Podcast
Questions and Answers
A patient with a history of asthma is prescribed propranolol for the management of atrial fibrillation. Which potential adverse effect should the healthcare provider be most concerned about?
A patient with a history of asthma is prescribed propranolol for the management of atrial fibrillation. Which potential adverse effect should the healthcare provider be most concerned about?
- Exacerbation of bronchospasm due to beta-blockade. (correct)
- Development of severe hypertension.
- Masking of hypoglycemic symptoms in diabetic patients.
- Increased risk of digoxin toxicity.
A patient is started on amiodarone for persistent ventricular tachycardia. Which baseline assessment is most critical for the nurse to perform, given the drug's potential adverse effects?
A patient is started on amiodarone for persistent ventricular tachycardia. Which baseline assessment is most critical for the nurse to perform, given the drug's potential adverse effects?
- Ophthalmologic examination for glaucoma.
- Renal function panel.
- Comprehensive neurological examination.
- Pulmonary function tests and chest X-ray. (correct)
A patient receiving digoxin for atrial fibrillation develops new-onset anorexia, nausea, and blurred vision with yellow halos around objects. Which of the following actions is the most appropriate initial step?
A patient receiving digoxin for atrial fibrillation develops new-onset anorexia, nausea, and blurred vision with yellow halos around objects. Which of the following actions is the most appropriate initial step?
- Administer an antiemetic.
- Administer a dose of furosemide to reduce fluid overload.
- Check the patient's most recent digoxin level and serum electrolytes. (correct)
- Administer potassium supplement.
A patient in the emergency department is unresponsive and has the following ECG: rapid, wide QRS complexes with no discernible P waves or T waves. The patient's history includes heart failure and a previous myocardial infarction. Which antiarrhythmic medication is most appropriate to administer initially?
A patient in the emergency department is unresponsive and has the following ECG: rapid, wide QRS complexes with no discernible P waves or T waves. The patient's history includes heart failure and a previous myocardial infarction. Which antiarrhythmic medication is most appropriate to administer initially?
A patient with supraventricular tachycardia (SVT) is treated with intravenous adenosine. Shortly after the injection, the patient experiences a brief period of asystole on the cardiac monitor but then converts back to sinus rhythm. What is the nurse's best course of action?
A patient with supraventricular tachycardia (SVT) is treated with intravenous adenosine. Shortly after the injection, the patient experiences a brief period of asystole on the cardiac monitor but then converts back to sinus rhythm. What is the nurse's best course of action?
A patient with newly diagnosed atrial fibrillation is prescribed diltiazem. What specific instruction regarding the medication should the nurse include in the discharge teaching?
A patient with newly diagnosed atrial fibrillation is prescribed diltiazem. What specific instruction regarding the medication should the nurse include in the discharge teaching?
A patient taking quinidine for atrial flutter reports experiencing tinnitus, blurred vision, and dizziness. What should the nurse suspect is occurring and what action should be taken?
A patient taking quinidine for atrial flutter reports experiencing tinnitus, blurred vision, and dizziness. What should the nurse suspect is occurring and what action should be taken?
A patient with a history of heart failure is prescribed digoxin. The healthcare provider should closely monitor which of the following electrolyte imbalances, as it can increase the risk of digoxin toxicity?
A patient with a history of heart failure is prescribed digoxin. The healthcare provider should closely monitor which of the following electrolyte imbalances, as it can increase the risk of digoxin toxicity?
A patient receiving IV lidocaine for ventricular arrhythmias develops slurred speech, altered mental status, and muscle twitching. What is the priority nursing intervention?
A patient receiving IV lidocaine for ventricular arrhythmias develops slurred speech, altered mental status, and muscle twitching. What is the priority nursing intervention?
A patient is prescribed flecainide for the treatment of symptomatic paroxysmal atrial fibrillation. Which pre-existing cardiac condition would be of greatest concern when considering the use of flecainide?
A patient is prescribed flecainide for the treatment of symptomatic paroxysmal atrial fibrillation. Which pre-existing cardiac condition would be of greatest concern when considering the use of flecainide?
Flashcards
Dysrhythmia
Dysrhythmia
Any deviation from the normal rhythm of the heart.
Antidysrhythmics
Antidysrhythmics
Medications used to treat and prevent disturbances in cardiac rhythm.
