Cardio Drugs Flashcards
the stretch of the heart
preload
the squeeze of the heart muscle
afterload
When preload and afterload are decreased =
blood pressure decreases
- assess how well the body is being perfused by blood carrying oxygen and nutrients
blood pressure
the mean (average) perfusion pressure across the entire cardiac cycle
Mean Arterial Pressure (MAP)
blood pressure and ___ help determine how well the body is perfusing
MAP
Blood pressure consistently over 140/90
Most common disease
hypertension
Diuretics
adrenergic drugs
Vasodilators
angiotensin-converting enzyme (ACE) inhibitors
angiotensin receptor blockers (ARBs)
calcium channel blockers (CCBs)
and direct renin inhibitors.
Risk factor for multiple diseases
most people have_________hypertension, and it means there is a cause that they are not aware of
essential
______ hypertension is due to a disease that is causing the high blood pressure
secondary
if person have 140/90 multiple times they will usually __________
start medication
Decreases Sympathetic response
2. Less norepinephrine released
Slower heart rate
Less force of contraction
Vasodilation
Less renin released
Equals less cardiac output (Blood pressure drops)
centrally acting alpha 2 adrernergics
works directly on the part of the brain that lowers blood pressure
renin is an enzyme that when decreased causes decreased bp
centrally acting alpha 2 adrenergics
What are the centrally acting adrenergics?
clonidine
methyldopa
Some Types of heart failure
Use with an MAOI
When Breastfeeding
contraindications with centrally acting adrenergics
Recent myocardial Infarction
Diabetes Mellitus
Peptic Ulcer
HX of stroke, asthma, COPD, diabetes mellitus, major depressive disorder, or chronic kidney disease.
cautions with centrally acting adrenergics
Reduce Hypertension (hTN)
Primary HTN
Manage symptoms of heart failure
indications for centrally acting adrenergics
bradycardia
Orthostatic hypotension/Dizziness
Drowsiness, sedation
Dry mouth
Rebound htn when discontinued
adverse effects of centrally acting adrenergics
Might be given twice a day
is often given at bed time instead bc it causes drowsiness
slows pulse
monitor “tilt” blood pressures –laying down, sitting up, and standing measure the bp in these positions
usually not the first choice medication to treat high bp
reflex tachycardia is also a symptom but is less common than bradycardia
notes/ adverse effects for centrally acting adrenergics
Fall and injury risks from hypotension, dizziness, lightheadedness
Routes include oral, epidural, and transdermal
usually administered BID in divided doses
May take larger dose at bedtime to decrease daytime sleepiness
Report heart rate less than 60 bpm to physician
avoid excessive alcohol use
Avoid abrupt discontinuation of medication
patient education for centrally acting adrenergics
hypertension does not make you feel bad, but it may give you a ________, a lot of people do not have any symptoms
headache
when is the best time to give clonidine (or the higher dose if BID?)
bedtime
CAAS (Clonidine/aldomet) cause what affect on the heart rate?
bradycardia
Fluid volume excess in joints, peripheral limbs, surrounding the cell
edema
excess fluid loss
dehydration
most edema is ?
peripheral (in the legs)
What is normal potassium levels?
3.5-5
Anything less than ___ is hypokalemia
3.5
anything over ____ is hyperkalemia
5
Hypotension
General Weakness & Fatigue
Muscle cramps
Constipation, N/V
Irritable, confused
Arrhythmias/tachycardia
Shallow respirations
s/s of hypokalemia
General Weakness
Muscle fatigue, twitches, cramps, up to paralysis
paresthesia
Abdominal cramps, distention, Nausea, Diarrhea
Irritable, anxious
Arrhythmias/hypotension
hyperkalemia
________ is pin and needle feelings in your hands and feet
paresthesia
if you are to the ______, there is a MAJOR problem with hyper and hypokalemia
arrhythmias,
if they have ______ they can have muscle twitches
hyperkalemia
both _____ and ____ cause GI issues
hyper and hypokalemia
Essential for nerve impulse conduction
Regulates acid/base balance
potassium
Give _______ for hyperkalemia
Kayexalate
sodium bicarbonate
What happen if the nurse gives potassium IV as a bolus dose?
its fatal!!!!!!!!
