Pharm Exam 4

Lidocaine

Class I - Sodium Channel Blocker Antidysrhythmic Drug 1B: accelerate repolarization, little negative effect on EKG - For acute treatment of ventricular dysrhythmias - Not all lidocaine is the same... - Solutions specific for IM, IO, or IV infusion - Solutions specific for SQ or topical Lidocaine for IV use is different from lidocaine used as a local anesthetic - Label for lidocaine for IV use should read "lidocaine for dysrhythmias" or "lidocaine without preservatives." (has epinephrine, can kill a patient if given IV) - Lidocaine administered with neuromuscular blocking agents (for patients on ventilator) may cause respiratory depression - Clarify orders: dose, strength/concentration, and route Emergency Drug for Cardiac Disorder - Anti-dysrhythmic class IB - Used to treat ventricular dysrhythmias - Given IV, IO, ETT - Anesthetic effect, reducing irritability - Requires continuous cardiac monitoring Lidocaine toxicity - Confusion - Drowsiness - Seizures - Cardiac arrest

Disopyramide phosphate (Norpace)

Class I - Sodium Channel Blocker 1A Antidysrhythmic Drugs Slows conduction, prolongs repolarization

Quinidine

Class I - Sodium Channel Blocker 1A Antidysrhythmic Drugs Slows conduction, prolongs repolarization

Atrial Fibrillation

- Rate 350 - 400 High risk of CVA...why? - Blood sits there and forms clots - Monitor mental status!!! Most common dysrhythmia; - Responsible for majority of hospitalizations for cardiac dysrhythmias High risk of A Fib after CABG! - Monitor closely - Counting atrial contractions is very difficult - Control the rate and improve function Beta Blockers - Atenolol (Tenormin) -Metoprolol (Lopressor, Toprol) - CCBs (Calcium Channel Blockers) - Digoxin Class III Antidysrhythmics - Amiodarone (Cordarone) - Sotalol (Betapace) - Ibutilide (Covert) - acute treatment given IV for recent onset, more effective with A Flutter than A Fib Prevent clots Anticoagulants - Warfarin (Coumadin) Other anticoagulation options - Apixaban (Eliquis) - Dabigatran (Pradaxa) - Edoxaban (Savaysa) - Rivaroxaban (Xarelto) Restore NSR - Cardioversion - electric shock or chemical conversion - Ablation via radiofrequency - kills those so they don't start the wrong electrical impulses - HTN is a major contributor to the development of AFib - Uncontrolled, long-standing hypertension, leads to left ventricular hypertrophy and eventually heart failure - Prevention via Bp control: A Fib is dangerous, expensive to treat, treatment is inconvenient for the patient and potentially deadly - Therefore, treatment for A Fib must also include a plan for managing Bp

Ventricular tachycardia

- Repeated firing of an irritable ventricular ectopic focus - Rate 140-250 - Assess the client's airway, breathing, and level of consciousness! - If unconscious or in respiratory arrest, defibrillation and CPR are begun - Call rapid response, they will go into vFib soon

Anatomy and Physiology (Conduction System)

- Sinoatrial (SA) node - The SA node is the dominant pacemaker of the heart - Initiates the electrical impulse Atrial conduction - Impulse travels rapidly - Impulse travels over atria from right to left and top to bottom Atrial depolarization - Produces the P wave on EKG (atrial depolarization) - Impulse travels to AV node Atrial ventricular (AV) node - Impulse delayed briefly while ventricles fill (PR interval on EKG) - The impulse enters the right and left bundle branches and then enters the Purkinje fibers. Bundle of His & Bundle Branches - Work together for ventricular depolarization and repolarization Left bundle branch goes into left ventricle; receives blood supply from left anterior descending (LAD) coronary artery - Blockage at LAD = "widow maker" - Right bundle branch supplies impulse to right ventricle; receives blood supply from right coronary artery Purkinje fibers - Network of specialized fibers - Transmit impulse to ventricular muscle cells, causing ventricular depolarization - Conduct impulses very rapidly

Supraventricular tachycardia

- Starts in a part of the heart above the ventricles - Includes: atrial tachycardia, atrial fibrillation, atrial flutter along with several other AV rhythms Supraventricular dysrhythmias generally not as harmful as ventricular dysrhythmias - Dysrhythmic activity within atria does not significantly reduce cardiac output (except in patients with valvular disorders and heart failure) - Paroxysmal (means it comes on sporadically) supraventricular tachycardia (PSVT)

Antiplatelets

- Used to prevent thrombosis primarily in the arteries by suppressing platelet aggregation Prophylactic use in - Prevention of acute or repeat MI or CVA - Prevention of a stroke for patients having TIAs Nursing Assessment/Intervention - Monitor for bleeding - Obtain history - GI bleed, head trauma, recent surgery may increase risk of bleeding - Review medications - NSAIDs increase bleeding

Magnesium sulfate

- Used to treat cardiac arrest associated with hypomagnesemia - Used to treat life-threatening ventricular dysrhythmias Used in treatment of torsades de pointes - Prolong QT interval - Many causes: medications (including antiarrhythmic) and electrolyte imbalances! Side Effect of mag sulfate: hypermagnesemia - Neuromuscular blockade: hypotension, bradycardia, and respiratory depression, decreased tendon reflexes Treat with calcium gluconate! - Must be readily available whenever giving magnesium

Insulin Shock

- What are S&Sx of hypoglycemia? Dextrose 50%: concentrated, high-carbohydrate solution given to treat insulin-induced hypoglycemia or insulin shock - Given IV - Phlebitis and extravasation are risks - Hyperglycemia can result Glucagon: pancreas-produced hormone that elevates blood sugar by stimulating glycogenolysis - IV, SQ, IM - Continue to monitor blood sugar and UO

Paroxysmal supraventricular tachycardia (PSVT)

- occur intermittently Causes - CHF - Previous MI - Medications: aminophylline, beta-agonists, potassium-wasting diuretics, or OTC cold/sinus medications that contain phenylephrine DRUG: Adenosine *Caution with afib, mostly contraindicated in aflutter Procainamide - IV bolus treats PSVT Terminates sustained episodes of SVTs - CCBs - Beta Blockers - Valsalva Maneuver - Cardioversion

An IV of NS 1,000mL is to infuse over 10 hours. The drop factor is 10gtt/mL. Calculate the flow rate in gtt/min

1,000 x 10hrs / 10mL / 60min = 16.66 -> 17gtt/min

Order: Heparin sodium 10,000 units subcutaneously stat. The label on the vial reads "40,000 units/mL" How many milliliters will you administer?

10,000units / 40,000units = 0.25

A patient was prescribed heparin sodium 18units/kg/h; titrate according to the weight based heparin protocol. The patient's weight is 123lbs. Heparin 25,000 units/250mL (100unit/mL) is available Calculate the flow rate in mL/h: aPTT is 40, and the protocol states to rebolus with 40 units.kg and increased the infusion rate by 2 units/kg/h How many more units did the patient receive: What is the new flow rate?

123lbs / 2.2 = 55.9kg 18u x 55.9kg = 10.1mL/h 40 x 55.9kg = 2,236u 2u x 55.9kg / 100u = 1.19 1.19 + 10.1u = 11.2

Order: Ampicillin 125mg IV q 8h. The directions on the package state "Reconstitution of the single-use vial with 4.8mL yields 250mg/5mL" How many milliliters will you administer?

125mg x 5mL / 250mg = 2.5mL

Na+

135-145 mEQ/L

Order: amiodarone 0.5mg/min Available: 1.8mg/mL What is the flow rate?:

1mL / 1.8mg x 0.5mg x 60min = 16.66mL/h round up 16.7mL/h

Patient is receiving nitroglycerin 0.25mg/min for unstable angina Available 100mcg/mL What is the flow rate?

1mL / 100mcg x 0.25mcg x 60min = 33mL/h

A patient was prescribed heparin sodium 18units/kg/h; titrate according to the weight-based heparin protocol. The patient's weight is 70kg. Heparin 12,500/250mL (50u/mL) is available. Calculate the flow rate in mL/h: aPTT is >90 and the protocol states to hold the infusion for 1 hour and decreased rate by 3units/kg/h. What is the new flow rate?:

1mL / 50u x 18u x 70kg = 25.2mL/h 1mL / 50u x 3u x 70g = 4.2 25.2 - 4.2 = 21mL/h

A patient was prescribed heparin sodium 18units/kg/h; titrate according to the weight based heparin protocol for a patient with pulmonary embolus. The patient's weight is 63 kilograms. Heparin 25,000 units/250mL (100 units/mL) is available. Calculate the flow rate in mL/hr aPTT is 45, and the protocol states to rebolus with 40 units/kg/hr and increase infusion by 2 units/kg. How many more units did the patient receive? What is the new flow rate?

1mL/ 100u x 18u x 63kg = 11.34mL/h 40u x 63kg = 2,520u 2u x 63kg / 100u = 1.26 1.26 + 11.34 = 12.6mL/h

Order: dobutamine 2mcg/kg/min as a continuous infusion. Titrate according to patient's hemodynamic response. Weight 63kg Available: 1000mcg/mL What is the flow rate?

1mL/1000mcg x 2mcg x 63kg x 60 min = 7.56mL/h

Order: domutamine 5mcg/kg/min as a continuous infusion. Titrate according to patients hemodynamic response. Weight 78kg Available: 1000mcg/mL What is the flow rate? Nurse is to increase the dobutamine infusion by 2mcg/kg/min. What is the new flow rate?

