Unit3 Chapter 24 Heart Failure Drugs

The best way to prevent heart failure is to control risk factors such as

-HTN -CAD -Obesity -DM

3 most important drug to drug interaction with Digoxin

-amiodarone -quinidine -verapmil

**4 common signs of heart failure

-dyspnea -fatigue -fluid retention -pulmonary edema

Pt calls and says "I know I'm supposed to take my Digoxin at the same time everyday but I forgot this morning" What should the nurse tell the patient

-if it has been less than 12 hours since the missed dose ok for patient to take med -If more than 12 hours, do not skip next dose and do no double dose

When would the use of immune Fab therapy be indicated (this treatment is used when significant Digoxin toxicity develops...1 vial binds with 0.5mg of Digoxin)

-serum potassium levels higher than 5mEq/L -life threatening cardiac dysrhythmia (ventricular tachycardia or fibrillation, severe bradycardi, heart block unresponvise to atropine -Overdose: more than 10mg in adults and 4 mg in children

**Normal therapeutic levels for Digoxin

0.5-2.0 (ng/ml)

Select all the statement that are true for Digoxin A. Causes a positive inotropic effect B. Causes a positive chronotropic effect C. Causes a negative chronotropic effect D. Causes a positive dromotropic effect E. Causes a negative dromotropic effect

A. Causes a positive inotropic effect (increase force of contraction; thus increase stroke volume) C. Causes a negative chronotropic effect (decrease heart rate) E. Causes a negative dromotropic effect (decreases electrical conduction)

. A patient weighing 44 lb is prescribed a digoxin (Lanoxin) loading dose of 0.03 mg/kg to be administered in three divided doses. How much will the nurse administer in each dose? a. 0.2 mg b. 0.3 mg c. 0.4 mg d. 0.6 mg

a. 0.2 mg

Milrinone indication

Acute heart failure

Hydralazine/isosorbide dinitrate (BiDil) was approved specifically for use in the ___________________ population.

African-American

Drugs ending in "tan" are classified as

Angiotensin II receptor blockers ARBs

Drugs ending in "ril" are know as

Angiotensin converting inhibitors (Ace-inhibitors)

MOA of ace inhibitors

Angiotension converting inhibitors stops Angiotensin I from converting into Angiotensin II thus decrease systemic vascular resistance

Nesiritide pharmacological classification

B-type natriuretic peptide

Which drugs are known for preventing catecholamine-mediated actions on the heart

Beta-blockers (this is known as cardioprotective )

ACE inhibitors are classified as category ____ drug for women in the first trimester of pregnancy and a category ______ drug for women in the second and third trimesters

C, D

Name the drug that acts like a non-selective beta-blocker , possibly a calcium channel blocker, and antioxidant

Carvedilol (Coreg)

ARBs is a pregnancy category ____ drug

D

The nurse is preparing to administer digoxin (Lanoxin) 0.25mg intravenous push to a patient. Which is an expected patient outcome related to the administration of digoxin? a. Low serum potassium b. Reduction in urine output c. Decrease in the heart rate d. Increase in blood pressure

Decreased heart rate Digoxin has a negative chronotropic effect (decreased heart rate).

Classify these drugs: Digoxin Milrinone Valsartan

Digoxin -->Digitalis cardiac glycoside Milrinone -->Phosphodiesterase inhibitor Valsartan -->ARB

****True or false: Digoxin has a broad therapeutic window

Digoxin has a narrow therapeutic window

**Adverse effects of Digoxin

Dysthymia blurred vision/halo vision bradycardia tachycardia hypotension, HA Anorexia nausea vomiting diarrhea

True or false: it is safe to take Digoxin with many herbal supplements

False: Ginseng: increase digoxin levels Hawthorn: may potentiate the effects of digoxin Licorice: may increase increase risk for cardiac toxicity due to potassium loss St. John's wort: may reduce digoxin levels.

