Cardiac 1 Flashcards
ADRs of Diuretics general
Dehydration
Hypovolemia
Hypotension
Acid-base imbalances
Electrolyte level imbalances
Sleep Disturbances (take diuretics in the am)
Classes of Diuretics
Loop (Furosemide)
Thiazide (Hydrochlorothiazide)
Potassium sparing (Spironolactone, Triamterene)
Osmotic (Mannitol) (not used for HTN)
Loop diuretics
Furosemide (lasix) - inhibits reabsorption of Na+ and Cl- in ascending loop of Henle - LARGE UOP
-indicated for emergent/urgent diuretic needs - edema r/t liver cirrhosis, HF, renal disease, fluid overload - indicated for HTN when thiazides not enough or need for rapid mobilization,
can be used with low gfr
-Potassium wasting
ADRs: hyponatremia, hypokalemia, ototoxicity, hyperglycemia, hyperuricemia (esp in gout pts)
-Use in pregnancy if necessary
Interactions: antihypertensive (additive effect), ototoxic drugs (aminoglycosides abx), NSAIDs blunt diuretic effect, digoxin toxicity (hypokalemia increases drug toxicity of digoxin), lithium (inc risk of lithium toxicity esp if low Na+)
positive interaction: K+ sparing drugs counteract loss of K+
s/s hypokalemia
arrhythmias, fatigue, weakness, confusion, drowsiness, flaccid paralysis, extreme thirst, thready pulse, GI disturbances, N/V, ileus
education for furosemide + thiazides
-Recognize Hyponatremia, hypochloremia, dehydration
-postural hypotension
-hypokalemia - dietary counseling, eat foods rich in potassium or supplement, recognize s/s
-hyperglycemia in pts with DM
-signs of gout - swollen, tender joints
- ototoxicity - alert to changes in hearing and balance
- NSAIDs - blunt effect, don’t take, use other analgesics
- daily weights
-monitor BP
-assess skin
- time of admin (avoid late dosing)
Diuretics - Thiazides
Thiazides - early distal convoluted tubule
action dependent on adequate GFR
indicated for mild/mod HTN, edema from HF, cirrhosis, renal failure
protection for postmenopausal osteoporosis - promotes tubular reabsorption of Ca+
*paradoxical antidiuretic effect in diabetes insipidus
ADRs:
Hyponatremia, hypochloremia, dehydration, hypokalemia, hyperglycemia, hyperuricemia
Caution in: renal disease (GFR), gout pts, unstable diabetes, hyperlipidemia, pregnancy and lactation
Potassium -sparing Diuretics
Aldosterone antagonist - spironolactone
Nonaldosertone antagonist-
triamterene, amiloride
Prototype K sparing Diuretic
Spironolactone- blocks the action of aldosterone in distal tubule - promotes Na+/water excretion
weak diuretic
indicated to counteract loss of K+ caused by thiazides/loop diuretics
indications: HTN, edema, HF
other - hyperaldosteronism, hormonal acne in women, PCOS, prevention/treatment of hypokalemia
ADRs - same as other diuretics
hyperkalemia (constipation, weakness, cramping, hypoactive reflexes, ecg changes)
steroid derivative - can lead to gynecomastia, menstrual irregularities, impotence, hirsutism, voice changes
potassium sparing interactions/contraindications
contraindications: hyperkalemia, anuria, AKI, hypersensitivity
drug-drug:
agents that increase K+ - ACEi, ARB, transplant drugs
NSAIDS, digoxin
hypotension w/ ETOH, antiHTN, nitrates
education: no supplement K+ - salt substitutes, monitor K+
osmotic diuretic
mannitol - stays in nephron and creates osmotic force
indicated for ICP, reduce intraocular pressure (glaucoma)
-prevention of acute renal failure - will pull water into kidneys
-toxic OD, GU irritation
ADR: edema - extreme caution in heart disease, HF, Pulmonary congestion (can leave vascular system in all capillaries except in brain), headache, N/V, F&E imbalances, GI: dry mouth, polyuria, weakness
rash, vision disturbances,
rebound ICP inc.
