Cardiac Flashcards
Loop Diuretic Drug
Furosemide
Furosemide MOA
Rapid acting loop diuretic inhibits Na and Cl reabsorption in ascending loop of henle
Decreasing edema and BP
Furosemide Use
Powerful diuretic given for massive movement of fluids (trying to unload cardiac system)
Both acute and chronic heart failure
-early or small amounts of fluid retention thiazide diuretics are normally given
Furosemide A/E
Postural hypotension Hypo K, Mg, Na, Cl N/V Dehydration-- leads to circulatory collapse Tinnitus * Aplastic anemia *
Furosemide Route/Dose
IVP starts acting in 5 minutes, duration about 2 hr
give 20mg/min, too fast can cause cardiac arrest
Furosemide Drug interactions
Digoxin: ↓ K = ↑ risk for dig toxicity ↳Dysrhythmias Ototoxic drugs (aminoglycosides) ↳Hearing loss Lithium: ↑Na level Other antihypertensives: hypotension
Furosemide Monitoring
BP (>110/60): hypotension due to high volume diuresis can cause circulatory collapse (before giving)
Weight (Daily)
K level ( 3.5-5) (before giving)
urine output needs to be greater than
30mL/hr
Thiazide diuretic Drug
Hydrochlorothiazide
Hydrochlorothiazide MOA
Blocks reabsorption of Na and Cl in early segment of the distal convoluted tubule
-not effective if GFR <15-20 mL
Hydrochlorothiazide Use
Hypertension: 1st choice especially in AA (most effective)
Mild-Moderate heart failure
Mobilize edema associated with hepatic and renal disease (GFR cant be too low though)
Hydrochlorothiazide Contraindications
Pregnancy and breast feeding
Hydrochlorothiazide A/E
Hypo K, Na, Cl
Dehydration
Increased BG in diabetes
May precipitate gouty arthritis
Hydrochlorothiazide Drug interactions
Digoxin toxicity due to loss of K
Other antihypertensives: causes hypotension
Osmotic Diuretic Drug
Mannitol
Mannitol MOA
In the proximal convoluted tubules, mannitol creates osmotic action that inhibits passive reabsorption of water
– no significant effect on excretion of K
Mannitol Use
Can prevent/ slow onset of renal failure in severe hypotension → not excreted like other drugs so it raises BP
Hypovolemic shock
Reduction of intraocular pressure in cases not responding to usual therapy (Glaucoma)
Mannitol Solution
normally icy/ crystallized → need to warm in water
Mannitol dose
given at a rate for 30-50mL/hr of urine output
Mannitol A/E
HA N/V Electrolyte imbalance Pulmonary edema Congestive heart failure edema
K Sparing (Aldosterone) Diuretic Drug
Spironolactone
Spironolactone MOA
Blocks action of aldosterone in the distal nephron
Since aldosterone promotes Na uptake in exchange for K secretion
Inhibition of aldosterone causes retention of K and excretion of Na
Works slowly over days
Spironolactone Use
Hypertension
Edema
Usually given in combo w/loop/ thiazide diuretic due to low diuresis
Spironolactone A/E
Hyperkalemia resulting in cardiac dysrhythmias such as V. fib
Gynecomastia
Menstrual irregularities
Hyperkalemia treatment
Injection of insulin
Spironolactone Patient educations
Never use salt substitutes or K replacements
Don’t increase intake of K or take another K sparing drug
K Sparing (Non Aldosterone Sparing) Diuretic Drug
Triamterene
Triamterene MOA
Disrupts Na-K exchange directly in the distal nephron
Works quickly over a few hr
Triamterene Use
Hypertension
Edema
Mainly to counteract the K wasting effects of other diuretics *
Triamterene A/E
N/V
Leg cramps: increase K
Dizziness
Hyperkalemia
Triamterene Drug interactions
ACE, ARB, Direct renin inhibitors ↑ K and can be deadly
K replacement Drug
KCl (potassium chloride)
KCl Use
When theres a loss of K from vomiting, diarrhea, wound drainage, prolonged diuresis, DKA
KCl A/E
Irritate GI tract: abdominal discomfort
N/V/D
Large pills can cause intestinal ulcers and result in bleeding/ perforation
Hyperkalemia
-mild: 5-7: prolonged PR, and tented T waves
-Severe: >7: cardiac arrest due to V-tac/ V-fib.