True or false: Patients taking omprazole (proton-pump inhibitor) may need an increase dose of Digoxin

False: proton pump inhibitors increase the levels of digoxin

Prior giving Digoxin why is it important to check potassium and magnesium levels

Low levels of potassium can lead to digoxin toxicity

Name 4 medications that interact with ARBs

NSAIDs (decreases effect of ARB) Potassium supplements (possible hyperkalemia) rifampin (decreased effect of ARB) lithium (increased lithium concentration)

Nesiritide (Natrecor) Indication

severe life threatening heart failure (newest class of medication for heart failure and this is the only prototype and is only offered in injectable form and only only used ICU)

Milrinone drug classification

Phosphodiesterase inhibitor

Positive/negative dromotropic drugs:

Positive → increase the electrical impulses through the hearts conduction system Negative → decreased the the electrical impulses through the hearts conduction system Greek word "dromos", meaning running, a course, a race.

Positive/negative inotropic drugs;

Positive → increase the force of myocardial contraction Negative → decreased the force of myocardial contraction inotropic; modifying the force or speed of contraction of muscles

Positive/negative chronotropic drugs:

Positive → increase the rate at which the heart beats Negative → decreased the rate at which the heart contraction

Mechanism of action of Valsartan

Potent vasodilator by decreasing systemic vascular resistance (a measure of afterload);

Stroke volume:

The amount of blood pumped by the left ventricle of the heart in one contraction

True or false: Patients taking anti-acids may need an increase dose of Digoxin

True: anti-acids such as TUMs decrease the bio availability of Digoxin

**What is heart failure

When your heart is too weak to pump efficiently; thus it can't provide the proper cardiac output your body metabolic needs. This is caused by numerous disorders . Diagnosed clinically

For a patient receiving a positive inotropic drug, which nursing assessments should be performed? (Select all that apply.) a. Check apical pulse. b. Obtain daily weights. c. Auscultate lung sounds. d. Monitor serum electrolytes. e. Review red blood cell count.

a. Check apical pulse. b. Obtain daily weights. c. Auscultate lung sounds. d. Monitor serum electrolytes. All of these assessments are appropriate for patients receiving an inotropic drug. Lung sounds and daily weights are appropriate assessments related to the treatment of heart failure with inotropic drugs. The apical pulse and serum electrolytes are important assessments related to potential adverse reactions (bradycardia, toxicity with hypokalemia).

When monitoring a patient who is receiving an intravenous infusion of nesiritide (Natrecor), the nurse will look for which adverse effect? a. Dysrhythmia b. Proteinuria c. Hyperglycemia d. Hypertension

a. Dysrhythmia

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

Phosphodiesterase inhibitors (PDIs) have an added advantage in treating heart failure. These drugs cause a positive inotropic effect and what other effect? a. Vasodilation b. Bronchodilation c. Vasoconstriction d. Platelet inhibition

a. Vasodilation Phosphodiesterase inhibitors are also called inodilators because they have both positive inotropic and vasodilator effects

Which heart failure drug can cause hyperkalemia

ace-inhibitors

Drug ending in "an"

angiotensin II receptor blockers (ARBs)

Valsartan(Diovan) belongs to which drug class?

angiotensin II receptor inhibitor (ARBs)

medication regimens for heart failure, most patients are advised to avoid

anti-acids, ice cream, milk products, yogurt, cheese, bran 2 hour before and 2 hours after taking medication

The nurse would question the use of milrinone (Primacor) in a patient with which condition? a. Acute renal failure b. Aortic regurgitation c. Systolic heart failure d. Mitral valve prolapse

b. Aortic regurgitation aortic regurgitation other severe aortic valvular disease severe pulmonary valvular disease diastolic HF

When teaching a patient regarding the administration of digoxin (Lanoxin), the nurse instructs the patient not to take this medication with which food? a. Bananas b. Wheat bran c. French toast d. Scrambled egg

b. Wheat bran Large amounts of bran taken with digoxin will decrease and negatively impact the drug's absorption.

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 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. beta blockers work by reducing sympathetic nervous system stimulation to the heart and heart's conduction system by preventing catecholamine medicated actions

A patient prescribed digoxin (Lanoxin) 0.25 mg and furosemide (Lasix) 40 mg for the treatment of systolic heart failure states, "I am starting to see yellow halos around lights." Which action will the nurse take? a. Perform a visual acuity test on each eye. b. Document the finding and reassess in 1 hour. c. Assess for other symptoms of digoxin toxicity. d. Prepare to administer digoxin immune fab (Digifab).

c. Assess for other symptoms of digoxin toxicity. Yellow or green halos around objects is a red flag symptom of digoxin toxicity.

