Sean Whitfield - NURS 3210 Active Learning Guide - Module 3 - CV Agents_ Part 1- Revised 1_7_24 - Complete.pdf

NURS 3210 Pharmacology and Nursing Active Learning Guide- Module 3- Medications Affecting and Protecting the CV System, Pa...

NURS 3210 Pharmacology and Nursing Active Learning Guide- Module 3- Medications Affecting and Protecting the CV System, Part 1 Purpose/Overview Active learning guides help students to focus their study time. They include knowledge level questions as well as those focusing on the application and analysis of information to provide greater context in relation to the course and career skills. Students should review the active learning guide before beginning to engage with the module content, then work to complete the guide during and after engaging with the content. An active learning guide is not the same as a study guide or a test blueprint. It serves as a guide to help the student navigate course or module content. Instructions Quickly review the active learning guide (ALG) before you begin reading and engaging with other content in the module. Looking at the questions beforehand will provide a preview of the information you should be alert to as your work through your reading or module resources. As you work through the module content, complete the active learning guide, topic-by-topic. You should use the resources provided and linked on the “Prepare” page in Canvas as the primary source for answering the questions in the active learning guide. Specific Agents for Module 3 1. Fill in the table with the drug’s classification/s. The drugs in the table are those you will be asked about on quizzes and exams. Keep in mind your assigned reading may include information about individual agents not listed here. You can check your work in the practice activity (flashcards) for each module. Common endings or other clues about the drug’s classification are italicized. Antihypertensives, Heart Failure, and Diuretics (Ch. 22, 24, 28): Agent Name Classification Agent Name Classification Agent Name Classification Lisinopril Angiotensin- Prazosin Antihypertens Dobutamine Aldosterone  NURS 3210 Pharmacology and Nursing Agent Name Classification Agent Name Classification Agent Name Classification Converting ive Drugs Antagonists Enzyme Inhibitors Spironolactone Aldosterone Mannitol Diuretic Digitalis Cardiac Glycosides Antagonists Dopamine Aldosterone Nitroprusside Vasodilators Atenolol Adrenergic Drugs Antagonists Amlodipine Calcium Acetazolamide Diuretic Epinephrine Adrenergic Drugs Channel Blockers Milrinone Phosphodieste Metoprolol Beta Blockers Nesiritide Diuretic rase Inhibitors Norepinephrine Adrenergic Clonidine Adrenergic Furosemide Diuretic Drugs Drugs Digibind Antidote Carvedilol Adrenergic Losartan Angiotensin II Drugs Receptor Blockers Hydrochlorathiazide Diuretic (HCTZ) Reading: Chapter 22 (Antihypertensives), Antihypertensives Article, JNC 8 Guidelines & Chapter 24 (Heart Failure) and CHF Articles 1. Most patients do not experience any indications of blood pressure elevation until they begin to have signs of end organ damage. Describe the effects of damage that can occur to the following organs, if hypertension goes untreated: a. Eyes: Vision loss. Retinopathy. b. Heart: Coronary Artery Disease. Left Ventricular Hypertrophy. Heart Failure. Arrhythmias. c. Brain: Stroke. Cognitive Decline/Dementia. Intracerebral Hemorrhage. Transient Ischemic Attacks. d. Kidneys: Glomerulosclerosis. Chronic Kidney Disease. Renal Artery Stenosis. End Stage Renal Disease.  NURS 3210 Pharmacology and Nursing 2. According to the JNC 8 Guidelines diabetic patients both with and without hypertension should be treated with ACEs and ARBs, why is this? ACE inhibitors also have been shown to have a protective effect on the kidneys, because they reduce glomerular filtration pressure. For this reason, they are among the cardiovascular drugs of choice for diabetic patients. Numerous studies have shown that the ACE inhibitors reduce proteinuria, and they are considered by many to be standard therapy for diabetic patients to prevent the progression of diabetic nephropathy. 