Stable Heart Failure and Dysrhythmia Drugs Flashcards
Describe Furosemide aka LASIX (type of drug, Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects, Drug-Drug Interactions)
Diuretic
Indication: Edema due to heart failure
Mechanism of action:
- Inhibits the reabsorption of sodium,
potassium, and chloride from the loop of Henle and distal renal tubule
- Increases renal excretion of water, sodium, chloride, magnesium, potassium, and
calcium
Evaluation/desired outcome:
- Decreases in edema
- Increases in urinary output
Contraindication: No common ones
Use cautiously in:
- Electrolyte depletion
- Diabetes mellitus – Diuretics lead to hyperglycemia. Exact mechanism is unknown. Theory: worsening insulin resistance, inhibition of glucose uptake, and decreased insulin release.
- Severe renal impairment
Adverse effects/side effects:
- Hypotension
- Dehydration
- Hypocalcemia – Increases renal calcium excretion. Mechanism -> not known
- Hypokalemia
- Hypochloremia
- Hypomagnesemia
Drug-drug interactions:
- Increased risk of hypotension with antihypertensives or nitrates
- Increased risk of hypokalemia
What should you describe in Furosemide aka LASIX nursing implication and patient/family teaching?
Nursing implications:
- Assess fluid status. Monitor daily weight, intake, and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes.
- Monitor BP and pulse before and during administration
- In older adults, diuretic use increases risk for falls. Assess for risk of falls when administering in older adults
- Closely monitor electrolytes, renal function, and serum glucose.
Patient/family teaching:
- Caution patient to change positions slowly to decrease the effects of orthostatic hypotension.
- Consult a healthcare provider regarding a diet with high potassium.
- Consult a healthcare provider if weight gain more than 3 pounds in a day.
Describe Potassium Chloride (Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects)
Indication: Treatment/prevention of potassium depletion
Action: Simple replacement
Evaluation and directed outcomes: Replacement and/or prevention of potassium depletion
Contraindications:
- Hyperkalemia
- Severe renal impairment
Use cautiously in:
- Cardiac disease
- Renal impairment
- Diabetes
Adverse effects/side effects:
- Arrhythmias
- Abdominal pain, diarrhea, nausea and vomiting – Potassium increases the release of
hydrogen ions into the lumen of the GI tract
What should you describe in Potassium Chloride nursing implication and patient/family teaching?
Nursing implications:
- Assess for signs and symptoms of hypokalemia [weakness, fatigue, ECG changes]
- Assess for signs and symptoms of hyperkalemia [slow, irregular heartbeat, fatigue,
muscle weakness, confusion, dyspnea, ECG changes]
Patient/family teaching:
- Emphasize the importance of regular follow-up exams to monitor serum levels of
potassium
- Instruct patient to report dark, tarry, or blood stools
Describe Beta-Blockers in the context of Heart Failure (Indication, MOA, Recommendation)
Indication: Management of stable or symptomatic (class II or III) heart failure due to ischemic, hypertensive, or cardiomyopathic origin.
Mechanism of action:
- Selective beta-blockers: block stimulation of beta1 (myocardial)-adrenergic receptors
- Non-selective beta-blockers: block stimulation of beta1 and beta 2 (pulmonary, vascular, uterine)-adrenergic receptors
- Decreased HR -> decreased O2 demand
- Decreased HR -> increased duration of diastole (time during which coronary arteries are perfused) -> increased O2 supply
- Decreased contractility -> decreased O2 demand
Recommendation: B-blockers should be initiated ASAP after the diagnosis of HF, including during the index hospitalization, provided that the patient is hemodynamically stable
Describe ACE Inhibitors/Angiotensin II Receptor Antagonists in the context of Heart Failure (Indication, MOA, Recommendation)
Indication:
- ACE-Inhibitors: Management of Heart Failure
- Angiotensin II Receptor Antagonists: Management of Heart Failure
Mechanism of action:
- ACE-Inhibitors: Blocks the conversion of angiotensin I to the vasoconstrictor angiotensin II
- Angiotensin II Receptor Antagonists: Blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at the receptor sites
- Impact on O2 supply and demand (applicable to both): Systemic vasodilation -> decreased afterload (decreases in O2 demand)
Recommendation: Recommend an ACEI or ARB in those with ACEI intolerance, in patients with acute MI with HF or an LVEF <40% post-MI to be used as soon as safely possible post-MI
What is one similarity and difference between Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP)? What do they promote? Lastly, how does Neprilysin affect these peptides?
Similarity: In response to high pressure/volume, myocardial stretching occurs
Difference: ANP is released from the atrial wall, while BNP is released from the ventricle wall
They promote balanced vasodilation by:
- dec. preload, by dec. Na+/H2O retention
- dec. afterload by dec. production and action of vasoconstrictor peptides
- inhibiting sympathetic tone
Neprilysin is an enzyme that degrades natriuretic peptides
Describe Angiotensin Receptor and Neprilysin Inhibitor (Drug example, Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects, Drug-Drug Interactions)
Sacubitril/Valsartan - Entresto
Indication:
- Chronic HF in adults
Action:
- Sacubitril: A pro-drug converted to LBQ657 (active form of the drug) -> inhibits the enzyme neprilysin.
- Neprilysin is an ezyme that degrades natriuretic peptides.