IVP will cause instant death
KCl Nursing considerations
ONLY given through IV pump
10meq/hr or slower
Never add KCl to an existing IV
Dilute 10 meq in 100ml, 40 meq in 500-1000ml (x3 doses)
Check K level before giving each dose
Mix KCl well in the IV solution
PO pill: patient needs to be sitting up right
Liquid KCl: dilute in orange juice according to directions
Removal of Excess K
- hold K containing food and meds
- infuse calcium gluconate (counteract cardiotox)
- infuse insulin and glucose to push k into cells
- infuse sodium bicarbonate to increase pH and cellular intake of k
- give either PO or enema Kayexalate to remove K through the intestines
- peritoneal or hemodialysis to remove (Last resort)
Hyperkalemia S/S
Cardiac Confusion Anxiety Dyspnea Heaviness and tingling of legs Numbness and tingling of hands, lips and feet
Atropine MOA
Muscarinic antagonists, selectively blocks the effects of acetylcholine at the muscarinic receptors
Increases heart rate
Atropine Use
Significant Bradycardia (symptomatic or doesnt respond to waking the patient up) Surgical pretreatment to prevent bradycardia during surgery
Atropine A/E
*Tachycardia* Dry mouth Blurred vision Photophobia Increased intraocular pressure Urinary retention Anhidrosis (decreased in sweating)
Atropine Drug interactions
Antihistamine
Phenothiazine
Antipsychotics
TCA
Alpha 1
Arterioles and vein constriction
Alpha 2
Nerves
Beta 1
Heart: increase rate, force, AV conduction speed
Kidney: release of renin
Beta 2
Bronchi: dilation, arterioles, heart, lung, skeletal muscles
Dopamine stimulates
Alpha 1, Beta 1 and dopamine
Epinephrine stimulates
Alpha 1,2 and Beta 1,2
Norepinephrine stimulates
Alpha 1,2 and Beta 1
Alpha Adrenergic antagonist Drug
Prazosin
Prazosin MOA
Inhibits alpha 1 receptors (arterioles and veins) causing vasodilation, resulting in decreased BP and CO
Prazosin Use
Essential hypertension
BPH
Raynaud’s (due to vasodilation)
Prazosin A/E
Dizziness HA Drowsiness Impotence Reflex tachycardia (decreased CO) Nasal congestion Edema Postural hypotension
Prazosin Drug interactions
Diuretics and other hypotensive agents potentiate effects
Prazosin Nursing considerations
Monitor for 1st dose effect
Impotence is a major reason for nonadherence in men
Beta Adrenergic Antagonist Drug
Propranolol
Metoprolol
Propranolol MOA
NON-SELECTIVE Beta 1 and 2 adrenergic blocker (lung, heart, kidney)
Blocks adrenergic receptors in the cardiac (beta 1) and the lungs (beta 2); renal (beta 1) suppresses renin secretion
Propranolol Use
MI
CAD
HTN - better at lowering HR but still used as a 1st line treatment for HTN
Cardiac dysrhythmias
Propranolol Therapeutic effect
Antihypertensive
Reduced HR, CO
Propranolol A/E
Hypotension Bradycardia Bronchoconstriction Depression Rapid withdrawal can cause angina or dysrhythmias that will lead to another MI
Propranolol Drug interactions
Ca Channel Blockers: cause cardiac suppression, very low HR/BP
Propranolol Contraindications
Bronchitis
COPD
T1DM
T2DM
Propranolol Nursing implementations
・Take apical pulse and BP before giving
↳ Do not give if pulse is <60 or BP is <90-110 and call MD
・May mask tachycardia symptoms of hypoglycemia
Beta blocker Indications
Angina HTN Cardiac dysrhythmias MI Heart failure
Metoprolol MOA
Selective beta blocker (better for those who have lung problems)
Blocks Beta 1 cardiac receptors (Heart and Kidneys)
Reduces HR, force contraction, AV duration through the nodes, reduces secretion of renin
Metoprolol Use
1st choice antihypertensive
Angina
MI
