NURS3415 Pharmacological Concepts PDF

**NURS3415 Pharmacological Concepts** **Module 2B** **Didactic Learning Guide** ***[Elimination]*** *[ATI RN Pharmacology for Nursing Text - Unit 4 Medications Affecting the Cardiovascular System]* *[Chapter 18 Medications **Affecting Urinary Output**]* - Furosemide -- **High ceiling loop di...

**NURS3415 Pharmacological Concepts** **Module 2B** **Didactic Learning Guide** ***[Elimination]*** *[ATI RN Pharmacology for Nursing Text - Unit 4 Medications Affecting the Cardiovascular System]* *[Chapter 18 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]*** *[ATI RN Pharmacology for Nursing Text - Unit 4 Medications Affecting the Cardiovascular System]* *[Chapter 19 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  - A - 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. *[Chapter 20 **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 *[Chapter 21 **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. - - *[Chapter 22 Medications **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.**