Chapter 23

A 74-year-old professional golfer has chest pain that occurs toward the end of his golfing games. He says the pain usually goes away after one or two sublingual nitroglycerin tablets and rest. What type of angina is he experiencing? a. Classic b. Variant c. Unstable d. Prinzmetal's

A

A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? A. Blood pressure of 88/62 mm Hg B. Apical pulse rate of 110 beats/min C. History of renal disease D. History of a myocardial infarction 2 years ago

A

When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? A. "Rotate application sites with each dose." B. "Use only the chest area for application sites." C. "Temporarily remove the patch if you go swimming." D. "Apply the patch to the same site each time."

A

The nurse is providing education about the use of sublingual nitroglycerin tablets. She asks the patient, "What would you do if you experienced chest pain while mowing your yard? You have your bottle of sublingual nitroglycerin with you." Which actions by the patient are appropriate in this situation? (Select all that apply.) A. Stop the activity, and lie down or sit down. B. Call 911 immediately. C. Call 911 if the pain is not relieved after taking one sublingual tablet. D. Call 911 if the pain is not relieved after taking three sublingual tablets in 15 minutes. E. Place a tablet under the tongue. F. Place a tablet in the space between the gum and cheek. G. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.

A,C,E,G

Discuss special considerations for nitrates.

Additive hypotensive effects can occur when taken with alcohol, beta blockers, CCBs, and drugs for erectile dysfunction- the "-afils" (i.e. sildenafil [Viagra]) ◦Drugs for ED contraindicated in patients taking nitrates.

What medication classification can interact with (or should not be given at the same time as) nitrates?

Additive hypotensive effects can occur when taken with alcohol, beta blockers, CCBs, and drugs for erectile dysfunction- the "-afils" (i.e. sildenafil [Viagra])◦Drugs for ED contraindicated in patients taking nitrates.

Why are beta-blocker drugs used during or after myocardial infarction (MI)?

After an MI, a high level of circulating catecholamines irritate the heart, causing an imbalance in supply and demand ratio and even leading to life-threatening dysrhythmias. b-blockers block the harmful effects of catecholamines, thus improving survival after an MI◦β blockers sometimes called cardioprotective for this purpose

Discuss general nursing implications for administering, monitoring, and educating regarding antianginal drugs.

Alcohol consumption and hot baths or spending time in whirlpools, hot tubs, or saunas will result in vasodilation, hypotension, and the possibility of fainting (cumulative effect) Teach patients to change positions slowly to avoid postural BP changes Encourage patients to keep a record of their anginal attacks, including precipitating factors, number of pills taken, and therapeutic effects

Discuss how you would place nitroglycerine paste patch on your patient in acute care (at the hospital).

Apply the patch to clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused. Choose a different area each day.

A nurse is teaching a client who has a new prescription for nitroglycerin transdermal patch for angina pectoris. Which of the following instructions should the nurse include?

Remove the patch each evening

A patient with a history of angina will be started on ranolazine (Ranexa). The nurse is reviewing the patient's history and will note potential contraindications to this drug therapy if which condition is present? (Select all that apply.) A. Type 2 diabetes mellitus B. Prolonged QT interval on the electrocardiogram C. Heart failure D. Closed-angle glaucoma E. Decreased liver function

B,E

List the 3 sub-classifications of calcium channel blocker drugs. List some drug names in each sub-classification.

Benzothiazepines -diltiazem (Cardizem, -Dilacor) Phenylalkamines -verapamil (Calan, Isoptin) Dihydropyridines -amlodipine (Norvasc)◦ -nicardipine (Cardene)◦ -nifedipine (Procardia

A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? A. Take up to 5 doses at 15-minute intervals for an angina attack. B. If the tablet does not dissolve quickly, chew the tablet for maximal effect. C. If the chest pain is not relieved after one tablet, call 911 immediately. D. Wait 1 minute between doses of sublingual tablets, up to 3 doses.

C

When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? A. To prevent low blood pressure B. To relieve shortness of breath C. To prevent the occurrence of angina D. To keep the heart rate from rising too high during exercise

C

When the nurse is administering topical nitroglycerin ointment, which technique is correct? A. Apply the ointment on the skin on the forearm. B. Apply the ointment only in the case of a mild angina episode. C. Remove the old ointment before new ointment is applied. D. Massage the ointment gently into the skin, and then cover the area with plastic wrap.

C

While assessing a patient who is taking a beta blocker for angina, the nurse knows to monitor for which adverse effect? A. Nervousness B. Hypertension C. Bradycardia D. Dry cough

C

Diltiazem

CCB used for angina, hypertension available oral and parenteral

Amlodipine

CCB used for angina and hypertension Available orally

A nurse is reinforcing teaching with a client who has angina pectoris and is learning how to treat acute anginal attacks. The client asks, "What is my next step if I take one tablet, wait 5 minutes, but still have anginal pain?" Which of the following responses should the nurse make?

Call the emergency response team

A calcium channel blocker (CCB) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. Which instruction is correct? A. Chew the tablet for faster release of the medication. B. To increase the effect of the drug, take it with grapefruit juice. C. If the adverse effects of chest pain, fainting, or dyspnea occur, discontinue the medication immediately. d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur.

D

A nurse is teaching a client who has angina how to use nitroglycerin transdermal ointment. Which of the following instructions by the nurse is appropriate?

Remove the prior dose before applying a new dose

A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? A. "Watch for unusual weight loss." B. "Monitor your pulse for increased heart rate." C. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." D. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."

