Quiz #3
DRUGS FOR HYPTERTENSION, CHF, and/ or DYSRHYTHMIAS
- ACE Inhibitors: Angiotensin converting enzyme inhibitor (ACE-I): captopril (CAPOTEN) - Angiotensin II Receptor Blockers: valsartan (DIOVAN); losartan (COZAAR) - Direct acting vasodilator (arteriolar dilator): hydralazine (APRESOLINE) - Arteriolar and venous dilators: nitroprusside (NIPRIDE) - Vasodilator-Antianginal: Organic nitrates (nitroglycerin; isosorbide dinitrate (ISORDIL); isosorbide mononitrate (IMDUR)
Anti-dysrhythmic Classification
- Group I: Na+ channel blockers - Group II: ß-adrenergic blockers: propranolol (INDERAL), metoprolol (LOPRESSOR) - Group III: Potassium channel blockers: Bretylium tosylate, amiodarone (CORDARONE), dofetilide (TIKOSYN), ibutilide (COVERT) - Group IV: Calcium channel blockers: verapamil (CALAN), diltiazem (CARDIZEM)
diuretics given for non-cardiac fluid volume excess
- Osmotic Diuretics Osmotic Diuretics: mannitol (OSMITROL) - Proximal Tubule Diuretics Carbonic anhydrase inhibitors: acetazolamide (DIAMOX)
Adrenergic Agonists/Sympathomimetics
2 types of Adrenergic Agonists- catecholamines and noncatecholamines. Catecholamines are the following meds listed below. Generally, they are given in a code situation. Catecholamines must be given IV and need to be given at reduced doses for patients taking MAO inhibitors or tricyclic antidepressants. They all may cause cardiac dysrhythmias and hypertension. Patients are frequently unable to participate in symptom assessment, direct teaching about these medications at the family if necessary. Administer into large vein, assess for extravasation frequently. All catecholamine-containing solutions are colorless but then turn pink or brown over time from oxidation. Discard discolored solutions. Non-catecholamines: examples are ephedrine, phenylephrine, albuterol and terbutaline. Have a longer half-life and can be given po. Can cross the blood-brain barrier.
Inotropic: dobutamine hydrochloride (DOBUTREX)
Actions: Stimulates ß1 receptors 🡪 ⭡force of contraction (positive inotropic). Method of Administration: Continuous IV infusion Adverse reactions: Tachycardia and dysrhythmias. Nursing Implications Important Assessments: Baseline cardiac, renal, and hemodynamic status. Interventions: Monitor cardiopulm. function, continuous ECG/BP monitoring, urine output, CVP and PCWP, monitor for s/s of decreased perfusion. Patient/family teaching: Report adverse reactions, chest pain, s/s ⭡CHF, pain at IV-site Indications for use: Heart failure.
Distal Tubule Diuretics Potassium-Sparing Diuretics: spironolactone (ALDACTONE) Other common names: Eplerenone (INSPERA),triamterene (DYRENIUM), amiloride
Action: Block Na+ reabsorption in the distal tubules; also an aldosterone antagonist, so Na+ and H2O are excreted and K+ is spared. Drug often given in combination with K+ depleting diuretics to counteract the potassium wasting effects. Method of Administration: PO Adverse reactions: See box above. Hyperkalemia (nausea/vomiting, diarrhea, numbness, paranesthesia, muscle irritability [early], muscle weakness [late], ventricular dysrhythmias [wide QRS, peaked T wave]🡪 cardiac arrest.) Binds with steroid hormone receptors and may cause deepening of the voice, gynecomastia, hirsutism, menstrual irregularities and impotence. This may or may not require discontinuing the drug. Patient teaching: Avoid salt substitutes which contain potassium. Eplerenone should not be taken with grapefruit juice and St. John's Wort! Indications for Use: HTN and edema.
Group IB- lidocaine (XYLOCAINE)[IV], mexiletine [po], phenytoin (for dig tox dysrhythmia only)
Adverse reactions: Accelerate repolarization. For v-dysrhythmias only. CNS effects: Drowsiness, confusion, paresthesia, convulsions, and resp. arrest. No EKG changes to monitor.
Group IC- flecanide (TAMBOCAR), propafenone (RYTHMOL)
Adverse reactions: For v-dysrhythmias only. Pronounced pro-dysrhythmic properties. Prolongs PRI, widens QRS and decreases contractility. Only for refractory VT.
Osmotic Diuretics Osmotic Diuretics: mannitol (OSMITROL)
Action: Elevates the osmolarity of the glomerular filtrate, which hinders the reabsorption of water resulting in loss of water, sodium, and chloride. The increased solute load of mannitol pulls fluid out of the intracellular compartment of the brain into the extracellular/vascular space, and fluid is excreted by the kidneys. Adverse reactions: Contraindicated with severe dehydration, severe pulmonary congestion, and intracranial bleeding. Use caution with renal dysfunction, heart & pulmonary impairment (b/c ⭡extracellular fluid can lead to circulatory overload & CHF). Test dose is commonly done to assess kidney tolerance. Indications for use: Treatment of cerebral edema. Given IV.
