Non-Opioid Analgesics Study Guide PDF

*[33 Non-Opioid Analgesics]* - **Aspirin** Be sure to list other first-generation NSAIDs, address client education, and address toxicity. - Purpose: It is used for [inflammation suppression], [analgesia] (relief of pain) for mild to moderate pain (with osteoarthritis and rheumatoid...

*[33 Non-Opioid Analgesics]* - **Aspirin** Be sure to list other first-generation NSAIDs, address client education, and address toxicity. - Purpose: It is used for [inflammation suppression], [analgesia] (relief of pain) for mild to moderate pain (with osteoarthritis and rheumatoid arthritis), [fever reduction], [dysmenorrhea] (moderate to severe menstrual pain), and [inhibition of platelet aggregation] (aspirin). - Complications: - Gastric upset, heartburn, nausea, and gastric ulceration. - Bleeding (less with non-aspirin NSAIDs) - Kidney Dysfunction - Salicylism (aspirin): if a client takes in more aspirin than they excrete. - Reyes syndrome (aspirin): giving aspirin to a child with a viral infection. - Contraindications/precautions: - Teratogenic - Hypersensitivity to aspirin and other NSAIDs - Peptic ulcer disease - Bleeding disorders (hemophilia, vitamin K deficiency) - Children or adolescents with chicken pox or influenza - Perioperative use prior to coronary artery bypass grafting (non-aspirin NSAIDs) - Discontinue within 1 week before any elective surgery - Interactions: - Anticoagulants, glucocorticoids, and alcohol increase the risk of bleeding. - Ibuprofen decreases the antiplatelet effect of low-dose aspirin. - ACE inhibitors and angiotensin receptor blockers increase the risk of kidney failure. - Antihypertensive effects of ACE inhibitors decrease the risk of lithium carbonate and methotrexate toxicity increase. - Nursing Administrations: - Ensure clients swallow enteric-coated or sustained-release forms whole and do not crush or chew them. - Discontinue 1 week before scheduled surgery. - Monitor for initial and continued therapeutic effects. - PO, - Nursing Evaluation of Medical Effectiveness: fever is reduced, client reports a lower level of pain, and inflammation has decreased. Monitor for initial and continued therapeutic effects. - Other first gen NSAIDs: - Naproxen, indomethacin, ketorolac, meloxicam, and diclofenac - Client Education: - Take with food, milk, or 8oz of water to minimize gastrointestinal effects - Avoid alcohol - Report gastric irritation and manifestations of bleeding - Report prolonged bleeding - Report changes in output, weight gain, or manifestations of fluid retention such as edema or bloating. - Report ringing or buzzing in the ears, sweating, headache, and dizziness. - Do not give aspirin or NSAIDs to children under 19 with a viral infection (particularly chickenpox or influenza). Use acetaminophen instead. - Report chest pain, heaviness, shortness of breath, sudden and severe headache, numbness, weakness, visual disturbances, or confusion. - Take aspirin once daily to reduce the risk of heart attack and stroke if prescribed. - Aspirin toxicity: Salicylism, for aspirin, if a client takes in more aspirin than they excrete. Salicylism will present with tinnitus, sweating, headache, dizziness, and respiratory alkalosis. - What information stands out about **Ketorolac**? Hint: This medication has unique administration principles. - What information stands out about **Celecoxib**? Hint: This medication is a unique type of NSAID and has a unique and life-threatening adverse effect and contraindication. - **Acetaminophen** (Be sure to address toxicity, antidote, and client education.) - Purpose: It is a COX inhibitor, BUT its effects are limited to CNS (no anti-inflammatory or anticoagulant effects. It Does not affect the gastric mucosa or platelets, decreasing the risk for gastric ulcers and cardiovascular events.) - Complications: Rare but acute toxicity can happen; details below. - Contraindications/precautions: Anemia, Immunosuppression, hepatic or kidney disease. - Interactions: - Nursing Administrations: Oral or rectal. Advise clients that many combination products exist and to read labels carefully. No more than 4g a day. - Nursing Evaluation of Medical Effectiveness: reduced fever and client reports reduced pain. - Acetaminophen antidote: Use antidote, acetylcysteine via duodenal tube to prevent emesis and subsequent aspiration. - Client Education: Teach the client to read med labels carefully to determine proper doses. And take only one product at a time that contains acetaminophen. - Acetaminophen toxicity: Rare but acute toxicity can happen, resulting in liver damage with manifestations of nausea, vomiting, diarrhea, sweating, and abdominal discomfort, progressing to hepatic failure, coma, and death. *[Opioid Agonists and Antagonists]* - **Morphine** (Be sure to list other opioid agonists, how to minimize the risk of adverse effects, and patient-controlled analgesia (PCA) pump.) Opioid agonist - Purpose: Analgesic for moderate to severe pain. Pre-op sedation, anxiety reduction, cough suppression (codeine), and reduction of bowel motility relief of diarrhea. - Complications: Have naloxone present in the client's room in case it is needed. - Contraindications/precautions: Pregnant women, renal failure, increased cranial pressure, biliary colic (pain caused by gallstones blocking the cystic duct), biliary surgery, and clients in preterm labor. - Interactions: Opioid agonists interact with CNS depressants, such as barbiturates, phenobarbital, benzodiazepines, and alcohol, by increasing their CNS depressant effects. When given medications with anticholinergic agents such as antihistamines and tricyclic antidepressants, their anticholinergic effects increase, causing constipation and urinary retention. Other antihypertensive medications increase hypotensive effects. St. John's wort can increase sedation. - Nursing Administrations: PO, IM, IV, subcutaneous, rectally, or epidurally. When ordered intravenously, give slowly over 4 to 5 minutes. - Nursing Evaluation of Medical Effectiveness: Ask the client to rate pain and wait 30-60 minutes after giving it orally to assess. Cough suppression Resolution of diarrhea - Client Education: - Other opioid agonists: Fentanyl, meperidine, methadone, codeine, oxycodone, hydromorphone - How to minimize the risk of adverse effects: - Patient-controlled analgesia (PCA) pump: closely monitor pump settings (dose, lockout, interval, 4-hr limit). Inform the client that safeguards are there to reduce the risk of excessive doses. - What information stands out about **Fentanyl**? Hint: This medication has unique routes of administration. - **Naloxone** (Purpose, Complications, Contraindications/Precautions, Interactions, Nursing Administration, Nursing Evaluation of Medication Effectiveness) - Purpose: it interferes with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids. It will temporarily reverse euphoria and respiratory depression. - Complications: Tachycardia and tachypnea. Abstinence syndrome (cramping, hypertension, vomiting, and reversal of analgesia). This happens when physically dependent clients are suddenly withdrawn the medication. Have oxygen and resuscitation equipment ready - Contraindications/precautions: - Interactions: reverses effects of opioids. - Nursing Administrations: IV, IM, subcutaneous, NO ORAL Rapid infusion can cause hypertension, tachycardia, nausea, and vomiting. The half-life of opioid analgesic can exceed the half-life of naloxone (60 to 90 min); give until crisis has passed. - Nursing Evaluation of Medical Effectiveness: *[Adjuvant Medications for Pain]* - **Ibuprofen** - with another primary pain medication, usually an opioid agonist, to increase pain relief while reducing the dosage of opioid agonists. Reduced dosage of opioids results in reduced adverse effects, and targeting the pain stimulus using different types of pain medications often provides improved pain reduction. - Purpose: Used to treat inflammation and fever and relieve mild to moderate pain and dysmenorrhea. - Complications: bone marrow suppression, GI distress (presenting as abdominal pain, elceration, nausea, vomiting, diarrhea, or constipation),and MI or stroke - Contraindications/precautions: Avoid after 30 weeks of gestation, use cautiously with lactation. It is contraindicated with clients who have a history of bronchospasms with aspirin or other NSAIDs and those who have severe kidney/hepatic disease. Use caution with clients with bleeding, GI, or cardiac disorders Use caution in older adults - Interactions: NSAIDs can reduce the effectiveness of antihypertensives, furosemide, thiazide diuretics, and oral antidiabetic medications. Aspirin, corticosteroids, alcohol, and tobacco can increase GI effects. NSAIDs can increase levels of oral anticoagulants and lithium. Increased risk of bleeding with the use of other NSAIDs, thrombolytics, antiplatelets, anticoagulants, and salicylates. - Nursing Administrations: Oral or IV - Nursing Evaluation of Medical Effectiveness: - Client education: *[Miscellaneous Pain Medications]* - **Sumatriptan** (Purpose: migraine-specific medication (serotonin receptor agonists). It works by narrowing the blood vessels around the brain and reducing substances that trigger headaches, pain, nausea, and sensitivity to light and sounds. - Complications: Chest pressure (Heavy arms or chest tightness \[manifestations are self-limiting and not dangerous\]) Coronary artery vasospasms/angina (do not administer