CV drugs part 1 Flashcards
Antihypertensives- Diuretics
What are the drug names?
Loop diuretics, Thiazide diuretics, Potassium sparing diuretics, Osmotic diuretics
Drug name of Loop diuretics
-ide
(but not thiazide)
Drug name of Thiazide diuretics
-thiazide
Drug name of Potassium-sparing diuretics
Spironolactone & Triamterene
Drug name of Osmotic diuretics
Mannitol
Diuretics:
Recognize signs and symptoms of orthostatic hypotension and describe safety measures to prevent it:
Orthostatic hyportension is a drop in blood pressure upon position changes.
Safety measures: Teach patients to change positions slowly to prevent orthostatic hypotension. Orthostatic hypotension = increased risk of falls.
How do diuretics lower BP?
Diuretics lower BP by increasing urine output and decreasing fluid volume
Review fluid and electrolyte depletion for loop diuretics. What are some signs and symptoms associated with hypokalemia?
Muscle cramps, muscle weakness, abnormal heart rhythms/cardiac dysrhythmias, fatigue
Loop diuretics can cause which toxicity if used for prolonged periods and high dosages?
Ototoxicity
How do loop diuretics affect potassium levels
hypokalemia r/t loss of water and electrolytes
How do thiazide diuretics affect potassium level
What to monitor?
hypokalemia: monitor BP frequently to prevent falls and monitor potassium levels
How do potassium-sparing diuretics affect potassium level
hyperkalemia
Adverse effects of loop diuretics
Decrease BP- orthostatic hypotension
Hypokalemia
Ototoxicity
Hypovolemia, hyponatremia, hypomagnesemia
Adverse effects of thiazides
Hypokalemia
Elevated levels of glucose, cholesterol, and uric acid
Hypotension, dizziness, hyponatremia
Adverse effects of Potassium-Sparing
Hyperkalemia, Gynecomastia/Hirsutism, impotence, menstrual irregularities
Patient teaching associated with Spironolactone (Aldactone)
Avoid potassium rich foods, DO NOT change your diet
Avoid drugs that will increase K levels like ACE inhibitors and ARBs
Diuretics should be taken…
In morning to prevent diuresis during night (sleep interruption)
Nursing considerations w Potassium-Sparing (Spironolactone):
Avoid potassium rich foods (dried fruits (raisins, apricots), dates, beans, lentils, potatoes, broccoli, green beans, leafy greens, legumes, avocado, bananas, oranges, squash, chicken, salmon.)
Avoid ACE inhibitors, avoid ARBs
Nursing considerations w Loop & Thiazides: Because these increase the loss of potassium.. it may lead to what
Increased potassium loss (hypokalemia) may lead to toxic levels of digoxin since K loss increases the effect of digoxin.
Osmotic (Mannitol) is only given by
IV
Overview: Discussing nursing considerations when administering each class of diuretics. What are points to teach the patients about these drugs?
Loop: Take during the day, move slowly, monitor for muscle cramps, take as prescribed.
Eat yummy foods: banana, orange, squash, meat, fish, legumes, broccoli
Thiazide: Take during the day, move slowly, monitor for muscle cramps, take as prescribed.
Eat yummy foods: banana, orange, squash, meat, fish, legumes, broccoli
Potassium Sparing: Avoid eating K+ rich foods - don’t eat the yummy goods above. Avoid ACE, ARBS.
How can you assess a patient for therapeutic effects of a diuretic?
Monitor electrolyte levels, monitor BP
Which is the post potent diuretic with the most rapid onset?
Loop diuretics
Why should serum potassium levels be monitored during diuretic therapy?
- They should be monitored because they can affect heart contractility and heart rate. (can cause dysrhythmias)
- You anticipate K supplementation with loops and thiazides
Normal range for blood potassium level:
3.5-5.0
With potassium supplementation..
NEVER give IV push/bolus -> only PO or IV
-IV is diluted and infused slowly (no faster than 20)
-Assess IV site: stop infusion and notify if there is burning or swelling at IV site
-Cardiac dysrhythmias w IV infusion if rapid or too much
What are the uses of mannitol and the associated adverse effect?
Uses: decreased intracranial pressure, decreased intraocular pressure, prevent renal failure
Adverse effect: pulmonary edema, need to listen to lung sounds
Antihypertensives- RAAS
Angiotensin-converting enzyme (ACE) inhibitors/Angiotensin II receptor blockers (ARBs):
Identify drug names and classes
ACE Suffix: -pril
ARB Suffix: - sartan
How do Angiotensin-converting enzyme (ACE) inhibitors/Angiotensin II receptor blockers (ARBs) lower blood pressure?