1mL/1000mcg x 5mcg x 78kg x 60min = 23.4mL/h 1mL/1000mcg x 2mcg x 78kg x 60min = 9.36mL/h 9.36mL/h + 23.4mLh = 32.76mL/h

Order: nitroprusside 100mg/250mL D5W at 25mL/hour for hypertension The patient weights 143 lb How many mcg/kg/min of nitroprusside is the patient receiving? What is the flow rate?

2.2lb / 143lb x 100 / 250mL x 25mL / 60min x 1000mcy = 2.6mcg/kg/min rnd up to 3mcg/kg/min flow rate: 25mL/hr (says it in question)

Calculate the infusion time for an IV of 2,000 mL running at 125mL/h

2000 / 125 = 16hrs

How many milliliters of full-strength Sustacal are needed to prepare 240mL of half-strength Sustacal?

240mL / 2mL = 120mL

Order dobutamine 10mcg/kg/min Patient's weight: 95kg Available: dobutamine 1000mg in 250mL D5W What is the flow rate?

250mL / 1000mg x 10mcg / 1000mcg x 95kg x 60 min = 14.25mL/h rnd up to 14.3mL/h

Order dopamine 300mcg/min Available dopamine 400mg in 250mL of D5W What is the flow rate?

250mL / 400mg x 300mcg / 1000 mcg x 60min = 11.25mL/hr rnd up to 11.3mL/hr

Order: dobutamine 5mcg/kg/min Patient's weight: 152lb Available: dobutamine 500mg in 250mL D5W What is the flow rate?

250mL / 500mg x 5mcg / 1000mcg x 69.1.x 60min = 10.37mL/h round up to 10.4mL/h

Order heparin at 800 units/h Available: heparin 25,000 units in 250mL of D5W What is the flow rate?

250mL/25,000u x 800u = 8mL/h

K+

3.5-5.0 mEq/L

Order: heparin 30,000 units/d continuous infusion Available: 12,500 USP units /250mL A. How many units/h is the patient receiving B. What is the flow rate?

30,000 / 24hrs = 1,250u/hr Flow rate 1,250u x 250mL / 12,500u = 25mL/hr

A continuous IV is infusing at the rate of 300mL/h. How many mL will infuse in a 12-hour period?

300mL x 12hr = 3600mL

Order: lidocaine 2g in 250mL of D5Q t 30mL/h How many mg/min is the patient receiving?: What is the flow rate

30mL x 2g / 250 mL / 60min x 1000mg = 4mg/min 30mL/h (says it in the question)

From a full strength hydrogen peroxide solution, how would you prepares 330mL of two thirds strength hydrogen peroxide solution for a wound irrigation using normal saline as the dilutent?

330mL / 3 = 110mL NS

Order: Itraconazole (Sporanox) 4mg/kg/d divided in equal doses q 8hr. The multi-dose vial reads "8 mg/mL" How many milliliters will you administer to a client who weights 84kg?

4mg x 84kg / 8mg / 3 = 14mL

Order dopamine 5mcg/kg/min Patient weights 130lb Available: dopamine 300mcg/min What is the flow rate?

500mL / 800mg x 5mcg / 1000mcg x 130lb / 2.2lb x 60 = 11.07mL/h rnd up to 11.1mL/h

Order 600mL D5W IV to infuse in six hours. At what rate in mL/h will you set the pump?

600mL / 6hr = 100mL/hr

Order: Pipracil (piperacillin sodium) 8g/day IV in four divided doses q 6hr. The directions on the package insert state, "Add 4mL suitable diluent (sterile water or 0.9% NaCl) to yield 1g/2.5mL." The patient weight 160lbs. How may milliliters will you administer per dosage.

8g x 2.5mL / 1g / 4 = 5mL/dose

What is the priority nursing diagnosis for a patient with a dysrhythmia? A. Alteration in cardiac output B. Imbalance of fluid and electrolytes C. Inadequate peripheral tissue perfusion D. Ineffective breathing pattern

A. Alteration in cardiac output Cardiac output affects all the other diagnoses; therefore, without adequate cardiac output, fluid balance, tissue perfusion, and breathing cannot be adequately maintained.

The nurse is caring for patient who is being treated with amiodarone. The nurse notes that the patient is experiencing a hacking cough. What is the nurse's priority action? A. Notify the provider regarding this symptom B. Document the findings in the patient's chart C. Administer medication to help the patient rest D. Administer the cough syrup that has been ordered

A. Notify the provider regarding this symptom The most serious adverse effect of amiodarone is pulmonary toxicity, which involves a clinical syndrome of progressive dyspnea and cough accompanied by damage to the alveoli. The nurse will also document the findings; however, this is not the priority. Administering the medication or a cough syrup will not address the pulmonary toxicity that may accompany amiodarone and may make it worse.

Emergency Drugs for Cardiac Disorders

AMI - CPR - Defibrillation MONA M = morphine O = oxygen N = nitroglycerin A = aspirin - "Time is muscle" minimize cardiac injury, prevent complications; nitroglycerin, ASA & O2 given on the way to ER by EMS - Given in the order of OANM

Lisinopril

AMI Treatment, Reperfusion ACE inhibitor

valsartan

AMI Treatment, Reperfusion ARB

abciximab (ReoPro)

AMI Treatment, Reperfusion Adjunct therapy to PCI include - Antiplatelet that may be used with PCI but NOT with fibrinolytic therapy

Ticagrelor (Brilinta)

AMI Treatment, Reperfusion Adjunct therapy to PCI include Antiplatelet - not with fibrinolytics

Heparin

AMI Treatment, Reperfusion Anticoagulant therapy - Start before, continue throughout and 48-72 hours after clot buster

Clopidogrel (Plavix)

AMI Treatment, Reperfusion Antiplatelet therapy

Alteplase

AMI Treatment, Reperfusion Fibrinolytic therapy

reteplase

AMI Treatment, Reperfusion Fibrinolytic therapy

tenecteplase

AMI Treatment, Reperfusion Fibrinolytic therapy

Multi-Tyrosine Kinase Inhibitors

Action - Directly inhibit activity of specific kinases in cancer cells and in cancer cell vasculature Drug - Sorafenib (Nexavar) - renal cell and thyroid carcinomas Side effects/adverse effects - Diarrhea - Fatigue - Dysrhythmias - High risk of bleeding!

Epidermal Growth Factor Tyrosine Kinase Inhibitors (EGFRIs)

Action - Inhibit tyrosine kinase indirectly, inhibit downstream signal transduction pathway for cell division - Results in severely limited cell proliferation Drugs Cetuximab (Erbitux) - IV - Interstitial lung disease (ILD) - teach patients to report breathing difficulties! Gefitinib (Iressa) - given orally - St John's wort decreases levels of gefitinib The Martha Stewart drug class (went to jail for insider trading in the stock market)

Angiogenesis Inhibitors

Action - Reduce vascular growth and inhibit metastatic disease progression - Don't kill tumor, however prevent further growth Drugs Bevacizumab (Avastin) - treatment of colon, lung, renal, and cervical CA Side effects/adverse effects - Boxed warning for gastrointestinal perforations, wound dehiscence, impaired wound healing, hemorrhage, and fistula formation after surgery. The drug should not be used within 28 days after major surgery

Tyrosine Kinase Inhibitors (TKIs)

Action - Stop proliferation of cancer cells - Resistance to drugs can develop - The cancer MUST be susceptible to the action of the med - Gold standard for treatment of chronic myeloid leukemia (CML) Imatinib mesylate (Gleevec) Side effects/adverse effects - N/V, H/A, fatigue Hematologic alterations - CBC to be done regularly Contents of the tablet are toxic! - Patient or nurse should wear gloves if the tablets are crushed or broken

Proteasome Inhibitors

Action - Suppresses cancer cell division, promoting apoptosis Drug - Bortezomib (Velcade) - treatment of multiple myloma Side effects/adverse effects - Nausea, vomiting, anorexia - Hematologic issues - Peripheral neuropathy - t. John's wort may decrease levels of bortezomib

PSVTs

Adenosine

Bevacizumab (Avastin)

Angiogenesis Inhibitors Action - Reduce vascular growth and inhibit metastatic disease progression - Don't kill tumor, however prevent further growth Side effects/adverse effects - Boxed warning for gastrointestinal perforations, wound dehiscence, impaired wound healing, hemorrhage, and fistula formation after surgery. The drug should not be used within 28 days after major surgery

A patient is ordered to receive digoxin (Lanoxin) to treat congestive heart failure. The nurse is most concerned about which assessment finding? A. Heart rate 56 beats/min B. BP 138/90 mm Hg C. RR 18 breaths/min D. 1+ pitting edema of the lower extremities

Answer: A A baseline pulse rate for the patient should be obtained for future comparisons. Apical pulse should be taken for a full minute and should be greater than 60 beats/min. The prescriber should be notified if the patient's pulse is less than 60 beats per minute. - Digoxin toxicity will slow the heart down, vital organs not perfused

Four patients are considered as potential candidates for thrombolytic therapy. Which patient is most likely to receive thrombolytic therapy? A. The patient who recently used acetaminophen (Tylenol) B. The patient with a history of severe hypertension C. The patient who recently had spinal surgery D. The patient with a history of warfarin (Coumadin) use

Answer: A Acetaminophen (Tylenol) does not interfere with the coagulation system. Contraindications for use of thrombolytics include a recent CVA, active bleeding, severe hypertension, recent history of traumatic injury, especially head injury, and anticoagulant therapy. The nurse should report if the patient takes aspirin or NSAIDs.