Inotropic, vasopressor: dopamine hydrochloride (INTROPIN)
Actions: Actions are dose dependent. Stimulates dopaminergic receptors (low doses) 🡪 renal vasodilatation; ß1 receptors (moderate doses) 🡪 indirectly releases NE 🡪 increases contractility, stroke volume, cardiac output, and BP. α receptors (high doses) 🡪 vasoconstriction 🡪 ⭡HR, BP. Method of Administration: IV infusion Adverse reactions: Increased myocardial oxygen consumption (MVO2) 🡪 tachy dysrhythmia and chest pain; and ⭡peripheral vascular resistance (PVR); ⭣ urinary output (UOP), and renal constriction at high doses. Can also cause necrosis at the IV site with infiltration. Nursing Implications Important Assessments: Baseline cardiac, renal, and hemodynamic status. Interventions: Monitor cardiopulm. status, urine output, weight, CVP and PCWP. Monitor infusion site for infiltration (remove IV and give subcutaneous blocking agent). Patient/family teaching: Report adverse reactions, chest pain, s/s ⭡CHF, pain at IV-site. Indications for use: circulatory shock, refractory heart failure, septicemia (systemic vasodilatation), renal failure, CHF.
Vasopressor: norepinephrine bitartrate (LEVOPHED)
Actions: At low doses ß1 receptors are stimulated. High affinity to alpha receptors 🡪 increases blood pressure by vasoconstriction of blood vessels (arteriolar & venous) in the visceral organs 🡪 ⭣ blood flow to kidneys & other organs. Method of Administration: IV Adverse reactions: chest pain, HTN, dysrhythmias, and local necrosis. Nursing Implications Important Assessments: cardiac, renal, and hemodynamic status. Interventions: Continuous monitoring of cardiopulm. and renal status. Patient/family teaching: Report adverse reactions, chest pain, s/s ⭡CHF, pain at IV-site. Indications for use: Hypotension; and cardiac arrest.
Bile-Acid Sequestrants: colesevelam (WELCHOL), colestipol (COLESTID), cholestyramine (QUESTRAN)
Actions: Binds cholesterol, TG and LDL to bile acids in the intestine to excrete in feces. Adverse reactions: Constipation, abdominal discomfort, bloating, and fat soluble vitamin deficiency (A, D, E, and K) Nursing Implications Important Assessments: Baseline lipid levels. Interventions: Monitor lipid levels, and for adverse reactions. Patient teaching: Mix powder with water, juice, soup, or pulpy fruit. ⭡fiber intake and water, and use a laxative. Take other medications 4 hours after this medication. Indications for use: to ⭣LDL and cholesterol. Biliary obstruction. Often taken with statins.
Diluting Segment Diuretics: Thiazides - hydrochlorothiazide (HCTZ, HYDRODIURIL) Other Common Names: Chlorothiazide (DIURIL), Chlorthalidone (THALITONE), Metolazone (ZAROXALYN)
Actions: Blocks reabsorption of Na+, Cl-, and H2O, so they are excreted. ⭣plasma and extracellular fluid volume 🡪 ⭣preload and cardiac output. ⭣peripheral vascular resistance by a direct action on peripheral blood vessels. Method of Administration: PO and IV Adverse reactions: See box above. Birth defects. May also ⭡Ca, glucose and uric acid levels. Patient Teaching: See box above. Eat foods high in K+, take supplemental K+ as prescribed, wear sunscreen for photosensitivity. Indications for use: First-line drug for HTN and peripheral edema. Not effective for immediate diuresis or for patients with impaired renal function.
ACE Inhibitors: Angiotensin converting enzyme inhibitor (ACE-I): captopril (CAPOTEN) Other Common Names: benazepril (LOTENSIN), enalapril (VASOTEC), lisinopril (PRINIVIL, ZESTRIL), moexipril (UNIVASC), quinapril (ACCUPRIL), ramipril (ALTACE), trandolapril (MAVIK)
Actions: Completely blocks ACE 🡪 vasodilation and ⭡water and Na+ excretion. Method of Administration: PO or IV Adverse reactions: Electrolyte imbalances (hyponatremia and hyperkalemia) d/t ⭣ aldosterone levels (need normal kidney function). Persistent dry cough. HTN (compensatory response for fluid loss). Fetal injury, angioedema, renal failure, rash, impaired sense of taste, and neutropenia. Nursing Implications Important Assessments: Assess kidney function/electrolytes, WBC/diff, and VS Interventions: Monitor BP 2 hours after first dose and regularly thereafter; WBC/ diff, signs of heart failure/ edema, and proteinuria in diabetics. Patient teaching: Report adverse effects. Do routine BP checks. Captopril and moexipril only: take on empty stomach. Monitor for hyperkalemia when combined with K-sparing diuretic, K-supplement or salt-substitute. Indications for use: HTN, CHF, acute MI, nephropathy.