- Valsartan: Blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at the receptor sites
Evaluation and directed outcomes:
- Decreased heart-failure-related hospitalization in patients with heart failure
Contraindications:
- History of angioedema from previous ACE-Inhibitors or ARBs
- Concurrent use of ACE-Inhibitors during or for 36 hr before or after
Use cautiously in:
- Volume or salt depleted patients or patients receiving high doses of diuretics
- Impaired renal function
Adverse effects/side effects:
- Hypotension
- Hyperkalemia – Secondary to the valsartan.
Drug-drug interactions:
- Increased risk of hypotension with other antihypertensives and diuretics
- Concurrent use of potassium-sparing diuretics or potassium supplements
- Concurrent use of ACE-Inhibitors
What should you describe in Angiotensin Receptor and Neprilysin Inhibitor nursing implication, patient/family teaching, and recommendation?
Nursing implications:
- Assess BP (lying, sitting, standing) and pulse frequently during initial dose adjustment and periodically.
- Correct volume or salt depletion prior to administration of therapy.
- Monitor daily weight and assess patient routinely for resolution of fluid overload.
- Assess patients for signs of angioedema (dyspnea, orofacial swelling).
- Monitor renal function
Patient/family teaching:
- Caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless directed by health care provider.
- Instruct patient to notify health care professional if swelling of face, eyes, lips, or tongue or if difficulty swallowing or breathing occur
Recommendation: ARNI be used in place of an ACEI or ARB, in patients with HFrEF, who remain symptomatic despite treatment
Describe Mineralocorticoid Receptor Antagonist (MRA) (Drug example, Indications, MOA, Evaluation/Desired Outcome, Contraindication, Cautious Usage, Adverse Reactions/Side Effects, Drug-Drug Interactions)
Spironolactone
Indication:
- New York Heart Association (NYHA) class III-IV Heart Failure
Action:
- Inhibition of sodium reabsorption in the kidney, while saving potassium and hydrogen ions
- Binds to Mineralocorticoid receptors (receptors to which aldosterone normally binds to) -> blocks theactivity of aldosterone -> decreased absorption of sodium and water, and decreased secretion of potassium
Evaluation and directed outcomes:
- Increases in diuresis and decrease in edema while maintaining serum potassium level
- Improved survival in patients with NYHA class II-IV HF
Contraindications:
- Hyperkalemia
- Acute renal insufficiency – Can dangerously cause hyperkalemia
- Significant renal impairment (CCr [creatinine clearance test < or equal to 30 mL/min)
Use cautiously in:
- Diabetes (increases risk of hyperkalemia) – Insulin causes potassium to move from extracellular space into intracellular space via the Na-H antiporter and Na-K ATPase. Therefore, in patients with DM, this mechanism may be less effective.
- Concurrent use of potassium supplements
Adverse effects/side effects:
- Stevens Johnson Syndrome (SJS)
Drug-drug interactions:
- Increased hypotension with other antihypertensives or nitrates
What should you describe in Mineralocorticoid Receptor Antagonist (MRA) nursing implication, patient/family teaching, and recommendation?
Nursing implications:
- Monitor intake and output ratios and daily weight during therapy
- Assess patient frequently for development of hyperkalemia (fatigue, muscle weakness, confusion, ECG changes)
- Assess patient for the development of rash
Patient/family teaching:
- Caution patient to avoid foods that contain high potassium levels
- Advise patient to notify health care professional if rash or muscle weakness or cramps
Recommendation: MRA treatment for patients with actute MI and LVEF </= 40% and HF symptoms or diabetes
Describe SGLT-2 Inhibitors (Drug example, MOA, Adverse Reactions/Side Effects, Contraindication)
Canagliflozin
Mechanism of action:
- Kidney Nephrons: Glucose is reabsorbed through co-transporter (sodium glucose cotransporter2)
- SGLT-2 inhibitors: inhibiting the reuptake of glucose. Glucose will pass through and get urinated out.
Adverse effect: Glucosuria, UTI, Vaginal infection, dehydration.
Contraindication: Severe renal impairment (eGFR <30 mL/min/1.73 m2)
What should you describe in SGLT-2 Inhibitors nursing implication, patient/family teaching?
Nursing implications:
- Observe patient for signs and symptoms of hypoglycemia
- Monitor for sings and symptoms of volume depletion after initial therapy
- Monitor for infection - UTI
- Monitor renal function prior to and periodically during therapy
Patient/family teaching:
- Instruct patient to take medication at the same time each day, as directed
- Review signs of hypoglycemia and hyperglycemia with patient
- If hypoglycemia occurs, instruct them to take 2-3 tsp of sugar or a glass of
orange juice
Describe Dopamine (Indication, MOA, Evaluation and Directed Outcomes, Contraindications, Cautious Usage, Adverse effects/Side effects)
Indication: Adjunct to standard measures to improve: BP and cardiac output
Action: Dose dependent stimulation of beta1-adrenergic receptors → cardiac stimulation
Evaluation and directed outcomes: Increased cardiac output, increased BP
Contraindications: Tachyarrhythmias
Use cautiously in:
- Hypovolemia
- Myocardial infarction
Adverse effects/side effects:
- Arrhythmias
- Hypotension – dopamine 1 receptors cause vasodilation
What should you describe in Dopamine nursing implication, patient/family teaching?
Nursing implications:
- Monitor BP, HR, ECG, cardiac output closely
- Palpate peripheral pulses and assess appearances of extremities routinely during dopamine administration
- IV vasoactive medications are dangerous. Always have a second RN to check original orders
Patient/family teaching:
- Explain purpose of dopamine to patient
- Advice patient to inform nurse immediately if chest pain, dyspnea, numbness, tingling of extremities occurs