The nurse identifies which drug as a calcium channel blocker used for the treatment of dysrhythmias? A. Diltiazem (Cardizem) B. Esmolol (Brevibloc) C. Flecainide (Tambocor) D. Sotalol HCl (Betapace)

Answer: A Diltiazem (Cardizem) - Diltiazem (Cardizem) is a calcium channel blocker used to treat dysrhythmias. - Esmolol (Brevibloc) is a beta blocker. - Flecainide (Tambocor) is a sodium channel blocker. - Sotalol HCl (Betapace) is a beta blocker.

Which finding indicates that administration of glucagon has been effective? The patient experiences A. an improvement in level of consciousness. B. an elevation in respiratory rate. C. suppression of heart rate. D. reduction in blood pressure.

Answer: A an improvement in level of consciousness Glucagon is used for treatment of patients with severe hypoglycemia. An improved level of consciousness indicates elevation of blood sugar. A blood sugar analysis should also be obtained.

A nurse is administering digoxin, 0.125 mg, to a patient. Which nursing interventions will the nurse implement? (Select all that apply.) A. Checking the apical pulse rate before administration B. Monitoring the patient's serum digoxin level C. Instructing patient to report pulse rate less than 60 D. Advising patient to avoid foods high in potassium E. Always giving an antacid with digoxin to reduce GI distress

Answer: A, B, C The apical pulse should be taken before digoxin administration and the drug withheld if the heart rate is less than 60. The patient's serum digoxin level should be monitored and withheld if in toxic range. Patient should be advised to avoid taking antacids with digoxin because they decrease absorption.

A patient presents to the emergency department with severe respiratory distress, hives, and edema after being stung on the face by a bee. Which are accurate nursing assessments of the situation? (Select all that apply) A. Hypotension and bronchospasm will progress rapidly if treatment is delayed. B. The patient is suffering from anaphylactic shock. C. Epinephrine and diphenhydramine are the drugs of choice as first-line agents. D. Prompt treatment with drug therapy will prevent this syndrome from occurring again.

Answer: A, B, C Treatment will not prevent anaphylaxis from occurring again. All other statements are true.

A patient arrived in the emergency department 2 hours after an acute ischemic stroke. The patient is given an intravenous (IV) injection of alteplase tPA (Activase). It is most important for the nurse to monitor what? (Select all that apply.) A. Bleeding B. Vital signs C. PT levels D. Allergic reactions E. Electrocardiogram

Answer: A, B, D, E The nurse should monitor the patient receiving thrombolytics for adverse effects, such as bleeding, allergic reactions, and cardiac dysrhythmias. An increased heart rate with a decreased BP usually indicates blood loss from bleeding.

A patient has angina pectoris. The patient's BP is 108/60 mm Hg. The nurse administers nitroglycerin 0.4 mg sublingual (SL). It is most important for the nurse to assess the patient for the development of A. bradycardia. B. hypotension. C. bradypenia. D. hypokalemia.

Answer: B A side effect of nitroglycerin is hypotension owing to the vasodilation of blood vessels. - Nitro dilates vessels What is a another common side effect of nitroglycerin? - Can cause problem with headaches - Morphine could help headache/make it worse

A patient is experiencing both atrial and ventricular dysrhythmias. The nurse anticipates administration of which medication? A. Adenosine B. Amiodarone C. Atropine D. Epinephrine

Answer: B Amiodarone Amiodarone is used for the treatment of atrial and ventricular dysrhythmias, including PVCs - Adenosine is used for the treatment of PSVT - Atropine is used for the treatment of symptomatic bradycardia Epinephrine is used for the treatment of cardiac arrest

A nurse is preparing to administer digoxin (Digitalis) to a patient. Which laboratory result is the nurse most concerned about? A. Sodium 138 mEq/L B. Potassium 3.0 mEq/L C. Digitalis level 1.8 ng/mL D. BNP 200 pg/mL

Answer: B Potassium 3.0 mEq/L A low serum potassium level enhances the action of digoxin and can cause digitalis toxicity. CAUTION with K+ wasting diuretics Normal serum: K+ 3.5-5.0 mEq/L Na+ 135-145 mEQ/L BNP 100-300 pg/mL suggestive of heart failure What is the therapeutic level of digoxin? What are S&SX of digoxin toxicity? - Therapeutic range: 0.5-2.0 ng/mL - Toxicity: Bradycardia, diarrhea, nausea, vomiting, halos in vision, and headache

A patient is on heparin therapy secondary to deep vein thromboses. The nurse has which medication on hand as an antidote in case it is needed? A. Vitamin K B. Protamine sulfate C. Warfarin (Coumadin) D. Aminocaproic acid (Amicar)

Answer: B Protamine sulfate Vitamin K is the antidote for warfarin (Coumadin), an anticoagulant aminocaproic acid (Amicar) is a plasminogen inactivator used to control excessive bleeding from hyperfibrinolysis.

A patient manifests symptoms of a thrombolic stroke. The emergency department nurse is aware that thrombolytics need to be administered in this situation within how many hours of the onset of symptoms? A. 1 hour B. 2 hours C. 3 hours D. 4 hours

Answer: C 3 hours A thrombolytic drug should be administered within 3 hours of a thrombolic stroke (CVA), within 4 hours of AMI

When administering antianginal drugs, the nurses identifies which as the most common response? A. Tachycardia B. Bradypnea C. Hypotension D. Dry mouth

Answer: C Hypotension The most common side effect of antianginal drugs is hypotension.

The nurse identifies which statement about targeted therapy for cancer as being true? Targeted therapies for cancer A. are more general in their mechanisms and effects than traditional cancer chemotherapy. B. exert their effects by damaging the DNA of nearly any cell. C. require a specific molecular target as the recipient of their effects. D. require fewer tests on cancer cells to determine if the therapy will be effective.

Answer: C require a specific molecular target as the recipient of their effects. Rationale: Targeted therapies require a specific molecular target as the recipient of their effects. Targeted therapies are more specific in their mechanisms and effects than traditional cancer chemotherapy agents. More tests are required on cancer cells to determine whether or not targeted therapy will be effective. Targeted therapies exert their effect on specific components of specific cells, not all cells.

When administering an intravenous infusion of Rituximab (Rituxan), it is most important for the nurse to A. restrict the patient's intake of fluids. B. premedicate the patient with morphine. C. stay with the patient during the first 15 minutes of the infusion. D. assess the patient for the development of ototoxicity.

Answer: C stay with the patient during the first 15 minutes of the infusion. Rationale: Infusion reactions are common with infusion of Rituximab (Rituxan). Resuscitation equipment should be nearby. The nurse should stay with the patient for the first 15 minutes of the infusion and monitor vital signs every 15 to 30 minutes during the infusion and for 1 hour after the infusion is complete. The patient should be well-hydrated before, during, and after therapy;

The nurse is caring for a patient who received alteplase tPA (Activase) for treatment of acute coronary syndrome. The patient starts to bleed. The nurse anticipates administration of which medication? A. Protamine sulfate (protamine) B. Vitamin K (phytonadione) C. Warfarin (Coumadin) D. Aminocaproic acid (Amicar)

Answer: D Aminocaproic acid (Amicar) is used to stop bleeding by inhibiting plasminogen activation, which inhibits thrombolysis.

Dabigatran (Pradaxa)

Anticoagulant A-fib prevent clots

Rivaroxaban (Xarelto)

Anticoagulant A-fib prevent clots

Warfarin (Coumadin)

Anticoagulant Atrial Fibrillation Used to treat heart failure

Apixaban (Eliquis)

Anticoagulant A-fib prevent clots

Edoxaban (Savaysa)

Anticoagulant A-fib prevent clots

Anticoagulants and Antiplatelets

Anticoagulants and antiplatelets prevent thrombosis in both arteries and veins, but each has a primary preventative action as well

Anticoagulants

Anticoagulants such as heparin sodium (Heparin) and warfarin (Coumadin) primarily prevent thrombosis in the veins (DVT, PE), and also work in the arteries (MI, CVA, artificial valves) Low-molecular weight heparins - Dalteparin sodium (Fragmin) - Enoxaparin sodium (Lovenox) Other Anticoagulants (Table 52.1) - Rivaroxaban (Xarelto) - Apixaban (Eliquis) - Dabigatran (Pradaxa) Negative side effects of newer products... - Rivaroxaban (Xarelto) - Apixaban (Eliquis) -Dabigatran (Pradaxa) Praxbind Approved by FDA for reversal of Pradaxa Risks - Clotting - Loss of the clot prevention effects of Pradaxa - CVA - Unless original cause of clotting is eliminated, patients should return to anticoagulant therapy as soon as possible

Class III

Antidysrhythmic Drug - Prolong (delay) repolarization - slow the rate of electrical conduction and prolong the time between contractions. Amiodarone (Cordarone) - For treatment of A.Fib, PVCs, life-threatening ventricular dysrhythmias, and cardiac arrest - IV form: first-line agent in the advanced cardiac life support algorithms - Know side effects! Sotalol (Betapace) - although it is a beta-blocker, it is considered a class III Dronedarone (Multaq) - less toxic and less effective than amiodarone Dofetilide (Tikosyn) - titrated while monitored on EKG until maintenance dose achieved Ibutilide (Corvert) - acute treatment given IV for recent onset

