pharm 2 cardiac/renal/anticoagulants
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What is the main drug used for CHF?
3 types of drugs given for CHF?
- ACE inhibitors
- cardiac glycosides
What is the use of cardiac glycosides?
increase heart contractility
What type of cardiac drugs are contraindicated in CHF but are sometimes given?
When should they not be give to CHF pt?
should not be given during CHF exacerbation
What type of drug is lanoxin/Digoxin?
2 pharm uses for digoxin?
- 1. manage s/s of CHF
- 2. treat atrial fibrillation and flutter
affect contractility of the heart
positive - increases and neg decreases
effect on conduction of current in the heart
positive increases and neg decreases
positive increases and neg decreases
3 actions of digoxin?
- 1. positive ionotropic effect
- 2. negative dromotropic effect
- 3. negative chronotropic effect
2 net effects of the action of digoxin?
increases CO and controls atrial rhythm
AE of digoxin are ____ related and are signs of _______.
What is the most frequent cause of digoxin toxicity?
Most common AE of ACE inhibitor?
How is it TX?
chronic cough - "ACE cough"
must stop med
3 S/S of digoxin toxicity?
- 1. GI disturbances
- 2. cardiotoxicity
- 3. CNS toxicity
Important consideration when giving digoxin IV push?
if pushed too quickly can decrease HR and cause death
What should always be done prior to giving a dose of digoxin?
take apical pulse for 1 minute
What things need to be monitored with mannitol/Osmitrol?
- 1. breath sounds r/t excess fluid initially
- 2. BP
- 3. electrolytes
Which diuretic requires filtered tubing?
What should the nurse teach pt to do prior to taking a dose of digoxin?
take their RADIAL pulse
Why can EPI not be given if a person OD's on beta blockers?
beta receptors are blocked to EPI
Antidote for OD of digoxin?
How does it work and how long does it take?
binds to digoxin and takes days to work
Hold digoxin if the apical pulse is < _____ BPM in adults and ____ BPM in children.
Most important thing to monitor in a pt on digoxin?
potassium level r/t K and digoxin use same receptors
What antihypertensive drug prevents reflex tachycardia?
Relationship of K and digoxin?
K and digoxin use the same receptors
giving digoxin with decreased K levels will cause digoxin toxicity b/c more will bind to receptors
giving digoxin when K levels are increased will decrease effects of digoxin
When should drug levels of digoxin be checked?
after starting, dose changes, if toxicity is supected
Therapeutic range of digoxin?
6 things to teach pt taking digoxin?
- 1. never stop abruptly
- 2. take pulse before each dose
- 3. weigh yourself daily & call MD with weight gain of 5 or more pounds in 24 h
- 4. wear medic alert bracelet
- 5. see MD q 6 months
- 6. seek help immediately for SOB
S/S of toxicity that should be reported to MD by digoxin pt?
- 1. irregular pulse
- 2. rapid weight gain
- 3. loss of appetite
- 4. NV
- 5. blurred or yellow vision
- 6. unusual tiredness
- 7. swelling in ankles, legs, or fingers
What type of drug is carvedilol/Coreg?
Important consideration with carvedilol/Coreg?
drops BP drastically
What is carvedilol/Coreg used for?
adjunct in treating mild to moderate CHF
Actions of carvedilol/Coreg?
- 1. decreases force of contraction & CO
- 2. increases vasodilation and decreases peripheral resistance
Important consideration for CHF pt taking carvedilol/Coreg?
may exacerbate CHF s/s at first
How is carvedilol/Coreg given initially?
start with small dose and gradually increase
Why may carvedilol/Coreg require a diuretic to take with it?
decreased force of contraction and decreased CO can exacerbate CHF - need fluid gone
Most important thing to monitor with carvedilol/Coreg?
What 2 drugs are considered short term Tx for CHF in pt who are not responding to other drug therapy?
What are their actions?
iamrinone/Inocor & milrinone/Primaccor
both increase contractility and vasodilate
Suffix for beta blockers?
What cardiac drug is metabolized into cyanide?
What assessment should be monitored when CHF pt is taking beta blocker?
lung sounds - if get crackles = going into failure
What diuretic may be used to decrease intracranial pressure?
Teaching for a pt on beta blockers?
teach s/s of CHF
How may digoxin affect K+ levels?
can cause hypokalemia
If a pt is having NV should you hold digoxin dose?
yes, can be a sign of digoxin toxicity
Yellow halo with digoxin is a sign of ____ toxicity.
