Week 10 Angina & Heart Failure Class Slides PDF

Angina, Heart Failure NUR 2303 – Week 10 Housekeeping Questions  Angina Ischemia Atherosclerosis Negative inotropic effect Glossary Negative chronotropic effect Dysrhythmia Heart failure Ejection fraction (65%)...

Angina, Heart Failure NUR 2303 – Week 10 Housekeeping Questions  Angina Ischemia Atherosclerosis Negative inotropic effect Glossary Negative chronotropic effect Dysrhythmia Heart failure Ejection fraction (65%) Hemostasis Chapter 24 Antianginal Drugs Drug Therapy for Angina Types of Angina: Chronic stable angina Triggered by a stressor Unstable angina ‘Pre-infarction’ At rest Vasospastic angina Follows a predictable pattern Drugs for Angina Nitrates ß-Blockers Calcium channel blockers MOA: ↑ blood flow or ↓ O2 demand or both Objective is to: Minimize the frequency of attacks and ↓ the duration and intensity of pain Improve the patient’s functional capacity few adverse effects as possible Prevent or delay MI Nitrates: Mechanism of Action Cause coronary vasodilation because of relaxation of smooth muscles *Dilate all vessels in the body Forms: Sublingual*, chewable tablets, oral capsules/tablets, IV solutions*, transdermal patches*, ointments, translingual sprays* *Bypass the liver and the first-pass effect. Rapid-acting forms Used to treat acute anginal attacks (SL tablets or spray; IV infusion) Long-acting forms Used to prevent anginal episodes Nitroglycerin IV form used for control of blood pressure in perioperative hypertension, treatment of HF, ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies AE: Headaches Reflex tachycardia Postural hypotension Tolerance may develop Irritation to skin caused by adhesive in patches Severe hypotension possible death with ED meds Other meds isosorbide dinitrate (ISDN), Nitrol, Imdur, Trinipatch Tolerance Occurs in patients taking nitrates around the clock or with long- acting forms Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish Transdermal forms: may be instructed to remove patch at bedtime for 8 hours, then apply a new patch in the morning Nitrates: Contraindications Known drug allergy Severe anemia Closed-angle glaucoma Hypotension Severe head injury (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra®) - ß-Blockers Angina (atenolol, metoprolol, propranolol, nadolol) ↓ heart rate, resulting in ↓ myocardial oxygen demand and increased oxygen delivery to the heart ↓ myocardial contractility, helping to conserve energy or decrease demand After MI, a high level of circulating catecholamines irritates the heart, leading to dysrhythmias, β-blockers block the harmful effects of catecholamines, thus improving survival after MI ß-Blockers Most effective in the treatment of exertional angina Blunt the physiological effects of an increase in heart rate and systolic BP that occur during exercise or stress, thereby decreasing myocardial oxygen demand Contraindications: systolic heart failure and res Adverse Effects: Bronchoconstriction and increased airway resistance, a decreased heart rate, cardiac output, and cardiac contractility CCBs for Stable Angina: MOA Amlodipine, diltiazem, nifedipine, verapamil Prevent calcium from entering excitation-contraction process Cause coronary artery vasodilation Cause peripheral arterial vasodilation, thus ↓ SVR Reduce the workload of the heart ↓ myocardial oxygen demand ↑ supply ↓ conduction through the SA and AV nodes CCBs: Contraindications and AEs Known drug allergy Acute myocardial infarction Second- or third-degree atrioventricular block (unless the patient has a pacemaker) Hypotension AEs: hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea Nursing Implications - Encourage clients to: Limit caffeine intake. Keep a record of their attacks, including precipitating factors, number of pills taken, and therapeutic effects. Monitor for adverse reactions: allergic reactions, headache, lightheadedness, hypotension, dizziness. Take extra care with ETOH, saunas, hot tubs –may cause vasodilation, hypotension, fainting Nursing Implications for Nitroglycerin Never chew or swallow the sublingual form. A burning sensation felt with sublingual forms indicates that the drug is still potent. Keep a fresh supply of sublingual medication on hand; potency is good for about 3 to 6 months. Should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler. Rotate sites of transdermal patches and remove old patch. To reduce tolerance, remove topical forms at bedtime and apply new doses in the morning, allowing for a nitrate-free period. Nursing Implications for Nitroglycerin Take as-needed nitrates at the first hint of anginal pain. If experiencing chest pain, the patient taking SL nitroglycerin should lie down to prevent or decrease dizziness and fainting If anginal pain occurs client should Stop activity and sit or lie down and take a SL tablet. If there is no relief in 5 minutes, call 911 immediately and take a second SL tablet. Take a third SL tablet If there is no relief in 5 minutes. Do not try to drive to the hospital. IV nitro must be given with non–polyvinyl chloride tubing and bags Question A patient who has had a myocardial infarction is taking a ß-blocker. What is the main benefit of ß-blocker therapy for this patient? A. Vasodilation of the coronary arteries B. Increased force of cardiac contraction C. Slowing of the heart rate D. Maintaining adequate blood pressure Question A person who is mowing the lawn on a hot Saturday afternoon notices chest pain. What should this person’s first action be? A. Take a nitroglycerin tablet. B. Stop mowing and sit or lie down. C. Go inside the house to cool off and get a drink of water. D. Call 911. Question A patient with extremely high BP is in the emergency department. The health care provider will order therapy with nitroglycerin to manage the patient’s blood pressure. Which form of nitroglycerin is most appropriate? A. Sublingual spray B. Transdermal patch C. Oral capsule D. Intravenous infusion Question A patient who was walking a dog developed