Class II - Beta-adrenergic blockers

Antidysrhythmic Drugs - Block beta receptors in the heart - Decreases cardiac contractility, slows heart rate - Decreases conduction velocity, automaticity, and myocardial contractility - Used mostly to treat supraventricular dysrhythmias - Propranolol (Inderal) - nonselective, caution with asthma! - Acebutolol (Sectral - cardio selective - Esmolol (Brevibloc) - cardio selective - SE: bradycardia, hypotension, impotence

Class I - Sodium channel blockers

Antidysrhythmic Drugs Result in: - Decreased conduction velocity, ie. slow impulse conduction - 1A: slows conduction, prolongs repolarization [quinidine, procainamide, disopyramide phosphate (Norpace)] 1B: accelerate repolarization, little negative effect on EKG Lidocaine - For acute treatment of ventricular dysrhythmias Phenytoin (Dilantin) - For treatment of atrial, AV and ventricular issues - Used to treat digoxin-induced dysrhythmias Mexiletine - Treatment of ventricular problems 1C: reduce conduction velocity; delay ventricular repolarization - Most effective for maintenance supraventricular dysrhythmias - Serious SE; used when other options are not tolerated - Flecainide - Propafenone (Rythmol)

Praxbind

Approved by FDA for reversal of Pradaxa Risks - Clotting - Loss of the clot prevention effects of Pradaxa - CVA - Unless original cause of clotting is eliminated, patients should return to anticoagulant therapy as soon as possible

Digitalis toxicity

- Anorexia - Diarrhea - Nausea and vomiting - Bradycardia, premature ventricular contractions, cardiac dysrhythmias - Headaches, malaise - Blurred vision, visual illusions (Halos) - Confusion and delirium

Drugs Used to Maintain or Restore Circulation

- Antiplatelets (antithrombotics): Primarily prevent arterial thrombosis; prevent platelet aggregation, clumping together of platelets to form a clot - Thrombolytics: Attack and dissolve blood clots that have already formed - clot busters

Nursing Process: Antidysrhythmics

- Assessment - Nursing diagnoses - Planning Nursing interventions - Patient teaching - Evaluation - Continuous monitoring during hospitalization when antidysrhythmia meds given - "I don't know why I'm in the hospital. They aren't doing anything for me..."

Targeted Therapy

- Breakthrough in cancer treatment - Can be taken alone or with traditional chemo - Some taken PO, at home The cancer MUST be susceptible to the action of the med - Require a specific molecular target as the recipient of their effects - Requires testing to verify the cancer cells have the molecular makeup - Expensive - Continues to be an area of research with new drugs and new applications for treatment

Traditional vs Targeted Therapy: Cancer

- Cancer cells: fast growing, invasive - Traditional chemotherapy: systemic, generalized, cytotoxic; kill healthy cells; numerous side effects - Targeted therapy: More specific action than traditional cancer chemotherapy Targeted therapy takes advantage of biologic features particular to cancer cells and targeting specific mechanisms - Defined as drugs or other substances that block the growth and spread of cancer by interfering with specific molecules involved in tumor growth and progression

Acebutolol (Sectral) belongs to what class of drugs?

- Cardio-selective beta blocker - Cardio-selective d/t beta 1 blocking - Treat dysrhythmias (Class II)

Sodium bicarbonate

- Correct metabolic acidosis with cardiac arrest - And the hyperkalemia and acidotic states related to specific drug overdose situations - Monitor ABGs

Premature atrial complexes (PACs)

- Electrical impulse from atrium is released before the next sinus impulse is due; forms a 'premature' P wave - Treatment - Patient education: reduce stimulants! Caffeine, tobacco, etc. - May be able to tx without medication P wave is basically on top of the T wave

Sinus Rhythms

- Electrical impulse originates from the SA Node Sinus dysrhythmias are a problem of: - Rate, or - Rhythm - Normal sinus rhythm (NSR) - good Sinus tachycardia - Treatment is aimed at fixing the underlying cause, such as pain, anxiety, fluid volume deficit Sinus bradycardia - Treat with Atropine - inhibits parasympathetically-induced hyperpolarization of the sinoatrial node; result is increased heart rate REMEMBER: stimulation of the sympathetic nervous system increases heart rate; parasympathetic decreases heart rate Sinus arrhythmia - Heart rate increases slightly during inspiration and decreases slightly during expiration (common in children) - If symptomatic and bradycardia, Atropine sulfate may be used

Atrial Dysrhythmias

- Electrical impulse originates from the atrium - When impulses from ectopic foci are faster than the SA node, they dominate the pace!

AV Heart Blocks

- First-degree—all sinus impulses eventually reach ventricles - Second-degree—some sinus impulses reach ventricles, others do not - Third-degree—no sinus impulses reach ventricles, complete block - 1st Degree Block, monitor 2nd & 3rd Degree Block - Pacemaker - Atropine & external pacemaker can be used to increase heart rate until permanent pacemaker can be implanted

Vemurafenib (Zelboraf)

- For treatment of metastatic melanoma - Suppresses tumor growth - Melanoma must be susceptible - Side effects include cutaneous squamous cell carcinoma, Stevens-Johnson syndrome, fatal dysrhythmias

You have administered a thrombolytic. What signs & symptoms might indicate hemorrhage?

- Initially increased HR, decreased Bp...if untreated, decreased HR, LOC - Monitor mouth and rectum for bleeding, IV sites, surgical sites, wounds, Foley catheter - Frequent monitoring for hemorrhage required for 24 hours after infusion Aminocaproic acid (Amicar) - - antithrombolytic Initially q15 min x 4, q30 for several hours, then q1h - No invasive procedure - Limited use of NSAIDS, anticoagulant and antiplatelet drugs - Minimize physical manipulation of patient - Avoid injections

Dysrhythmia Treatment

- Key concept regarding pharmacologic treatment of dysrhythmias: - The meds we use to treat dysrhythmias have many side effects, including causing dysrhythmias! - Balance between whether drug is helping or making it worse

Patient Safety!: Antidysrthymics

- Many adverse effects are dose-related and resolve with reducing the dosage or discontinuing therapy. - Patients should be taught to rise slowly from a supine or sitting position and sit or lie down if feeling faint.

Oxygen as an Emergency Drug

- May have beneficial and adverse effects - Promote optimal oxygenation and ventilation before administering any pharmacologic agents Oxygen whenever O2 sat <90% O2 saturation readings affected by: - Anemia - CO poisoning Shock - Hypothermia - Vasoconstriction Oxygen devices of choice For adults - Nasal cannula, non-rebreather, positive pressure (CPAP, BiPAP), bag-valve-mask, mechanical ventilation For children - O2 tent - High oxygen concentration detrimental in COPD

Premature ventricular complexes (PVCs)

- Premature beat originates from irritable site (ectopic focus) within ventricle before expected sinus conducted QRS Treatment: - Stop caffeine - Class II Beta Blocker - Most of the time PVCs are benign With an acute myocardial infarction (MI), the onset of PVCs may be considered as a warning for impending ventricular tachycardia or ventricular fibrillation! - Class II Beta Blocker for potentially life-threatening rhythm

Ventricular fibrillation

- Rapid firing of multiple ectopic ventricular foci at a rate over 150 per minute with chaotic rhythm - The most serious arrhythmia!!!! - Emergency!!!! - Patient can't survive if this continues, no perfusion

Atrial Tachycardia

- Rate 150- 220 bpm - Often self-limiting - If no comorbidities, monitor Short-acting Adenosine - More on adenosine coming! - NOTE: don't confuse adenosine and atropine! One is for tachycardia treatment, one if for bradycardia treatment - Atrial tachycardia terminating with resumption of sinus rhythm - The P waves of the tachycardia (rate: about 150 beats/min) are superimposed on the preceding T waves

Atrial flutter

- Rate 220 - 350 - P wave flutter, sawtooth look on EKG - Classic Sawtooth Tracing - What symptoms might the patient have? - Palpitations - Shortness of breath - Anxiety! - Fatigue Treatment Class IC - Flecainide - Propafenone (Rhythmol) Class III - Amiodarone (Cordarone) - Dronedarone (Multaq) - Sotalol (Betapace) - Dofetilide (Tikosyn) - Ibutilide (Covert) - acute treatment given IV for recent onset, converts to NSR very quickly when effective (during infusion or within 90 minutes of completion of infusion) Class II Antidysrhythmic Drugs Beta Blockers - Acebutolol (Sectral) - Esmolol (Brevibloc) - Propanolol HCl (Inderal) Class IV Antidysrhythmic Drugs Ca Channel Blockers - Diltiazem (Cardizem) - Verapamil HCl (Calan, Isoptin) - Anticoagulation and Cardioversion - Ablation

3rd Degree Heart Block

Atria and ventricles are depolarizing independently - Cannot survive long

S1 is the closing of which valves?