HR of a person exp. digoxin toxicity?
What may be done to stabilize HR with digoxin toxicity?
If BP systolic is < ____ will hold BP meds.
Risk with a pt who is taking diuretic and digoxin?
some diuretics decrease K+ and digoxin decreases K
What antihypertensive drug is broken down if exposed to light?
What is digitizing a pt?
when pt HR really high will give IV dig to decrease HR in seperate doses then go to po
Watch for toxicity r/t higher doses
What receptors are involved in regulating BP?
adrenergic alpha and beta receptors
Stimulation of alpha I receptor causes ______.
Formula for calculating BP?
CO X PR = BP
PR - peripheral resistance
Drug therapy to reduce hypertension is designed to reduce either _____, _____ _____, or both.
Hypertension is a sustained BP > _____.
What drug is used for hypertensive crisis?
How must it always be admin?
Hypertensive crisis = BP of _____ or more.
2 Tx for hypertension?
lifestyle changes: low Na, weigh loss, exercise, DASH & TLC diets
drug therapy is started with q pt who has been diagnosed as having hypertension
How is BP med dosed?
start low and titrate up
First line drugs for hypertension?
- 1. diuretics
- 2. beta blockers
- 3. Ca channel blockers
- 1. ACE inhibitors
- 2. ARB - angiotensin II receptor blockers
How do diuretics lower BP?
decrease peripheral resitance by decreasing BF volume thru increasing Na & water excretion
increase effecacy of other antihypertensives
Action of ACE inhibitors?
block conversion of angiotensin I to angiotensin II = vasodilation
prevents Na & water retention, decreases peripheral vascular resistance, and lowers BP
What type of drug is captopril/Capoten
4 significant AE of ACE inhibitors?
- 1. chronic cough
- 2. first dose hypotension
- 3. angioedema
- 4. hyperkalemia
Where does angioedema occur in catopril/Capoten ACE inhibitor?
laryngeal, throat, tongue, face
When can angioedema occur with catopril/Capoten/ACE inhibitors?
can occur with first dose
Why does K need to be monitored with ACE inhibitors?
When is pt especially at risk for K imbalance?
ACE inhibitors can cause hyperkalemia
esp at risk if the pt is taking K sparing diuretic also
What occurs when a beta II receptor is stimulated?
bronchial and peripheral dilation & decreased BP
losartan/Cozaar is what type of drug?
What should be assessed prior to giving a diuretic?
electrolyte levels esp K
Action of losartan/Cozaar/ARBS?
prevents antiotensin II from binding to receptors in many tissues & blocks its vasoconstricting & aldosterone secreting effects
= vasodilation and excretion of Na & water
2 uses for ARB drug/losartan/Cozaar?
CHF & increased BP
Most important thing to monitor with losartan/Cozaar/ARB meds?
When are ARB drugs/losartan/Cozaar usually prescribed?
when pt can't take ACE inhibitor due to AE like ACE cough
Do ARB meds/losartan/Cozaar cause chronic cough like ACE inhibitors?
no, but they cause upper resp infections
Action of selective aldosterone blockers?
block aldosterone receptors
EX of a selective aldosterone blocking drug?
Action of eplerenone/Inspra (aldosterone blocker)?
blocks aldosterone = decreased BP
Eplerenone/Inspra (selective aldosterone blocker) can cause the 2 electrolyte imbalances ____ & ______ which can result in ______.
Why is eplerenone/Inspra (selective aldosterone blocker) considered a K sparing diuretic?
because it blocks the effect of aldosterone water and Na are excreted but K is not
What type of drug is labetalol/Normodyne?
alpha/beta blocking agent
When should BP be checked when giving labetalol/Normodyne?
before and after giving
What are the alpha and beta blocking effects of labetalol/Normodyne?
alpha blocking causes peripheral vasodilation that reduces BP
beta blocking prevents reflex tachycardia
How should cardiac drugs always be administered?
What is reflex tachycardia?
if drug causes significant vasodilation the heart will get decreased BF and will speed up HR in response
HR can get very high 170-180
What type of drug is clonidine/Catapres?
Important consideration with clonidine/Catapres?
it is a very potent antihypertensive
The diuretic _____ causes nocturia.