Give _________ for hyperkalemia can be given PO or enema, pulls potassium out into GI lumen and causes diarrhea
kayexalate
Give kayexalate for ______ can be given PO or enema, pulls potassium out into GI lumen and causes diarrhea
hyperkalemia
t/f: NEVER GIVE POTASSIUM IV BOLUS OR FAST IV PUSH
true
Dilute iv dose with saline
no more than 40 meq/l at a time
no faster than 10 meq/hr
admin instructions for potassium
GI related
Diarrhea
Nausea
Vomiting
Adverse-
GI bleeding
Ulceration
IV fluid- has to be mixed to a certain concentration to give safely
IV infusion causes discomfort
adverse effects of potassium
when given too fast, it causes cardiac arrest
IV infusion can discomfort [possible thrombophlebitis]
potassium
Complex syndrome that impairs cardiac functioning decreased cardiac output
heart failure
Dyspnea
Fatigue
Fluid retention (peripheral edema)
Pulmonary edema (fluid lungs)
Reduced ability to exercise
Persistent cough or wheezingwith white or pink blood-tinged phlegm
Increased need to urinate at night
Swelling of abdomen (ascites)
Sudden weight gain from fluid retention
Lack of appetite/nausea
s/s of heart failure
occurs when your heart muscle doesn’t pump blood as well as it should. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently
congestive heart failure
What are the two medication classes used to treat heart failure?
cardiac glycosides
diuretics
what are the cardiac glycosides?
digoxin
what are the diuretics
Thiazide diuretics-hydrochlorothiazide (HCTZ)
Loop diuretics- furosemide
Potassium-sparing diuretics- spironolactone
Osmotic diuretics-Mannitol
calculation that determines how well the blood is filtered by the kidneys
glomerular filtration rate
measures the amount of the waste product creatinine
Serum creatinine/creatinine clearance
anytime you give a med that is going to pull fluid off you need to know the
GFR and Serum creatinine clearance level
Works on the nephron
Block na and h2o reabsorption
Cause Direct arteriolardilation decreases peripheralvascular resistance
Reduces extracellular fluid volume, plasma volume, and cardiac output decrease in BP
diuretics
What are the different diuretic classes?
loop diuretics
mannitol (osmotic diuretic class)
metolozone (thiazide-like diuretic class)
thiazides
potassium sparing diuretics
the osmotics you don’t need to know as much about them bc most of the time ______ is given in the ICU for increased intracranial pressure
mannitol
Dehydration
electrolyte imbalance
muscle cramps
dizziness
adverse effects of all diuretics
Blocks reabsorption of sodium, potassium, chloride
Water is lost
arterioles relax
Reduced peripheral vascular resistance (After load)
how thiazide diuretics work
causes body to excrete fluids
______ is not a very powerful diuretic
is used as a first line for hypertension bc it pulls fluid off pretty easily without causing a lot of side effects
thiazide diuretics
What are the thiazide diuretics?
hydrochlorothiazide
chlorothiazide
metolazone (is thiazide like)
Hypertension
Mild to moderate Heart failure
Edema
Hepatic cirrhosis
Various others
indications for thiazide diuretics
remember, thiazide diuretics are not ______
very potent
if allergic to sulfonamides (Sulfa) (uncommon cross allergy)
Avoid if pregnant or breastfeeding
Avoid in patients who have anuria/Severe renal failure
High levels of creatinine in the blood (indicating poor kidney function)
contraindications for thiazide diuretics
Hx of cardiovascular disease, DM, hypokalemia, hyperlipidemia, hypomagnesemia, and gout
taking digoxin, lithium, or antihypertensives
SIDE EFFECTS MORE PRONOUNCED IN THE ELDERLY
cautions with thiazide diuretics
KIDNEYS HAVE TO FUNCTION FOR THIS DIURETIC TO WORK
thiazide diuretics
Dehydration
Electrolyte disturbances
Reduction of potassium
Reduction of sodium, Chloride, and magnesium to a
lesser degree
Increase of Calcium, lipids (LDL), glucose
Others:
Headache, impotence, decreased libido
Dizziness from Orthostatic Hypotension
adverse reactions to thiazide diuretics
patient who is diabetic may still take this drug, just know that it can increase their glucose levels so you need to monitor their blood sugar.