Vasodilator-Antianginal: Organic nitrates (nitroglycerin; isosorbide dinitrate (ISORDIL); isosorbide mononitrate (IMDUR)
Actions: Dilate veins 🡪 pooling of blood in the veins/periphery 🡪 ⭣ venous return (⭣preload). Dilate arterioles to decrease peripheral vascular resistance 🡪 ⭣afterload. Some dilation of coronary arteries. Combined effect: ⭣myocardial oxygen demand (MVO2) and more efficient distribution of blood/oxygen throughout the myocardium. Method of Administration: Given inhaled, SL, PO, transdermal and IV. Adverse reactions: Headache; orthostatic hypotension and reflex tachycardia. Nursing Implications: Important Assessments: VS, cardiopulm. system, I & O, weight, edema, angina Interventions: Monitor for resolution of chest pain, and for adverse reactions. Use glass bottle and specialized tubing to deter absorption of IV-NTG into standard. IV-administration requires cardiac and BP monitor. Need drug free period, usually overnight, to prevent development of tolerance. Patient teaching: How to administer NTG-sl spray. Clear instructions for administration and storage of NTG-sl pills. Rotate sites for transdermal patches, schedule patch removal. Do not chew/crush sustained release drug. Use analgesics to counteract initial headache. Report adverse reactions. Indications for use: Management of chronic angina. CHF and HTN, relief of acute angina.
Block cholesterol absorption: Ezetimibe (ZETIA)
Actions: Inhibits the absorption of cholesterol in the lining of the small intestine, but does not inhibit cholesterol synthesis in the liver, so it ⭣ the amount of intestinal cholesterol available to the liver. Method of Administration: PO Adverse reactions: liver damage when combined with statins. ⭡risk for gall stones when combined with fibrate. Also rhabdomyolysis, pancreatitis, and thrombocytopenia. Patient Teaching: Take once a day with or without food. Indications for use: ⭣ both total cholesterol and LDL cholesterol. Commonly used in conjunction withHMG-CoA Reductase Inhibitors- Statins.
Arteriolar and venous dilators: nitroprusside (NIPRIDE)
Actions: Directly acts on smooth muscles of the peripheral arterioles and veins🡪 lowering peripheral vascular resistance (PVR) and blood pressure. Immediate/short-acting. Method of Administration: IV Adverse reactions: Excessive hypotension, less reflex tachycardia, sodium and water retention; cyanide poisoning (acidosis, hypoxemia, tachycardia, ⭣LOC, almond-breath) and thiocyanate toxicity (weakness/hyperreflexia/seizures, tinnitus, confusion/psychosis/coma) at high doses. Nursing Implications Important Assessments: VS, cardiac and resp. system, I & O, weight, and edema. Interventions: Monitor VS closely, cardiac monitor, plasma cyanide and thiocyanate levels, check s/s of adverse reactions. Protect medication from light (foil wrapping), discard colored solution. Patient teaching: Report tinnitus, dyspnea, headache, blurred vision. Indications for use: HTN, hypertensive crisis, cardiogenic shock and CHF.
Angiotensin II Receptor Blockers: valsartan (DIOVAN); losartan (COZAAR) Other Common Names: candesartan (ATACAND), eprosartan (TEBETEN), irbesartan (AVAPRO), olmesartan (BENICAR), telmisartan (MICARDIS).
Actions: Directly blocks the receptor for Angioensin II, thus blocks vasoconstriction and aldosterone release 🡪vasodilation (⭣ afterload) and ⭡sodium and water excretion (⭣ preload). (Similar to ACE Inhibitors, but has little effect on serum K+). Method of Administration: PO Adverse reactions: Fewer side effects of cough and hyperkalemia than ACE-I. May experience angioedema, fetal injury, and renal failure. Nursing Implications Important Assessments: See box above. Interventions: See box above. ⭡ Patient teaching: Report adverse effects. Do routine BP checks. Take with or without meals. Indications for use: HTN, CHF, acute MI, nephropathy for patients intolerant of ACE-I.
Group I: Na+ channel blockers
Actions: Fast sodium channel blockade in cardiac muscle resulting in slowed conduction in atria, ventricles, and HIS-Purkinje system. Indications for Use of Class I anti-dysrhthymics: Supraventricular and ventricular dysrhythmias (SVT/VT). Adverse effects for Class I: hypotension, HF, worsened or new dysrhythmias, cardiotoxicity (widening of QRS and QT intervals), arterial embolism if used for afib., heart block Nursing Implications: monitor cardiac rhythm, VS, adverse reactions., serum drug levels and CBC/diff.