Heart failure
Metoprolol A/E
Bradycardia Decreased CO AV heart block 1st, 2nd degree Heart failure Cardiac excitation (when suddenly stopped can cause another MI if previously had one)
Centrally acting Alpha 2 agonist Drug
Clonidine
Clonidine MOA
Activates the central Alpha 2 receptors (nerves) in the brainstem and this reduces sympathetic outflow to blood vessels and the heart
Clonidine Use
Hypertension
Sometimes pain
Clonidine A/E
Drowsiness Sedation Xerostomia (dry mouth) Constipation Impotence Rebound hypertension (when stopped abruptly) Fetal harm Euphoria Hallucinations Abuse
ACE Inhibitor Drug
Captopril, Lisinopril, Enalapril
Captopril MOA
Lowers BP by inhibition of Angiotensin Converting Enzyme
- This disrupts the conversion of angiotensin 1 to 2 in the kidneys
- Since angiotensin 2 is a powerful vasoconstrictor, vasodilation occurs and BP is lowered
Captopril Use
Hypertension
Heart failure
MI
BP med of choice for DM since it slows progression of ESRD
Captopril A/E
1st dose hypotension
Arthralgia
Cough (increased bradykinin in lungs) - may need to change to a different class
Angioedema
Bradycardia
Neutropenia (will occur within the 1st week)
Agranulocytosis (will occur within the 1st week)
Fetal injury
Hyperkalemia
Captopril Drug interactions
other antihypertensives: hypotension
Captopril Nursing implementation
・Take BP and apical pulse before giving
・Report unexpected fever
・May cause hypoglycemia in Dm → check BG
Angiotensin 2 Receptor Blocker (ARB) Drug
Losartan
Losartan MOA
Blocks access of angiotensin 2 to its receptors in blood vessels, the adrenals and other tissues
-causing dilation of arteries and veins
Losartan Use
Hypertension
Diabetic retinopathy (type 1) - slows development
Those who cannot tolerate ACE inhibitors
Losartan A/E
Angioedema
Renal failure
Losartan Drug interactions
Other antihypertensives
Ca Channel Blockers Drugs
Verapamil
Diltiazem
Nifedipine
Verapamil MOA
Inhibits Ca influx through slow channels into myocardial muscle cells
Increases myocardial O2 delivery
Blocks influx of Ca in both blood vessels and the heart
Nifedipine MOA
Dilates coronary artery and inhibits coronary spasm
-Prevents Ca influx into the slow Ca channel, only works on the arteries not the heart its self
Verapamil Use
Hypertension Reduces HR Antiarrhythmic for SVT (supraventricular tachycardia) Antianginal Decreases force of contraction
Nifedipine Use
Hypertension
Angina
Verapamil A/E
Dizziness HA Fatigue Sleep Disturbances Hypotension Bradycardia Constipation (not with Nifedipine) Nausea Edema in legs (more common and serious) Elevated LFTs Severe: Hypotension, Cardiogenic shock, CHF
Nifedipine A/E
Flushing
Reflex tachycardia
Along with the all from Verapamil
Verapamil Drug interactions
Grapefruit juice ↑ drug level (no large amounts)
↑ level of digoxin
Potentiates other antihypertensives
Verapamil patient education
Monitor grapefruit intake - avoid large amounts
Report wt gain
Verapamil Nursing implementations
Take BP and HR before giving
Verapamil Monitoring
LFTs
BUN
Cr
Hydralazine
Vasodilator
Selective dilation of arteriole, no effect on veins
HR increases
Hydralazine Use
Essential hypertension
Hypertensive Crisis
Heart failure
Hydralazine A/E
Reflex tachycardia
↑ Blood volume
lupus like syndrome
Hydralazine Drug interactions
Combo w/ beta blockers to avoid reflex tachycardia
-excessive hypotension
Hydralazine IV
Most commonly given to HTN crisis BP >220/180
Nitroglycerine MOA
Vasodilator (Anti-anginal)
Relaxes smooth muscle vasculature by unknown mech.