3. Based on the JNC 8 Guidelines: A. Which antihypertensive therapies are (or are not) recommended as first-line therapy for treatment of Black patients with hypertension? Are: Both thiazide-type diuretics and calcium channel blockers (CCBs) are recommended as first- line therapy for management of hypertension in black patients. Are Not: ACE Inhibitors and Angiotensin II Receptor Blockers. Why? For the majority Black patients have low renin hypertension. ACE Inhibitors and ARBs target the renin-angiotensin-aldosterone system B. What would you recommend instead? Both thiazide-type diuretics and calcium channel blockers (CCBs) are recommended as first- line therapy for management of hypertension in black patients. 4. A. Based on the article you read is a beta-blocker an appropriate choice for single-drug therapy for hypertension? Beta blockers are not recommended as first line monotherapy for hypertension. B. How do Beta-blockers lower blood pressure?  NURS 3210 Pharmacology and Nursing Beta blocker reduce the heart rate. This reduces the cardiac output. Reduces strength of heart contractions. Increases bladder contractions, increasing urination leading to reduced blood volume and decreased hypertension. 5. Describe the Renin-Angiotensin-Aldosterone System (RAAS) and how its activation affects fluid volume, and blood pressure, as well as its relationship to “cardiac remodeling.” Angiotensin II is a potent vasoconstrictor and induces aldosterone secretion by the adrenal glands. Aldosterone stimulates sodium and water resorption, which can raise blood pressure. Together, these processes are referred to as the renin-angiotensin-aldosterone system. Cardiac Remodeling. Continued activation of the RAAS can start cardiac hypertrophy or thickening of the heart muscle. An increase in collagen deposits in the heart can lead to stiffness (fibrosis). The remodeling of the heart can impair the cardiac function of the heart and add the possible progression of heart failure. 6. A. What heart failure medications are used for late-stage heart failure and/or cardiogenic shock? Inotropic Dobutamine:Raises cardiac output by raising myocardial contractability. Dopamin: Increased higher doses increase cardiac output and SVR. Vasopressors Epinephrine:Supplies both inotropic/vasopressor benefits. Used in extreme situations. Norepinephrine:Increases vasoconstriction to increase blood pressure. Used for severe hypotension. Milrinone: Phosphodiesterase inhibitor that helps cardiac output and decreases pulmonary vascular resistance.  NURS 3210 Pharmacology and Nursing B. Compare and contrast them with those used in early stages of heart failure. Early Stage Heart Failure Medications are centered on long term management by decreasing blood pressure, stopping fluid retention and decreasing chances of cardiac remodeling. Late Stage Heart Failure Medications are centered on acute management to improve cardiac output, steady hemodynamics and as interventions for severe symptoms or shock. 7. Beta-blockers are usually recommended therapy for heart failure patients, but heart failure can be a contraindication for beta-blocker use. Describe a clinical scenario in which a patient with heart failure would need to stop beta-blocker therapy; why is this? If the dose is too high and has had a negative impact on the heart’s ability to pump oxygenated blood around the body. 8. List common signs and symptoms associated with digoxin toxicity? ▪ Hyperkalemia (serum potassium level higher than 5 mEq/L) in a patient with digoxin toxicity; ▪ Life-threatening cardiac dysrhythmias, sustained ventricular tachycardia or fibrillation, and severe sinus bradycardia or heart block unresponsive to atropine treatment or cardiac pacing; and ▪ Life-threatening digoxin overdose: more than 10 mg digoxin in adults and more than 4 mg digoxin in children. 9. Complete the Hypertension Case Study Questions #1, #2, #3, #4 found in Chapter 22, p. 353. 1. What type of diuretic was probably prescribed for G. at this time? Explain your answer. Thiazide diuretic (HCTZ), First line therapy for hypertension. 2. What possible adverse effects does G. need to be aware of while taking captopril? Hyperkalemia, hypotension, Renal Impairment and Angiodema. Expected are rash, taste disturbances and cough. 3. G. tells you that she uses an over-the-counter pain reliever for occasional headaches. What potential interaction is of concern?  NURS 3210 Pharmacology and Nursing NSAIDs decrease antihypertensive effect. Decreased effect of ARB can lead to a potential to cause renal failure. 