Dilation of arteries & veins and decreases aldosterone
Recognize adverse effects and warnings associated with ACE inhibitors
o First dose postural (orthostatic) hypotension (worse 1-3 hours after first dose due to vasodilation)
o Dry, nonproductive cough, which reverses when therapy is stopped
o Hyperkalemia
o Angioedema (1% rare, but life-threatening)
o Can cause fetal toxicity; avoid in pregnancy
o Worsening of renal function
What’s angioedema?
Treatment?
swelling of tongue and lips and can cause respiratory distress.
treatment = epinephrine
How do ACE inhibitors work?
They stop the formation of ACE in the RAAS system, which stops the conversion of AG1 > AG2, so we don’t retain water, and we don’t vasoconstrict.
If ACE is inhibited, it results in inhibited formation of angiotensin ll: Vasodilation, decreased BV, slow cardiac remodeling, and potassium retention (hyperkalemia)
It also results in inhibition of the breakdown of bradykinin: Vasodilation, nonproductive cough, angioedema
Remember:
Angioedema
Cough
Elevated K+
What is an alternative to ACE inhibitors if patients develop a dry cough on ACE inhibitors?
Angiotensin ll Receptor Blockers (ARB) (Does NOT inhibit bradykinin metabolism (so no cough)
Nursing considerations for ACE Inhibitors
- Avoid ACE inhibitors in pregnancy
- Monitor electrolytes, especially potassium (hyperkalemia)
- Monitor BP closely; have patients change positions slowly (fall precaution when first initiated)
- Assess for cough
- Never use if patient has history of angioedema with ACE inhibitor or ARB
- Reduce dose if patient has renal dysfunction
Recognize the drug names of ACE inhibitors/ARBs
ACE Inhibitors: ends with -pril (lisinopril, ramipril, captopril)
Angiotensin 2 preceptor blockers/ARBs: ends with -sartan (losartan, valsartan)
Beta-adrenergic antagonist (Beta Blockers):
Identify drug names and classes
Generic name ends in -lol (propranolol, metoprolol, atenolol)
Double L’s = low BP and low HR
Nonselective beta blockers..
block beta1 & beta2
Drug name of Nonselective beta blockers: block beta1 & beta2
Propranolol (Inderal)
Nonselective beta blocker w/vasodilating actions: block
block beta1, beta2, & alpha1
Drug name for: Nonselective beta blocker w/vasodilating actions: block beta1, beta2, & alpha1
- Labetalol (Normodyne)
- Carvedilol (Coreg)
Cardioselective beta blocker:
block beta1
Drug: Cardioselective beta blocker: block beta1
- Metoprolol (Lopressor)
- Atenolol (Tenormin)
How do beta blockers lower BP?
Inhibits/blocks stimulation of the sympathetic nervous system (SNS)- this slows HR and decreases BP
Know the difference between nonselective beta blockers and selective beta blockers
Nonselective beta blockers block both beta1 and beta2 receptors, while selective beta blockers primarily block beta1 receptors. Nonselective beta blockers have a wider range of effects on the body, including potential bronchoconstriction, while selective beta blockers have a more specific action on the heart.
Remember beta 1 = affects heart. Side effect of beta 1 = bradycardia
Beta 2 = affects lungs. Side effect of beta 2 = bronchoconstriction/wheezing
Review the precautions & warnings associated with nonselective beta blockers
Nonselective: Propranolol adverse effects:
Beta1 blockade
* Bradycardia
* AV heart block
* Mask early symptoms of hypoglycemia such as tachycardia, tremor, or nervousness
Beta2 blockade
* Bronchoconstriction, wheezing, caution in pts with asthma & COPD
CNS effects
* Depression, fatigue, unusual dreams, sexual dysfunction (impotence)
Adverse effects of Nonselective beta blocker w/vasodilating actions:
No beta1 selectivity (also blocks beta2) – can cause bronchoconstriction, must assess breath sounds, do not give to patients with asthma, COPD; do not give if pulse is low
Be familiar with the nursing implications and patient teaching for beta blockers. (Lower both BP and HR) When would a nurse consider holding beta blockers?