thiazide diuretics
Report s/s of hypokalemia (potassium level is below 3.5)
anorexia, nausea, lethargy, muscle weakness, irritability, confusion, hypotension, shallow respirations, fast and thready pulse, decreased intestinal mobility, dysrhythmias
eat foods rich in potassium, potassium supplements if ordered
Take measures to avoid dehydration
Minimize alcohol and caffeine beverages (Replace fluids during exercise or hot weather
Avoid exposure to intense heat for prolonged periods
Take small frequent amounts of ice chips or clear liquids if vomiting
Replace fluids with fruit juice or bouillon if diarrhea occurs
If diabetic, check blood glucose periodically
education for thiazide diuretics
often you don’t need to have a potassium supplement with ______diuretics, but you may need to increase your dietary intake of potassium
thiazide
All given orally Except ______ can begiven iv
Avoid giving in evening, night time
administration for thiazide diuretics
chlorothiazide
Creatinine clearance
Electrolytes
glomerular filtration rate (GFR)
monitor these labs for thiazide diuretics
Vital signs
I & o, daily weight
Signs of dehydration
Prevent falls/injuries
assessments for thiazide diuretics
GIVE IN THE MORNING SO THAT THEY PEE DURING THE DAY AND NOT AT NIGHT (IS ALSO A FALL RISK IF THEY TAKE IT AT NIGHT) [only exception is if they take it more than once a day]
thiazide diuretics (also for other diuretics too I think)
Decrease in blood pressure to normal range
Decrease in edema
Increase in urine output (at least 30ml/hour)
Preserved bone integrity in postmenopausal women. **
indications that thiazide diuretic is working
Are the most potent diuretics
loop diuretics
not used for hypertension, mostly used for heart failure
loop diuretics
What are the loop diuretics?
ethacrynic acid
torasemide
furosemide
azosemide
bumetanide
_______ (is the most common) –can be used IV, causes sodium Chloride and water to leave, also caused potassium calcium and magnesium to leave as well which causes even more water to leave the body. Can cause ototoxicity (especially if given too rapidly IV).
FUROSEMIDE
What is the strongest loop diuretic?
bumetanide
hyponatremia
hypokalemia
hypomagnesemia
ototoxicity
adverse effects of loop diuretics
Manage edema associated with heart failure, hepatic or renal disease
To control htn (not as often as the thiazide diuretics though)
Increase the excretion of calcium in someone with hypercalcemia
Rapid diuresis (works PO, very well IV)
loop diuretic indications
NSAIDS- decrease diuretic therapy from loop diuretic
Digoxin (Lanoxin)- digoxin toxicity/Hypokalemia
Corticosteroids- further hypokalemia
Antidiabetic medications- decreased effectiveness of antidiabetics- increased blood glucose
loop diuretic interactions
Useful if rapid diuresis (removal of fluid) needed
PO are usually effective in once a day dosing
Prolonged high doses can rarely cause ototoxicity (can be permanent)
loop diuretics
What are the 5 best sources of potassium from foods?
dried apricots
white beans
leafy greens
potato
acorn squash
bananas
t/f: patient on loop diuretics or thiazide diuretics need to increase their dietary intake of potassium?
true
______ are often given with potassium supplement
loop diuretics
Anuria (no urine)
severe electrolyte depletion or dehydration present
contraindications for loop diuretics
Hx of cardiovascular, DM, and gout
If taking digoxin, lithium, ototoxic medications, NSAIDs, or antihypertensives
caution for loop diuretics
Dehydration – leg pain?
Electrolyte disturbances :
hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypocalcemia, hyperuricemia*
Hypotension
Ototoxicity (specific to the loop diuretics)
Hyperglycemia
decrease in HDL (good)cholesterol levels, increase in LDL (bad) cholesterol levels
adverse reactions to loop diuretics
electrolytes
lipids
renal labs
glucose
labs you need to monitor with loop diuretics
Signs of dehydration
BP
kidney damage or hearing damage
Monitor I/O, weight
assessment for loop diuretics
Give iv over 2 minutes- GO slow!