4. G. states that she and her husband are planning to start a family in 1 year. What will you, as her nurse, tell her about pregnancy and therapy with these drugs? All ACE inhibitors have detrimental effects on the unborn fetus and neonate. They used to be classified as pregnancy category C drugs for women in their first trimester and as pregnancy category D drugs for women in their second or third trimester. Recent data suggest that ACE inhibitors are best avoided by pregnant women and used only if there are no safer alternatives. 10. Complete the Critical Thinking Questions #1 and #2 found in Chapter 22, p. 354. 1. A 79-year-old woman has been admitted to the emergency department after experiencing severe headaches and “feeling faint.” Upon admission, her blood pressure is measured as 286/190. A sodium nitroprusside infusion is started, and the nurse is monitoring the patient closely. After 8 minutes of infusion, the nurse notes that the patient’s blood pressure suddenly drops to 100/60. What is the nurse’s priority action at this time? Routinely check blood pressure, respirations and heart rate. Assess for hypotension, weakness, level of conciousness change and dizziness. 2. During a follow-up appointment, a 58-year-old man is pleased to hear that his blood pressure is 118/64. He says, “I’ve been hoping to hear this good news! Now I can stop taking these pills, right?” What is the nurse’s best answer? With successful therapy, the patient’s condition will improve; however, the patient must understand to never abruptly stop taking the medication just because he or she is feeling better. Lifelong therapy is usually required.  NURS 3210 Pharmacology and Nursing Always reinforce the fact that these medications are never to be abruptly stopped because of the risk for a hypertensive rebound. 11. Complete the Critical Thinking Question #2 found in Chapter 24, p. 381: 1. A nurse administered 125 mg of digoxin instead of 0.125 mg of digoxin intravenously. The patient has developed a severe heart block dysrhythmia, and the slow heart rate has not responded to administration of atropine and other measures. The nurse stays with the patient while the charge nurse notifies the cardiologist. What will be the priority in this situation? What will the nurse expect to give next? How could this situation have been prevented? Priority is to stabilize the patient. The nurse will expect to give digoxin immune Fab. When significant toxicity develops as a result of digoxin therapy, the administration of digoxin immune Fab may be indicated. Digoxin immune Fab is an antibody that recognizes digoxin as an antigen and forms an antigen-antibody complex with the drug, thus inactivating the free digoxin. Digoxin immune Fab therapy is indicated only for the following: ◦ Hyperkalemia (serum potassium level higher than 5 mEq/L) in a patient with digoxin toxicity; ◦ Life-threatening cardiac dysrhythmias, sustained ventricular tachycardia or fibrillation, and severe sinus bradycardia or heart block unresponsive to atropine treatment or cardiac pacing; and ◦ Life-threatening digoxin overdose: more than 10 mg digoxin in adults and more than 4 mg digoxin in children. This situation could have been prevented by having the dose verified by another nurse.  NURS 3210 Pharmacology and Nursing 12. Compete the Heart Failure Case Study Questions #1, #2, #3, #4, #5 found in Chapter 24, p. 380: 1. Describe the drug effects of the medications J. is receiving for the heart failure. Milrinone shares a similar pharmacologic action with methylxanthines such as theophylline (see Chapter 37). Both types of drug inhibit the action of phosphodiesterase, which results in an increase in intracellular cyclic adenosine monophosphate (cAMP). However, milrinone is more specific for phosphodiesterase type III, which is common in the heart and vascular smooth muscles. The beneficial effects of milrinone come from the intracellular increase in cAMP, which results in two beneficial effects in a patient with heart failure: a positive inotropic response and vasodilation. For this reason, this class of drugs also may be referred to as inodilators (inotropics and dilators). Milrinone has a 10 to 100 times greater affinity for smooth muscle fibers surrounding pulmonary and systemic blood vessels than it does for cardiac muscle. This suggests that the primary beneficial effects of inodilators come from their vasodilating effects, which cause a reduction in the force against which the heart must pump to eject its volume of blood. Finally, inhibition of phosphodiesterase results in the availability of more calcium for myocardial muscle contraction. This leads to an increase in the force of contraction (i.e., positive inotropic action). The increased calcium present in heart muscle is taken back up into its storage sites at a much faster rate than normal. As a result, the heart muscle relaxes more than normal and is also more compliant. In summary, milrinone has positive inotropic and vasodilatory effects. It may also increase heart rate and thus may also have positive chronotropic effects. 