CV drugs part 2 Flashcards
What is angina pectoris?
Chest pain from lack of oxygenated blood supply to the heart- insufficient blood flow to heart
How do nitrates relieve angina?
They ____ the vessels to allow..
They _______ both ____ and _____
Results?
They dilate the vessels to allow for more blood flow/o2 flow.
Decrease preload and afterload -
Results:
increase o2, decrease o2 demand.
Nitroglycerin (nitrates): how to treat acute anginal attack?
Fast acting, SL or IV nitrates
Something important about Nitroglycerin/ NTGs/ Nitrates:
NTG is the first line treatment for acute/immediate angina
Use for sublingual NTGs
Used to trat acute anginal attacks
o Sublingual (SL), spray, intravenous (IV)
Proper administration for sublingual NTG:
Place one sublingual (SL) nitroglycerin under the tongue every 5 minutes for a maximum dose of three (3) tablets
Pt. teaching for sublingual NTG
- Tell the patient, “If chest pain not improved after 1 dose, call 911”
- Tell patient they will experience a tingling/burning feeling under their tongue
3 nursing considerations for sublingual NTGs
-Tablets are in an airtight, dark colored glass bottle – away from light, heat, moisture
-Sit or lie patient down and take medication to prevent orthostatic hypotension
-Keep a fresh bottle of SL nitroglycerin, because drug is only stable for 3 to 6 months
Review the use of nitroglycerin transdermal patch and ointments.
What area will you use?
Use a hairless area of the upper arms or body, rotate sites
When should you remove the nitroglycerin patch?
- Tolerance develops with continuous use of transdermal patches/ointments. To decrease tolerance, remove at night to allow 8 hours without patch
For NTG patches, you want to apply it…
Wear the NTG patch for ___ hours
When do you remove the patch?
- Apply once a day, wear for 12 hours; remove after wearing for 12-14 hours a day
How to apply NTG patch?
Squeeze the prescribed amount of ointment onto the paper & apply to the skin without rubbing. Tape the paper in place.
Why do we wear gloves when applying a NTG patch
Use gloves to avoid getting ointment on hands (vasodilation, ↓BP)
What is nitrates free period, how long, and why?
-Nitrate free period is a time frame where patients take a break from the medication. They need to take a break from the medication for 8-12 hours, so tolerance does not develop. Tolerance (a person’s diminished response to a drug) can develop with continuous use of transdermal patches/ointments.
- Generally, we apply the patch once a day in the morning.
Patients wear the patch for 12 hours and we remove the patch before they go to bed, so they take a break from the medication.
How to treat headaches from NTG?
How does NTG affect BP?
Headaches can be managed with acetaminophen.
NTG decreases BP (hypotension)
MOA of nitrates
Dilate (widens) veins and arteries causing smooth muscle relaxation. This decreases preload and afterload.
Adverse effects of nitrates
- CNS – headaches (expected), syncope, flushed feeling, dizziness, weakness
- CV – hypotension; reflex tachycardia
2 contraindications of nitrates
Why? (for first one)
- Contraindicated: phosphodiesterase type 5 inhibitors (sildenafil [Viagra])
- Why? It can cause life-threatening hypotension
- Contraindicated in patients with head trauma and intracranial bleeding
Pt teaching for nitrates
- Careful when taking other medications that can decrease BP
- Avoid alcohol while using
Rapid acting forms of nitrates
- Used to treat acute anginal attacks
- Sublingual (SL), spray, intravenous (IV)
Long acting forms of nitrates
For chronic angina
o Used to prevent anginal attacks
o PO (extended-release), transdermal
Pt teaching with long-acting forms
- Nitrates are not habit-forming, but tolerance may develop
- Have a home monitor BP cuff; rise slowly
- If patient has nitro patch and experiences sudden/acute chest pain, take SL nitro and monitor vital signs (esp. BP and heart rate)
- Be compliant with medication even if experience headaches
- Nursing: can give acetaminophen
- If needs to discontinue, will need to do so slowly to prevent rebound angina
- Remind patients that taking a long-acting NTG preparation should not keep them from using SL or spray nitroglycerin if chest pain develops.
How to evaluate the effectiveness of nitrates?