for clients at risk for coronary artery disease) Dizziness or vertigo (avoid driving or operating heavy machinery) - Contraindications/precautions: Pregnancy, lactation, reproductive precautions - Interactions: Concurrent use of MAOIs can lead to MAOI toxicity Concurrent use with ergotamine or another triptan can cause vasospastic reactions. Selective serotonin reuptake inhibitors (SSRIs) taken with triptans can cause serotonin syndrome (confusion, agitation, hyperthermia, diaphoresis, possible death). - Nursing Administrations: Oral, subcutaneous, inhalation, transdermal - Nursing Evaluation of Medical Effectiveness: Reduction in intensity of migraines Termination of migraine headaches - Client education: - **Lidocaine** - Purpose: decrease pain by blocking the conduction of pain impulses in a circumscribed area. Loss of consciousness does not occur. Pain management for dental procedures, minor surgical procedures, labor and delivery, and diagnostic procedures. And regional anesthesia - Complications: CNS excitation and seizures followed by respiratory depression, leading to unconsciousness. Hypotension cardiosuppression, bradycardia, heart block, reduced contractile force, and cardiac arrest (common in spinal anesthesia due to sympathetic block) - Contraindications/precautions: Patients with a known hypersensitivity to local anesthetics. Use cautiously in patients with severe liver disease, heart block, or a history of malignant hyperthermia. - Interactions: It can interact with other medications that affect heart rhythm, such as beta-blockers and antiarrhythmics. - Nursing Administrations: Parenteral (injection), monitor for signs of adverse effects. - Nursing Evaluation of Medical Effectiveness: - Client education: Advise clients to avoid activities requiring alertness until the effects of lidocaine have worn off. Avoid hot food or drinks if applied in the mouth. - What information stands out about **EMLA**? Hint: This medication has unique administration principles. Topical cream for anesthesia before procedures. Apply to intact skin 1 hr before routine procedures or superficial puncture and 2 hr before more extensive procedures or deep puncture. Apply to the smallest surface area needed to minimize systemic absorption. Prior to the procedure, remove the dressing and clean the skin with aseptic solution. It can be applied at home before coming to the facility. *[Medications **Affecting Urinary Output**]* - Furosemide -- **High ceiling loop diuretic** - Purpose - Pharm action: high ceiling loop diuretics work in the loop of Henle to: - block reabsorption of sodium and chloride and prevent reabsorption of water - cause extensive diuresis even with severe renal impairment. - Increase kidney excretion of water, potassium, sodium, chloride, magnesium, and calcium. - Therapeutic uses: high-ceiling loop diuretics are used when there is an emergent need for rapid mobilization of fluid, like: - Pulmonary edema caused by heart failure - Conditions not responsive to other diuretics (edema caused by liver, cardiac, or kidney disease) - Unlabeled use: Hypercalcemia - Complications - Dehydration (dry mouth, increased thirst, oliguria, and lethargy) - Hypotension (postural hypotension) - Ototoxicity (develops hearing or balance problems due to med) - Hypokalemia (K+ less than 3.5mEq/L) - Other electrolyte imbalances (hyponatremia, hypomagnesemia, hypochloremia, hypocalcemia) - Others include hyperglycemia, hyperuricemia (elevated levels of uric acid in the blood), decrease in HDL in cholesterol levels, increase in LDL cholesterol levels, and increase in triglycerides levels. - Contraindications/Precautions - Pregnant and lactating women - Clients with ANURIA (no urine output) - Use cautiously in clients who have severe liver disease, diabetes mellitus, dehydration, electrolyte depletion, and gout. - Use cautiously in clients taking digoxin, lithium, ototoxic medications, NSAIDs, or antihypertensives. - Interactions - Digoxin toxicity (ventricular dysrhythmias) can occur in the presence of hypokalemia. - Potassium-sparing diuretics are often used in conjunction with loop diuretics to reduce the risk of hypokalemia. - Concurrent use of antihypertensives can have additive hypotensive effects. - Lithium carbonate blood levels can increase, which can lead to toxicity if hyponatremia occurs due to the loop diuretic. - NSAIDs decrease blood flow to the kidneys, which reduces the diuretic effect. - Nursing Administration - Oral (w/out food), IV, IM - Obtain baseline data, including orthostatic blood pressure, weight, electrolytes, and location of edema. - Including orthostatic blood pressure, weight, electrolytes, location, and extent of edema. - Weigh clients at the same time each day with the same clothing and bed linen, usually upon waking. - Monitor BP and I&O. - Avoid administering late in the day to prevent nocturia - Administer furosemide orally, IM, IV bolus dose, or continuous IV infusion. Administer IV bolus at 20 mg/min or slower to avoid abrupt hypotension and hypovolemia. - If the potassium level drops below 3.5mEq/L, monitor ECG and notify the provider because the client might require a potassium supplement. - Initiate fall precautions for older adult clients taking diuretics. - Monitor for pain in the chest, calves, or pelvis and notify the provider if these occur. - Nursing Evaluation of Medication Effectiveness - Decrease in pulmonary or peripheral edema - Weight loss - Decrease in blood pressure - Increase in urine output - Decrease in calcium level - Be sure to address the client's education  - If used for hypertension, self-monitor blood pressure, and weight by keeping a log. - Get up slowly to minimize postural hypotension, monitor BP, and assess for hypovolemia. - Report significant weight loss, lightheadedness, dizziness, GI distress, or general weakness to the provider (indications of hypervolemia). - Consume foods high in potassium. - If the client has diabetes, monitor for elevated blood glucose levels. - Monitor for findings of electrolyte imbalances and report to the provider. - Report manifestations for ototoxicity (vertigo, ringing, buzzing, or sense of fullness in the ears) - Hydrochlorothiazide -- **Thiazide Diuretic** - Purpose - Pharm action: - Thiazide diuretics work in the early distal convoluted tubule. - It blocks the reabsorption of sodium and chloride and prevents reabsorption of water at this site. - Promotes diuresis when renal function is not impaired. - Therapeutic actions: - Thiazide diuretics are often the medication of first choice for essential hypertension. - Used for edema of mild to moderate heart failure and liver and kidney disease - Used in combo with antihypertensive agents for BP control - Reduce urine production in patients who have diabetes insipidus - Promote reabsorption of calcium and can reduce the risk for post-menopausal osteoporosis - Complications - Dehydration and hyponatremia (monitor I&Os, electrolytes and weight) - Hypokalemia and hypochloremia (monitor cardiac status) - Hyperglycemia (monitor blood glucose levels) - Hyperuricemia, hypomagnesemia, increased lipids. - Contraindications/Precautions - Pregnant and lactating women - Clients with renal impairment - Caution in clients who have cardiovascular disease, diabetes, hypokalemia, hyperlipidemia, hypomagnesemia and gout - Caution in those taking digoxin, lithium, or hypertensives. - Interactions - Digoxin toxicity (ventricular dysrhythmias) can occur in the presence of hypokalemia. - Concurrent use of antihypertensives can have an additive hypotensive effect. - Lithium carbonate blood levels can increase, which can lead to toxicity if hyponatremia occurs due to the loop diuretic. - Thiazide diuretics cause no risk of hearing loss and can be combined with ototoxic meds. - Nursing Administration - Administered orally and by IV. Others are only given orally. - Obtain baseline data for orthostatic BP, weight, electrolytes, and location and extent of edema. - Monitor potassium levels - Alternate-day dosing can decrease electrolyte imbalances. - Weigh clients at the same time every day. - Monitor BP and I&Os. - If potassium drops below 3.5mEq/L, monitor ECG and notify the provider. - Advise clients to get up slowly. - Nursing Evaluation of Medication Effectiveness - Decrease in BP - Decrease in edema - Increase in urine output - Reduced urine output in diabetes insipidus - Preserved bone integrity in postmenopausal clients - Be sure to address the client's education  - Take meds first thing in the morning. If twice a day, be sure to take the second dose by 14:00. Weigh yourself at the same time each day wearing the same clothes and notify the provider for a gain of more than 3 pounds in one day. - Consume foods high in potassium and maintain adequate fluid intake - If GI upset occurs, take it with or after meals - If used for hypertension, self-monitor BP and keep a weight log. - Report significant weight loss, lightheadedness, dizziness, GI distress, or general weakness. Can indicate hypokalemia or hypovolemia. - If diabetic, monitor for elevated blood glucose levels - Observe for manifestations of low magnesium levels (weakness, muscle twitching, tremors) - Spironolactone **-- potassium sparing diuretic** - Purpose - Pharm action: - Potassium-sparing diuretics block the action of aldosterone (sodium and water retention), which results in potassium retention and the excretion of sodium and water. - Therapeutic uses: - Potassium-sparing diuretics are combined with other diuretics (loop and thiazide diuretics) for potassium-sparing effects to treat hypertension and edema. - Administered for heart failure - Potassium-sparing diuretics block actions of aldosterone in primary hyperaldosteronism by retaining potassium and increasing sodium excretion, causing an opposite effect of the action of aldosterone in the distal nephrons. - Therapeutic effects can take 48 to 72 hours. - Complications - Hyperkalemia (monitor potassium level, monitor for higher than 5mEq/L) - Endocrine effects (deep voice, impotence, irregularities in menstrual cycle, gynecomastia, hirsutism) - Drowsiness, metabolic acidosis (drowsiness and restlessness) - Contraindications/Precautions - Pregnant and lactating women - Do not administer for clients who have hyperkalemia or are taking potassium. - Do not administer to clients who have severe kidney failure and anuria. - Caution with clients who have kidney or liver disease, electrolyte imbalance, or metabolic acidosis. - Interactions - Concurrent use with ACE inhibitors, angiotensin receptor blockers, and direct renin inhibitors increases the risk of hyperkalemia. - Concurrent use of potassium supplements, salt substitutes, and other potassium diuretics increases the risk of hyperkalemia. - Nursing Administration - Oral - Take w/ food - Obtain baseline data - Weigh clients same time each day - Monitor I&Os - Monitor ECG periodically - Monitor potassium levels - Nursing Evaluation of Medication Effectiveness - Maintenance of expected potassium levels: 3.5 to 5mEq/L - Weight loss - Decrease in blood pressure and edema - Be sure to address the client's education  - Avoid salt substitutes that contain potassium and reduce your intake of potassium-rich foods. - Self-monitor BP - Keep a log of BP and weight - Triamterene can turn urine a bluish color - Report cramps and diarrhea, thirst, altered menstruation, or deepened voice - Avoid activities that require alertness until the effects of medication are known. - Mannitol -- **Osmotic diuretic** - Purpose - Pharm action - Osmotic diuretics reduce intracranial pressure and intraocular pressure by raising serum osmolality and drawing fluid back into vascular and extravascular space. - Therapeutic Use: - Prevents kidney failure in specific situations (hypovolemic shock and severe hypotension) because mannitol is not reabsorbed and remains in the nephron, drawing off water, thus preserving urine flow and preventing kidney failure - Decreases intracranial pressure (ICP) caused by cerebral edema by drawing fluid from the brain into the bloodstream - Decreases intraocular pressure by drawing fluid into the bloodstream - Promotes sodium retention and water excretion in clients who have hyponatremia and fluid volume excess - Administered for oliguria phase of acute kidney injury. - Complications - Heart failure, pulmonary edema - Rebound increased intracranial pressure - Fluid and electrolyte imbalances, metabolic acidosis - Contraindications/Precautions - Clients with intracranial bleed, anuria, severe pulmonary edema, severe dehydration, and renal failure - Use extreme caution in clients who have heart failure, are pregnant or breast feeding, renal insufficiency, and electrolyte imbalances. - Pregnant and lactating women - Interactions - Lithium excretion through the kidneys is increased - Increased risk for hypokalemia with cardiac glycosides. - Nursing Administration - Administer by continuous IV infusions - To prevent microscopic crystals, use a filter needle to draw med and a filter in the IV tubing - Monitor daily weight, I&Os, and blood electrolytes - Monitor for manifestations of dehydration and increased edema\]obtain baseline data, including orthostatic blood pressure, weight, electrolytes, and location and extent of edema. - Weigh clients same time each day. - Monitor BP - If the potassium level drops below 3.5mEq/L, monitor ECG and notify the provider (the client might need a potassium supplement) - Monitor for increased ICP - Monitor for metabolic acidosis - Nursing Evaluation of Medication Effectiveness - Normal kidney function demonstrated by: - Urine output of at least 30mL/hr - Blood creatinine 0.6 to 1.3 mg/dL for males and.5 to 1.1 mg/dL for females - BUN levels 10 to 20 mg/dL - Decrease in intracranial pressure - Decrease in intraocular pressure - Be sure to address the client's education  - Get up slowly to minimize postural hypotension, monitor BP, and assess for hypovolemia - Report significant weight loss, lightheadedness, dizziness, GI distress, and general weakness to the provider. ***[Perfusion]*** *[Medications **Affecting Blood Pressure**]* - Captopril -- **Angiotensin-converting enzyme inhibitor** - Purpose: - Pharm actions: - ACE inhibitors reduce production of angiotensin II by blocking the conversion of angiotensin I to angiotensin II and increasing levels of bradykinin, leading to the following: - Vasodilation (mostly arteriole) - Excretion of sodium and water and retention of potassium by action in the kidneys - Reduction in pathological changes in the blood vessels and heart that result from the presence of angiotensin II and aldosterone - Therapeutic actions - Hypertension - Heart failure - Myocardial infarction - Diabetic and nondiabetic nephropathy - For clients at high risk for cardiovascular event, ramipril is used to prevent MI, stroke, or death - Complications - First-dose orthostatic hypotension (if client is already taking a diuretic, stop the medication temporarily for 2 to 3 days prior to the start of an ACE inhibitor) - Taking another type of antihypertensive medication increases the hypotensive effects of an ACE inhibitor - Start treatment with a low dosage of the medication - Monitor BP for several hours after initiation of treatment - Cough - Hyperkalemia (monitor for numbness/tingling, and paresthesia in hands and feet) - Rash and dysgeusia (altered taste) - Angioedema (swelling of tongue and pharynx) \[treat severe effects with epinephrine and discontinue\] - Neutropenia (low neutrophils, a white blood cell essential in the immune system) - Contraindications/Precautions - Pregnant and lactating women - Contraindicated for clients who have a history of allergy to or angioedema from ACE inhibitors, in bilateral renal artery stenosis, or in clients with one kidney - Use caution with clients who have kidney impairment and collagen vascular disease because they are at greater risk for developing neutropenia. Closely monitor for infections. - Interactions - Diuretics can contribute to first-dose hypotension - Antihypertensive meds can have an additive hypotensive effect - Potassium supplements and potassium-sparing diuretics increase the risk of hyperkalemia - ACE inhibitors can increase levels of lithium - Use of NSAIDs can decrease the antihypertensive effect of ACE inhibitors - Nursing Administration - Administer ACE inhibitors orally [ *except*] enalaprilat, which is the ONLY ACE inhibitor for IV use. - Be sure to list other angiotensin-converting enzyme (ACE) inhibitors - Other ACE inhibitors include Enalapril, Enalaprilat, Fosinopril, Lisinopril, Ramipril, Moexipril, Benazepril, Quinapril, Trandolapril, and Perindopril - Be sure to address the client's education  - Prescribed as a single formulation or in combination with hydrochlorothiazide (a thiazide diuretic) - BP should be monitored after the first dose for at least 2 hours to detect hypotension - Take captopril and moexipril at least 1 hour before meals. Others can be taken with or without food. - Notify the provider if cough, rash, dysgeusia (altered taste), or indications of infection occur/ - Rise slowly from sitting - Avoid activities that require alertness until effects are known. - Losartan -- **Angiotensin II receptor blockers (ARBs)** - Purpose - Pharm action: - These meds block the action of angiotensin II in the body. Which results in VASODILATION and EXCRETION OF SODIUM AND WATER. - Therapeutic uses: - Hypertension - Heart failure (valsartan and candesartan) - Stroke prevention (LOSARTAN) - Delay progression of diabetic nephropathy (losartan) - Slow the development of diabetic retinopathy (losartan) - Complications Major difference between ARBs and ACE inhibitors is that ARBs block the action of angiotensin II and ACE inhibitors block the formation of angiotensin II. In contrast ACEI, ARBs do not cause hyperkalemia and have a much lower risk of cough. - Angioedema (treat with epinephrine and discontinue medication) - Fetal injury (use contraception of childbearing age) - Hypotension (monitor BP) - Dizziness, lightheadedness (avoid activities that require alertness) - Contraindications/Precautions - Pregnant and lactating women - Reproductive age clients - Bilateral renal stenosis or a single kidney because of risk for kidney injury - Use cautiously in clients who experienced angioedema with ACE inhibitor - Interactions - Antihypertensive meds can have an additive effect - Increased risk for lithium toxicity - Nursing Administration - Administer meds by oral route - Take ARBs with or without food - Be sure to address the client's education  - Med is prescribed by a single formulation or in combination with hydrochlorothiazide - If taken for heart failure, monitor weight and edema - Verapamil, Diltiazem -- **Calcium channel blockers** - Purpose - Pharm action - Blocking of calcium channels in blood vessels leads to vasodilation of peripheral arterioles and arteries/arterioles