Anticoagulants: Heparin
Actions: Heparin inactivates clotting factors of the intrinsic pathway and prevents the formation of a stable fibrin clot. Method of Administration: Administered as continuous infusion with rapid onset of action, or SubQ Adverse reactions: hemorrhage, heparin-induced thrombocytopenia (HIT), hypersensitivity reactions, hypotension. Nursing Interventions: Blood levels: To maintain a therapeutic level of anticoagulation when receiving a continuous infusion of heparin, the aPTT should be 1.5 to 2.5 X the normal value. aPTT should be measure every 4-6 hours during initial continuous infusion therapy and then daily. If aPTT is longer than 80 seconds, dosage should be lowered. If aPTT is less than 60 seconds the dosage should be increased. Consult your institutional nomogram. Indications for use: Prevents clot formation and extension of clots, but does not dissolve clots. Used during open heart surgery and dialysis. Used in disseminated intravascular coagulation (DIC). Antidote: protamine Sulfate
Loop Diuretics: furosemide (LASIX) Other Common Names: Bumetanide, ethacrynic acid (EDECRIN), torsemide (DEMADEX)
Actions: High ceiling loop diuretics inhibits Na+ and Cl- reabsorption in the ascending loop of Henle. (Actions are similar to thiazide diuretics but produce higher urine volume. Most effective diuretic.) Method of Administration: PO and IV Adverse reactions: See box above. Ototoxicity (transient deafness). May also ⭡glucose and uric acid levels. Indications for use: Pulmonary edema (CHF), edema (hepatic, renal, cardiac origin), and HTN. Rapid acting. Also effective in patient with decreased renal function
Proximal Tubule Diuretics Carbonic anhydrase inhibitors: acetazolamide (DIAMOX)
Actions: Inhibit the enzyme (carbonic anhydrase), which inhibits reabsorption of HCO3 from the proximal tubule 🡪 osmotic diuresis 🡪 Na+ and H2O excretion. Causes a bicarbonate diuresis that rids the body of excess fluid and induces metabolic acidosis. Method of Administration: Oral, IM, or IV. Adverse reactions: Malaise, anorexia, fatigue, paresthesia, reduced appetite, and GI disturbances. Indications for use: ⭣ intra ocular pressure in Glaucoma (⭣ formation of aqueous humor); used prior to ophthalmic surgery.
ß Adrenergic Blockers: Cardioselective ß-blockers: metoprolol (LOPRESSOR) Other Common Names: Acebutolol (SECTRAL), Atenolol (TENORMIN), Betaxolol, Bisoprolol (ZEBETA, ZIAC), esmolol
Actions: Inhibit ß1 receptors by competing with the catecholamine at the receptor site. Negative inotrope, chronotrope and dromotrope. Anti-angina effects also occur from ⭣myocardial oxygen demand. Also, there are anti-hypertensive actions from ⭣sympathetic stimulation to blood vessels and an inhibition of renin release by the kidneys. Method of Administration: PO and IV
HMG-CoA Reductase Inhibitors (Statins): atorvastatin (LIPITOR) Other Common Names: Fluvastatin (LESCOL), Lovastatin (MEVACOR), Pitavastatin (LIVALO), Pravastatin (PRAVACHOL), Rosuvastatin (CRESTOR), Simvastatin (ZOCOR)
Actions: Inhibits HMG-CoA, the enzyme that catalyzes the first step in the cholesterol synthesis. Adverse reactions: Hepatoxicity, myopathy, peripheral neuropathy. Headache, rash, GI distress. Nursing Implications Important Assessments: Baseline lipid profile, cardiac enzymes, and liver function tests. Interventions: Monitor labs, and for adverse reactions. Patient teaching: Take lovastatin with the evening meal; other statins can be taken without regard to meals. Address cardiac risk factors: diet, exercise, obesity; stress med adherence. Avoid grapefruit juice and fruit. Should receive an annual eye examination for cataract formation. Report any unexplained muscular pain to the HCP immediately. Indications for use: ⭡cholesterol, triglycerides, and LDLs. To increase HDLs.
Anti-platelets: aspirin, clopidogrel (PLAVIX), ticagrelor (Brilinta), abciximab (REOPRO), eptifibatide (INTEGRILIN), tirofiban (AGGRASTAT)
Actions: Inhibits platelet aggregation and delays initiation of clot formation May be used in combination with anticoagulants. Method of Administration: Oral, IV Adverse reactions: See box above. During IV administration: protect patient from bleeding. Patient teaching: Instruct to monitor for S/S of bleeding and in the measures to prevent bleeding. Indications for use: PO- prevention of MI and stroke (analgesic and anti-pyretic). IV- acute coronary syndrome and any associated percutaneous coronary artery interventions. Given w/ASA and heparin. IV meds are expensive.
Nicotinic Acid: Niacin
Actions: Inhibits the release of free fatty acids from adipose tissue and increases lipoprotein activity, which ⭣ triglycerides. Method of Administration: PO Adverse reactions: Flushing, hepatoxicity, hyperglycemia, hyperuricemia (gouty arthritis), elevation of homocysteine. GI reactions. Nursing Implications Important Assessments: Baseline lipid and liver function tests. Interventions: Monitor lipid and liver function tests, and for adverse reactions. Patient teaching: Address cardiac risk factors: diet, exercise, obesity; stress med adherence. Limit alcohol use. Warn patients of intense flushing of the face, neck, and ears- this reaction should diminish in several weeks. To diminish flushing take an aspirin or nonsteroidal anti-inflammatory drug 30 minutes before administration of nicotinic acid. Take with meals to reduce GI discomfort. Indications for use: ⭡triglycerides and cholesterol. To ⭣LDL and ⭡HDL.