If the patient reports a relief of chest pain
We evaluate the effectiveness of nitrates by asking the patients about the chest pain and evaluating their vital signs. The pain level should be 0/10 and vital signs should be stable (BP not low/pulse not high).
Antiplatelet drugs
Aspirin
Clopidogrel (Plavix)
Prasugrel (Effient)
What do antiplatelets do
Decreases platelet aggregation & inhibits thrombus formation
Anticoagulant drugs
- Heparin
- Warfin
- Enoxaparin
New anticoagulant drugs:
* Rivaroxaban (Xarelto) PO
* Apixaban (Eliquis) PO
* Fondaparinux (Arixtra) SQ
* Dabigatram (Pradaxa), PO
What do anticoagulants do
Inhibit certain clotting factors- NO direct effect on a blood clot that’s already formed
Thrombolytic drugs
Drugs (IV infusion):
* Alteplase (tPA)
* Streptokinase
* Tenecteplase
* Reteplase
* Urokinase
* Anistreplase
What type of drug is clopidogrel?
Antiplatelet
Contraindications of Clopidogrel
Contraindicated in bleeding disorders (peptic ulcer, hemorrhagic stroke)
- Due to the increased risk of bleeding from decreased platelet aggregation, clopidogrel should be withheld…
5 days before elective surgery to decrease the risk of hemorrhage during surgery.
Indications for use of anticoagulants
Uses:
o Stroke, atrial fibrillation
o Myocardial infarction (MI)
o Deep vein thrombosis (DVT)
o Pulmonary embolism (PE)
o Mechanical heart valves
When is it appropriate to use _______ ______ as an antidote for heparin?
protamine sulfate-
If aPTT gets too long
(means they are taking too long to clot. we still want them to clot, but not hemorrhaging)
Adverse effects of heparin
o Monitor for hemorrhage (hematuria, epistaxis, ecchymosis, petechiae, melena, black/tarry stools, bleeding gums)
o Allergic reaction may occur heparin-induced thrombocytopenia (HIT) (an antibody-mediated reaction characterized by a profound decrease in platelets; potentially life-threatening and can cause thrombosis; monitor CBC esp. platelets levels)
o Platelet levels
should be monitored. Medication stopped for platelet levels <100,000/mm3
What is used to treat heparin-induced thrombocytopenia (HIT)
Argatroban
Monitor therapeutic effects for heparin:
o Requires frequent monitoring of activated partial thromboplastin time (aPTT) levels, measures how long it takes blood to clot
o Goal: aPTT between 1.5 – 2.5 times normal control level
How long should aPTT be on heparin?
If it’s too long, what is an antidote
APTT should be 60-80 seconds while on heparin
Antidote: effects reversed by IV protamine sulfate, if aPTT gets too long
Nursing implications for heparin:
- Assess for bleeding (urine, stool, venipuncture sites, nose, gums, wounds/incisions)
- Rotate sites for SQ & do not rub the injection site; use abdomen for SQ route; assess for IV site reactions (pain, bruising, redness)
- Monitor aPTT, which should be 1.5 to 2.5 times the normal range for a therapeutic effect and monitor platelet levels
- Use caution in patients with recent spinal surgery, epidural or spinal catheters
- Use caution with other medications that promote bleeding
(NSAIDs, aspirin, warfarin, ginkgo)
Enoxaparin is what type of drug
Anticoagulant
What is the use of Enoxaparin
Prevents DVT
Pt teaching for enoxaparin
- Do not need to monitor aPTT, but need to monitor platelet count (CBC) due to risk of thrombocytopenia
- Adverse effect: bleeding – can use protamine sulfate as antidote
- Given subcutaneously (SQ) – rotate sites
- Patient may be instructed for home administration
- Bleeding precautions – use caution in patients with recent spinal surgery, epidural or spinal catheters
- Use caution with other medications that promote bleeding (NSAIDs, aspirin, warfarin, ginkgo)
Adverse effects of warfarin
Bleeding, hemorrhage, melena
Lab monitoring values of warfarin
- Requires frequent monitoring of PT/INR (international normalized ratio); PT should be 1.5 times the reference value. INR target is 2.0 to 3.0.