D

The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? A. The solution will be slightly colored green or blue. B. The intravenous form is given by bolus injection. C. It can be given in infusions with other medications. D. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.

D

What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? A. Omit a dose once a week. B. Leave the patch on for 2 days at a time. C. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.

D

Why would beta-blocker drugs be used to treat angina? Discuss their mode of action.

Decreased HR Decreased myocardial contractility Decreased myocardial oxygen demand

What is the mode of action of nitrates?

Decreases oxygen demand *Dilate all vessels, but predominately veins *Vasodilation decreases venous return to the heart (decreases preload), and ultimately the workload of the heart Increases oxygen supply *Relaxes/prevents coronary artery spasm

Describe the difference in how to properly administer sublingual nitroglycerine in acute care (as an RN giving it to a patient in the hospital) versus how a patient should be educated to take it at home (when should they call 911?).

ER at home situation: Instruct patients to lie down and take prn nitrates at the first hint of anginal pain◦Instruct patients in proper technique and guidelines for taking sublingual NTG for anginal pain◦Take 1 SL tab, wait 5 minutes, if no relief, call 911. Can take 2 additional tablets at 5 minute intervals for a total of 3 tablets, but should call 911 if no relief in 5 minutes.◦Instruct patients never to chew or swallow the SL form◦Instruct patients that a burning sensation felt with SL forms indicates that the drug is still potent In hospital: used IV for hypertensive patients, ischemic pain, heart failure, and pulmonary edema post MI

List common adverse effects of nitrates.

Headaches◦Usually diminish in intensity and frequency with continued use◦ Reflex tachycardia, postural hypotension◦ Tolerance may develop

How do we treat angina?

Increase oxygen supply and/or...Decrease myocardial oxygen demand

Why would calcium channel blocker drugs be used to treat angina? Discuss their mode of action.

Increase oxygen supply◦Dilates coronary arteries◦Relaxes/prevents coronary artery spasm◦Decrease oxygen demand◦Decrease myocardial contractility

List important interprofessional care and considerations to properly store and administer nitroglycerine (all routes).

Instruct patients to keep a fresh supply of NTG on hand; potency is lost in 3-6 months after the bottle has been opened◦Medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler to preserve potency◦Instruct patients in the proper application of nitrate topical ointments and transdermal forms, including site rotation and removal of old medication

vasospastic angina

Ischemia-induced myocardial chest pain caused by spasms of the coronary arteries; also referred to as Prinzmetal or variant angina

Ischemia

Lack of blood supply

A nurse is caring for a client who is prescribed isosorbide mononitrate for chronic stable angina and develops reflex tachycardia. Which of the following medications should the nurse expect to administer?

Metoprolol

What 3 drug classifications are typically used to treat angina?

Nitrates Beta Blockers Calcium Channel Blockers

Discuss tolerance related to nitrate usage. How do we combat tolerance?

Occurs in patients taking nitrates around the clock or with long-acting forms ◦Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish ◦Transdermal forms: remove patch at bedtime for 8 hours, then apply a new patch in the morning◦Some controversy regarding this practice

ischemic heart disease

Poor blood supply to the heart muscle Atherosclerosis Coronary artery disease

What is the difference between rapid-acting and long-acting forms of nitrates?

Rapid-acting forms *Used to TREAT acute anginal attacks◦Commonly sublingual tablets or sprays or intravenous infusion Long-acting forms *Used to PREVENT anginal episodes◦Commonly oral tablets, capsules, ointments, patches

List the different formulations (routes) that nitroglycerine comes in

Sublingual Buccal Chewable tablets Oral capsules/tablets Intravenous solutions Ointments Transdermal patches Translingual sprays

Pathophysiology of angina pectoris

When the supply of oxygen in the blood is insufficient to meet the demands of the heart, the heart muscle "aches"

Ranolazine

antianginal drug used for chronic angina does not reduce HR and BP

List common side effects of beta-blockers (remember that beta-blockers are found on your pharmacology alphabet form).

bradycardia, lethargy, GI, CHF, decreased BP, depression

Atenolol

cardioselective beta1-adrenergic receptor blocker used for angina and post MI Available orally

Metoprolol

cardioselective beta1-adrenergic receptor blocker used for angina and post MI available immediate and long acting release as well as parenteral

angina pectoris

chest pain

unstable angina

chest pain at rest or chest pain of increasing frequency

chronic stable angina

chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms

List common side effects of calcium channel blocker drugs. (Remember that CCBs are found on your pharmacology alphabet form).

decreased BP, bradycardia, May precipitate AV block, headache, abdominal discomfort, peripheral edema

a nurse is taking a medication history from a client who has angina and a new prescription for ranolazine. which of the following medications in the client's history can interact with ranolazine?

digoxin simvastatin verapamil

coronary artery disease

disease of the arteries surrounding the heart

Atherosclerosis

hardening of the arteries

Besides nitroglycerine, give examples of other nitrate medications.

isosorbide dinitrate (Isordil, Sorbitrate, Dilatrate SR) ◦isosorbide mononitrate (Imdur, Monoket, ISMO)◦nitroglycerin (Nitrobid, Nitrostat, etc)

Isosorbide mononitrate

nitrate for angina available immediate release and sustained release

Nitroglycerine

nitrate prototype used for angina and BP available orally, sublingually, IV

Isosorbide dinitrate

organic nitrate used for angina available immediate release and long acting

coronary arteries

supply oxygen-rich blood to the myocardium

reflex tachycardia

temporary increase in heart rate that occurs when blood pressure falls