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

Which are therapeutic effects of digoxin (Lanoxin)? a. Positive inotropic, positive chronotropic, and negative dromotropic b. Positive inotropic, negative chronotropic, and positive dromotropic c. Positive inotropic, negative chronotropic, and negative dromotropic d. Negative inotropic, negative chronotropic, and negative dromotropic

c. Positive inotropic, negative chronotropic, and negative dromotropic Digoxin increases cardiac contractility (positive inotropic effect), decreases heart rate (negative chronotropic effect), and decreases conductivity (negative dromotropic effect).

During assessment of a patient who is receiving digoxin, the nurse monitors for findings that would 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. a. apical pulse rate of 62 beats/min. (FALSE: only concerned if less than 60 bpm) b. digoxin level of 1.5 ng/mL. (FALSE: therapeutic levels are between 0.5-2 ng/ml) c. serum potassium level of 2.0 mEq/L. (True: The normal potassium level in the blood is 3.5-5.0 ..2.0 is low and hypokalemia is known to increase digoxin toxicity ) d. serum calcium level of 9.9 mEq/L. (FALSE: this a normal calcium level)

******The patient's serum digoxin level is 0.4 ng/mL. How does the nurse interpret this laboratory value result for digoxin? a. Normal therapeutic level b. A toxic serum blood level c. Above the therapeutic level d. Below the therapeutic level

d. Below the therapeutic level Therapeutic serum digoxin levels are 0.5 to 2 ng/mL

The nurse reviews an adult patient's laboratory values and notes a digoxin level of 11 ng/mL and a serum potassium level of 6.2 mEq/L. The nurse would notify the health care provider and anticipate which medication will be prescribed to administer? a. Sodium polystyrene sulfonate (Kayexalate) b. Atropine c. Epinephrine (Adrenalin) d. Digoxin immune Fab

d. Digoxin immune Fab Digoxin immune FAB is indicated for severe digoxin toxicity as evidenced in this question by a digoxin level of 10 and hyperkalemia.

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 Ventricular dysrhythmia occur in approximately 12% of patients treat with Milrione

Contraindications of digoxin

drug allergy second or third degree heart block ventricular fibrillation heart failure resulting from diastolic dysfunctions

Contraindication of Nesiritide

drug allergy and patient's with know low cardiac filling

Contraindication of Valsartan

drug allergy, pregnancy (category D)

Milrinone adverse effects

dysthymia (typical ventricular dysrthmias)

Digoxin can be taken with meals, however not with food high in _______________

fiber (bran) fiber will bind to digitalis and leas to altered absorption

Digoxin mechanism of action

has an inotrophic effect by inhibiting the sodium potassium adenosine triphophatase pump thus increasing intra cellular Ca+. Also is prolongs the refractory period and decreases conduction through the SA and AV node, by increasing vagal nerve stimulation → this is how it helps with A-fib and A-flutter

Reduced ratio of ejection fraction and left ventricular end-diastolic volume

heart failure ejection fraction: amount of blood ejected with each contraction Left ventricular end-diastolic volume: total amount of blood in the ventricle just before ejected

Indication for valsartan (diovan)

heart failure and HTN

Milrinone contraindication

heart failure from diastolic dysfunction aortic or pulmonary valvular dz (NOT mitral valve prolapse ) Aortic regurgitation

Milrinone MOA

postive inotropic vasodilation postive chronotropic

Adverse effects of Valsartan

renal insufficiency, chest pain, fatigue, hypoglycemia, diarrhea, UTI, anemia, and weakness

****Indication for Digoxin use

systolic heart failure and atrial fibrillations

**Ejection fraction

the amount of blood ejected with each contractions compared with the ventriculcar filling volume

Automaticity :

the cardiac cell's ability to spontaneously generate an electrical impulse (depolarize)

Nesiritide mechanism of action

vasodilating affects on both the veins and the arteries

when teaching a patient regarding the administration of digoxin (Lanoxin), the nurse instructs the patient not to take this medication with which food?

wheat bran dairy products other bran products