contraindications: inc serum osmolarity, renal/cardiac dysfunction, active IC bleeding, pulmonary edema
nursing implications: monitor VS, UOP, s/s dehydration, fluid overload, neuro status, intraocular pressure, check renal function - do not give if high osmo. (>310), IV line filter (crystalizes at low temps), effects last 6-8 hrs, use indwelling catheter - must have accurate i&o
other: crystallizes in low temps -
beta blockers (beta1) 4 useful actions for HTN
- dec HR, conduction, contractility
- suppress reflex tachycardia (r/t vasodilators also used as antiHTN)
- inhibits renin release
- decreases PVR (moa unknown)
more effective in white people
beta blockers - indications and ADRs
HTN
MI- prevent 2nd occurrence - cardioprotective
Angina goal HR 50-60, exertion 100
cardiac dysrhythmias
HF* caution
hyperthyroidism
migraine prophylaxis
anxiety/stage fright
pheochromocytoma (tumor on adrenal - oversecretion of epi)
glaucoma
ADRs: bradycardia, decreased AV conduction - avoid in HB,
exacerbation of HF - pulmonary edema, asthma, heart blocks, slow heart
bronchoconstriction in nonselective
mask s/s of hypoglycemia (elevated HR)
can antagonize hypoglycemia (inhibits glycogenolysis in 1st gen)
rebound tachycardia
mask
fatigue, drowsiness, depression, sexual dysfunction, impotence
insomnia, bizarre dreams
mask hypothyroidism
mask hypoglycemia in DM
beta blockers education
do not stop abruptly (beta blockers rarely held)
teach early signs of HF: SOB, cough PM, edema in extremities
Avoid OTCs - decongestants pseudophedrine, phenylephrine
check HR - <50 may meet hold parameter
BP, orthostatic hypotension
assess - signs of depression, fatigue, sexual dysfunction
diabetics: warn s/s hypoglycemia
Doxazosin, Prazosin, Terazosin
apha1 antagonists
- second line in HTN
arteriole and vein constriction blocking - promotes vasodilation of arterioles and veins –> decreased BP
indications: HTN & BPH
ADRs:
-orthostatic hypotension (!1ST DOSE!)
-reflex tachycardia
-nasal congestion
-sexual dysfunction
-sodium/fluid retension - edema
-Weakness, GI sx, HA, syncope, SOB
education:
-first dose hypotensive rxn - avoid postural changes - fainting and falls
-effects may take 4-6 wks
-may relax bladder sphincter
-extravasation with IV!
Alpha/Beta Blockers
Carvedilol, Lebetalol
blocks alpha 1 and beta receptors
- dilates arterioles and veins
- reduces heart rate and contractility
-suppresses renin release
ADRs
orthostatic hypotension
bradycardia
AV HB
bronchoconstriction
mask the signs of hypoglycemia
CentrAl acting alpha agonist
Clonidine - acts within brainstem to reduce sympathetic outflow to blood vessels and heart (dec HR, PVR & BP)
indications - mild - mod HTN, relief of severe pain -neuropathic, ADHD
off-label - opioid/methadone withdrawal, smoking cessation, tourette’s syndrome, Behavioral disorders in children
ADRs: HA, dizzy, drowsy, sedation, fatigue
rebound HTN - high risk if stopped abruptly - bradycardia, AV HB
dry mouth
dermititis
NOT SAFE IN PREGNANCY
Abuse - euphoria, hallucination, can act synergistically with cocaine, benzos, opioids
if overused - severe hypotension, can spill over to alpha1 receptors and lead to severe hypertensive crisis
safety alert - inappropriate in geriatric pts due to high risk of ADRs CNS effects, bradycardia, hypotension
methyldopa
central acting alpha (2) agonist
preferred drug in pregnancy
only approved for HTN
RAAS agents
ACEi - angiotensin converting enzyme inhibitors
ARBS - angiotensin 2 receptor blockers
Direct Renin Inhibitors
Aldosterone antagonist
RAAS - ACEi indications & ADRs
“prils”
Indications: HTN, HF,
