Cardiovascular Part 2

Question 1

Medication Administration

Thiazide Diuretics - hydrochlorothiazide

Answer 1

Available orally alone and in fixed-dose combination with multiple other drugs, such as potassium-sparing diuretics, ACE Inhibitors, ARBs, beta blockers, and other hypertensive drugs
Chlorothiazide is available in IV form
Give with food to minimize GI effects
Give last dose of day by 3pm to prevent nocturia and sleep loss

Question 2

Client Education

Thiazide Diuretics - hydrochlorothiazide

Answer 2

Eat foods rich in potassium (if indicated) such as citrus fruits, potatoes, bananas
Report signs of electrolyte imbalance, such as confusion, muscle twitching, weakness, irregular pulse, nausea, and others
Clients who have diabetes mellitus need to carefully monitor blood glucose levels and notify provider for persistent hyperglycemia
Be aware that this effect may occur; usually without symptoms
Clients with history of gout need to report symptom onset to provider

Question 3

Interactions

Thiazide Diuretics - hydrochlorothiazide

Answer 3

Lithium toxicity may occur
Increased risk of digoxin toxicity with potassium or magnesium deficiency
Corticosteroids and amphotericin B increase risk for hypokalemia
Decreased absorption with cholestyramine (Questran) or colestipol (Colestid)
NSAIDs can reduce effectiveness

Question 4

Therapeutic Use

Loop Diuretics - furosemide

Answer 4

Treats pulmonary edema in HF
Treats edema caused by renal, hepatic, or cardiac failure not affected by other diuretics
Treats hypertension not controlled by other diuretics

Question 5

Adverse Effects

Loop Diuretics - furosemide

Answer 5

Electrolyte imbalance: hyponatremia, hypochloremia, severe fluid loss (dehydration), and hypokalemia
Hypotension
Ototoxicity (all loop diuretics, can be temporary or permanent)
Hyperglycemia (especially in clients who have diabetes mellitus)
Increased uric acid levels (hyperuricemia) with possible gouty arthritis in susceptible clients

Question 6

Interactions

Loop Diuretics - furosemide

Answer 6

Digoxin toxicity is a high risk with hypokalemia
Other diuretics increase the diuretic effect
NSAIDs can decrease diuretic effect
Lithium toxicity can occur
Amphotericin B can corticosteroids increase risk for hypokalemia
Other ototoxic drugs (e.g. aminoglycoside antibiotics) increase risk for ototoxicity

Question 7

Adverse Effects

Potassium-Sparing Diuretics - spironolactone

Answer 7

Hyperkalemia
Menstrual irregularities, abnormal hair growth (e.g. on face) and deepening of voice may occur in women; gynecomastia (growth of breast tissue) and impotence may occur in men

Question 8

Interactions

Potassium-Sparing Diuretics - spironolactone

Answer 8

Counteracts adverse effect (hypokalemia) of loop and thiazide diuretics (may be the desired effect).
ACE inhibitors, ARBs, direct renin blockers, potassium supplements, salt substitutes increase risk of hyperkalemia.
Increased risk of hypotension can occur with concurrent ingestion of alcohol, nitrates or other antihypertensives.

Question 9

Adverse Effects

Inotropic Agents Cardiac Glycosides - digoxin

Answer 9

Cardiac dysrhythmias, especially likely with digoxin toxicity
Any dysrhythmia may occur, with AV block being most common
GI symptoms – early signs of toxicity - Nausea, vomiting, anorexia
CNS symptoms
Fatigue, visual disturbances, such as yellow vision and blurred vision
Increased mortality in women

Question 10

Nursing Interventions

Inotropic Agents Cardiac Glycosides - digoxin

Answer 10

Erythromycin and some other antibiotics increase digoxin levels.
Other antidysrhythmic (verapamil, quinidine, amiodarone, flecainide) increase digoxin levels; decrease digoxin dosage for concurrent administration.
Diuretics increase the risk of digoxin toxicity by decreasing potassium levels.
Herbal ginseng increases risk of digoxin toxicity; St John’s wort decreases digoxin levels

Question 11

Evaluation of Medication Effectiveness

Inotropic Agents Cardiac Glycosides - digoxin

Answer 11

Improvement in heart failure (ability to perform activities of daily living, improved breath sounds, and absence of edema)
Absence of cardiac dysrhythmias

Question 12

Adverse Effects

Inotropic/Sympathomimetic - dobutamine

Answer 12

Tachycardia, cardiac dysrhythmias, and possible angina pain

Question 13

Nursing Interventions

Inotropic/Sympathomimetic - dobutamine

Answer 13

Monitor ECG rhythm and vital signs continuously during infusion
Treat cardiac dysrhythmias as needed and prepare to decrease or
discontinue dobutamine for tachydysrhythmias

Question 14

Adverse Effects

Inotropic/Phosphodiesterase Inhibitors - milrinone

Answer 14

Hypokalemia
Cardiac dysrhythmias, hypotension
Anginal chest pain

Question 15

Nursing Interventions

Inotropic/Phosphodiesterase Inhibitors - milrinone

Answer 15

Correct fluid deficits and hypokalemia before beginning infusion.
Monitor potassium levels and correct hypokalemia as needed during infusion.
Monitor vital signs and ECG rhythm continuously during infusion.
Decrease dosage for dysrhythmias or blood pressure failing below prescribed parameters.
Monitor for chest pain during infusion.