- If PT is > 2.5 times the reference value, or INR > 4.0, the person will have bleeding tendencies. if its too high, at risk for bleeding. Too low - can form clots. Need to be in this range. WE ARE STOPPPING IF THE LEVELS ARENT OPTIMAL
What is the antidote of warfarin (if toxicity/hemorrhage occures)
Vitamin K
Nursing implications of warfarin
- Given orally only – take exactly as prescribed at same time daily
- Uses: in patients at risk for blood clots; takes 3-5 days for full effect; heparin is continued to prevent clots until PT/INR levels indicate therapeutic effect
- Maintain consistent amount of vitamin K foods: leafy green vegetables – kale, spinach, collard green (do not increase or decrease)
- Alcohol can affect how warfarin works and increase risk of bleeding
- Monitor PT-INR regularly—keep follow-up appointments
Potential drug interactions—there are many! Warfarin interacts with many antibiotics and antifungal medications & increase the risk of bleeding.
- Use caution with other medication that promote bleeding (aspirin, NSAIDs, ginkgo); contraindicated in bleeding disorders
- Take exactly as prescribed
- Avoid in pregnancy or breastfeeding (Pregnancy D)
List interventions to protect patients from anticoagulant-induced bleeding
- Avoid other medications/herbals that promote bleeding (aspirin/NSAIDs, ginkgo biloba, garlic)
- Avoid IM injections and unnecessary venipuncture
- Use soft toothbrush and electric razor because this can be less likely to cause cuts
- Avoid going barefoot, especially outside
- Place patients on fall precautions
- Instruct patient to avoid straining
- Wear medical alert bracelets
- Eat a consistent amount of vitamin K foods if taking warfarin
- Monitor labs regularly; keep follow-up appointments
Use of thrombolytic (fibrinolytic) drugs
Uses: dissolving clots in stroke, MI, PE, DVT
Adverse effects of thrombolytic (fibrinolytic) drugs
BLEEDING (if they are bleeding we hold the med)
- Nausea, vomiting, hypotension
- Cardiac dysrhythmias
Contraindications of thrombolytic drugs
- Internal bleeding
- Severe uncontrolled hypertension
- Recent trauma
- Pregnancy
Nursing implications of thrombolytic drugs
Monitor and observe for..
- Monitor IV sites for bleeding, redness, pain
- Monitor for bleeding from gums, mucous membranes, nose, injection sites
- Observe for signs of internal bleeding (decreased BP, restlessness, weak peripheral pulses, confusion, abdominal/back pain)
Know the effects of ginkgo biloba with anticoagulants and NSAIDs
Listed above- Use caution with other medications that promote bleeding (NSAIDs, aspirin, warfarin, ginkgo) The effect is that it increases the risk of bleeding in patients taking NSAIDs, antiplatelets, and anticoagulants
Drug names of HMG-CoA inhibitors
-statin
Adverse effects/warnings/labs for patients on HMG-CoA reductase inhibitors (statins)
- Myopathy: report muscle pain or tenderness, check creatine kinase/creatine phosphokinase (CPK) levels, may be
- Rhabdomyolysis (rare, but fatal) – breakdown of skeletal muscle fibers causing myoglobin to be release into the blood stream, can lead to kidney damage
- Hepatotoxicity: check liver enzymes every 6 months; may be , jaundice
- Report muscle pain, persistent GI upset – vomiting, constipation, abnormal bleeding.
- Category X for pregnancy: not for pregnant women, alcoholic, or viral hepatitis
Pt teaching for patients on HMG-CoA reductase inhibitors (statins)
- Statins-most effective when taken at evening meal/bedtime
- Eat high fiber diet; avoid foods high in fat or cholesterol
- It takes 6 to 8 weeks to see a change in cholesterol levels
Diet teaching for patients taking statins
Decrease fat in the diet and increase fiber
Recognize names of bile acid sequestrants
Prefex is chole or cole
o cholestyramine (Questran)
o colesevelam (Welchol)
o colestipol (Colestid)
Adverse effects for bile acid sequestrants
o Constipation (need to increase fiber intake)
o Heartburn, nausea, belching, bloating (disappear over time)
Nursing implications for bile acid sequestrants
What to asses for?
o Assess for GI distress, bowel habits, vitamin K deficiency; may need vitamin supplementation
Nursing implications for bile acid sequestrants:
May…
Powder forms must be taken with at least..