Anticoagulant: Low-Molecular-Weight Heparin- enoxaparin (LOVENOX)
Actions: Made by chemically processing heparin into fragments based on molecular weight. Inactivates factor Xa. Method of Administration: SubQ into the abdominal wall. Do not expel the air bubble from the prefilled syringe or aspirate during injection. Can be used at home in fixed dosages and does not require PTT monitoring (differs from Heparin, has longer half-life). Adverse reactions: Bleeding, thrombocytopenia. Indications for use: Prevention and treatment of DVT and PE, and prevention of ischemic complications in patient with unstable angina, and MI. Antidote: protamine sulfate
Vasopressor, antiasthmatic, bronchodilator: epinephrine HCL (ADRENALIN HCL)
Actions: Naturally occurring neurotransmitter 🡪 stimulates α & ß receptors (nonselective). Primary action is on ß receptors of the heart, smooth muscle of the bronchi, & blood vessels. Epinephrine stimulates ß1 receptors 🡪 ⭡HR, force of contraction & CO. Epinephrine stimulates ß2 receptors 🡪 bronchodilation from relaxation of bronchial smooth muscles in the lung thus relieving bronchospasms. Stimulation of Alpha receptors 🡪 constricts arterioles of the bronchioles and inhibits histamine release 🡪 reduces nasal congestion. Method of Administration: IV, IM, SQ, intracardiac, intraspinal, topically, and inhalation. Comes in different concentrations, always double check concentration prior to administration! Wrong concentrations can cause death! Adverse reactions: Can cause chest pain, dysrhythmias, HTN, tissue necrosis, hyperglycemia. If extravasation occurs, infiltrate the region with phentolamine to minimize injury. Nursing Implications Important Assessments: Baseline cardiac, renal, and hemodynamic status. Interventions: Monitor cardiovascular status and for adverse reactions. Patient/family teaching: Report adverse reactions, chest pain, s/s ⭡CHF, pain at IV-site. Indications for use: Used to treat bronchial asthma, pulmonary bronchospasm (chronic bronchitis/ emphysema) and anaphylactic reactions. Also used to control superficial bleeding, restart the heart after cardiac arrest, and delay absorption of local anesthetics
Cardiac Glycosides: Digitalis (LANOXIN)
Actions: Positive inotropic effects 🡪 heart to beat more forcefully 🡪 ⭡cardiac output and ⭣ oxygen use. Negative chronotropic effects 🡪 ⭣ HR Negative dromotropic effects 🡪 slows conduction velocity at SA and AV nodes (helpful with Atrial Fibrillation). Method of Administration: PO, IV Adverse reactions: Bradycardia; prolonged refractory period and heart block; narrow therapeutic range creates risk for digitalis toxicity. Nursing Implications Important Assessments: Baseline vital signs, cardiac rhythm, and electrolyte levels. Interventions: Monitor vital signs, cardiac rhythm; digitalis levels, & adverse rxs. Patient teaching: Pulse taking; report adverse reaction especially signs of digitalis toxicity (nausea, vomiting, diarrhea, fatigue, and visual disturbances [blurred yellow vision] and hypokalemia [muscle weakness]. Indications for use: second line drug for CHF (⭡cardiac output); atrial fibrillation.
Group III: Potassium channel blockers: Bretylium tosylate, amiodarone (CORDARONE), dofetilide (TIKOSYN), ibutilide (COVERT)
Actions: Prolongs cardiac repolarization. Prolongs the action potential and lengthens the refractory period (QT interval). Indications for use: Ventricular fibrillation (VF) and symptomatic VT. Adverse reactions: BP, HR. N/V. Monitor EKG for prolonged QT interval and torsades de pointes
Thrombolytics: alteplase (tPA), reteplase (RETAVASE), tenecteplase (TNKASE)
Actions: Reacts with plasminogen to convert to plasmin, which dissolves fibrin clots. Method of Administration: continuous IV infusion Adverse reactions: Hemorrhage, reperfusion dysrhythmias, and allergic reactions. There are specific relative and absolute contraindications related to active or potential bleeding for the use of these drugs. Nursing Interventions: monitor for ⭣BP and ⭡HR, and neurological changes such as slurred speech, lethargy, confusion, and hemiparesis. Immobilize the infusion site; avoid any invasive interventions/procedures. Avoid concurrent use of anticoagulants and antiplatelets. If bleeding develops, stop the medication and notify the HCP. Apply pressure dressing. Patient teaching: may need to maintain certain activity restrictions during duration of treatment. Indications for use: Used only in acute, life-threatening conditions: MI, massive PE, ischemic stroke, and acute arterial or venous clots. Antidote: Aminocaproic acid (Amicar), blood products.