Action Potential in Cardiac Cells
Action Potential in Cardiac Cells
A change in the distribution of ions that causes cardiac cells to become excited, leading to muscle contraction.
Resting Cardiac Cell Charge
Resting Cardiac Cell Charge
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Sinoatrial (SA) Node
Sinoatrial (SA) Node
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Antidysrhythmic mechanisms.
Antidysrhythmic mechanisms.
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Vaughan Williams Classification
Vaughan Williams Classification
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Class 1a: Sodium Channel Blockers
Class 1a: Sodium Channel Blockers
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Class II: Beta Blocker Administration
Class II: Beta Blocker Administration
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Adenosine
Adenosine
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Study Notes
Antidysrhythmic Drugs
- Used for treating and preventing cardiac rhythm disturbances
- Dysrhythmia means any heart deviation from its normal rhythm
Basic Cardiac Electrophysiology
- A change in ion distribution causes cardiac cells to become excited
- Ion movement across a cardiac cell's membrane results in an electrical impulse spreading across the cells
- This impulse leads to myocardial muscle contraction in atria or ventricles
- A resting cardiac cell has a net negative charge relative to the outside
- Uneven ion distribution (sodium, potassium, calcium) across the cell membrane results in this charge difference
- The sodium-potassium ATPase pump maintains the charge difference
- Sinoatrial (SA) node is the natural pacemaker
Measuring Cardiac Activity
- ECG or EKG is used to measure cardiac activity
- Key components of ECG are P wave, PR interval, QRS complex, ST segment, and T wave
- P wave represents atrial depolarization
- QRS complex indicates ventricular depolarization
- T wave indicates ventricular repolarization
Cardiac Dysrhythmias
- Common atrial dysrhythmias include supraventricular tachycardia, atrial fibrillation, and atrial flutter
- Ventricular dysrhythmias include ventricular tachycardia and ventricular fibrillation
Antidysrhythmic Drug Actions
- Prolong the AV node
- Increase or reduce conduction speed
- Alter ectopic pacemakers and SA node
- Reduce myocardial excitability
- Simulate autonomic nervous system
- Multiple classes of medications can achieve the above
Other Heart Medications
- Inotropic drugs affect the force of contraction, which can be positive or negative
- Chronotropic drugs affect the rate of contractions
- Dromotropic drugs affect electrical current
Vaughan Williams Classification
- Commonly used to classify antidysrhythmic drugs
- Class I: Sodium Channel Blockers
- Class Ia
- Class Ib
- Class Ic
- Class II: Beta Blockers
- Class III: Potassium Channel Blockers, can cause pulmonary fibrosis
- Class IV: Calcium Channel Blockers
- Other agents include Digoxin and Adenosine
Vaughan Williams Class Ia: Sodium Channel Blockers
- Medications include procainamide (Pronestyl), Quinidine gluconate, and disopyramide (Norpace)
- Block sodium (fast) channels and delay repolarization
- Used for atrial fibrillation, atrial flutter, ventricular tachycardia, supraventricular tachycardia, and Wolff-Parkinson-White Syndrome
- Adverse effects of procainamide include systemic lupus syndrome, neutropenia/thrombocytopenia, cardiotoxicity, and hypotension
- Contraindications/precautions include Pregnancy Risk Category C and liver or renal disorders
- Interactions with antidysrhythmics and antihypertensives exist
- Do not crush or chew sustained-released medications
Vaughan Williams Class Ib: Sodium Channel Blockers
- Common medications include lidocaine (Xylocaine), mexiletine (Mexitil), and tocainide (Tonocard)
- Decrease electrical conduction and increase the rate of repolarization
- Used for ventricular dysrhythmias
- Contraindications include liver and renal dysfunction
- Beta Blockers and Phenytoin increase serum levels of lidocaine
- IV administration is usually started with a weight-based dose and then a maintenance dose
- Use for no more than 24 hours
Vaughan Williams Class Ic: Sodium Channel Blockers
- Medications include propafenone (Rhythmol) and flecainide (Tambocor)
- Decrease electrical conduction, decrease excitability, and increase the rate of repolarization
- Used for supraventricular tachycardia
- Contraindications include severe heart failure, and severe hypotension
- Digoxin, oral anticoagulants, and beta blockers