o May bind with other drugs (advise to take other meds 1 hour before or 6 hours after)
o Powder forms must be taken with at least 4 to 6 ounces of liquid or fruits (applesauce), mixed thoroughly, and never taken dry
Recognize names of fibrates or fibric acid derivates
o Fenofibrate (Tricor)
o Gemfibrozil (Lopid)
o Fenofibric acid
Use of fibrates or fibric acid derivatives
o Lower triglyceride levels; increase HDLs
Adverse effects of fibrates or fibric acid derivatives
- GI: nausea, diarrhea, abdominal discomfort
- Increased risk of gallstones (right upper quadrant abdominal pain)
- Increased risk of myopathy, rhabdomyolysis when combined with statins
- Increased risk of bleeding when combined with warfarin
Warnings of fibrates or fibric acid derivatives
contraindication
- Contraindicated for patients with gallbladder disease and liver disease
Monitor: Liver function, assess for history of gallstones
Nicotinic acid or Niacin therapy is :
Vitamin B3
Side effect of vitamin B3 (Niacin therapy)
o Flushing of face and neck, lasting up to an hour (minimize flushing w/aspirin or NSAIDs 30 minutes prior) <- Patient teaching
o GI distress (take with meals to avoid GI irritation) <- Patient teaching
Adverse effects of vitamin B3 (Niacin therapy)
o Hepatotoxicity (jaundice, clay-colored stools; dark urine), hyperglycemia, hyperuricemia, orthostatic hypotension
Nursing implications for vitamin B3 (Niacin therapy)
Monitor for jaundice, clay-colored stools, & dark urine
Recognize names and mechanism of action of HMG-CoA reductase inhibitors
Suffix: -statins
MOA: decrease the amount of cholesterol that is made by HMG CoA reductase in the liver.
(decrease the rate of cholesterol production by inhibiting HMG-CoA reductase. The liver requires HMG-CoA reductase to produce cholesterol)
Adverse effects for patients on HMG-CoA reductase inhibitors (statins)
Myopathy/ and or rhabdomyolysis (break down of muscle)- LIFE THREATENING, hepatotoxicity
Warnings with HMG-CoA reductase inhibitors (statins)
Category X for pregnancy: not for pregnant women, alcoholic, or viral hepatitis
Pt teaching for HMG-CoA reductase inhibitors (statins)
Report muscle pain, persistent GI upset – vomiting, constipation, abnormal bleeding
Take at bedtime/evening meal (most effective then)
With HMG-CoA reductase inhibitors (statins), it takes
6-8 weeks to see a change in cholesterol levels
Diet teaching for patients take statins
Eat high fiber diet; avoid foods high in fat or cholesterol
Labs to monitor w statins
Creatine, LFTs
Recognize names of bile acid sequestrants
Prefix: chole-
cholestyramine, colesevelam, colestipol
Adverse effects of bile acid sequestrants
Constipation, heartburn, nausea, belching, bloating
Nursing implications of bile acid sequestrants (3)
Assess for..
May..
Powder forms must..
Nursing Implications:
- Assess for GI distress, bowel habits, vitamin K deficiency; may need vitamin
supplementation - May bind with other drugs (advise to take other meds 1 hour before or 6
hours after) - Powder forms must be taken with at least 4 to 6 ounces of liquid or fruits
(applesauce), mixed thoroughly, and never taken dry
Recognize the names of fibrates or fibric acid derivates
Drugs:
* Fenofibrate (Tricor)
* Gemfibrozil (Lopid)
* Fenofibric acid
Main use of fibrates or fibric acid derivates
Lower triglycerides and increase HDLs
Adverse effects of fibrates or fibric acid derivates
- GI: nausea, diarrhea, abdominal discomfort
- Increased risk of gallstones (right upper quadrant abdominal pain)
- Increased risk of myopathy, rhabdomyolysis when combined with statins
- Increased risk of bleeding when combined with warfarin
Fibrates are..
Contraindicated for patients with gallbladder disease and liver disease
Pt teaching with Niacin (B3) therapy
Tell them they can minimize flushing w/aspirin or NSAIDs 30 minutes prior to taking it
Tell them they can take w meals to avoid GI irritation
Antidysrhythmic drugs are broken into
4 classes
Class 1 is broken into 1a, 1b, 1c
Antidysrhythmic drugs: Class 1A drugs
quinidine, procainamide
Class 1 (1a,1b,1c) are..