2. What laboratory values will you need to monitor while J. is receiving the milrinone?  NURS 3210 Pharmacology and Nursing  Serum laboratory values such as potassium, sodium, magnesium, and calcium levels (as prescribed)  Electrocardiogram (ECG)  Results of renal function tests, including BUN and creatinine levels  Results of liver function tests such as AST, ALT, CPK, LDH, and ALP levels  Results of BNP and NT-proBNP laboratory values are important to monitor because these peptides are produced by the heart and found to be increased with heart failure. The charge nurse is in J.’s room when another nurse comes in to give J. the intravenous dose of furosemide. As the nurse reaches for the tubing of the milrinone infusion to administer the diuretic, the charge nurse gently stops the nurse from giving the medication. Out in the hallway, the charge nurse speaks to the nurse. 3. What was the potential problem? Crystalization/Precepitate 4. Is there a concern? Concurrent administration of diuretics may cause significant hypovolemia and reduced cardiac filling pressure. Additive inotropic effects may be seen with coadministration of digoxin. Furosemide must not be injected into intravenous lines with milrinone because it will precipitate immediately. What will the nurse need to do at this point? Administer via PO. After 4 days, J.’s condition has improved greatly. The milrinone was stopped, he was transferred to a regular room, and today he is ready to go home. 5. In addition to receiving education regarding his medications, what should J. be taught to monitor while recovering at home?  NURS 3210 Pharmacology and Nursing  Instruct the patient on how to take the radial pulse before each dose of digoxin or as indicated. Daily weights are important and need to be done at the same time every morning and with the exact amount of clothing. For the older adult patient and/or the physically or mentally challenged patient, it is important that home health care personnel or a heart failure/hospital-based clinic supervise the medication regimen. This is important because these individuals are at risk for adverse effects, toxicity, and drug interactions. If the pulse rate is below 60 beats/min or is erratic, if the pulse rate is 100 beats/min or higher, or if there is anorexia, nausea, or vomiting, the health care provider must be contacted. Emphasize the importance of the patient reporting any palpitations or a feeling that the heart is racing, change in heart rate and/or irregular heart rate, the occurrence of dizziness or fainting, any changes in vision, and weight gain (2 lb or more in 24 hours or 5 lb or more in 1 week).  Advise the patient to keep a daily journal with notation of medications, daily weights, dietary intake and appetite, any adverse effects or changes in condition, and a rating of how he or she is feeling day to day.  Instruct the patient to wear a medical alert bracelet or necklace and to keep a current medication and medical history card on his or her person at all times that lists allergies, medical diagnosis, and medications. Medical information and lists of medications need to be updated frequently or with each visit to the prescriber.  Digoxin is usually taken once a day. Encourage the patient to take it at the same time every day. If a dose is missed, the patient may take the omitted dose if no more than 12 hours has passed from the time the drug was to have been taken. Instruct the patient that if more than 12 hours has passed since the missed dose,  NURS 3210 Pharmacology and Nursing the patient should not skip that dose, not double up on the next digoxin dose, and contact the prescriber immediately for further instructions.  Instruct the patient to never abruptly stop any of the medications being taken for heart failure. If problems occur, advise the patient to always contact the prescriber.  