Cardio Drugs Flashcards by Glen McCormick

the stretch of the heart

preload

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the squeeze of the heart muscle

afterload

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When preload and afterload are decreased =

blood pressure decreases

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assess how well the body is being perfused by blood carrying oxygen and nutrients

blood pressure

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the mean (average) perfusion pressure across the entire cardiac cycle

Mean Arterial Pressure (MAP)

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blood pressure and ___ help determine how well the body is perfusing

MAP

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Blood pressure consistently over 140/90
Most common disease

hypertension

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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

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most people have_________hypertension, and it means there is a cause that they are not aware of

essential

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______ hypertension is due to a disease that is causing the high blood pressure

secondary

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if person have 140/90 multiple times they will usually __________

start medication

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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

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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

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What are the centrally acting adrenergics?

clonidine
methyldopa
guafacine (tenex)

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Some Types of heart failure
Use with an MAOI
When Breastfeeding

contraindications with centrally acting adrenergics

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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

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Reduce Hypertension (hTN)
Primary HTN
Manage symptoms of heart failure

indications for centrally acting adrenergics

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bradycardia
Orthostatic hypotension/Dizziness
Drowsiness, sedation
Dry mouth
Rebound htn when discontinued

adverse effects of centrally acting adrenergics

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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

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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

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hypertension does not make you feel bad, but it may give you a ________, a lot of people do not have any symptoms

headache

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when is the best time to give clonidine (or the higher dose if BID?)

bedtime

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CAAS (Clonidine/aldomet) cause what affect on the heart rate?

bradycardia

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Fluid volume excess in joints, peripheral limbs, surrounding the cell

edema

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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

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

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?

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