of the heart. - Blocking of calcium channels in the myocardium, SA node, and AV node leads to decreased force of contraction, decreased heart rate, and slowing of the heart rate of conduction through the AV node. - These meds act on arterioles and the heart at therapeutic doses. - Veins are not significantly affected. - Therapeutic uses - Angina pectoris - Hypertension - Cardiac dysrhythmias (atrial fibrillation, atrial flutter, SVT) - Complications - Orthostatic hypotension and peripheral edema (observe for swelling, monitor BP/edema/weight; diuretic can be prescribed) - Constipation (primarily verapamil)(increase intake of high-fiber food and oral fluids) - Suppression of cardiac function (bradycardia and heart failure) - Dysrhythmias (QRS is widened, and QT is prolonged) - Acute toxicity (resulting in hypotension, bradycardia, AV block, and ventricular tachydysrhythmias - Contraindications/Precautions - Pregnant and lactating women - Verapamil is contraindicated in clients with hypotension, heart block, digoxin toxicity, and severe heart failure - Use cautiously in older clients who have kidney or liver disorders, mild to moderate heart failure or GERD - Interactions - Consuming grapefruit juice and verapamil or diltiazem can lead to toxicity (decreased BP, heart rate, and AV block) - Verapamil can increase digoxin levels, increasing the risk of digoxin toxicity. Digoxin can cause an additive effect and intensify AV conduction suppression. (monitor digoxin levels and vital signs for bradycardia and for manifestations of AV block) - Concurrent use of beta-blockers can lead to heart failure, AV block, and bradycardia. - Nursing Administration - For IV administration of verapamil, administer injections slowly over a period of 2 to 3 minutes. - Teach clients to monitor BP and HR, as well as keep BP record. With hold if pulse less than 50/min, and systolic less than 90 mm Hg. - Be sure to list other calcium channel blockers - Nifedipine, Amlodipine, Felodipine, Nicardipine, Isradipine, Nislodipine - - - - - Clonidine -- **Centrally acting alpha~2~ agonist** - Purpose - Pharm actions: These meds act within the CNS to decrease sympathetic outflow, resulting in decreased stimulation of the adrenergic receptors (both alpha and beta receptors) of the heart and peripheral vascular system. - A decrease in sympathetic outflow to the myocardium results in bradycardia and decreased cardiac output (CO). - A decrease in sympathetic outflow to the peripheral vasculature results in vasodilation, which leads to decreased blood pressure - Therapeutic use: - Primary hypertension (administered alone, with a diuretic, or with another hypertensive agent) - Severe cancer pain (administered parenterally by epidural infusion) - Management of ADHD - Investigational use: - Migraine headache - Flushing from menopause - Management of Tourette syndrome - Management of withdrawal from alcohol, tobacco, and opioids - Complications - Drowsiness and sedation (will diminish as use of med continues) - Dry mouth (usually resolves in 2 to 4 weeks) - Rebound hypertension if abruptly discontinued (discontinue over 2 to 4 days) - Contraindications/Precautions - Pregnant and lactating women - Avoid use of transdermal patch on affected skin in scleroderma and systemic lupus erythematosus - Contraindicated in clients who have a bleeding disorder or are on anticoagulants. - Use cautiously in clients who have had a stroke, asthma, COPD\< recent MI, diabetes, depressive disorder, or chronic kidney disease. - Interactions - Antihypertensive medications can have additive hypotensive effects. - Concurrent use of prazosin, MAOIs, and tricyclic antidepressants can counteract the antihypertensive effect of clonidine. (monitor BP) - Additive CNS depression can occur with concurrent use of other CNS depressants (alcohol). - Nursing Administration - Administer meds by oral, epidural, and transdermal routes (clonidine only) - Medication is usually administered twice a day in divided doses. Take larger doses at bedtime to decrease the occurrence of daytime sleepiness. - Transdermal patches are applied every SEVEN days. Apply on hairless intact skin on torso or upper arm. - Be sure to address the client's education  - - Metoprolol, Propranolol: **Beta-adrenergic blockers (sympatholytics)** - - a decreased heart rate, - decreased heart muscle contractility, - decreased rate of conduction through the AV node - Vasodilation and excretion of sodium from the reduced release of renin. - Primary hypertension (with long-term use causing a reduction in peripheral vascular resistance). - Chest pain and discomfort, tachydysrhythmias, heart failure, and myocardial infarction (aka heart attack) - Suppress reflex tachycardia due to vasodilators. - Other uses include hyperthyroidism, migraine headaches, pheochromocytoma, and glaucoma. - For Metoprolol and propranolol: - Bradycardia - Decreased cardiac output - AV block - Orthostatic hypotension - Rebound myocardium excitation (myocardium becomes sensitized to catecholamines with long-term beta blockers, so need to discontinue use of beta-blockers over 1 to 2 weeks). Specifically for propranolol, complications include: - Bronchoconstriction (avoid in clients with asthma) - Glycogenolysis is inhibited (the process of converting glycogen is impaired, so clients with Diabetes receive a beta1 selective agent). - - Pregnant and lactating women. - Clients who have an AV block and sinus bradycardia. - Nonselective beta-adrenergic blockers are contraindicated in clients who have asthma, bronchospasm, and heart failure. - Use cardio-selective beta-adrenergic blockers cautiously in clients who have asthma. - In general, use cautiously in clients who have myasthenia gravis (an autoimmune disorder), hypotension, peripheral vascular disease, diabetes, depression, in older adults, and those with a history of severe allergies. - Sympatholytics have interactions with: - Calcium channel blockers (verapamil and diltiazem) intensify the effects of beta blockers. Resulting in decreased heart rate, myocardial contractility, and rate of conduction through the AV node. - Concurrent use of antihypertensive medications with beta-blockers can intensify the hypotensive effects of both medications. - Specifically for propranolol, it can mask the hypoglycemic effect of insulin and prevent the breakdown of fat in response to hypoglycemia. - When administering, nurses need to make sure to - Administer medications orally, usually only once or twice a day. - Metoprolol and propranolol can be administered through IV. - Take with food to increase absorption - - The absence of chest pain - Absence of cardiac dysrhythmias - Normal blood pressure readings - Control of heart failure manifestations - Be sure to list other beta-adrenergic blockers (sympatholytic) - Other Beta-adrenergic blockers (or sympatholytic) are Atenolol and esmolol, which are cardio-selective, and Nadolol, which is nonselective. - **Be** sure to address client's education The nurses should educate the client on: - Not discontinuing the medication without consulting a provider - Avoid sudden changes in position to avoid orthostatic hypotension - Self-monitor heart rate and blood pressure at home, daily. - - Nitroprusside: centrally acting vasodilator. - - - Excessive hypotension - Cyanide poisoning/thiocyanate toxicity - Bradycardia, tachycardia, ECG changes - - Pregnant and lactating women - Clients who have heart failure with reduced peripheral vascular resistance or an AV shunt. - Use cautiously in clients who have liver and kidney disease, hypothyroidism, hypovolemia, fluid and electrolyte imbalances, and in older adults. - - - Prepare the medication by adding to diluent for IV infusion. - Note the color of the solution. It should be light brown in color and any other color solution needs to be discarded/ - Protect the IV container and tubing from light. - Discard the medication after 24hr. - Monitor Vital signs and ECG continuously. - - Decreased blood pressure and maintenance of normal blood pressure. - Improvement of heart failure (or ability to perform activities of daily living, improved breath sounds, and absence of edema) - Be sure to list other medications for hypertensive crisis Other medications for hypertensive crisis include Nitroglycerin, Nicardipine, Clevidipine, Enalaprilat, Esmolol, and Labetalol. ***[Cardiac Glycosides and Heart Failure]*** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Alpha1 receptors - Pharmacological action: Vasoconstriction - Therapeutic use: anaphylactic shock, slows absorption of local anesthetics, manages superficial bleeding, decreased congestion of nasal mucosa, increased blood pressure. - Beta1 receptors - Pharmacological actions: increased HR, increased myocardial contractility, increased rate of conduction through the AV node, increased cardiac output, improved tissue perfusion - Therapeutic use: treatment of [AV block, heart failure, shock, and cardiac arrest]. - Beta2 receptors - Pharmacological actions: bronchodilation - Therapeutic use: Asthma - - Hypertensive crisis, due to activation of Alpha1 receptors in the blood vessels, can lead to cerebral hemorrhage. - Cardiac complications and dysrhythmias are due to the activation of beta1 receptors in the heart. Beta1 receptor activation also leads to an increased workload on the heart and increases oxygen demand, leading to the development of angina. - Necrosis can occur from extravasation (leakage