Question 16

Therapeutic Use

Class 1A Sodium Channel Blockers - quinidine

Answer 16

Broad-spectrum antidysrythmics treat atrial fibrillation, and supraventricular and ventricular tachycardias
Quinidine used more for long-term treatment while procainamide is used only for short-term treatment due to severe adverse effects

Question 17

Adverse Effects

Class 1A Sodium Channel Blockers - quinidine

Answer 17

severe with oral administration than IV), widen the QRS complex and prolongs QT interval, ventricular dysrhythmias occur due to toxicity; oral or IV therapy (QRS too wide or QT interval too long), arterial embolism (caused by dislodging small clots) if treating atrial fibrillation, speed shock with too rapid IV infusion (flushing, headache, irregular heart rate, severe hypotension, loss of consciousness, cardiac arrest), quinidine- cinchonism (tinnitus, visual disturbances, headache, N, V), procainamide (system lupus erythematosus- like syndrome (SLE) seen in70% of clients after 1 year of oral therapy), blood dyscrasis (procainamide with continued used).

Question 18

Client Education

Class 1A Sodium Channel Blockers - quinidine

Answer 18

Take with food if GI symptoms occur
Report GI symptoms to provider (especially severe diarrhea)
Teach client to monitor pulse rate and report changes from prescribed
parameters; keep record of pulse rate
Report dizziness, syncope to provider
Avoid hazardous activities, such as driving, if hypotension occurs
Do not change prescribed dose or dosage intervals; take at fixed times
daily
Be aware that monitoring of blood, ECG occurs
Report sudden chest pain, dyspnea to provider; call 911 for severe
symptoms
Be aware of the reasons for use of the IV infusion pump, vital sign
equipment, and cardiac monitors
Report flushing, headache or feeling of faintness to staff immediately
Report symptoms of cinchonism to provider
Report onset of fever, fatigue, and joint pain to provider
Report fatigue, weakness, easy bruising or infection to provider

Question 19

Adverse Effects

Class 1B Sodium Channel Blockers - lidocaine

Answer 19

CNS effects- toxicity- confusion, drowsiness, restlessness, paresthesia, muscle twitching or tremors, seizures, respiratory arrest
Hypotension, bradycardia, heart block with high doses

Question 20

Nursing Interventions

Class 1B Sodium Channel Blockers - lidocaine

Answer 20

Monitor for CNS effects; hold dose and notify provider

Monitor vital signs and cardiac rhythm

Question 21

Expected Pharmacological Action

Class 1C Sodium Channel Blockers - felcainide

Answer 21

Blocks sodium channel in the heart, slowing the upstroke of the cardiac action potential
This slows conduction of the electrical impulse within the heart

Question 22

Client Education

Class 1C Sodium Channel Blockers - felcainide

Answer 22

Report any visual changes to provider
Have regular ophthalmic examinations
Report shortness of breath, edema to provider
Instruct on temporary use of Holter monitor if necessary

Question 23

Adverse Effects

Class II Beta Blockers - propranolol

Answer 23

Bradycardia due to blockade of beta1 receptors; may lead to reduced cardiac output, heart failure, rebound excitation causing angina pain or MI with sudden withdrawal of beta blockers in client with CHD
Peripheral arterial insufficiency (similar to Raynaud’s disease), CNS effects (confusion, fatigue, drowsiness)

Question 24

Client Education

Class II Beta Blockers - propranolol

Answer 24

Check pulse rate daily before taking drug and report to provider for pulse slower than 60beats/min (or prearranged parameter)
Report shortness of breath, peripheral edema, night cough to provider
Do not stop taking this drug abruptly; talk to the provider
Report increase in angina or new onset of chest pain to provider
Report sensations of cold, numbness in hands or feet
Protect extremities from severe cold
Report CNS effects to provider
Avoid hazardous activities such as driving until effects are known

Question 25

Therapeutic Use

Class III Potassium Channel Blockers - amiodarone

Answer 25

Manages life-threatening ventricular tachycardia or fibrillation that is resistant to other drugs
May treat some atrial dysrhythmias, such as atrial fibrillation

Question 26

Expected Pharmacological Action

Class III Potassium Channel Blockers - amiodarone

Answer 26

Blocks potassium channels, but also affect sodium and calcium channels, and block beta adrenergic receptors. Amiodarone works on the electrical system of the heart by decreasing automatically, slowing conduction through the AV node, ventricles and Purkinje fibers, decreasing contractility, and dilating both coronary and peripheral blood vessels. Changes to the ECG seen when clients take this drug include a widened QRS complex, and prolonged PR and QT interval. The other drugs in this class all act to prolong the QT interval, but the other ECG changes for amiodarone may not be present

Question 27

Client Education

Class III Potassium Channel Blockers - amiodarone

Answer 27

day)
Comply with chest x-ray and pulmonary function testing
Report fever, dry cough, shortness of breath or other respiratory symptoms to provider
Report sensitivity to light and changes in vision
Obtain regular opthalmic checkups
Wear sunglasses when out in sunlight
Avoid frequent sun exposure
Report dizziness, syncope to provider
For ora; therapy, monitor pulse rate and report rates slower than 60beats/min to provider
Report weight gain and edema to provider
Be aware that skin discoloration may occur with amiodarone
Report tremor, dizziness, hallucinations to provider
Avoid hazardous activity such as driving if dizziness occurs
Due to long half-life of this drug, avoid pregnancy and breastfeeding during therapy and for several months after therapy with amiodarone is discontinued

Question 28

Therapeutic Use

Class IV Calcium Channel Blockers - verapamil

Answer 28

Treats mild to moderate hypertension. Treats stable (exertional) angina and variant (vasospastic) anginas
Convert supraventricular tachycardia to a sinus rhythm
Slow rate of atrial fibrillation and flutter

Question 29

Adverse Effects

Class IV Calcium Channel Blockers - verapamil

Answer 29

Hypotension, especially with IV dose or overdose
Bradycardia, especially with IV dose, but also with oral therapy
Heart failure, peripheral edema of feet and legs
Lightheadedness, dizziness (caused vasodilation)