Prevent falls by planning ahead
Avoid licorice or licorice extract/Herb
If daily give diuretic in the am
administration for loop diuretics
teach patient on potassium dietary potassium
teach to weight daily
they should measure blood pressure daily and keep a log
change position slowly
education for loop diuretics
low potassium increases risk for _________
digoxin toxicity
block aldosterone receptors (different meds, different ways)
Sodium and water are excreted, Potassium is Retained
potassium sparing diuretics
Relatively weak compared to other diuretics:
Synergistic effect use in conjunction with other diuretics
Counteract the adverse metabolic effects (electrolyte loss)
potassium sparing diuretics
What are the potassium sparing diuretics?
spironolactone
triamterene
Decrease potassium loss from other diuretics
Reduce Edema of multipleetiologies
children with heart failure
Heart failure
Hypertension (is not a first line for blood pressure)
indications for potassium sparing diuretics
Hyperkalemia (potassium greater than 5 mEq/mL)
Taking potassium supplements
With another potassium sparing diuretic
Anuria, renal failure
contraindications for potassium sparing diuretics
client with diabetes mellitus
Impaired hepatic function (avoid Triamterene)
Other electrolyte imbalances
metabolic acidosis
cautions for potassium sparing diuretics
if the patient is only taking a potassium sparing diuretics, do they need to take a potassium supplement?
no, they do not need to take a K+ supplement
make sure theyre not using a potassium salt substitute with this med unless theyre using a potassium sparing diuretic with a loop diuretic
potassium sparing diuretic
Hyperkalemia
Increased urinary frequency
Triamterene specific:
Low folate Kidney stones
Anemia
Colored urine
adverse reactions with potassium sparing diuretics
What is this?
colored urine from triamterene (a potassium sparing diuretic)
BP, daily I/O
Changes in LOC
slow/Continued diuresis
Fall risk and environment
assessment for potassium sparing diuretics
What labs do you need to get for potassium sparing diuretics?
Glucose, BUN, CREATinine, and Hepatic funciton labs
Caution salt substitutes and potassium rich foods
Give in morning or early afternoon
Avoid driving or activities requiring alertness
education for potassium sparing diuretics
What is the osmotic diuretic?
mannitol
How are the osmotic diuretics administered?
IV
Often used to decrease cerebral edema and intracranial pressure related to head trauma
Intraocular pressure
indications for osmotic diuretics
Pulmonary edema- loop diuretics would be used
Severe kidney disease
Intracranial bleeding (head trauma)
contraindications for osmotic diuretics
causes increasing osmotic pressure in the kideys which causes water to not be reabsorbed as much
[can be given with other diuretics but not a whole lot]
does not cause a lot of loss of electrolytes
osmotic diuretics, mannitol is one
Convulsions
Thrombophlebitis
Pulmonary congestion (fluid build up in the lungs)
adverse reactions to osmotic diuretics
Crystals can form in low temperatures
cannot let it get cold
There are different concentrations of the medication/ double check dose with other nurse
nurse notes for osmotic diuretics
One of the oldest groups of cardiac drugs
cardiac glycosides
Treatment of heart failure, atrial fibrillation
cardiac glycosides
History: first line drug for 200 years (heart failure)
Present: ______ is Only cardiac glycoside available in U.S.
Digoxin
Increased force of heart’s contraction
Improves cardiac output
Decreases heart rate
Promotion of diuresis (due to improved blood circulation)
method of action for cardiac glycosides
What are the cardiac glycosides?
digoxin, digitoxin
heart failure
Dysrhythmias (atrial fibrillation, Atrial Flutter)
indications for cardiac glycosides
heart blocks and other dysrhythmias
contraindication for cardiac glycosides
Hypokalemia, Advanced heart failure, impaired kidney function
Licorice
St. john’s wort (herb used for depression)
Amiodarone, verapamil, quinidine
all Increase digoxin levels by 50%!!!
cautions for cardiac glycosides
Cardiovascular
dysrhythmias, Bradycardia, tachycardia, hypotension
vision changes
green, purple, yellow colored vision,
halo vision
flickering lights
adverse effects of cardiac glycosides
What is the therapeutic range of digoxin?