Take HR (apical pulse rate) and BP before administering drug (hold the drug if HR < 50-60 bpm or if SBP < 100 mm Hg; and notify healthcare provider)
What is an important teaching point about beta blockers especially if patient is traveling? Why do not stop taking beta blockers suddenly?
Do NOT discontinue medication abruptly- carry an adequate supply while traveling.
If discontinued suddenly = **tachycardia, dysrhythmias, elevated BP, angina.
They need to be slowly weaned off the beta blockers** to avoid rebound tachycardia and angina.
What are some nursing considerations for beta blockers?
- Safety measures to prevent orthostatic hypotension such as changing positions slowly, hold onto railings when using stairs
- Any chest pain experienced during activity should be discussed with the HCP so that safe activity levels can be discussed.
- Beta blockers may attenuate the response to epinephrine in the treatment of anaphylactic reactions.
- Extended-release forms of the drug should never be crushed and taken
Adverse effects for beta blockers such as labetalol
Nonselective beta blocker w/vasodilating actions- Labretaol: Weight gain (fluid retention) is a side effect. Assess breath sounds. Remember weight is one of the best indicators of fluid gain or loss.
Indirect-acting antiadrenergic agents (Centrally acting Alpha2 Agonists):- Identify drug names and class
Clonidine and Methyldopa
Indirect-acting antiadrenergic agents:
________ treats ________ in _____ ____
Methyldopa treats hypertension for pregnant women
How to prevent rebound hypertension with use of clonidine (Catapres)?
- Teach patient not to discontinue drug abruptly
- Slowly withdraw drug (under supervision)
Adverse effects of Clonidine:
- Orthostatic hypotension
- Depression
- Drowsiness/fatigue: 35%
- Xerostomia (dry mouth): 40%
- Rebound HTN –r/t abrupt withdrawal
- Constipation – increase fiber & fluids intake
- Abuse – high doses can cause euphoria, sedation
What is the desired effect of clonidine (Catapres)?
o Slows down the heart rate (bradycardia)
o Decrease cardiac output
o Promotes vasodilation
o All leads to decrease in BP
What are some nursing considerations with clonidine?
Xerostomia:
Caution pt. ab:
o Xerostomia – ice chips, good oral hygiene, sugar free hard candy, frequent sips of fluid, chewing gum
o Caution pt. about sedation/drowsiness
Clonidine: transdermal patch..
changed every 7 days; place on hairless, intact skin; use only upper arms or torso, remove old patch before applying a new one
Calcium channer blocker classes and drugs
- Dihydropyridines (nifedipine)
- Phenylalkylamine (only drug is verapamil)
- Benzothiazepine (only drug is diltiazem)
How do calcium channel blockers lower BP
Reduce the amount of calcium available to contract blood vessels.
Nifedipine/Amlodipine: blocks calcium channels in the ____ ______ only, which causes _______. _______ –> ______ in ___
Nifedipine/Amlodipine: blocks calcium channels in the blood vessels only, which causes vasodilation. Vasodilation –> decrease BP
Uses of Nifedipine/Amlodipine
hypertension, stable, variant angina
Adverse effects of Nifedipine/Amlodipine
Hypotension
Reflex tachycardia
Lightheadedness, dizziness, flushing due to vasodilation
Peripheral edema
Gingival hyperplasia (inspect gums daily)
Verapamil: blocks calcium channels in the ____ that leads to ________ ____, _______ ___, slowed conduction (hold if SBP <___ or HR <____)**
Verapamil: blocks calcium channels in the heart that leads to decreased BP, decreased HR, slowed conduction (hold if SBP <100 or HR <60)
Uses of verapamil
hypertension and dysrhythmias
Adverse effects of verapamil
Common side effects: constipation – increase veggies/fiber intake
Cardiac effects: hypotension, bradycardia, heart block (AV)
Drug and food interactions w verapamil
Verapamil can raise digoxin levels – can lead to dig toxicity; both drugs slows heart
Verapamil & beta blockers – both drugs decrease HR, decrease AV conduction, & decrease contractility. Risk of excessive cardiosuppression. Give drugs several hours apart and monitor VS
Avoid grapefruit juice – increases serum levels, can lead to overdose
Diltiazem: blocks calcium channels in _____ ______ and in the _____
blocks calcium channels in blood vessels and in the heart
Adverse effects of diltiazem
Hypotension, bradycardia, heart block, flushing, & peripheral edema, constipation
Nursing considerations of diltiazem
Do not give if pulse is low or BP is low
Diltiazem drug and food interation
Same as verapamil:
Can raise digoxin levels
Diltiazem & beta blockers – both drugs decrease HR, decrease AV conduction, & decrease contractility. Risk of excessive cardiosuppression. Give drugs several hours apart and monitor VS
Avoid grapefruit juice – increases serum levels, can lead to overdose
When would you hold verapamil
If pt SBP is under 100 or HR is under 60
What are some nursing considerations and adverse effects w calcium blockers
- Monitor BP & pulse
- Monitor EKG pattern & avoid when heart block present
- Increase fiber and fluids to prevent constipation
- Assess lower limbs for edema
- Measure intake and output and record daily weights
- Avoid grapefruit juice
- Calcium channel blockers & thiazide diuretics are first-line therapy for management of hypertension in African Americans (JNC-8)
Vasodilators: Identify drug names and classes
- Drugs acting on Renin-Angiotensin-Aldosterone System
- Calcium Channel Blockers
- Nitrates
What are some other vasodilators?