of fluid, such as blood, lymph, or other substances, from a blood vessel or other tube in the surrounding tissues) - - Pregnant (use only if the benefit outweighs the risk to the fetus) and lactating women (low dose safe) - Older clients have an increased risk of susceptibility to adverse effects - Epinephrine should be used with caution in clients who have hyperthyroidism, angina, cardiac dysrhythmias, and hypertension. - - MAOIs prevent the inactivation of epinephrine and prolong the effects of epinephrine. - Tricyclic antidepressants block the uptake of epinephrine, which will prolong and intensify the effects of epinephrine. - General anesthetics can cause the heart to become hypersensitive to the effects of epinephrine, leading to dysrhythmias. - - Meds must be administered IV by continuous infusion. Use IV pump to control infusion. - Dosage is titrated based on blood pressure response - Assess/monitor for chest pain. Notify provider if chest pain occurs. - Monitor urine output frequently for indications of decreased kidney perfusion - Monitor ECG and blood pressure continuously and notify the provider of any tachycardia or dysrhythmias. - Monitor perfusion to extremities - Monitor cardiac output, capillary wedge pressure, central venous pressure - Monitor client s who have diabetes for hyperglycemia while taking epinephrine. - - Depending on therapeutic intent, effectiveness is evidenced by improved perfusion as evidenced by urine output of greater than or equal to 30mL/hr (with adequate kidney function), improved mental status, and systolic blood pressure maintained at greater than or equal to 90 mm Hg. - Be sure to list other catecholamines - Dopamine and Dobutamine. Not in ATI, norepinephrine. - - - What information stands out about Dopamine?  Hint: This medication has a unique purpose, complications, and contraindications. - - Dopamine receptors in the kidney cause renal blood vessels to dilate, increasing renal perfusion (blood flow through kidneys) and reducing the risk of renal failure. - Low dose: dopamine receptors - Pharm action: renal blood vessel dilation - Therapeutic use: shock, heart failure, acute kidney injury - Moderate dose: beta1 receptor - Pharm action: renal blood vessel dilation, increased HR, increased myocardial contractility, increased rate of conduction through the AV node. - Therapeutic use: shock and heart failure - High dose: dopamine, beta1, & alpha1 receptors - Pharm action: renal blood vessel dilation, increased HR, increased myocardial contractility, increased rate of conduction through the AV node, vasoconstriction, and mydriasis - Therapeutic action: shock and heart failure - - [Cardiac complications:] beta1 receptor activation in the heart can cause dysrhythmias. Beta1 receptor activation also increases the heart\'s workload and oxygen demand, leading to the development of angina. - Necrosis: can occur from extravasation of high doses of dopamine - - Dopamine is contraindicated in clients who have tachydysrhythmias and ventricular fibrillation - Use dopamine cautiously in clients who have hypovolemia, angina, a history of myocardial infarction, hypertension, and diabetes. - What information stands out about Dobutamine?  Hint: This medication has a unique purpose, complications, and contraindications. - - Beta1 receptors - Pharm action: increased HR, increased myocardial contractility and cardiac output, and increased rate of conduction through the AV node. - Therapeutic action: heart failure - - Increased heart rate, provide continuous cardiac monitoring, report vital sign changes to provider - - Dobutamine is contraindicated in clients who have tachydysrhythmias and ventricular fibrillation ***[Angina and Antilipemic Agents]*** - - - - In chronic stable exertional angina, nitroglycerin dilates veins and decreases venous return (preload), which decreases cardiac oxygen demand. - In variant angina, nitroglycerin prevents or reduces coronary artery spasms, thus increasing the oxygen supply. Oxygen demand is not decreased. - - Treatment of acute angina attack - Prophylaxis of chronic stable angina or variant angina - - Headache (use aspirin or acetaminophen for relief) - Orthostatic hypotension - Reflex tachycardia - Tolerance - Contraindications - Pregnant or lactating women - Contraindicated in clients who have hypersensitivity to nitrates. - Contraindicated in clients who have [severe anemia], [closed-angle glaucoma], and [traumatic head injury] because the medication can increase intracranial pressure. - Use caution in clients taking antihypertensive meds and clients who have hyperthyroidism or kidney or liver dysfunction - Inhibitors of phosphodiesterase type 5 (PDES5) for erectile dysfunction administered with nitroglycerin can intensify the nitroglycerine-induced vasodilation and result in life-threatening hypotension. - Interactions - The use of alcohol can contribute to the hypotensive effect of nitroglycerin - Antihypertensive medications (beta-blockers, calcium channel blockers, and diuretics) can contribute to the hypotensive effects. - Nursing Administration  - Oral: slow onset and long duration - Used to treat long-term prophylaxis against anginal attacks - Sublingual tablet and translingual spray: rapid onset and short duration - Used to treat acute attack or prophylaxis of acute attack when exertion is anticipated. - Topical: slow onset and long duration - Used for long-term prophylaxis against anginal attacks - Remove the prior dose before the new dose is applied, measure the specific dose with applicator paper, and spread it over 2.5-3.5 inches of paper. Apply to a hairless area of the body and cover with plastic wrap. Avoid touching with hands. - Transdermal patch: slow onset and long duration - Used for long-term prophylaxis against anginal attacks - Do not cut patches; place on hairless areas, wash skin with soap and water, and dry before placing the new patches. Remove the patch at night to avoid developing tolerance to nitroglycerin (be med-free between 10 to 12hrs a day) - IV - Used to control angina not responding to other meds - Control of hypertension during the perioperative period creates controlled hypotension during surgery, - Used in heart failure resulting from acute MI. - Start slow (5mg/min), and titrate gradually until the desired response is achieved or for a maximum of 2 mcg/min. - Treatment of anginal attack using sublingual tablets or translingual spray - Stop activity or lie down - Immediately put one tablet under the tongue - If not relieved, call 911 and take a second tablet - If not relieved, take a third but no more than 3 tablets. - If using a spray, translate to the same use. - Nursing Evaluation of Medication Effectiveness  - Depending on therapeutic effects, effectiveness is evidenced by: - Prevention or termination of acute anginal attacks - Long-term management of stable angina - Control of preoperative blood pressure - Control of heart failure following acute MI - Be sure to address the client's education  - Sit or lie down if experiencing dizziness or faintness. - Lie down with feet elevated to promote venous return and increase blood pressure. - Monitor vital signs. - Avoid use of alcohol - Use rapid-acting nitrate at the first sign of chest pain, do not wait until pain is severe. - Do not stop taking long-acting nitroglycerin abruptly and follow the provider's instructions. - If having angina, record pain frequency, intensity, duration, and location. Notify the provider if attacks increase in frequency, intensity, and /or duration. - Do not crush or chew oral nitroglycerin or isosorbide tablets because sublingual nitroglycerin is ineffective if swallowed. - Atorvastatin -- **HMG -CoA reductase Agents** - Purpose - Pharm action - Decrease the manufacture of LDL and VLDL cholesterol - Lowers triglycerides in some clients - Increase the manufacture of HDL - Other beneficial effects include the promotion of vasodilation, decrease in plaque site inflammation, thromboembolism, and risk of atrial fibrillation - Therapeutic Uses - Primary hypercholesterolemia - Prevention of coronary events (primary and secondary) - Protection against myocardial infarction (MI) and stroke for clients who have diabetes mellitus - Increasing levels of HDL in clients who have primary hypercholesterolemia - Primary prevention in clients who have normal LDL - Complications - Hepatotoxicity (evidenced by increase in aspartate transaminase \[AST\]) (obtain baseline liver function and monitor liver function after 12 weeks and then every 6 months. Discontinue if abnormal liver tests) - Myopathy (evidenced by muscle aches, pain, and tenderness) (obtain baseline creatine kinase \[CK\] level. advise clients to report muscle aches and pain) - Contraindications/Precautions - Pregnant, lactating, and reproductive women - Contraindicated for clients with liver disease - For clients of Asian descent, rosuvastatin should be avoided or prescribed in a smaller dose than for other clients. - Use caution in clients who have had liver disease. Reduce dosage for clients who have severe kidney injury. - Interactions - Fibrates (gemfibrozil, fenofibrate) and ezetimibe increase the risk of myopathy and liver and kidney injury. (obtain baseline CK levels and monitor Ck, liver enzymes, and kidney function periodically during treatment) - Medications that suppress CYP3A4 (erythromycin and ketoconazole), along with HIV protease inhibitors, amiodarone, and cyclosporine, can increase