diabetic/nondiabetic nephropathy
MI - reduces risk of CV mortality
advanatages - safe for asthmatics, no weakness, sx dys, no hyperglycemia, safe in gout
*use with adequate hydration
ADRs
orthostatic hypotension
persistent dry cough
hyperkalemia
renal failure (x bilateral renal stenosis)
angioedema
fetal danger
drug-drug
NSAIDs - reduce effects
meds that inc K levels
lithium - causes inc levels
education
effects may take several weeks
taste impairment disappears 2-3 wks
cough - not infection or lung disease
hypotension
hyperkalemia - avoid supplements, k-sparing diuretics
avoid in pregnancy
renal failure - use with adequate hydration
RAAS - ARBs indications and ADRs
Angiotensin 2 Receptor Blockers
Losartan, Valsartan
decreases the release of aldosterone
work wherever angiotesin II receptors are
–> heart -cardiac changes, vessels -vasodilation, adrenals- reduce salt and water volume
indications:
HTN, MI, Stroke
Diabetic neuropathy, diabetic retinopathy
ADRs - similar to ACEi
NO COUGH, NO HYPERKALEMIA
can cause renal failure (xind: renal artery stenosis)
still: angioedema, fetal danger, renal failure
(adequate hydration)
RAAS - DRI indications and ADRs
Ex. Aliskiren
not considered 1st line, but as effective as ACEi and ARBs
ADRs
-less hyperkalemia
-less cough
-less angioedema
-similar fetal harm
GI, diarrhea
CCBs - Vasodilators
first line drugs
▪VESSELS: calcium entry causes vasoconstriction
▪HEART: calcium entry increases heart rate, AV conduction, and myocardial contractility, (nearly identical effect - bblkrs)
3 actions - vessels, negative inotropic, negative chronotropic
dihydropyridines and non-dihydropyridines
ADRs
vasodilation - HA, dizziness, flushing
grapefruit juice inhibits metabolism (N, F risk highest)
drug drug - digoxin (inc risk of AV HB), beta blockers (same action)
caution in renal/hepatic pts (reduced clearance)
education/implications
ASSESS HR before dose, teach s/s edema
Verapamil especially causes constipation (*elderly - reduced motility anyway)
CCBs
non-dihydropyridines
non-dihydropyridines very definitely heart
Diltiazem, Verapamil
vascular + heart (NONselective)
indicated for supraventricular dysrhythmias, AFIB, svt, atrial flutter
unique ADR: risk of brady, AV HB, worse HF
CCBs
dihydropyridines
dihydropyridines - n/a to the heart
Amlodipine, Nifedipine
only vascular
unique ADR: reflex tachycardia
*safety alert - immediate release nifedipine implicated in higher risk for MI (but not with sustained release)
Direct Acting Vasodilators - Arteriolar
Hydralazine
Minoxidil
less postural hypotension (less effect on veins)
indicated for HTN, HF, HTN crisis, angina, MI
decreases afterload
ADR -
reflex tachy - palpitations
fluid retention (bp drop stim renin rls)
excessive hypotension
SLE (lupus) like - muscle, joint pain, fever
HA, dizziness, fatigue
Direct Acting Vasodilators -Arteriol and Venous
Sodium nitroprusside - drug of choice
hypertensive emergencies
-rapid halflife 2 mins - continuous IV use
-requires cardiac monitoring
ADRs - severe hypotension, HA, N/V, diaphoresis, reflex tachycardia, angina, MI
prolonged infusion - cyanide thiocyanate toxicity
protect drug in sleeve, always use smart pump
others for HTN emergency: fenoldopam (activates dopamine receptors on arterials),
labetalol (alpha and beta blocker) - **drug of choice in preeclampsia
Diabetes
beta blockers and diuretics can decrease morbidity and mortality. Beta blockers can suppress/mask early signs of hypoglycemia; therefore, they must be used with caution. Thiazides and loop diuretics promote hyperglycemia, and should be used with care