Anti-cholinergic: Atropine (ATRO-PEN)
Actions: Selective blockade of muscarinic cholinergic receptors. Method of Administration: PO, IV, IM, and SubQ Adverse Reactions: Xerostomia (dry mouth), blurred vision, photophobia, ⭡intra-ocular pressure, urinary retention, constipation, tachycardia, asthma, anhidrosis (sweaty palms), and hyperthermia. Nursing Implications Important assessments: Baseline hemodynamic assessment, abdominal and ocular assessments. Interventions: Monitor hemodynamics. Indications for use: Symptomatic bradycardia, intestinal hypermotility, muscarinic agonist poisoning, pre-anesthetic, and disorders of eye.
Central acting (α2) Adrenergic Agonist: clonidine (CATAPRES)
Actions: Stimulate presynaptic alpha 2 receptors in brain 🡪 less norepinephrine (NE) released from the brain to the blood vessels & heart 🡪 ⭣ CO, HR, PVR, and BP (Systolic & Diastolic). Method of Administration: Given PO and transdermal. Adverse reactions: Drowsiness, dry mouth, rebound HTN, birth defects. Also can experience Na+ and H2O retention with chronic use of high doses. Nursing Implications Important Assessments: Baseline blood pressure and vitals. Interventions: Monitor blood pressure. Patient teaching: Take at bedtime to minimize daytime sleepiness, apply transdermal medications to hairless areas, routine blood pressure screenings, and report adverse reactions. Indications for use: HTN.
Direct acting vasodilator (arteriolar dilator): hydralazine (APRESOLINE) Other Common Names: Minoxidil
Actions: Vasodilators directly act on smooth muscles of the peripheral arterioles, 🡪 ⭣ peripheral resistance and blood pressure. Adverse reactions: Hypotension, reflex tachycardia (may need to combine w/ß-blocker), ⭡blood volume (Na & water retention, combine w/diuretic), and lupus syndrome. Method of Administration: PO and IV Nursing Implications Important Assessments: VS, heart and lung sounds, I & O, weight, and edema. Interventions: Monitor for adverse reactions. Patient teaching: Routine BP checks. Report adverse effects. Indications for use: HTN, hypertensive crisis, and CHF.
Anticoaculant: warfarin (Coumadin, Jantoven)
Actions: Works on the extrinsic pathway, leading to slower onset and longer action. Interferes with liver synthesis of Vitamin K dependent clotting factors. Method of Administration: Oral Adverse reactions: Hemorrhage and birth defects. Unsafe during pregnancy and lactation. Contraindicated in liver disease and alcoholism. Nursing Interventions: Monitor PT and INR. Be aware that Warfarin has many drug interactions. Blood levels: Normal PT is 9.6 to 11.8 seconds. Warfarin prolongs the PT- therapeutic range is 1.5 to 2 X the control value (for example 14.4-23.6). INR- normally 1.3-2. An INR of 2-3 is appropriate for most patients but may be 3-4.5 for mechanical heart valves. Patient Teaching: maintain a consistent level of intake of vitamin K in your diet. Indications for use: Prevents clot formation and extension of clots, but does not dissolve clots. Prevention of thrombophlebitis, PE, atrial fibrillation/ prosthetic heart valves 🡪stroke. Antidote: Vitamin K/phytonadione.
Group II: ß-adrenergic blockers: propranolol (INDERAL), metoprolol (LOPRESSOR)
Actions: adrenergic stimulation of the heart. Indications for use: Sinus tachycardia, VT, exercise induced sinus and atrial tachycardia. HTN. MVO2 with acute myocardial injury Adverse effects: dizziness, fatigue, BP, HR/HB, CHF, bronchospasm, GI distress. Aggravates depression/ insomnia. Erectile dysfunction and decreased libido. Do not use in patients with acute heart failure! Mask s/s of hypoglycemia. Nursing Implications Important Assessments: Orthostatic blood pressures, cardiac rhythm, and symptoms of angina. Note pulmonary, diabetic, and depression history. Interventions: Monitor orthostatic blood pressures, cardiac rhythm, resolution of angina, and for adverse reactions. Patient teaching: Take as prescribed, record incidences of angina. Do routine BP checks, and do not stop taking medication (will cause rebound SVT); report adverse reactions, e.g. ↓HR .