- Monitor ECG during treatment, monitor for bradycardia and hypotension
- Take medication with food; do not crush extended-release
Vaughan Williams Class II: Beta Blockers
- Medications include propranolol hydrochloride (Inderal), esmolol hydrochloride (Brevibloc), and metoprolol (Lopressor)
- Prevent sympathetic nervous system stimulation of the heart, decrease heart rate, and slow conduction through the SA node
- Make it so albuterol will not work properly in asthma patients
- Used for atrial fibrillation, atrial flutter, and SVT
- Adverse effects include bradycardia, hypotension, and impotence
- Contraindications include severe heart failure and asthma
- Interact with verapamil and diltiazem
- Can mask the hypoglycemic effect of insulin
- Take apical pulse daily, and administer IV form slowly
Vaughan Williams Class III: Potassium Channel Blockers
- Medications include amiodarone (Cordarone, Pacerone), sotalol (Betapace), and dofetilide (Tikosyn)
- The medications can cause Pulmonary toxicity and Pulmonary fibrosis
- Prolong the action potential and refractory period of the cardiac cycle, decrease the rate of repolarization, decrease electrical conduction, and decrease contractility
- Used for atrial fibrillation (oral route), recurrent ventricular fibrillation, and ventricular tachycardia
- Adverse effects include pulmonary toxicity, sinus bradycardia, and visual disturbances
- Contraindications include AV block and bradycardia, and liver, thyroid, or respiratory dysfunction
- Interact with diltiazem, digoxin, and warfarin and grapefruit juice
- Amiodarone is highly toxic
- Adverse effects may continue until discontinued
Vaughan Williams Class IV: Calcium Channel Blockers
- Medications include verapamil (Calan) and diltiazem (Cardizem)
- Depress depolarization, decrease myocardial oxygen demand, decrease the force of contraction, and decrease heart rate
- Used for atrial fibrillation/flutter and SVT
- Adverse effects include bradycardia, hypotension, and constipation
- Contraindications include SA/AV dysfunction and heart blocks
- Interact with beta-blockers and digoxin
- May cause orthostatic hypotension
- Take medication with food and do not crush extended-release
Other Antidysrhythmics
- Have properties of several classes and are not placed into one particular class
- Digoxin and Adenosine are included in this group
Digoxin (Lanoxin)
- Slows conduction between the SA & AV node
- Used to slow the rate in atrial fibrillation/flutter
- Can be administered PO or IV
- Long half-life and duration of action
- High risk for toxicity; narrow therapeutic index
- Follow Digoxin levels to determine dose
- Adverse Effects include cardiac arrhythmias and yellow halos
- Antidote is Digoxin Immune Fab (Digibind)
- Chronotropic: ↓ rate of contractions
- Dromotropic: ≈ electrical current
- Pt will have low heart rate & *Low heart rate & seeing yellow halos
Adenosine (Adenocard)
- Used in emergent situations
- Slows conduction through the AV node and slows/stops conduction
- Used to convert paroxysmal supraventricular tachycardia to sinus rhythm
- Very short half-life—less than 10 seconds
- Only administered as fast IV push (6mg)
- May cause asystole for a few seconds
- Other adverse effects minimal
Nursing Implications
- Obtain a thorough drug and medical history
- Measure baseline BP/P, I & O, and cardiac rhythm
- Measure serum potassium levels before initiating therapy
- During therapy, monitor cardiac rhythm, heart rate, BP, general well-being, skin color, temperature, heart and lung sounds.
- Assess plasma drug levels as indicated
- Monitor for toxic side effects
- Instruct patients to take medications as scheduled and not to skip doses or double up for missed doses
- Instruct patients to contact their physician for instructions if a dose is missed
- Instruct patients not to crush or chew oral sustained-release preparations
- Administer IV infusions with an IV pump
- Teach patients taking beta-blockers, digoxin, and other drugs how to take their own radial pulse for 1 full minute, and to notify their physician if the pulse is less than 60 beats/minute before taking the next dose
- Ensure that the patient knows to notify health care provider of any worsening of dysrhythmia or toxic effects.
Social Determinants of Health (SDOH)
- Older adults with HTN, heart failure, diabetes and thyroid disease are more at risk of developing dysrhythmias
- Cost of Lidocaine = $5 for 20 doses
- Propranolol = $30-$80 for a 30 day supply
- Digoxin = $50 for 100 tablets
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