If angiotensin receptor-neprilysin inhibitors (ARNis) are used, educate about the common side effects of hypotension, hyperkalemia, and increased serum creatinine. Because of these side effects, periodic monitoring of serum potassium, renal functioning, and blood pressure is needed.  If potassium-depleting diuretics are being taken as part of the therapy, encourage the patient to consume foods high in potassium and to report any weakness, fatigue, or lethargy. In addition, any worsening of dizziness or dyspnea or the occurrence of any unusual problems should be reported immediately.  With medication regimens for heart failure, most patients are encouraged to avoid using antacids or eating ice cream, milk products, yogurt, cheese (dairy products), or bran for 2 hours before or 2 hours after taking medication to avoid interference with the absorption of the oral dosage forms of these medications. Reading: Chapter 28 1. A. Why are diuretics an important part of therapy for conditions like heart failure or renal failure? (In other words, what [nursing] problem do these conditions have in common?) Loop diuretics have renal, cardiovascular, and metabolic effects. They act primarily along the thick ascending limb of the loop of Henle blocking chloride and, secondarily, sodium resorption. Loop diuretics are also thought to activate renal prostaglandins, which results in dilation of the blood vessels of the kidneys, the lungs (Left side HF), and the rest of the body (Right side HF) (i.e., reduction in renal, pulmonary, and systemic vascular resistance). The hemodynamic effects  NURS 3210 Pharmacology and Nursing of loop diuretics are a reduction in both the preload and central venous pressures (which are the filling pressures of the ventricles). These actions make loop diuretics useful in the treatment of the edema associated with heart failure, hepatic cirrhosis, and renal disease. B. How do diuretics aid in the management of these conditions? Decrease edema and fluid overload Decrease blood pressure Decrease the heart’s workload Helps manage electrolyte imbalances 2. Electrolyte imbalances are commonly associated with diuretic therapy. Potassium imbalances are of particular significance. A. Describe the signs, symptoms, and complications associated with hypo and hyperkalemia. Hypokalemia may be manifested by anorexia, nausea, lethargy, muscle weakness, mental confusion, and hypotension. With potassium-sparing diuretics, monitor for the adverse effect of Hyperkalemia manifested by nausea, vomiting, and diarrhea B. Provide the normal reference range for potassium. The normal potassium levels for potassium is 3.5 to 5.2 mEq/L. 3. Complete the table comparing and contrasting the different classes of diuretics. Diuretic Effect on Indication for Tx Indication for Effective in Potassium of HF or HTN? Cerebral Edema patients with Level? Increase Y/N or Glaucoma? kidney failure? or Decrease or Y/N Y/N none? Loop (Furosemide) potassium Dehydration, In both cases it Y depletion blood volume can be used to reduction, reduce hypotension, intracranial electrolyte pressure. imbalance, hypokalemia Aldosterone Potassium HF→ Ejection Aldosterone will Y. Must be  NURS 3210 Pharmacology and Nursing Diuretic Effect on Indication for Tx Indication for Effective in Potassium of HF or HTN? Cerebral Edema patients with Level? Increase Y/N or Glaucoma? kidney failure? or Decrease or Y/N Y/N none? Inhibitor sparring fraction less exacerbate both carefully (Spironolactone) than or equal to conditions by monitored due 40%. increasing fluid to increased retention water retention resulting in to increase BP increased can impair pressure. kidney function in some cases. Thiazides (HCTZ) potassium Electrolyte In both cases it Y. Not depletion imbalance, can be used to recommended hyperglycemia reduce as first line intracranial treatment, pressure through possibly impair diuresis and renal function. decreasing fluid accumulation. Osmotic (Mannitol) potassium Electrolyte loss, Mannitol N. May depletion dehydration, specifically pulls exacerbate circulatory water out of electrolyte failure. brain tissue to imbalance and Headache, reduce swelling impair renal N/V/D, and pressure. function. increased heart Mannitol rate,difficulty specifically pulls breathing. water out of the eye to reduce the risk of optic nerve damage and vision loss. CAI Inhibitor potassium Metabolic Acetazolamide N. Due to drug (Acetazolamide) depletion acidosis, prescribed to clearance electrolyte reduce impairment. imbalance, cerebrospinal confusion, fluid to reduce drowsiness, pressure from muscle tumors, weakness. traumatic brain injuries. Used to reduce aqueous humor in the eyes leading to reduced  NURS 3210 Pharmacology and Nursing Diuretic Effect on Indication for Tx Indication for Effective in Potassium of HF or HTN? Cerebral Edema patients with Level? Increase Y/N or Glaucoma? kidney failure? or Decrease or Y/N Y/N none? pressure. 