the levels of some statins when taken concurrently (avoid concurrent use with atorvastatin. Lovastatin, and simvastatin, the dosage of statin may need to be decreased). - Grapefruit juice suppresses CYP3A4 and can increase levels of some statins. (avoid concurrent use with atorvastatin, lovastatin, and simvastatin) - Nursing Administration - Administer statins via ORAL route - Administer lovastatin with evening meal (others without food, but the evening is good for cholesterol synthesis at night). - Be sure to list other HMG-COA reductase inhibitors (statins) - Simvastatin, lovastatin, Pravastatin, Rosuvastatin, Fluvastatin, Pitavastatin - Combo meds: Simvastatin and ezetimibe - - - Gemfibrozil - **Fibrates** - Purpose - Pharm action: - Decrease in triglyceride levels (increase in VLDL excretion for clients unable to lower triglyceride levels with lifestyle modification or other antilipemic medications) - Increase in HDL levels by promoting the production of precursors to HDLs - Therapeutic uses: - Reduction of plasma triglycerides (VLDL) - Increase levels of HDL - Complications - Gi distress (mild and self-limiting usually) - Gallstones (observe for indications \[RUQ pain, fat intolerance, bloating\]) - Myopathy or muscle tenderness and pain (obtain baseline CK level, monitor CK levels periodically, monitor for muscle pain and weakness. Stop if CK levels are elevated) - Hepatotoxicity (obtain baseline liver function tests and monitor periodically, top if elevated) - Contraindications/Precautions - Pregnant, lactating, and reproductive-capable women - Contraindicated for clients with liver disease - Interactions - Concurrent use of warfarin increases the risk of bleeding. (obtain baseline prothrombin time \[PT\] and INR and monitor periodically. The client reports indications of bleeding). - Statins increase the risk of myopathy (avoid concurrent use) - Nursing Administration - Administer orally. - - ***[Affecting Cardiac Rhythm]*** *These meds act by altering cardiac electrophysiologic function to treat or prevent dysrhythmias.* - Amiodarone -- **Potassium Channel blockers (Class III)** Prolongs the action potential and refractory period of the cardiac cycle. - Purpose - Pharm action: - Delays repolarization - Prolongs action potential - Reduced automaticity in the SA node - Reduced contractility and conduction in the AV node, ventricles, and His-Purkinje system - Dilates coronary blood vessels - Therapeutic uses: - Conversion of atrial fibrillation: oral route - Recurrent ventricular fibrillation - Recurrent ventricular tachycardia - Atrial flutter using dronedarone, sotalol (also a beta blocker), dofetilide, and ibutilide - Complications - Pulmonary toxicity (obtain a baseline chest x-ray and pulmonary function test, continue to monitor pulmonary function) (observe for dyspnea, cough, and chest pain) - Sinus bradycardia and AV block can lead to heart failure (monitor BP and ECG, monitor for indication of heart failure) - If AV block occurs, meds need to be discontinued; insert a pacemaker if indicated. Discontinue med if indicated. - Visual disturbances (photophobia, blurred vision, can lead to blindness) - Other - Liver and thyroid dysfunction. GI disturbances, CNS effects, photosensitivity, and blue-gray discoloration of the skin. - Phlebitis with IV administration (use of central venous catheter is indicated. - Hypotension, bradycardia, AV block (monitor cardiac status and BP) - Contraindications/Precautions - Pregnant and lactating women - Contraindicated in newborns, infants, and clients who have AV block and bradycardia. - Use cautiously in clients who have liver, thyroid, or respiratory dysfunction, heart failure, and fluid and electrolyte imbalances. - Interactions - Amiodarone can increase plasma levels of quinidine, procainamide, digoxin, diltiazem, and warfarin. - **Cholestyramine, St. John's wort, and rifampin** decrease the level of amiodarone. - Diuretics, other antidysrhythmic, and antibiotics (erythromycin, azithromycin) can increase the risks of dysrhythmias. - Concurrent use of beta-blockers, verapamil, and diltiazem can lead to bradycardia. - Amiodarone can increase digoxin level - Consuming grapefruit juice can lead to **toxicity**. - Nursing Administration - Amiodarone is **highly toxic.** Monitor closely for adverse effects (lung injury, visual impairment). - Oral or IV - Obtain baseline ECG, eye examination, chest x-ray, potassium and magnesium levels, and tests for thyroid, pulmonary, and liver function. - Provide clients with written information regarding potential toxicities. - Client education - Adverse effects can continue for weeks or months after the medication is discontinued. - Adenosine -- **Other med(?)** - Purpose - Pharmacological action: - decrease electrical conduction through the AV node and decrease automaticity in the SA node. - Therapeutic use: - Paroxysmal SVT (an irregular heartbeat that originates in the heart\'s upper chambers). - Complications - Sinus bradycardia, hypotension, dyspnea, and vasodilation (monitor ECG; effects usually last 1 min or less; administer IV bolus, monitor for manifestations). - Contraindications/Precautions - Pregnant and Lactating women - Contraindicated in clients who have second- and third-degree heart block, AV block, atrial flutter, and atrial fibrillation. - Use cautiously in older adults and clients with asthma. - Interactions - Methylxanthines, such as theophylline and caffeine, block adenosine receptors, preventing therapeutic effects. - Theophylline and aminophylline decrease the effect of adenosine. - Cellular uptake of dipyridamole is blocked, leading to intensification of effects of adenosine. - Nursing Administration - Adenosine has a very short half-life, so adverse reactions are mild and last for less than 1 minute. - The administration should be by **IV BOLUS,** flushed with saline the following administration. - Administer an IV bolus through an IV lone close to the heart because the **half-life is approximately 1.5 to 10 seconds.** *[Medications **Affecting Coagulation**]* *These meds are used to prevent clot formation or break apart an existing clot. These meds work in the blood to alter the clotting cascade, prevent platelet aggregations, or dissolve a clot. All carry a significant risk of bleeding.* *The goal is to increase circulation and perfusion, decrease pain, and prevent further tissue damage.* - Heparin - **Anticoagulant** - Purpose - Pharm actions: - Heparin prevents clotting by activating **antithrombin,** thus indirectly inactivating both thrombin and factor Xa. **This inhibits fibrin formation**. - Therapeutic uses: - Conditions necessitating prompt anticoagulant activity (evolving stroke, pulmonary embolism \[PE\], massive deep-vein thrombosis) - An adjunct for clients having open heart surgery or dialysis - Low-dose therapy for prophylaxis against postoperative venous thrombosis (for example, Hip/knee or abdominal surgery). - Treatment of disseminated intravascular coagulation - Complications - Heparin toxicity - Administer protamine (the antidote), which should be given slowly. - Hemorrhage secondary to heparin toxicity or other factors - This can occur if medication administration leads to high-activated partial thromboplastin time. Other risk factors include a client\'s history of a bleeding disorder or taking antiplatelet medications concurrently. - Monitor vital signs and advise clients to observe for bleeding, increased HR, decreased BP, and bruising: Petechiae, hematomas, and black tarry tools. - Monitor activated partial thromboplastin time (aPTT) and keep the value at 1.5 to 2 times the baseline. - Epidural or spinal hematoma - The risk of hematoma at the puncture site for spinal or epidural medication administration is increased when taking heparin. - Heparin-induced thrombocytopenia - This is evidenced by low platelet count and increased development of thrombi, mediated by antibody development (white clot syndrome) - Stop heparin if the platelet count is less than 100,000/mm^3^ - Hypersensitivity reactions (chills, fever, urticaria) - Administer a small test dose prior to the administration of heparin. - Contraindications/Precautions - Pregnant and lactating women should be used with caution. - Contraindicated in clients with low platelet counts (thrombocytopenia) or uncontrolled bleeding. - Should not be used following surgeries of the eye(s), brain, spinal cord, lumbar puncture, or regional anesthesia. - Use cautiously in clients who have hemophilia, increased capillary permeability, dissecting aneurysm, peptic ulcer disease, severe hypertension, hepatic or kidney disease, or threatened abortion. - Heparin and LMWH are used during pregnancy if an anticoagulant is desired. - Interactions - Antiplatelet agents (aspirin, NSAIDs, and other anticoagulants) can increase the risk of bleeding. Resveratrol and saw palmetto can also have antiplatelet effects. - Garlic, ginger, glucosamine, or ginkgo biloba can increase the risk of bleeding. - Nursing Administration - Obtain baseline vital signs - Obtain and monitor aPTT, platelet count, and hematocrit levels - Read labels carefully. [Heparin is dispensed in units] and in a variety of concentrations. - Check doses with another nurse before administration - Use an infusion pump for continuous IV administration - Monitor rate every 30 -- 60 minutes - Monitor aPTT every 4 to 6 hours until the appropriate dose is determined. - Administer deep subcutaneous injections