows for the continuous slow delivery of nitroglycerine (bypass first pass). Patches are worn for 12-14 hours/day. Remove patch at bed time for 8 hours and then apply new patch in the morning (this prevents tolerance to drug). Patch site should be clean/dry, patch site should be rotated, patch should not be placed on open skin, or in skin folds. If patch becomes loose, remove, clean with soap and water, drya and place new patch. Take frequent vitals when you first initiate nitro because BP can tank in the treatment of R-MI (treat with fluid fast). Ensure patient safety r/t hypotension, potent hypotensive drug. Contraindications to the use of nitrates include use of erectile dysfunction drugs, which can cause severe hypotension because of the vasodilatory effects. (Also not used with anemia, closed angle glaucoma, hypotension, severe head injury). If AED is used on pt with a patch remove prior to avoid burning of sikin. o Ointment: use proper dosing paper supplied by drug company to apply to clean hairless skin on upper arm or body. Avoid area below knee or elbow. Don't use fingers to apply unless the hand/ finger is gloved. Don't rub ointment in to skin, cover area with an occlusive dressing and rotate sites. Remove residual from previous dose with soap and water, pat try.

What is angina? Describe the 2 major types of angina.

Types of Angina: Chronic Stable Angina "classic or effort angina": Usually 2º to arthrosclerosis, triggered by exertion, or other stress. Nicotine, coffee, alcohol and other drugs can exacerbate it. Usually intense pain but subsides in 15 minuets with rest or antianginal drug therapy. Relieved by rest and nitro. Unstable Angina "pre-infarction or crescendo angina": early stage of progressive coronary artery disease. It often ends in an MI in the following years. Pain increases in severity as do the frequency of attacks, it late stages pain may occur even at rest. Not relieved by rest or nitro. Vasospastic Angina "Prinzmetal or variant angina": 2º to spasms in the layer of smooth muscle that surrounds coronary arteries. This type of pain occurs at rest and without any precipitating cause. It usually occurs at the same time of day. Dysrhythmias and ECG changes often accompany.

When are vasodilators typically used in management of hypertension. What type of patients are most likely to receive this type of therapy?

Vasodilators are used alone or in combination with other antihypertensive drugs Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Nitropress is used in intensive care for hypertensive emergencies and is titrated to effect by intravenous infusion. Hydralazine (Apresoline) is taken PO to treat routine cases of essential HTN, or IV for hypertensive emergencies

What is digoxin? When is it used?

What is Digoxin and When is Digoxin used: A cardiac glycoside, used for HF and to control the ventricular response in v-fib. (primarily for systolic HF and v-fib)