4. Complete the Diuretics/HCTZ Case Study Questions #1, #2, & #3 found in Chapter 28, p. 455. Dr. G. diagnosed with primary hypertension and will be taking 50 mg of hydrochlorothiazide (HCTZ) daily. Dr. G. complains of “feeling so tired” and asks whether the medication causes sleepiness. When questioned, she says that she takes the HCTZ at dinnertime because she is afraid it will “interfere with her classes.” 1. What do you suspect is happening with Dr. G., and what would you recommend? Dr. G. is not adhearing to the prescribed time of day to administer hydrochlorothiazide. The medications should be taken once in the morning. An overdose of these drugs can lead to an electrolyte imbalance resulting from hypokalemia. Symptoms include anorexia, nausea, lethargy, muscle weakness, mental confusion, and hypotension. Treatment involves electrolyte replacement. Dosages exceeding 50 mg/day rarely produce additional clinical results and may only increase drug toxicity. This property is known as a ceiling effect. 2. During this follow-up appointment, you ask Dr. G. if she is eating foods high in potassium. She looks embarrassed and answers, “I lost that pamphlet about the foods with potassium, but I try to drink orange juice every day.” What foods should she eat for their potassium content? Foods high in potassium include bananas, oranges, apricots, dates, raisins, broccoli, green beans, potatoes, tomatoes, meats, fish, wheat bread, and legumes.  NURS 3210 Pharmacology and Nursing 3. The report on Dr. G.’s potassium levels comes back from the laboratory, and the results are 3.4 mEq/L. She asks, “Am I going to be put on a potassium pill too?” What is your answer? I would say yes, to supplement the patients potassium intake throughout the day with each meal. The normal potassium levels for potassium is 3.5 to 5.2 mEq/L. 5. Complete the Critical Thinking Question #2 found in Chapter 28, p. 456: 2. The nurse is administering a thiazide diuretic to a patient who has been receiving digoxin for several months as part of treatment for a cardiac dysrhythmia. Considering the use of these two drugs together, what is the priority for regular assessment? Thiazides interaction with Digoxin results in increased Digoxin toxicity. Carbonic anhydrase inhibitors require close assessment of sodium and potassium levels. These drugs are not to be used in patients with a history of renal or liver dysfunction. As with any diuretic-induced hypokalemia, excluding the potassium-sparing diuretics, if digoxin is being taken by the patient, toxicity may occur. The nurse will need to check and maintain potassium levels within normal values to stop the progression of hypokalemia and decrease the risk of Digoxin toxicity. The signs and symptoms to monitor for toxicity are: Human Need Statements 1. Altered oxygenation, decreased cardiac output, related to drug effects and adverse effects of diuretics (e.g., fluid and electrolyte loss) 2. Altered fluids, decreased, related to drug effects and adverse effects of diuretics 3. Altered safety needs, risk for injury, related to postural hypotension and dizziness. Implementation for above finding;  NURS 3210 Pharmacology and Nursing Measure and document blood pressure, pulse rate, intake, output, and daily weights during diuretic therapy. Changes from the initial baseline assessment data that alert you to possible problems with diuretics include the presence and/or complaints of dizziness, fainting, lightheadedness on standing or changing positions, weakness, fatigue, tremor, muscle cramping, changes in mental status, or cold, clammy skin. Because diuretic therapy may precipitate cardiac irregularities or palpitations, closely monitor heart rate and rhythm. Fluid loss from the action of the diuretic may lead to the adverse effect of constipation, so preventive measures are needed, such as increased intake of fluids and fiber (unless contraindicated) and/or the use of natural bulk-forming products. If constipation continues, the prescriber may need to provide alternatives to psyllium- based bulk-forming laxatives.