in the abdomen, ensuring 2 inches from the umbilicus. Do not aspirate. - Advise clients to use an electric razor for shaving and a soft toothbrush. - Nursing Evaluation of Medication Effectiveness - aPTT levels of 60 to 80 seconds during treatment - No development or no further development of venous thrombi or emboli - - - - - - - - Enoxaparin -- **Low molecular weight (LMW) heparin** - Purpose - Pharm actions - LMW heparins and activated factor Xa inhibitors only inactivate factor Xa. - Therapeutic actions: - Prevent deep-vein thrombosis (DVT) in clients who are postoperative - Treat DVP and PE - Prevent complications in angina, non-Q wave MI, and ST elevation MI. - Complications - Hemorrhage -- (monitor vital signs and platelet count) - Neurologic damage from hematoma formed during spinal or epidural anesthesia (asses insertion site for indications of hematoma formation \[redness and swelling\] - Heparin-induced (immune-mediated) thrombocytopenia (monitor platelets) - Toxicity (administer protamine (**heparin antagonist)** - Contraindications/Precautions - Pregnant and lactating women - Caution in clients who have prosthetic heart valves - Contraindicated in clients who have low platelet counts (thrombocytopenia) or uncontrolled bleeding - Should not be used following surgeries of the eye(s), brain, spinal cord, lumbar puncture, or regional anesthesia. - Use cautiously in clients who have hemophilia, increased capillary permeability, dissecting aneurysm, peptic ulcer disease, severe hypertension, hepatic or kidney disease, or threatened abortion. - Heparin and LMWH are used during pregnancy if an anticoagulant is desired. - Interactions - Antiplatelet agents (aspirin, NSAIDs, and other anticoagulants) can increase the risk of bleeding. Resveratrol and saw palmetto can also have antiplatelet effects. - Garlic, ginger, glucosamine, or ginkgo biloba can increase the risk of bleeding. - Nursing Administration - Monitoring is not required, safe for home use - Provide instruction for self-administration; meds are available in prefilled syringes in various doses. (25 to 31 gauge, 3/8 to 5/8 length needle. Deep subcutaneous injection). - Rotate sites - Do not rub the site - Nursing Evaluation of Medication Effectiveness - No development or no further development of venous thrombi or emboli. - - - - - - - - Warfarin -- **Vitamin K inhibitors (Coumarins)** - Purpose - Pharm action: - Antagonizes vitamin K, thereby preventing the synthesis of four coagulation factors: factors VII, IX, X, and prothrombin. - Therapeutic uses: - Prevention of venous thrombosis and PE (pulmonary embolism) - Prevent thrombotic events for clients with atrial fibrillation or prosthetic heart valves. - Reduction of the risk for recurrent transient ischemic attacks or myocardial infarction. - Complications - Hemorrhage (monitor vital signs and observe for bleeding) - Hepatitis (monitor liver enzymes. Assess for jaundice) - Toxicity (administer vitamin K~1~ antidote) - Contraindications/Precautions - Pregnant and reproductive-capable women - \*\*\*SAFE for lactating women - Contraindicated in clients who have low platelet counts (thrombocytopenia) or uncontrolled bleeding. - Should not be used following surgeries of the eye(s), brain, spinal cord, lumbar puncture, or regional anesthesia. - Use cautiously in clients who have hemophilia, increased capillary permeability, dissecting aneurysm, peptic ulcer disease, severe hypertension, hepatic or kidney disease, or threatened abortion. - Contraindicated for clients who have vitamin K deficiencies, liver disorder, and alcohol use disorder for risk of bleeding. - Interactions - Concurrent use of heparin, aspirin, acetaminophen, glucocorticoids, sulfonamides, and parenteral cephalosporins increases the effects of warfarin. (avoid if possible or monitor carefully for bleeding and increased PT, INR, and aPTT levels) - Concurrent use of phenobarbital, carbamazepine, phenytoin, oral contraceptives, and vitamin K decreases anticoagulant effects (avoid concurrent use, and if not, monitor carefully for reduced PT and INR) - Foods high in Vitamin K (green leafy veggies, cabbage, broccoli, Brussels sprouts, mayo, canola, and soybean oil) can decrease anticoagulant effects. - Reserveratol and saw palmetto increased the risk of bleeding through antiplatelet effects. CoQ-10 can decrease warfarin's effectiveness due to a similar structure in vitamin K. - Feverfew, garlic, ginger, glucosamine, or ginkgo biloba can increase the risk of bleeding. - Multiple other medications interact with warfarin - Nursing Administration - Administrations are usually oral once daily and at the same time each day. - Obtain baseline vital signs. - Monitor PT (prothrombin Time \[to clot\] )(therapeutic levels 18 to 24 seconds) and INR levels (therapeutic levels 2 to 3 \[how long blood takes to clot\]). INR is the most accurate; hold the dose and notify the provider if levels exceed therapeutic levels. - Obtain baseline and monitor CBC, platelet count, and Hct levels. - Plan for frequent PT monitoring for clients who are prescribed medications that interact with warfarin. The most significant risk for harm when interacting with medication is being deleted or added. - Be prepared to minister vitamin K1 for warfarin toxicity - Nursing Evaluation of Medication Effectiveness - Depending on therapeutic intent, effectiveness can be shown by: - PT 1.5 to 2 times control - INR of 2 to 3 for treatment of acute myocardial infarction, atrial fibrillation, venous thrombosis, or tissue heart valves - INR of 2.5 to \_\_ for treatment of a PE - INR of 3 to 4.5 for mechanical heart valve or recurrent systemic embolism - No development or no further development of venous thrombi. - Be sure to address the client's education.  - Anticoagulant effects can take 8 to 12 hrs., and full therapeutic effect is not achieved for 3 to 5 days. If in the hospital setting, [continued heparin infusion is needed when starting oral warfarin.] - Anticoagulation effects can persist for up to 5 days following discontinuation of medication due to long half-life. - Avoid alcohol and OTC and nonprescription meds to prevent adverse effects and medication interactions (risk of bleeding) - Prevent thrombi by avoiding sitting for prolonged periods of time, not wearing constricting clothing, and elevating and moving legs when sitting. - Wear a medical alert bracelet indicating warfarin use - Record dosage, route, and time of warfarin administration on a daily basis. - Use a soft-bristle toothbrush to prevent gum bleeding and an electric razor for shaving. - Follow up with the provider for regular PT and INR monitoring or monitor the INR at home. - - - - - - - Clopidogrel -- **Antiplatelet/ ADP inhibitors** - Purpose - Pharm action: - Antiplatelets prevent platelets from clumping together by inhibiting enzymes and factors that normally lead to arterial clotting. - Antiplatelet medications inhibit platelet aggregation at the onset of the clotting process. These medications alter bleeding time. - Therapeutic uses: - Primary prevention of acute myocardial - Prevention of infarction in clients following an acute myocardial infarction - Prevention of ischemic stroke or transient ischemic attack - Acute coronary syndrome (clopidogrel) - Intermittent claudication - Complications - Bleeding (prolonged, gastric bleed, thrombocytopenia) \[monitor for bruising\] - GI effects (diarrhea, dyspnea, pain) - Contraindications/Precautions - Pregnant: use only if needed - Lactating: contraindicated, breast-feeding clients should not take. - Reproductive: notify the provider if pregnancy is suspected or planned. - Clients who have thrombocytopenia or a history of bleeding due to peptic ulcer disease and severe kidney or hepatic disorder. - Interactions - Concurrent use of other meds that enhance bleeding (NSAIDs, heparin, warfarin, thrombolytics, antiplatelets) increases the risk of bleeding. - Proton pump inhibitors or other medications that inhibit CYP2C19 (fluoxetine, fluconazole, etravirine, felbamate) decrease effectiveness, - Nursing Administration - Clopidogrel is sometimes prescribed concurrently with aspirin, which increases the risk of bleeding. - Clopidogrel should be discontinued 5 to 7 days before an elective surgery. - Nursing Evaluation of Medication Effectiveness - Depending on the intended therapeutic effect, effectiveness can be seen by the absence of arterial thrombosis, adequate tissue perfusion, and blood flow without the occurrence of abnormal bleeding. - Alteplase- **Thrombolytic medication,** often called tPA (tissue plasminogen activator) - Purpose - Pharm action - Thrombolytic meds dissolve clots that have already formed. Clots are dissolved by converting plasminogen to plasmin, which destroys fibrinogen and other clotting factors. - Therapeutic uses: - Treat myocardial infarction - Treat massive PE (\*\*alteplase) - Treat acute ischemic stroke (\*\*alteplase) - Restore patency to central IV catheters (\*\*alteplase) - Complications - Bleeding (internal GI or GU and cerebral bleeding) - Superficial bleeding from wounds, IV catheter sites - Limit venipunctures and injections - Monitor vital signs, aPTT, PT, Hgb, and Hct. - It might require blood replacement treatment. - For severe bleeding, fibrinolysis following alteplase can be reversed by administration of aminocaproic acid IV. - Contraindications/Precautions - Not for pregnant and/or lactating women - Because of additive