Sodium channel blockers
Quinidine adverse effects
- Cinchonism (tinnitus, headache, nausea, vertigo), thrombocytopenia
- Cardiotoxic – hypotension, high doses – QT prolongation, heart block
- GI: Diarrhea (common)
Class 1b drugs
Lidocaine and Phenytoin
Side effects of lidocaine
- CNS toxic effects: twitching, seizures (convulsions), confusion
- Must continuously monitor BP and cardiac rhythm (ECG)
Lidocaine may be used with a..
Patch (neuropathic pain) or throat spray and injections (local anesthesia)
-If used to anesthetize the throat- check for gag reflect: NPO until gag reflex returns
Class IC drug
Flecainide
Class IC: Flecainide side effects
Side effects: dizziness, visual disturbances, dyspnea (shortness of breath)
Black box warning of flecainide
Proarrhythmic, increased mortality in patients with non life threatening ventricular dysrhythmias
Class 2 drugs are
beta blockers
Already covered beta blockers, but remind me of something to be cautious about
- Caution: Diabetes – BBs slow down the heart rate and mask signs/symptoms of hypoglycemia
- Abrupt withdrawal of a beta-blocking drug can cause rebound hypertension.
Class 3 drugs are considered what type of channel blockers?
What drug does it classify?
Potassium Channel Blockers
Amiodarone
Use of amiodarone
life-threatening ventricular dysrhythmias, atrial fibrillation or flutter that is resistant to other drugs
Generally, what is the purpose of antidysrhythmic drugs
trying to restore the normal conductivity of the heart so it beats regularly.
Amiodarone has MANY adverse effects- list them :(
Pulmonary toxicity (dyspnea – shortness of breath, cough, fibrosis), careful respiratory assessment, chest x-ray
- Thyroid toxicity: hypothyroidism or hyperthyroidism (monitor thyroid function)
- Hepatotoxicity (monitor LFTs, constipation, GI upset)
- Corneal microdeposits(visual halos, photophobia, dry eyes); eye exams
- Photosensitivity; alteration in skin color (bluish) if prolonged sun exposure
- Dysrhythmias (monitor ECG, QT prolongation)
- Hypotension, bradycardia (monitor BP & pulse closely)
- Neurologic: abnormal gait, changes in mood, hallucinations; supervision
Class IV is what type of blocker
Calcium channel blocker
Remind me of the drugs and adverse effects of Class IV calcium channel blockers
verapamil (Calan), diltiazem (Cardizem)
- Adverse effects: dizziness, hypotension, bradycardia, edema, heart block, constipation
Pt teaching for amiodarone
wear sunglasses, visit your eye doctor and use sunscreen, report if BP is low, or if HR is low <60.
DO NOT TAKE WITH GRAPEFRUIT JUICE
Nursing implications for amiodarone
Monitor LFT (baseline and periodic), xray, pulmonary function tests, thyroid function, eye exams. Anticipate CNS symptoms within a week after therapy. Will need help with ambulating
All antidysrhythmic drugs can cause…
With antidysrhythmic drugs in general, monitor ____ and avoid ____
All antidysrhythmic drugs can cause dysrhythmias!
- Monitor VS (pulse and BP); avoid caffeine
Antidysrhythmic drugs in general:
- Ensure patient knows to notify provider of any worsening of dysrhythmia or toxic effects:
Ensure the patient notifies the HCP for any allergic reactions, N/V, blurry vision, dizziness,
Other antidysrhythmic drugs: Adenosine- what to know ab it?
- Used to convert paroxysmal supraventricular tachycardia to sinus rhythm
-May cause asystole for a few secs
-Very short half life
Other antidysrhythmic drugs:
Magnesium Sulfate
First line for TdP, which is Torsade de Pointes- variant of v tach that can result from prolonged QT interval
Epinephrine- why is it the DOC for anaphylaxis
Vasoconstriction and bronchodilation = raise BP and open lungs
AE of epinephrine
Hypertensive crisis, necrosis following extravasation
NI of epinephrine
If giving IV, use central line
Dopamine is used for
If giving..
shock, HF, and acute renal failure
-If giving IV use central line (never peripheral)