chest pain and sat down. The patient continues to experience chest pain when sitting down. When should the patient call 911? A. Immediately B. If the pain becomes more severe C. If one sublingual tablet does not relieve the pain after 5 minutes D. If the pain is not relieved after three sublingual tablets, taken 5 minutes apart Chapter 25 Heart Failure Drugs Heart Failure: Left versus Right Left Sided Heart Failure Right Sided Heart Failure Pulmonary Edema Systemic Venous Congestion Coughing Pedal Edema Shortness of Breath Jugular Vein Distention Dyspnea Ascites Hepatic Congestion Heart Failure: Causes Myocardial deficiency Increased workload Inadequate contractility Pressure overload Myocardial infarction Pulmonary hypertension Coronary artery disease Systemic hypertension Cardiomyopathy Outflow obstruction Valvular insufficiency Volume overload Inadequate filling Hypervolemia Atrial fibrillation Congenital abnormalities Infection Anemia Tamponade Thyroid disease Ischemia Infection Diabetes Heart Failure Classifications Class I Angina only during strenuous or prolonged physical activity Class II Slight limitation, with angina only during vigorous physical activity Class III Symptoms with everyday living activities, i.e., moderate limitation Class IV Inability to perform any activity without angina or angina at rest, i.e., severe Drug Therapy for Heart Failure First options: Angiotensin-converting enzyme inhibitors (ACE Inhibitors) Angiotensin receptor blockers ß-Blockers Diuretics If that doesn’t work only then….positive inotropic drugs: ↑ the force of myocardial contraction Phosphodiesterase inhibitors Cardiac glycosides ACE Inhibitors Prevent sodium and water resorption by inhibiting aldosterone secretion Diuresis results, which decreases preload, or the left ventricular end volume, and the work of the heart lisinopril Angiotensin II Receptor Blockers Potent vasodilators; decrease systemic vascular resistance (afterload) Used alone or in combination with other drugs such as diuretics in the treatment of hypertension or heart failure valsartan β-Blockers ↓ SNS stimulation to the heart, ↓ myocardial automaticity Cardioprotective quality of ß-blockers: prevent catecholamine- mediated actions on the heart by reducing or blocking sympathetic nervous system stimulation to the heart and the heart’s conduction system metoprolol Aldosterone Antagonists Useful in severe stages of heart failure Action: blocks activation of the renin-angiotensin-aldosterone system (causes increased levels of aldosterone, which causes retention of sodium and water, leading to edema that can worsen heart failure). spironolactone Phosphodiesterase Inhibitors Work by inhibiting the enzyme phosphodiesterase Results in Positive inotropic response Vasodilation Increase in calcium for myocardial muscle contraction. Inodilators (inotropics and dilators) milrinone (only drug in Canada) Used in ICUs (cause dysrhythmias) Cardiac Glycosides (Digoxin) No longer used as first-line treatment Not been shown to reduce mortality Originally obtained from the Digitalis plant (foxglove) Digoxin is the prototype. Used in heart failure and to control ventricular response to atrial fibrillation Digoxin: MOA Positive inotropic effect Increased force and velocity of myocardial contraction (without an increase in oxygen consumption) Negative chronotropic effect Reduced heart rate Negative dromotropic effect Decreased automaticity at sinoatrial node, decreased atrioventricular nodal conduction Digoxin: Drug Effects Increased stroke volume Reduction in heart size during diastole Decrease in venous blood pressure and vein engorgement Increase in coronary circulation Decrease in exertional and paroxysmal nocturnal dyspnea, cough, and cyanosis Promotion of tissue perfusion and diuresis Cardiac Glycosides: Nursing Considerations Very narrow therapeutic window. Drug levels must be monitored. 0.8 to 2 ng/mL Hypokalemia may precipitate digoxin toxicity. Before giving any dose, count apical pulse for 1 full minute Apical pulse 100 beats/min -hold dose, notify prescriber AE: dysrhythmias, including bradycardia or tachycardia headaches, fatigue, malaise, confusion, convulsions coloured vision (seeing green, yellow, purple), halo vision anorexia, nausea, vomiting, diarrhea Digoxin Immune Fab can be used in toxicity Toxicity symptoms: anorexia, nausea, vomiting Question A patient is receiving digoxin 0.25 mg/day as part of treatment for heart failure. The nurse assesses the patient before administering medication. Which assessment finding would be of most concern? A. Apical heart rate of 62 beats/min B. Ankle edema +1 bilaterally C. Serum potassium level of 2.9 mmol/L D. Serum digoxin level of 0.8 ng/mL Case Study Sandra is a 55-year-old woman with diabetes who is being seen in the emergency department for jaw pain and nausea that began while she was pruning the bushes in front of her house. The patient is diagnosed with angina. The nurse administers the ordered sublingual nitroglycerine, and the patient immediately has shortness of breath and breaks out in hives along her neck, chest, and upper arms. The patient is treated with oral diphenhydramine (Benadryl®) and intravenous (IV) dexamethasone (Decadron), and she recovers without incidence. a. Sandra asks the nurse how a problem with the heart can manifest as jaw pain and nausea. How will the nurse respond? b. The patient asks the nurse, “What am I going to do if I experience more chest pain? Isn’t nitroglycerine the only medication that treats chest pain?” How will the nurse respond? c. What type of angina is Sandra experiencing? d. Two months later, Sandra is sweeping out her garage when she develops shortness of breath and becomes diaphoretic. She sits down to rest, and the “heaviness” does not go away. What would be the priority action? Take Home Reflection What might the health teaching be for a client prescribed the combination of Hydralazine and isosorbide dinitrate? Wrap-up Week 11: Dysrhythmia, Coagulation Modifiers, Anti-lipemics