bleeding, contraindicated for clients who have: - Any prior intracranial hemorrhage (hemorrhagic stroke) - Known structural cerebral lesion (arteriovenous malformation, neoplasm) - Active internal bleeding - Ischemic stroke in the past 3 months other than the current episode (4.5 hours) - Use cautiously in clients who have severe or uncontrolled hypertension, cerebral disorders, bleeding within 2 to 4 weeks, active peptic ulcer, or presence of vascular punctures that cannot be compressed and in older clients. - Interactions - Concurrent use of other meds that enhance bleeding (NSAIDs, heparin, warfarin, thrombolytics, antiplatelets) increases the risk of bleeding. - Nursing Administration - IV ONLY - Use of thrombolytic agents should take place as soon as possible after onset of manifestations (within 3 hours is best). - Clients receiving a thrombolytic agent should be monitored in a setting that provides for close supervision and continuous monitoring during and after the administration of the medication. - Obtain the client's weight to calculate dosage. Obtain baseline platelets, hemoglobin (Hgb), hematocrit (Hct), aPTT, PT, INR, and fibrinogen levels. Monitor periodically. - Obtain baseline vitals (HR, BP) and monitor frequently. - Nursing care includes continuous monitoring of hemodynamic status to assess for therapeutic and adverse effects of thrombolytics (relief of chest pain and indications of bleeding). - Ensure adequate IV access for administration of emergency meds and availability of emergency equipment. - DO NOT MIX ANY meds in an IV with thrombolytic agents. - Limit skin punctures (IM and IV). Hold direct pressure to the injection site for 30 minutes or until oozing stops. - Discontinue of life-threatening bleeding occurs. - Following thrombolytic therapy, administer heparin or aspirin as prescribed to decrease the risk of rethrombosis. - Following thrombolytic therapy, administer beta-blockers as prescribed to decrease myocardial oxygen consumption and to reduce the incidence and severity of reperfusion arrythmias. - Administer H~2~ antagonists (cimetidine) or proton pump inhibitors (omeprazole) as prescribed to prevent GI bleeding. - Nursing Evaluation of Medication Effectiveness - Depending on intent, effectiveness can be shown by thrombosis lysis and restoration of circulation (relief of chest pain, reduction of initial ST segment injury pattern as shown on ECG 60 to 90 min after start of therapy). ***[Growth Factors]*** *Blood cells and platelets are produced in the body by the biological process of hematopoiesis. In the body, this process is naturally controlled by hormones, also known as hematopoietic growth factors.* - Epoetin alfa: **Erythropoietic Growth Factors-** AKA erythropoietin - Purpose - Pharm action - Hematopoietic growth factors act on the bone marrow to increase the production of red blood cells. - Therapeutic uses: - Anemia related to chronic disease - Clients who have anemia caused by chemotherapy (non-myeloid cancers) - To increase erythrocyte counts in clients who will undergo elective surgery - Clients who have anemia caused by taking zidovudine for HIV/AIDS - Complications - Hypertension (secondary to elevations in hematocrit level) - Monitor Hgb levels and blood pressure. If elevated, administer antihypertensive medications. - Risk for thrombotic event - Such as MI or stroke if the client has a Hgb of 11 g/dL or higher or an increase of more than 1 g/dL in 2 weeks. Seizures can also occur with too rapid a rise in blood counts. - Deep-vein thrombosis - Headache and body aches - Report frequent or severe headaches to the provider. Hypertension can be the cause. - Contraindications/Precautions - Pregnant: use ONLY when benefits outweigh risks to the fetus. - Lactating: SAFE - Contraindicated in clients who have uncontrolled hypertension - Contraindicated in some cancers due to possible tumor growth. - Interactions - - Nursing Administration - Obtain baseline BP. In clients who have chronic kidney disease, control hypertension before starting. - Monitor BP frequently because adjustments in antihypertensive medication can also be required as treatment progresses. - Administer by subcutaneous or IV Bolus injection. Dosage is based on the client\'s weight. - Do not mix the medication with any other med in the syringe. - Dosing is usually 3 times per week but can be once because of chemo. - Monitor iron levels and ensure iron stays in a constant range. RBC growth depends on adequate quantities of iron, folic acid, and vitamin B12. - Monitor Hbg and Hct once weekly (darbepoetin) or at least twice per week (erythropoietin until they reach the target range. - Ensure clients receive the FDA's risk evaluation and mitigation strategy medication guide that explains the risks and benefits of ESAs - Nursing Evaluation of Medication Effectiveness - Effectiveness can be evidenced by an Hgb level of 10 to 11 g/DL and a maximum Hct of 33%. - Filgrastim - Purpose - Pharm action: - Leukopoietic growth factors stimulate the bone marrow to increase production of neutrophils. - Therapeutic uses: - Decrease the risk of infection in clients who have neutropenia (low neutrophil count) from cancer and other conditions. - To build up numbers of hematopoietic stem cells prior to harvesting for autologous transplant. - Complications - Elevation of plasma uric acid, lactate dehydrogenase, and alkaline phosphate (usually moderate and reverse spontaneously) - Bone pain (administer acetaminophen, opioid analgesic if acetaminophen is not effective). - Leukocytosis - Monitor WBCs two times per week during treatment. - Decrease dose or interrupt treatment if WBC is greater than 100,00/mm3 or neutrophil count exceeds 10,000/mm3. - Splenomegaly and risk of splenic rupture - With long-term use. evaluate reports of LUQ abdominal pain or shoulder tip pain. - Contraindications/Precautions - Pregnant women: when benefits outweigh risks to the fetus - Lactating women: use with caution - Contraindicated in those who are sensitive to Escherichia coli protein - Use cautiously in clients who have cancer of bone marrow, sickle cell, or respiratory disease in clients who are breastfeeding and in children. - Interactions - - Nursing Administration - Administer via intermittent bolus, continuous IV, subcutaneous infusion, or subcutaneous injection. - Do not agitate a vial of medication, and do not mix it with other meds. - Monitor CBC two times per week. - Nursing Evaluation of Medication Effectiveness - Depending on therapeutic intent, effectiveness can be evidenced by the following: - Absence of infection - WBC count and differential within expected reference ranges. ***[Blood and Blood Products]*** - Whole blood -- - Purpose - Expected pharm action: - Increases circulating blood volume - Therapeutic uses: - Replacement therapy for acute blood loss secondary to traumatic injuries or surgical procedures - Volume expansion in clients who have extensive burn injury, dehydration, shock - Complications - Acute hemolytic reaction (chills, fever, low back pain, tachycardia, tachypnea, hypotension) - Febrile nonhemolytic reaction - Anaphylactic reaction (anxiety, urticaria, wheezing, shock, cardiac arrest) - Mild allergic reaction (flushing., itching, urticaria) - Circulatory overload 9cough, shortness of breath, hypertension, tachycardia, distended neck veins) - Hyperkalemia - due to lysis of blood cells (bradycardia, hypotension, irregular heartbeat, paresthesia of extremities, muscle twitching, potassium level 5.0 mEq/L or greater) - Transfusion-associated graft-versus-host disease (rare, occurring 1 to 2 weeks following transfusion). - Sepsis (rapid onset of chills, fever, vomiting, diarrhea, hypotension, and shock) - Contraindications/Precautions - Contraindicated in clients with hypersensitivity reactions - Respect the client\'s cultural or religious values regarding blood transfusion. In some cases, infusing colloids and other plasma expanders can be acceptable when whole blood is not allowed. - Nursing Administration - Obtain baseline lab values: Hgb, Hct, platelet count, total protein, albumin levels, PT, PTT, fibrinogen, potassium, pH, and blood calcium. - Prior to the start of the transfusion, assess lab values and blood transfusion history, verify the prescription, and ensure the client has signed consent for transfusion. - Assess for fluid risk overload; a diuretic can be prescribed between units for clients at risk for fluid overload. - Obtain baseline vitals before transfusion. Stay with the client and monitor vitals per facility policy for 15 to 30 minutes and then at least hourly till completed. - Use 20 gauge or larger IV catheters to avoid hemolysis of blood cells. - Obtain blood just before beginning transfusion (at least 4 hrs). - Carefully perform all safety checks. - Use only 0.9% sodium chloride solution to administer with blood products: prime IV and blood tubing with this solution. Use a blood filter for most products and either a Y-type or straight tubing set, depending on facility policy. CHANGE TUBING after EVERY 2 UNITS to prevent sepsis. - Document blood product type, blood bank number of product, total volume infused, time of start and completion of transfusion, vital signs, and any adverse effects, as well as actions taken. - Observe universal precautions during the handling and administration of blood products. - Do not administer blood products with any other MEDS - Be sure to address blood typing and crossmatching -