Atrioventricular - Mitral (biscupid) - Triscupid S2 is the closing of Aortic and Pulmonic valves

Profound bradycardia

Atropine sulfate

Atenolol (Tenormin)

Beta Blocker A fib treatment

Metoprolol (Lopressor, Toprol)

Beta Blocker A fib treatment

Rituximab (Rituxan)CD-Directed Antibodies

CD-Directed Antibodies - treatment of B-cell non-Hodgkin's lymphoma, B-cell chronic lymphocytic leukemia - Stimulates the immune system to cause lysis of cancer cells Severe side effects - Hypotension, bronchospasm, angioedema - have epinephrine and other emergency support available when infusing; monitor closely Tumor Lysis Syndrome - 12-24 hours after infusion, electrolyte abnormalities, renal failure - Teach patient to report N/V, muscle cramps, and decreased urination

verapamil (Calan)

Calcium Channel Blocker Used to treat atrial dysrhythmias

Digitalis preparations (digoxin)

Cardiac Glycoside Actions (Don't need to remember these terms) Positive inotropic - Increases myocardial contractility Negative chronotropic - Decreases heart rate Negative dromotropic - Decreases conduction Increase stroke volume - Increases cardiac output Digoxin used to treat: -Heart failure - Atrial fibrillation - Atrial flutter Other drugs used to treat atrial dysrhythmias if digoxin not effective: -Calcium channel blocker: verapamil (Calan) -Warfarin (Coumadin) - For treatment of supraventricular dysrhythmias - Monitor for signs of toxicity - Digoxin improves contractions so it can do it less and more efficiently, less work on the heart with adequate perfusion.

Phenytoin (Dilantin)

Class I - Sodium Channel Blocker Antidysrhythmic Drug 1B: accelerate repolarization, little negative effect on EKG - For treatment of atrial, AV and ventricular issues - Used to treat digoxin-induced dysrhythmias

Mexiletine

Class I - Sodium Channel Blocker Antidysrhythmic Drug 1B: accelerate repolarization, little negative effect on EKG - Treatment of ventricular problems

Antidysrhythmic Drugs

Class I - Sodium channel blockers Result in: - Decreased conduction velocity, ie. slow impulse conduction - 1A: slows conduction, prolongs repolarization [quinidine, procainamide, disopyramide phosphate (Norpace)] 1B: accelerate repolarization, little negative effect on EKG Lidocaine - For acute treatment of ventricular dysrhythmias Phenytoin (Dilantin) - For treatment of atrial, AV and ventricular issues - Used to treat digoxin-induced dysrhythmias Mexiletine - Treatment of ventricular problems 1C: reduce conduction velocity; delay ventricular repolarization - Most effective for maintenance supraventricular dysrhythmias - Serious SE; used when other options are not tolerated - Flecainide - Propafenone (Rythmol) Class II - Beta-adrenergic blockers - Block beta receptors in the heart - Decreases cardiac contractility, slows heart rate - Decreases conduction velocity, automaticity, and myocardial contractility - Used mostly to treat supraventricular dysrhythmias - Propranolol (Inderal) - nonselective, caution with asthma! - Acebutolol (Sectral) - cardio selective - Esmolol (Brevibloc) - cardio selective - SE: bradycardia, hypotension, impotence Class III - Prolong (delay) repolarization - slow the rate of electrical conduction and prolong the time between contractions. Amiodarone (Cordarone) - For treatment of A.Fib, PVCs, life-threatening ventricular dysrhythmias, and cardiac arrest - IV form: first-line agent in the advanced cardiac life support algorithms - Know side effects! Sotalol (Betapace) - although it is a beta-blocker, it is considered a class III Dronedarone (Multaq) - less toxic and less effective than amiodarone Dofetilide (Tikosyn) - titrated while monitored on EKG until maintenance dose achieved Ibutilide (Corvert) - acute treatment given IV for recent onset

Procainamide

Class I - Sodium channel blockers Treat PSVT - Class IA - Acute treatment - for ventricular tachycardia and rapid supraventricular dysrhythmias unresponsive to adenosine - Class IA - Effective for both atrial and ventricular dysrhythmias - Used in acute and long-term treatment SE: Systemic Lupus Erythematosus-Like Symptoms - Monitor antinuclear antibodies (ANA) - Discontinuation of the drug eliminates symptoms Neutropenia, thrombocytopenia, agranulocytosis - CBC weekly or if s&sx of infection - D/C drug if blood dyscrasias appear - EKG changes, widening QRS, prolonged QT interval Emergency Drug for Cardiac Disorder - Class IA - Antidysrhythmic agent for ventricular tachycardia, PVCs - SVTs unresponsive to adenosine Side effects - Severe hypotension - Dysrhythmias - Contraindicated with Torsades de pointes or any drug that causes prolong Q-T interval

Propafenone (Rythmol)

Class I - Sodium channel blockers Antidysrhythmic Drug 1C: reduce conduction velocity; delay ventricular repolarization - Most effective for maintenance supraventricular dysrhythmias - Serious SE; used when other options are not tolerated

Flecainide

Class I - Sodium channel blockers Antidysrhythmic Drug Class IC Atrial Flutter - Treatment 1C: reduce conduction velocity; delay ventricular repolarization - Most effective for maintenance supraventricular dysrhythmias - Serious SE; used when other options are not tolerated

Propafenone (Rhythmol)

Class IC Atrial Flutter - Treatment

Propranolol (Inderal)

Class II - Beta-adrenergic blockers Antidysrhythmic Drug nonselective, caution with asthma! - SE: bradycardia, hypotension, impotence Class II - Beta-adrenergic blockers - Block beta receptors in the heart - Decreases cardiac contractility, slows heart rate - Decreases conduction velocity, automaticity, and myocardial contractility - Used mostly to treat supraventricular dysrhythmias

Propanolol HCl (Inderal)

Class II Antidysrhythmic Drugs Beta Blocker Atrial Flutter - Treatment

Amiodarone (Cordarone)

Class III Antidysrhythmics A fib treatment Atrial Flutter - Treatment Class III - Prolong (delay) repolarization - slow the rate of electrical conduction and prolong the time between contractions. - For treatment of A.Fib, PVCs, life-threatening ventricular dysrhythmias, and cardiac arrest - IV form: first-line agent in the advanced cardiac life support algorithms - Know side effects! - IV amiodarone may cause bradycardia and atrioventricular (AV) block - If bradycardia occurs, slow the infusion rate - IV amiodarone requires continuous monitoring, switch to PO before hospital discharge - Abruptly ceasing may lead to fatal dysrhythmias! - Lung damage! Sx of dyspnea, cough, and chest pain STOP medication! Teach patient to report - Hypothyroidism or hyperthyroidism may develop, monitor with periodic bloodwork, treat as needed Amiodarone, IV form: - First-line agent in the advanced cardiac life support algorithms for treatment of life-threatening ventricular dysrhythmias and cardiac arrest - Also used for treatment of atrial dysrhythmias - May be given IVP, continuous infusion, and PO

Ibutilide (Covert)

Class III: Antidysrhythmic Drug Atrial Flutter - Treatment - acute treatment given IV for recent onset, converts to NSR very quickly when effective (during infusion or within 90 minutes of completion of infusion) Also used for Afib - acute treatment given IV for recent onset, more effective with A Flutter than A Fib

Dronedarone (Multaq)

Class III: Antidysrhythmic Drug Atrial Flutter - Treatment less toxic and less effective than amiodarone Class III - Prolong (delay) repolarization - slow the rate of electrical conduction and prolong the time between contractions.

Verapamil HCl (Calan, Isoptin)

Class IV Antidysrhythmic Drugs Ca Channel Blocker Atrial Flutter - Treatment Class IV Block calcium influx (calcium channel blockers) - Slow automaticity - Delay conduction - Decrease contractility - Slow ventricular rate - For acute and maintenance therapy - Use with digoxin increases risk of AV block - Continuous monitoring required for IV dosing SE: Nausea, vomiting, bradycardia, hypotension

Diltiazem (Cardizem)

Class IV Antidysrhythmic Drugs Ca Channel Blocker Atrial Flutter - Treatment Class IV Block calcium influx (calcium channel blockers) - Slow automaticity - Delay conduction - Decrease contractility - Slow ventricular rate - For acute and maintenance therapy - Use with digoxin increases risk of AV block - Continuous monitoring required for IV dosing SE: Nausea, vomiting, bradycardia, hypotension Emergency Drugs for Cardiac Disorders IV bolus treats PSVT; - Ca channel blocker - Used if adenosine contraindicated or ineffective - Slows ventricular response rate in atrial fibrillation or flutter - IV infusion requires continuous monitoring! - May be given via IV bolus and/or continuous infusion Adverse Effects - Arrhythmias - Bradycardia - hold if <50 bpm - Hypotension - Monitor digoxin levels! May cause toxicity

A patient has a history of systolic heart failure and A-V block. Which medication will the nurse expect to administer for the short-term relief of angina? A. Atenolol (Tenormin) B. Diltiazem (Cardizem) C. Amlodipine (Norvasc) D. Nitroglycerin (Nitrostat)

Correct D. Nitroglycerin (Nitrostat) - Administers sublingual nitroglycerin for angina in a patient with heart failure - Atenolol, diltiazem, and amlodipine are indicated in the treatment of angina; however, these medications are used for maintenance therapy. - Atenolol is contraindicated for patients with systolic heart failure - Amlodipine and diltiazem are contraindicated with A-V block.

The cardiac unit nurse is providing discharge education to a patient with stable angina. The patient has been prescribed nitroglycerin for treatment of the angina. Which statement by the patient indicates an accurate understanding of the education provided? A. "I shouldn't take the nitroglycerin for mild chest pain." B. "It mostly helps by increasing oxygen supply to my heart." C. "I should call 911 if the chest pain isn't relieved after two doses of nitroglycerin." D. "The nitroglycerin works mostly on my veins, causing them to open wider."