Other oral anticoagulants: dabigatran (PRADAXA), apixaban (Eliquis), rivaroxaban (Xarelto)
Actions: affect different clotting factors. Reach therapeutic levels in 1-3 days. Method of Administration: PO, fixed dose once or twice daily Adverse reactions: Hemorrhage and birth defects. Unsafe during pregnancy and lactation. Contraindicated in liver disease and alcoholism. Nursing Interventions: monitor for s/s of bleeding Blood levels: not required Patient Teaching: antidote is now available only for dabigatran (Praxbind). Indications for use: atrial fibrillation without valve disease, VTE/PE treatment and prevention
Nonselective ß-Adrenergic Agonist: isoproterenol hydrochloride (ISUPREL)
Actions: exhibits both ß1 and ß2 agonist activity. ß1 - ⭡HR/ force of contraction/ CO/ venous return & ⭣ vascular resistance. ß2 - relaxation of bronchial smooth muscle, skeletal muscle, GI tract, blood vessels of splanchnic bed causing dilation. Stimulates insulin secretion. Method of Administration: IV and IM Adverse reactions: chest pain, dysrhythmias, hyperglycemia. Nursing Implications Important Assessments: Baseline cardiac, pulmonary, renal, & hemodynamics. Interventions: Monitor cardiovascular and pulmonary status and for adverse reactions. Patient/family teaching: Report adverse reactions, chest pain, s/s ⭡CHF, pain at IV-site. Indications for use: Used as a cardiac stimulant (in cardiac arrest); AV block; cardiogenic shock. Can also be used to treat bronchospasm.
ß Adrenergic Blockers: Nonselective ß blockers propranolol (INDERAL) Other Common Names: nadolol (Corgard), nebivolol (Bystolic), penbutolol (Levatol), pindolol, sotalol (ßspace). The following also block α-adrenergic receptors: carvedilol (Coreg), labetalol (Trandate).
Actions: inhibit both ß1(cardiac muscle) and ß2 (smooth muscle of bronchi) receptors. Method of Administration: PO and IV Adverse reactions: See box above. May cause bronchoconstriction and SOB, use with caution in people with pulmonary disease. Blunts signs of hypoglycemia (tachycardia) in diabetic patients and suppresses glyconeogenesis 🡪can cause hypoglycemia.
Peripheral Adrenergic (α1) Blockers: prazosin (MINIPRESS) Other Common Names: doxazosin (Cardura), terazosin (Hytrin).
Actions: ⭣BP by preventing the catecholamine-norepinephrine from activating α1 receptors on vascular smooth muscle (of peripheral blood vessels) to produce vasoconstriction 🡪 arteriolar and venous vasodilatation occurs 🡪 ⭣ peripheral vascular resistance 🡪 ⭣BP. Also ⭣contraction in smooth muscle of prostatic capsule. Method of Administration: PO Adverse reactions: Orthostatic hypotension (and reflex tachycardia), severe orthostatic hypotension with first dose; nasal congestion; inhibition of ejaculation. With long term use & high doses may see Na+ & H2O retention 🡪 need concurrent diuretic treatment. Nursing Implications Important Assessments: VS, I&O, wt.; symptoms of BPH. Interventions: Monitor and trend BP and resolution of BPH symptoms. Patient teaching: Take first dose at bedtime. May cause dizziness/drowsiness. Report adverse reactions. Indications for use: HTN and benign prostate hyperplasia.
Unclassified: Adenosine (ADENOCARD)
Actions: ⭣automaticity, slows AV conduction. Will see a prolonged PRI. Adverse reactions: Intermittent bradycardia, dyspnea, hypotension, flushing. Indications for use: SVT and Wolff Parkinson White syndrome.
Fibric Acid Derivatives: gemfibrozil (LOPID)
Actions: ⭣plasma triglycerides (VLDL). Inhibits peripheral lipolysis and ⭣ the hepatic excretion of free fatty acids resulting in ⭣triglyceride production by inhibiting the synthesis of VLDL. Method of Administration: PO Adverse reactions: Rash and GI disturbances. Gallstones, myopathy, and liver disease. Increases the effects of warfarin. Nursing Implications Important Assessments: Baseline lipid levels, liver function tests Interventions: Monitor lipid levels, and look for adverse reactions. Patient teaching: Take 30 minutes before a meal. Report signs of gallbladder disease. Report any S/S of muscle injury, especially in patients taking a statin drug. Report adverse reactions. Indications for use: To ⭣VLDL, and ⭡HDL as in hypertriglyceridemia.
Group IA- quinidine sulfate (prototype); procainamide (PRONESTYL)
Adverse effects: Delay repolarization. For SVT and v-dysrhythmias. Quinidine: Cinchonism (tinnitus, HA, nausea, vertigo), diarrhea, digoxin toxicity. Procainamide: lupus syndrome and blood dyscrasias. Disopyramide : strong negative inotropic and anticholinergic effects 🡪 limited use.
Adrenergic Agonists
Alpha 2 receptors (CNS) control the release of NE to blood vessels and heart. When stimulated, they reduce the sympathetic outflow of NE 🡪 relaxation of smooth muscles and ⭣ BP.
Sotalol
Also blocks beta receptors. For otherwise refractory VT and atrial dysrhythmias. Same adverse effects as beta blockers and all class III antidysrhythmics. Also started on in-patient basis.