0.5-0.8 ng/mL or 0.5-2 ng/ml
Signs can appear even at 1.75 ng/ml level
Decreased renal function, Low potassium, or low magnesium can contribute to toxicity
digoxin toxicity
GI issues usually first effects
bradycardia, headache, dizziness, confusion, nausea, visual disturbances (sees halo), changes in normal heart rhythms
signs of digoxin toxicity
Low ____ increases risk of digoxin toxcity
potassium
hold next dose
Draw Labs
serum digoxin level, electrolytes
Administer potassium supplements if hypokalemic
Continuous cardiac monitoring
administer an anti-dysrhythmic medication (Phenytoin or Lidocaine), if needed
Administer atropine for bradycardia
For excessive overdose
activated charcoal, cholestyramine, or digoxin immune Fab (DIGIBIND)
protocol for digoxin toxicity
__________________ therapy
Available only as 40mg vial, parenteral form
Antibody that inactivates free digoxin
Used in Severe cases only
Given IV over 30 minutes
Digoxin immune Fab
loading dose will be larger than maintenance dose
Assessment apical pulse (rate and rhythm) before administration
Record findings
Notify the provider if heart rate is less than 60/min in an adult
Administer digoxin at the same time daily
Monitor digoxin levels and potassium levels periodically during treatment
If administering IV digoxin, infuse over at least 5 min, (10-15 min in clients who have pulmonary edema)
administration and nursing notes for digoxin
When oxygen and nutrient supply is insufficient
heart muscle will ache = ______
angina pectoris
Ischemic conditions -> heart shifts to ______ metabolism
anaerobic
Anaerobic product is lactic acid ->accumulates
Lactic acid and other byproducts stimulate the pain receptors = _____
angina!
Dilates blood vessels
Dose dependent
relaxation of smooth muscle cells in walls of vein/ arteries
Redistributes blood and oxygen to ischemic myocardial tissue
Reduce venous return reduce preload angina relieved
nitrates/nitrites method of action
used to treat and prevent angina
nitrates/nitrites
What are the nitrates/nitrites?
nitroglycerin
isosorbide mononitrate
can take up to three doses with five minutes in between doses
nitrates/nitrites
if it doesn’t resolve with ______ doses, you need to go to the hospital
three
severe anemia – increases vasodilation
closed‑angle glaucoma and traumatic brain injury (TBI) - increases intracranial pressure
can be life threatening when taken with erectile dysfunction medications (within 24-48 hours of ntg administration)
sildenafil (Viagra), tadalafil (cialis), and vardenafil (Levitra)
contraindications for nitrates/nitrites
Client taking antihypertensive medications
clients who have hyperthyroidism
Clients with kidney or liver dysfunction
cautions for nitrates/nitrites
Vasodilation effects:
Headache
Orthostatic Hypotension (fall prevention needed)
Reflex Tachycardia if vasodilated too fast
Topical:
can cause contact dermatitis (not a true allergy)
Local burning or tingling sensation
Tolerance can occur quickly
Nitrate “vacation” needed
adverse effects of nitrates/nitrides
First dose? Sit/Lie down for 15 mintues
Spray translingual spray against oral mucosa and do not inhale
Take long acting capsules on an empty stomach with 8 oz of water
Vitals prior to administration -Hold for SBP less than 90
Avoid use with erectile dysfunction medication (decrease bp)
Always have it accessible (Fast acting)
Replace sublingual tablets (Fast Acting)every 3 months and remove the cotton, store in original brown container in cool, dry place
need to replace every three months
Can swim or bathe with a NTG patch in place
Use rapid‑acting nitrate at the first indication of chest pain
Use prior to activity that is known to cause chest pain
Be medication free 8-12 hours a day
Remove the prior dose before a new dose is applied
easily forgotten when it’s a transdermal or topical med
Measure specific dose with applicator paper and spread over 2.5 to 3.5 inches of the paper
See next slide for example
nursing notes for nitrates/nitrides
prn angina treatment: Take 1 dose q5 minutes x3
Rest- sit or lie down immediately
Take each dose 5 minutes apart
Need emergency help if not relieved after 3 doses
Take no more than 3 doses
Instruct client to report all attacks
Include details
patient education for nitrates/nitrides