D. "The nitroglycerin works mostly on my veins, causing them to open wider." Nitroglycerin, a nitrate, acts directly on vascular smooth muscle to promote vasodilation and acts predominantly on veins. It should be taken when chest pain begins; the patient should not wait for it to become more severe. The main effect of nitroglycerin is through decreasing cardiac oxygen demand, not increasing oxygen supply.

Hypermagnesemia

Decreased Deep Tendon Reflexes

Electrophysiology

Depolarization - Sodium quickly enters the cardiac cell changing them from negative to positive, result is action potential; causes mechanical contraction (systole) Repolarization - Following depolarization, potassium moves out and calcium enters cells changing them to negative charge; cardiac muscles relax (diastole) Refractory Period - Time in which cells resist depolarization until they have recovered; no action potential can occur at this time Automaticity - Ability of a group of cells to generate electrical impulse spontaneously; self-excitation (ex. SA Node) Excitability - Capacity of the cardiac cell to depolarize in response to electrical stimulation Conductivity - Ability of cardiac cells to transmit an electrical impulse Contractility - Ability of cardiac muscle to contract in response to electrical stimuli

STEMI

E -> ST is Elevated

Thrombolytic Adverse Effects

EKG monitoring, risk of dysrhythmias with reperfusion - Anti-dysrhythmic medications may be required Patients receiving thrombolytics may experience hypotension when it is first administered and may require an adjustment in dosage - Differentiate from hypotension r/t hemorrhage!

Epinephrine

Emergency Drug for Cardiac Disorder - Treat profound bradycardia and hypotension, AV block, asystole, pulseless ventricular tachycardia, and ventricular fibrillation - Small doses (0.1 to 0.5 mcg/kg/min) to treat bradycardia - Larger doses (1 mg q 3-5 min) to treat pulseless V Tach and V Fib Causes peripheral vasoconstriction, improves perfusion to brain and heart => improved CO - SE: myocardial ischemia r/t increased O2 demand as both HR and BP are increased when epi is given - Peripheral tissue ischemia is risk - Improves chance of successful defibrillation - SQ mixed with numbing agent - Constriction of vessels reduces bleeding - Used with procedures - General Rule: No Epi on fingers, nose, penis, and toes - Caution in patients with hx of angina and poor peripheral perfusion the drug of choice in the treatment of anaphylactic shock - Vasoconstriction + increased HR - Bronchodilation + improved cardiac performance - SE: HTN, dysrhythmias, tachycardia - Diphenhydramine HCl: antihistamine, administered with epinephrine to treat anaphylactic shock - Steroids to reduce inflammation and allergic response - All 3 may be given, but Epi is FIRST! - Albuterol: beta-adrenergic bronchodilator used to reverse bronchoconstriction in anaphylactic shock Continue to monitor as symptoms of shock may return!

Flumazenil (Romazicon)

Emergency Drug for Poisoning - Reversal agent for the respiratory depressant and sedative effects of benzodiazepine medications - Reversing benzodiazepine may lead to withdrawal seizures - Seizure precautions must be in place

Morphine sulfate

Emergency Drug for Pulmonary Edema - Produces venous vasodilation - Decreases pulmonary congestion - Decreases cardiac preload - Decreases Bp Emergency Drugs for Cardiac Disorders - Relieves pain & anxiety - Dilates vessels - Reduces the workload on the heart, improving hemodynamics - May give IVP 1-4 mg every over 1-5 minutes; may repeat every 5-30 minutes until relief of pain is achieved Assess - Blood pressure Respirations - What medication is used to reverse respiratory depression brought on my morphine? - NARCAN - Exception for administering Morphine: Dyspnea caused by pulmonary edema is NOT a contraindication for morphine treatment!

Furosemide

Emergency Drug for Pulmonary Edema promotes the renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium and - Peripheral and renal vasodilating effects lower BP - Depletes potassium! - Monitor electrolytes, I&O, respiratory effort, lung sounds, VS

Norepinephrine

Emergency Drug for Shock - vasoconstrictor used in shock when dopamine and dobutamine fail to increase blood pressure As with dopamine... - Peripheral vasoconstriction provides positive result of increased BP - However: risk of poor perfusion of tissues and organs, including heart (risk of cardiac arrest!) - Continuous monitoring - Taper slowly, else risk of hypotension Risk of extravasation and tissue necrosis - Treat with phentolamine (Regitine)

Dobutamine

Emergency Drug for Shock Hypotension from shock - Increases heart rate + force of contraction = increased CO & BP - As with Dopamine, gradual weaning of medication is required - Continuous monitoring - Risk for myocardial ischemia - c/o chest pain, arrhythmias; slow or d/c dobutamine

Beta Blockers

Emergency Drugs for Cardiac Disorders - Used in treatment of STEMIs IV or PO can be started - Patients should have discharge Rx, unless contraindicated - Reduce oxygen demand - Reduce cardiac pain Reduce infarct size Contraindicated: - Asthma, COPD unless cardioselective beta blocker is used Pronounced bradycardia, <50 bpm - Severe heart failure or heart block

Atropine sulfate

Emergency Drugs for Cardiac Disorders - treatment of hemodynamically significant bradycardia and some types of heart block - May be given IV, IO, ETT - Requires tight titration - Short half life Anticholinergic effects - Increased HR - Decreased secretions (used pre-surgically) - Pupil dilation - Decreased UO - Relaxation of bronchi - Decreased GI motility Adverse Effects - Dysrhythmias MI - Requires continuous monitoring!

Nitroglycerin

Emergency Drugs for Cardiac Disorders dilates both veins and arteries, and improves blood flow to an ischemic myocardium - Decreases preload and oxygen demand, lessens work of the heart - Decreases blood pressure - Heart doesn't have to work as hard 0.4 mg SL q 5 min x 3 - If pain unrelieved IV nitroglycerin to be started (instruct patient to call for help at this point) Do not give: - Systolic Bp <90 mmHg - Heart rate <50 OR >100 bpm - Suspected right ventricular infarction - Patient has taken drugs for treatment of ED [vardenafil (Levitra), avanafil (Cialis), sildenafil (Viagra)] lead to SEVERE HYPOTENSION! If ingested within 24-48 hours of nitroglycerin

Adenosine

Emergency Drugs for Cardiac Disorders paroxysmal supraventricular tachycardia - Adenosine - Drug of choice for PSVT Short half-life (5 seconds), given fast intravenous push, used to abruptly stop supraventricular tachycardia - Adenosine causes brief asystole, corrects the dysrhythmia, return to NSR - Cautious use with A fib - more coming on adenosine in future PPTs - Mostly contraindicated in A Flutter first-line drug of choice to treat paroxysmal supraventricular tachycardia (PSVT) - Results in brief asystole - Prolongs repolarization which slows the rate down - Short half-life, <5 seconds; slam & flush! - Requires continuous cardiac monitoring! Caution with A fib... - Causes death with IRREGULAR A fib - If rhythm is too fast to determine regularity, DO NOT USE - Rarely used with A flutter

Aspirin

Emergency Drugs for Cardiac Disorders decreases platelet aggregation at site of coronary artery occlusion Order: 325 mg ASA PO (chew!) now - What instruction will you give the patient? - May use rectal suppository with N/V Contraindications? - GI bleed, allergy, hemorrhage "I don't have aspirin. Can I chew Advil?" - NO! - Other NSAIDs can do far more harm than good - Increased mortality, HTN, heart failure, myocardial rupture! Effective treatment for suppressing platelet aggregation - Long-term, low-dose therapy - Inhibits cyclooxygenase, enzyme needed by platelets - Inexpensive - Enteric coated available - Stop 7 days before any procedures, including dental - Contraindicated with PUD (peptic ulcer disease) - Chest pain: instruct patient to chew one 325 mg tablets or four 81 mg tabs; F/U emergency care!

Labetalol

Emergency Drugs for Hypertensive Crises and Pulmonary Edema Hypertensive crisis: diastolic blood pressure that exceeds 110 to 120 mm Hg, and pulmonary edema lowers heart rate, blood pressure, myocardial contractility, myocardial oxygen consumption, and reduces the vasoconstriction that results from sympathetic nervous system stimulation - IVP or continuous IV infusion - Continuous monitoring - SE hypotension, dysrhythmias, bronchospasm (caution with asthma), bradycardia

Nitroprusside sodium

Emergency Drugs for Hypertensive Crises and Pulmonary Edema immediate direct arterial and venous vasodilation - Requires continuous BP monitoring - Short duration of action (<10 min), taper slowly else return HTN! - Protective foil wrap kept in place during infusion - Toxicity: vomiting, hypotension, SOB

Mannitol

Emergency Drugs for Neuro Disorders Head trauma, ICP, Intracranial Hypertension - Osmotic (follows salt..full edema out of tissue such as brain, into the vessels and then diurese it)diuretic used in emergency, trauma, critical care, and neurosurgical settings to treat cerebral edema and to reduce increased intracranial pressure - Use filtered needle when drawing up medication, it can develop crystals which make clots Assessment: - Electrolytes - I & O - Hydration level Neuro status Side Effects: - Edema - H/A - N/V

Naloxone (Narcan)

Emergency Drugs for Poisoning - reverses the effects of opiate drugs - May also be given to patients brought to an emergency department in a coma of unknown etiology to see if they respond - If no improvement within 10 minutes, a nonopiate cause for coma should be suspected

Activated charcoal

Emergency drug for poisoning prevents absorption of toxins - Binds with poison/toxin - Slurry given via NG - Works best within 30 minutes of poison ingestion Passes through GI system, taking inactivated toxin with it - Cathartics can be given to increase bowel activity - Repeat doses may be required - Poison antidotes must be given after activated charcoal or they will bind and be inactivated SE - Vomiting - risk of aspiration! Protect airway - Black stools

Cetuximab (Erbitux)

Epidermal Growth Factor Tyrosine Kinase Inhibitors (EGFRIs) Action - Inhibit tyrosine kinase indirectly, inhibit downstream signal transduction pathway for cell division - Results in severely limited cell proliferation - IV - Interstitial ling disease (ILD) - teach patients to report breathing difficulties!