Reduces preload, afterload, and myocardial O2 consumption
Nitroglycerine Use
Reduces BP, Chest pain,
Angina
Nitroglycerine A/E
HA (give Aspirin or Tylenol)
Postural hypotension
Facial flushing
Nitroglycerine Sublingual dosing
Give 1 tab every 5 minutes 3x if chest pain did not subside with the previous dose
-If not better after 3rd dose call 911 or use MI protocal
Nitroglycerine IV
Titrate IV drip according to BP
-Used when chest pain isn’t being subdued by Morphine
Nitroglycerine Cream
Measured in increments
Will not stop sudden chest pain and can take Sublingual tabs for it
Applied to hairless area (chest, upper back, arm, legs)
Nitroglycerine Patch
Applied same as cream
Clean area before application and after removal
Can be worn in shower or while swimming
Local buring can happen and is not significant
Remove at night to prevent tolerance
Nitroglycerine Capsule
Prevent chest pain
Nitroglycerine Drug interactions
Alcohol: worsen hypotension
IV nitro may antagonize heparin ( don’t give in same IV line)
Nitroglycerine Nursing implementations
Take before known chest pain causing activity
Take BP before giving and 1 hr after for transdermal
Unrelieved chest pain after 15 minutes is usually indicative of MI
Digoxin MOA
Increases force of myocardial contraction (slow hard pumps) Increases contractility (positive inotropic action) -- antiarrhythmic (changes heart rhythm)
Other Inotropes
Dopamine, Dobutamine: Used when BP is too low and will not go up with other drugs, will turn finger and toes black, for those who had MI or Open heart surgery
Digoxin Therapeutic action
Increases diuresis
Digoxin Use
A. Fib
CHF
Heart failure: 2nd line drug
Digoxin A/E
Bradycardia Heart blocks: slows conduction from SA→AV→Purkinje fibers (1st, 2nd, 3rd degree heart blocks) Other dysrhythmias Visual disturbances N/V Confusion Agitation
Digoxin toxicity
More common in elderly
Digoxin Drug interactions
Many! Antacids Antibiotics Amiodarone Verapamil Quinidine
Digoxin Nursing implementations
❊Absolutely must take apical pulse for 1 full minute before giving (must be above 50-60 in adults and 60-70 in children)
Digoxin Monitoring
Digoxin level: daily when first started then periodically
K level: hypokalemia can increase risk for Digoxin Toxicity and it’s the most common reason for toxicity
Digoxin antidote
Digibind
Adenosine MOA
Decreases automaticity in the SA node and slows conduction through the AV node
Inhibits cyclic AMP-induced Ca influx
-Basically stops the heart and resets the automaticity
Adenosine Use
Terminating SVT
Wolff parkinson white syndrome
Adenosine Route
IV bolus closest to the heart
Short half life: 1.5-10 seconds
Adenosine A/E
Sinus bradycardia
Bronchoconstriction
Amiodarone MOA
K channel blocker
Slows AV conduction and prolongs AV refractoriness
Blocks repolarization
Amiodarone Use
Recurrent V. fib
Unstable V. tach
AKA: cardiac arrest
Amiodarone A/E
Severe hypotension
Bradycardia
Will most likely need pacemaker after
Lipid lowering drugs
‘Statin’
Atorvastatin
Lovastatin
Statins MOA
Reduce LDL-C
Elevate HDL
May lower Triglycerides but not prescribed for that
HMG-CoA reductase inhibitor
Statin A/E
Dyspepsia Camps Flatulence Constipation Abdominal pain Myopathy/ Rhabdo (Calf pain) ↳increase CK levels
Statin Toxicity
Nephrotoxic
Hepatotoxic
Statin Patient education
Cannot eat or drink grapefruit
Inhibits CYP3A4 enzyme
Statin Nursing implementations
Most effective for lowering LDLs and total cholesterol
Improve cardiac outcomes: lower risk for HF, MI, sudden death
Rovastatin has the highest risk: dosages need to be reduced in asians
LDL goal for Heart disease patients
70
Statin Monitoring
Lipids Q6 mo-annually
Ezetimibe MOA
Cholesterol blocker
Inhibits dietary absorption of cholesterol secreted in bile
Treatment reduces total cholesterol, LDL-C, TG, slight rise in HDL
Ezetimibe A/E
Rhabdo
Hepatitis when combo with statin
Ezetimibe Toxicity
Pancreatitis
Fibrates
Gemfibrozil
Gemfibrozil MOA
Decreases VLDL’s there by lowering TG levels
Increase HDL’s
No effect on LDL-C
Gemfibrozil Use
Treatment usually limited to those in which dietary restriction of saturated fats fails
Gemfibrozil A/E
Gallstones
Statin induced myopathy
Gemfibrozil Toxicity
Hepatotoxicity
Gemfibrozil Drug interactions
Displaces warfarin from albumin
Increasing anticoagulation
Should not be given w/statins