- Hydralazine
- Minoxidil
- Sodium nitroprusside
How do vasodilators lower blood pressure?
Open (dilate) blood vessels
Hydralazine adverse effects:
When would you discontinue?
- Reflex tachycardia (trigger of baroreceptors)
- Edema from sodium & water retention (as a response to increased BP)
- Headache, fatigue
Discontinue for systemic lupus erythematous like symptoms (joint pain, rash, fever)
Minoxidil adverse effects:
- Reflex tachycardia
- Edema from sodium & water retention
- Hypertrichosis (80% taking > 4 weeks)
Sodium Nitroprusside adverse effects:
- Severe hypotension
- Cyanide poisoning (sensitive to light- do not expose)
Review general nursing care when administering antihypertensive agents
Goal: Stable blood pressure & heart rate
- Monitor BP & pulse – if too low, do not give the BP medication
- Prevent falls – orthostatic (postural) hypotension – teach patients to change position slowly
- Observe for dizziness, fatigue, postural hypotension, and changes in LOC (level of consciousness)
- Patients will take the medications indefinitely to maintain stable control of BP
- Monitor renal function – creatinine
- Monitor fluid status by measuring intake & output and daily weights
-
Monitor lab values especially potassium & sodium
o Abnormal potassium levels can cause muscle cramps/weakness & increase risk of digoxin toxicity - Teach symptoms to report edema, cough, & weight gain
Terms to know:
Inotropic:
force of contraction
* + inotropic: strengthen force
* - inotropic: decrease force
Terms to know:
Chronotropic
Heart rate
+ chronotropic: increase rate
- chronotropic: decrease rate
Terms to know:
Dromotropic
Conduction
* + dromotropic: speeds conduction
* - dromotropic: slows conduction
Why do nurses need to check heart rate before giving digoxin?
Because digoxin can slow down the heart and make patients bradycardic, if its low already, you do not want to administer and drop the HR even further!
- Increasing myocardial contractility (+ inotropic)
- Increase vagal activity: conduction slowed through AV node and refractory time
(– chronotropic, – dromotropic)
When is it appropriate to withhold a dose of digoxin?
Therefore…
If apical pulse/ heart rate < 60, do not administer
Always take apical pulse for a full minute before administering
Which electrolyte imbalance increases the risk of digoxin toxicity?
Dehydration and electrolyte imbalances (hypokalemia, hypomagnesemia) increase sensitivity to digoxin; making toxicity more likely even with a lower concentration of serum digoxin
Potassium and magnesium normal levels?
Potassium: 3.5-5
Magnesium: 1.7-2.2
What is the specific antidote for digoxin toxicity?
Digoxin immune Fab (Digibind, Digifab)
S/S for toxicity w digoxin; early vs late signs
Early signs: anorexia, nausea, vomiting, bradycardia
Later: confusion, visual disturbances – blurred vision, yellow vision, seeing halos around bright objects; eventually, hyperkalemia
Teach clients symptoms of toxicity and report them immediately
Know the therapeutic drug range for digoxin
0.5 to 2.0 mg/mL (narrow therapeutic index)
Miscellaneous drugs: Uses of Atropine
- Sinus bradycardia
- Heart block
- Decrease secretions during surgery
What to monitor with Atropine?
Monitor HR and rhythm
Adverse effects of atropine?
- Urinary retention
- Dry mouth
- Palpitations, tachycardia
- Angle-closure glaucoma