Gefitinib (Iressa)

Epidermal Growth Factor Tyrosine Kinase Inhibitors (EGFRIs) Action - Inhibit tyrosine kinase indirectly, inhibit downstream signal transduction pathway for cell division - Results in severely limited cell proliferation - given orally - St John's wort decreases levels of gefitinib

Anaphylactic shock

Epinephrine

AMI Treatment, Reperfusion

Fibrinolytic therapy - Alteplase, reteplase, tenecteplase Adjunct therapy to fibrinolytics include Anticoagulant therapy Heparin - Start before, continue throughout and 48-72 hours after clot buster Antiplatelet therapy - Clopidogrel (Plavix), ASA ACE or ARB - Lisinopril, valsartan - Percutaneous Coronary Intervention (PCI) - 'balloon treatment' & stenting Adjunct therapy to PCI include: - Heparin Antiplatelet - Clopidogrel (Plavix) - Ticagrelor (Brilinta) - not with fibrinolytics Glycoprotein Iib/IIIa Inhibitors abciximab (ReoPro) - Antiplatelet that may be used with PCI but NOT with fibrinolytic therapy - Aspirin ACE & ARBs

Monitor electrolytes

Furosemide

You are working in the ER when a patient with palpitations and shortness of breath arrives. What are some baseline assessments you will want to do?

General Survey - Color, distress, fatigue? Respiratory Assessment -Oxygenation? - Rate, rhythm, effort, SOB? Cardiovascular Assessment - Distress, Pain? - Color, diaphoresis, clutching chest? - EKG - Mental status (awake, alert, orientated) - Health history - Medications

Normal Cell Growth Regulation: Cancer

Genetic control over cell division - Signal transduction - Tyrosine kinases - Transcription factors - Cyclins Genetic control over cell death Apoptosis - programmed cell death, designed to ensure that tissues contain only healthy and optimally functional cells. -Regulated by different gene products What happens when cancer occurs? Growth regulation and cancer - Loss of genetic control of cell growth - Loss of apoptosis

Dopamine

Hypotension from shock - Used to treat hypotension and bradycardia - Goal: increase BP, adequately perfuse organs/tissue Increases contractility + HR = increased CO Vasoconstriction increases BP, but... - Adverse vasoconstriction may cause poor organ perfusion - Use lowest possible dose to avoid vasoconstriction - Gradual weaning...abrupt d/c causes hypotension - Continuous monitoring! EKG, VS, UO - Acidosis may result - give sodium bicarbonate in separate IV line - EXTRAVASATION! Assess site for edema, coolness, paleness!

Amiodarone: What are some important nursing assessments and interventions r/t side effects?

If side effect bradycardia occurs, slow the infusion rate, abruptly ceasing may lead to fatal dysrhythmias! - Treat hypotension with fluids, vasopressors - Treat bradycardia with pacemaker if indicated

How do you explain why budesonide helps to improve control of asthma?

Inhaled corticosteroids reduce inflammation and swelling in the airways. Regular use helps control asthma symptoms. Remind patients this is NOT a rescue inhaler.

How will prednisone benefit a patient with allergy to cats? Why can't she "stay" on it?

It provides a systemic effect that decreases the immune response. This child is having an allergic reaction to cats, which is severely aggravating her asthma. Too many side effects! It suppresses the immune response, which could make her susceptible to serious illness

The doctor adds a Singulair and increases the dose of the inhaled-corticosteroid Her parents ask you how monteleukast will help her asthma, what do you say?

Leukotrienes assist with management of allergies. Allergens, such as cats, can trigger an asthma attack.

PVCs, Vtach, Vfib

Lidocaine

Dalteparin sodium (Fragmin)

Low-molecular weight heparins Anticoagulant

Enoxaparin sodium (Lovenox)

Low-molecular weight heparins Anticoagulant

The American Heart Association Guidelines for Thrombolytics (CVA)

MUST be able to say YES to EACH - Symptoms not suggestive of subarachnoid hemorrhage - Onset of symptoms less than 3 hours before beginning treatment - No head trauma or prior stroke in past 3 months - No MI in prior 3 months - No GI/GU hemorrhage in previous 21 days - No major surgery in prior 14 days - No history of prior intracranial bleed - Systolic blood pressure <180 mm Hg, diastolic pressure <110 mm Hg - No evidence of acute trauma or bleeding - Not taking oral anticoagulant, or if so, INR under 1.7 - If taking heparin within 48 hours, a normal aPT - Platelet count of more than 100,000/μL - Blood glucose greater than 50 mg/dL - No seizure with residual postictal impairments - The patient and family understand potential risks & benefits of therapy

Torsades de pointes

Magnesium sulfate

The doctor orders a patient to be NPO. Do you administer his oral anti-diabetic medications?

Many oral anti-diabetic agents work by increasing insulin sensitivity in peripheral tissue and decreasing hepatic glucose production. Biguinides, like metformin, and Thiazolinediones, such as Avandia, have very low risk of causing hypoglycemia. Other classes of drugs like Metaglitinides (includes meds such as Prandin) and sulfonoureas (like Glucotrol) work by increasing insulin production. Knowing this, there is no need to hold his metformin. Since he is not eating, he will not get his repaglinide (Prandin).

Torsades de Pointe What symptoms will your patient complain about with this rhythm

More on Prolonged QT Interval - Many medication can cause this as a side effect - This can lead to torsades de pointe, a nonperfusing type of ventricular tachycardia - Major side effect is dizziness/fainting

Sorafenib (Nexavar)

Multi-Tyrosine Kinase Inhibitors Action - Directly inhibit activity of specific kinases in cancer cells and in cancer cell vasculature - renal cell and thyroid carcinomas Side effects/adverse effects - Diarrhea - Fatigue - Dysrhythmias - High risk of bleeding!

ThrombolyticsIndications for Use

Myocardial infarction - Thrombus, or blood clot, disintegrates when a thrombolytic drug is administered within 4 hours of symptoms Thrombolic stroke - Thrombolytic drug should be administered within 3 hours of symptoms (text says 4.5 hours, drug website still says 3 h) - Pulmonary embolism - NOT all three agents can be used for all of these conditions!

Opioid overdose

Naloxone

Angina pectoris

Nitroglycerin

Hypoxemia

Oxygen

EKG

P-Wave - Represents atrial depolarization and subsequent atrial contraction - Upright (positive) and rounded QRS Complex - Represents ventricular depolarization and beginning of ventricular contraction Q Wave - Represents activation of intraventricular septum, from left to right - First negative deflection after the P wave - Not always present R Wave - Represents activation of the bulk of ventricular muscle - First positive deflection after the P wave S Wave - Represents activation of a few small areas of the ventricles - Downward deflection following an R wave T Wave - Represents ventricular repolarization - Normally upright, rounded, larger than the P wave U Wave - Comes after the T Wave before the next P Wave - Rare to see, maybe in electrolyte imbalances

2nd Degree Heart Block

PR Interval gets gradually longer, eventually there is a P but no QRS complex

Thrombus Formation

Pathophysiology Formation of clot in artery or vein - Caused by decreased circulation (stasis), platelet aggregation on vessel wall, blood coagulation Arterial clot formation - Platelets initiate process. - Fibrin formation occurs. - RBCs are trapped in fibrin mesh. Venous clot formation - Platelet aggregation with fibrin that attaches to RBCs

Extravasation of dopamine

Phentolamine

Ventricular Dysrhythmias

Premature ventricular complexes (PVCs) - Premature beat originates from irritable site (ectopic focus) within ventricle before expected sinus conducted QRS Treatment: - Stop caffeine - Class II Beta Blocker Ventricular tachycardia - Repeated firing of an irritable ventricular ectopic focus - Rate 140-250 - Assess the client's airway, breathing, and level of consciousness! - If unconscious or in respiratory arrest, defibrillation and CPR are begun

Hypovolemic shock

Primary therapy: - Correct cause (bleeding, fluid loss) Replace fluids - blood products - IV therapy - lactated ringers Results in acidosis - Inadequate tissue perfusion causes anaerobic activity...lactic acid - monitor serum lactic acid levels - Treat persistent hypotension pharmacologically only after volume depletion has been corrected

Enoxaparin should be held for platelet levels below what?

Product labeling states enoxaparin should be stopped when platelet count falls below 100,000/mm3.

Bortezomib (Velcade)

Proteasome Inhibitors Action - Suppresses cancer cell division, promoting apoptosis Side effects/adverse effects - Nausea, vomiting, anorexia - Hematologic issues - Peripheral neuropathy - t. John's wort may decrease levels of bortezomib

A mother is concerned that her daughter isn't using her inhalers correctly. What can be done to ensure she is getting the full dose of the medication?