DRUGS THAT PREVENT OR TREAT BLOOD CLOTS
Antiplatelets: Suppress platelet aggregation, work primarily for arterial clots. Anticoagulants: Drugs that reduce formation of fibrin. Most effective for venous clots. Thrombolytic: Dissolve a new fibrin clot. Use for acute MI, acute ischemic stroke, and acute massive PE. Occasionally used for dissolving arterial clots in the legs. Important Assessments: VS, blood cell counts, platelet counts, bleeding times, monitor for bruising or occult bleeding (in the nose, stool, and urine). Can cause spinal/epidural hematoma in patients undergoing spinal puncture or spinal/epidural anesthesia- monitor for S/S of neurological impairment. Interventions: heparin: keep PTT 1 ½ to 2 times > baseline, use nomogram. Warfarin: keep PT & INR in the prescribed range. Platelet Count, Fibrinogen. Give antidotes as ordered for excessive bleeding: Protamine (Heparin), Vitamin K (Coumadin), and Amicar (tPA). Avoid injections. Patient teaching: Regular lab draws, signs of bleeding; promote adherence; avoid prolonged immobilization, avoid constrictive garments, exercise with caution, wear support hose. Wear Medic Alert bracelet. Avoid vigorous teeth brushing. Use electric razor. Avoid excessive alcohol. Notify dentist and surgeon that you are on these medications.
Nursing implications for diuretics
Check for sulfa allergy; monitor I&O; daily weights; check drug interactions; administer a.m.; provide assistance with urination in a timely manner; assess for dehydration and hypotension; monitor diabetics for increased blood glucose
Amiodarone
Effective for both atrial and ventricular dysrhythmia, but only approved for v-dysrhythmias due to serious side effects. Blocks sodium and calcium channels and beta receptors. Dilates coronary and peripheral blood vessels. Method of Administration: PO and IV Adverse reactions: stored in the liver and lung, toxic effects take a very long time to wear off 🡪 pulm.//hepatic/thyroid/derm./cardiotoxicity, lethal dysrhythmias, blurred vision and optic neuropathy, GI reactions. Not during pregnancy and lactation. Monitor EKG for prolonged QT interval and torsades de pointes. Nursing Implications Important Assessments/interventions: lab values. Monitor cardiac rhythm, s/s of lung injury, monitor for hypo and hyperthyroidism, monitor vision: can progress to blindness. Monitor for drug interactions. Patient teaching: inform about serious side effects, s/s of HF, s/s liver failure, avoid pregnancy, and wear sunscreen. No grapefruit juice. Indications for use: approved for refractory VT only, however, frequently prescribed for afib. Dronedarone is a less potent version of amiodarone and approved for atrial flutter and paroxysmal afib. Adverse effects wear off more quickly and consist of GI and skin reactions.
Patient teaching for diuretics
Expect ↑ urine output. Change positions slowly to prevent orthostatic hypotension. Take daily weight at the same time every day, monitor BP and keep record. Monitor blood glucose closely if diabetic. Report adverse events especially hypotension, hearing loss, and signs of gout. Restrict potassium rich foods with potassium sparing diuretics. Take with food if GI upset occurs. Teach-back the need for medication adherence. Life style changes for HTN and HF: Restrict sodium and alcohol, encourage smoking cessation. Encourage stress management and exercise.
CHOLESTEROL LOWERING AGENTS
For all cholesterol lowering agents: treatment of high cholesterol starts with therapeutic lifestyle changes such as weight control, dietary changes, smoking cessation and exercise. Drugs should only be used as adjunct. Combinations of various drug categories to increase the effectiveness of lipid lowering therapy are available. Discontinue meds that do not work! Statins are the most effective to reduce LDL cholesterol and have few adverse effects. Fibrates are the most effective to lower triglyceride levels.
Dofetilide
For symptomatic, otherwise refractory supraventricular dysrhythmias. Given po, but must be started as in-patient, with monitoring.
Ca++ Channel Blockers: verapamil (CALAN); diltiazem SR (CARDIZEM SR); nifedipine (PROCARDIA) Other Common Names: Amlodipine (NORVASC), clevidipine (CLEVIPREX), felodipine (PLENDIL), isradipine, nicardipine (CARDENE), nimodipine, nisoldipine (SULAR).
Method of Administration: PO and IV Adverse reactions: negative inotropic and chronotropic effects can worsen HF. Verapamil may cause gingival hyperplasia. Nursing Implications Important Assessments: VS, cardiopulm. and GI systems, liver and kidney function studies. Interventions: Monitor for adverse reactions. IV administration, requires cardiac monitor. Patient teaching: Swallow pills whole; keep log of angina symptoms, and report adverse reactions. ⭡fluid and fiber in diet. Indications for use: HTN (combine with diuretic), vasospastic CP and dysrhythmias (Class IV).
Summary of Diuretics
Monitor for S/S of hypovolemia, acid base imbalance, and altered electrolyte levels (K, Na, Cl, or K weakness, dizziness, confusion, and orthostatic hypotension). Note: Loop diuretics are the most effective diuretics. Once a day drug therapy is best. Diuretics are the first line treatment for hypertension.
Adrenergic Inhibiting Agents
α1 receptors (SNS) are responsible for contraction or vasoconstriction of peripheral blood vessels, so if you block α1 receptors, vasodilatation occurs