Provide patient instruction. Have the patient demonstrate what she has learned. Use a practice model. Teach the patient to use a spacer.

Thrombolytics

Purpose - Dissolve clot - attack and dissolve a thrombus that has already formed in the circulation Function - Promotes conversion of plasminogen to plasmin, which digests fibrin and degrades clotting factors Thrombolytic Drug - Alteplase tPA (Activase) - Reteplase rPA (Retavase) - Tenecteplase TNK-tPA (TNKase) Risks - Hemorrhage, esp. intracranial bleed (if you don't know for sure it's an ischemic stroke DONT use) - Must rule out hemorrhagic CVA - Reperfusion dysrhythmias Contraindicated - Recent surgery - Liver disease - Head trauma - Anticoagulant therapy - See AHA guidelines! Why is liver disease a contraindication? - Liver is responsible for clotting factor

5 RIGHTs of Medication Safety

RIGHT 1. Patient 2. Medication 3. Route 4. Dose 5. Time

Home medications were found in the patient's bed. Upon further investigation, it was discovered that patient was mistakenly double-dosing on prescribed medications. Not only was he taking at least one of them incorrectly at home, he also continued to take his home medications while hospitalized. In addition to his knee pain, he is reporting generalized muscle pain, fatigue and weakness this morning. You note dark colored urine in his Foley catheter. What do you suspect? From what medication?

Rhabdomyolysis from his Lipitor (atorvastatin). Statins increase the risk of rhabdomyolysis. Symptoms include muscle aches/weakness (muscle cells are being destroyed) and dark, concentrated urine

1st Degree Heart Block

Rhythm: Regular Rate: That of underlying rhythm PRI: is > than .2 seconds QRS: usually normal

CD-Directed Antibodies

Rituximab (Rituxan) - treatment of B-cell non-Hodgkin's lymphoma, B-cell chronic lymphocytic leukemia - Stimulates the immune system to cause lysis of cancer cells Severe side effects - Hypotension, bronchospasm, angioedema - have epinephrine and other emergency support available when infusing; monitor closely Tumor Lysis Syndrome - 12-24 hours after infusion, electrolyte abnormalities, renal failure - Teach patient to report N/V, muscle cramps, and decreased urination

R-R Interval

Should be same spacing in between them

Treat metabolic acidosis

Sodium Bicarbonate

Electrical Activity & Mechanical Action of the Heart`

There may be electrical activity without mechanical action but there may not be mechanical action without electrical activity

Give within 4 hours of AMI

Thrombolytic

Alteplase tPA (Activase)

Thrombolytic Drug Used for treatment of - Acute MI - Acute ischemic stroke - Acute PE The goal - Re-perfuse the area of infarct and prevent further ischemia - Penumbra is saved without permanent damage - Cannot be used for a BLEEDING stroke

Reteplase rPA (Retavase)

Thrombolytic Drug - For treatment of acute MI

Tenecteplase TNK-tPA (TNKase)

Thrombolytic Drug - For treatment of acute MI - Single IV bolus (vs. 90 minute infusion of Alteplase)

Order ClarificationTJC Safe Medication Policy

Titration Orders - orders in which the dose is progressively increased or decreased in response to patient status 1. Submit very clear, precise parameters for the initial dose, subsequent dose adjustment, and dose limits! 2. NO! - (cited in survey) - "Dobutamine start at 5mcg/kg/min and titrate to improve perfusion up to 10 mcg/kg/min" What is "improved perfusion"? 3. NO! - (cited) - "Propofol IV titrate for light sedation". 4. YES - "Levophed IV titrate to MAP >65 starting at 2 mcg/min to a max dose of 15 mcg/min. Titrate by 0.5 mcg/min every 5 minutes as needed to achieve goal blood pressure

IV Infiltration Extravasation

Treat with Phentolamine (Regitine) SQ

Atropine

Treats - 2nd & 3rd Degree heart block - Sinus arrhythmia - Sinus bradycardia *

Imatinib mesylate (Gleevec)

Tyrosine Kinase Inhibitors (TKIs) Action - Stop proliferation of cancer cells - Resistance to drugs can develop - The cancer MUST be susceptible to the action of the med - Gold standard for treatment of chronic myeloid leukemia (CML) Side effects/adverse effects - N/V, H/A, fatigue Hematologic alterations - CBC to be done regularly Contents of the tablet are toxic! - Patient or nurse should wear gloves if the tablets are crushed or broken

BRAF V600E Kinase Inhibitors

Vemurafenib (Zelboraf) - For treatment of metastatic melanoma - Suppresses tumor growth - Melanoma must be susceptible - Side effects include cutaneous squamous cell carcinoma, Stevens-Johnson syndrome, fatal dysrhythmias

How does Verapamil work?

Verapamil inhibits entry of calcium ions into arterial smooth muscle cells as well as the myocytes and conducting tissue. These actions lead to reversal and preventions of coronary artery spasm, reduction in afterload through peripheral vasodilatation and reduction in ventricular rate in patients with chronic atrial flutter or fibrillation and reduction in the occurrence of paroxysmal supraventricular tachycardia. Verapamil reduces BP, relieves angina and slows AV conduction.

Order heparin bolus 80 units/kg, thenmaintenance infusion of 18units/kg/h Patient weight: 180lbs Available: 25,000units / 250mL What is the patient's weight in kg? How many units for the bolus? Calculate the maintenance infusion flow rate

Weight: 81.8kg 80u x 81.8kg = 6,544u 18 hr x 81.8kg x 250mL / 25,000 = 14.7mL/hr

What s&sx will you see with hypovolemic shock?

What s&sx will you see with hypovolemic shock? - Anxiety (may state they feel like theyre dying) - Increased respirations Increased HR (initially) Initially increased BP - Remember Bp is a combination of HR, stroke volume, and peripheral resistance - HR goes up, because the demand for 02 is increasing as tissue is not being perfused - Peripheral resistance is increased as a protective mechanism - Monitor EtC02 to help determine if 02 exchange is occurring

Trigeminal PAC's

When PAC's occur every third beat, it's called "Trigeminal" or in "Trigeminy"

The nurse is assessing a patient who was recently admitted to the emergency department with dysrhythmias and shortness of breath. Which baseline nursing assessments are priorities? (Select all that apply.) a. ECG monitoring b. Medication history c. Oxygen saturation d. Presence of chest pain, dyspnea, fatigue e. Mental status f. Sleep pattern

a. ECG monitoring b. Medication history c. Oxygen saturation d. Presence of chest pain, dyspnea, fatigue e. Mental status

Ibutilide (Corvert)

acute treatment given IV for recent onset Class III - Prolong (delay) repolarization - slow the rate of electrical conduction and prolong the time between contractions.

Sotalol (Betapace)

although it is a beta-blocker, it is considered a class III - Prolong (delay) repolarization - slow the rate of electrical conduction and prolong the time between contractions. Class III: Antidysrhythmic Drug Atrial Flutter - Treatment A fib treatment

Aminocaproic acid (Amicar)

antithrombolytic Initially q15 min x 4, q30 for several hours, then q1h

A patient with suspected myocardial infarction is seen in the emergency department. The nurse is preparing to administer 325 mg of aspirin. The nurse will perform which action? a. Administer an enteric-coated tablet. b. Ask the patient to chew the tablet. c. Give the tablet with a small sip of water. d. Place the tablet under the patient's tongue.

b. Ask the patient to chew the tablet.

Acebutolol (Sectral)

cardio selective - SE: bradycardia, hypotension, impotence Class II - Beta-adrenergic blockers - Block beta receptors in the heart - Decreases cardiac contractility, slows heart rate - Decreases conduction velocity, automaticity, and myocardial contractility - Used mostly to treat supraventricular dysrhythmias Class II - Beta-adrenergic blockers Antidysrhythmic Drug Beta Blocker Atrial Flutter - Treatment

Esmolol (Brevibloc)

cardio selective - SE: bradycardia, hypotension, impotence Class II - Beta-adrenergic blockers - Block beta receptors in the heart - Decreases cardiac contractility, slows heart rate - Decreases conduction velocity, automaticity, and myocardial contractility - Used mostly to treat supraventricular dysrhythmias Class II - Beta-adrenergic blockers Antidysrhythmic Drug Beta Blocker Atrial Flutter - Treatment

Antidote for digitalis toxicity

digoxin immune Fab (ovine, Digibind, DigiFab) Side effects include - Hyperkalemia - Dysrhythmias, esp. AV Blocks! - Confusion, headache - Exacerbation of CHF, SOB - High risk drug with a lot of side effects - Patients don't feel well! - digoxin immune Fab is rarely used - usually monitoring for a bit toxicity resolves itself - control potassium

A Nitroglycerin drip is ordered for your patient to control his chest pain. The concentration is 100 mg in 250 mL D5W. The order is to begin the infusion at 20 mcg/min. What is the rate you would begin the infusion on the infusion pump? ________ mL/h IV nitroglycerin requires continuous monitoring of Bp and EKG

mL/h = 250mL/100mg x 20mcg/min x 60min/h x mg/1000mcg = 3 mL/h

Dofetilide (Tikosyn)

titrated while monitored on EKG until maintenance dose achieved Class III - Prolong (delay) repolarization - slow the rate of electrical conduction and prolong the time between contractions. Class III: Antidysrhythmic Drug - titrated while monitored on EKG until maintenance dose achieved Atrial Flutter - Treatment