Action and results of clonidine/Catapres (alpha 2 agonist)
inhibits SNS response and reduces sympathetic outflow from the CNS
decreased HR, BP, vasoconstriction, and renal vascular resistance
2 most important considerations when admin lasix?
- 1. check K level - very K wasting
- 2. DO NOT EVER PUSH - give slowly by PUMP
Use for clonidine/Catapres (alpha 2 agonist) other than antihypertensive?
controls w/d symptoms from abused substances because of sympatholytic effects
2 AE of clonidine/Catapres (alpha 2 agonist)?
- 1. dry mouth
- 2. drowsiness
Pt teaching when taking clonidine/Catapres?
need to make sure how it affects them before driving etc
What type of drug is hydralazine/Apresoline?
direct acting vasodilator
Action of hydralazine?
decreases peripheral resistance and arterial BP
3 uses for hydralazine?
- 1. adjunct with other antihypertensives
- 2. with beta blockers or clonidine to prevent reflex tachycardia from the peripheral vasodilation
- 3. with diuretics to offset fluid retention from increased production of angiotensin II
2 things important to monitor with hydralazine?
BP & HR
ANY drug that decreases BP can cause _____ ______ including diuretics. This puts pt at risk for falls.
teach to dangle, etc
If ortho BP drops by ____ or more = positive for orthostatic hypotension.
What/where is nitroprusside/Nipride given?
given for hypertensive crisis
must be in unit setting with monitoring
What is the most important assessment when in the beginning of nitroprusside/Nipride therapy?
Action of nitroprusside/Nipride?
directly relaxes vascular sm mus, dilates veins more than arteries = decreased preload & afterload & lowers BP dramatically
Which diuretic is K - sparing?
How is nitroprusside/Nipride administered?
admin via IV pump
MUST BE ON PUMP
3 important considerations with nitroprusside/Nipride?
- 1. monitor BP constantly
- 2. can cause cyanide poisoning
- 3. protect the drug from light
How does nitroprusside/Nipride cause cyanide poisoning?
metabolism of nitroprusside produces cyanide as a metabolite
need to check levels after 24 h of therapy
What should the nurse do if a pt taking nitropursside/Nipride becomes nauseated?
check the BP - it may be too low
if it is decrease the med
What type of drugs are used for shock?
EX of a vasopressor drug?
What is dopamine?
catecholamine that is a precursor to NE
Effect of dopamine on the heart?
When/where is dopamine given?
give IV only in acute care setting
How may diuretics causes othrostatic hypotension?
dehydration can cause orthostatic hypotension
What is imperative in a pt receiving dopamine?
continuous monitoring of pt cardiovascular status
Most common adverse effects of dopamine?
CV system effects
3 dopamine actions?
- 1. dopaminergic action with doses of .5-3 mcg/kg/min = renal vasodilation
- 2. beta adrenergic with doses 2 -10 mcg/kg/min = cardiac stimulation
- 3. alpha adrenergic with doses 10-20mcg/kg/min = increased peripheral vascular resistance
What can occur with extreme vasoconstriction caused by dopamine or levafed?
ischemia and amputation
What diuretic drug can exacerbate gout?
HCTZ - b/c it increases uric acid levels
What drug may be used if dopamine doesn't work?
levafed = more potent vasoconstrictor than dopamine
levafed = leave em dead
What is the biggest concern for diuretics?
electrolytes esp. K wasting or sparing
What can be an adverse effect of diuretics and other meds that lower BP?
6 uses for diuretics?
- 1. hypertension
- 2. CHF
- 3. cirrhosis
- 4. renal disease
- 5. increased intracranial pressure
- 6. increased intraocular pressure
Action of diuretics?
decrease reabsorption of Na and water in renal tubule
increases urine output
Major AE of diuretics?
What may be given along with a diuretic to decrease AE?
What is an AE of diuretics that affects when the pt should take the med?
can cause excessive urination
What teaching needs to be done for a pt taking HCTZ?
K+ rich foods
mildly K-wasting so may not require supplements
HCTZ drug type and action?
thiazide diuretic - weak diuretic
increases excretion of Na, Cl, K, and water
What condition is contraindicated with HCTZ (thiazide diuretic)?
preexisting renal disease, because it may reduce GFR
Do all pt taking diuretics have high BP?
What effect do ACE inhibitors have on K level?
How is this helpful if take ACE and HCTZ/thiazide diuretic together?
ACE increases K
HCTZ decreases K = if take together will balance out
If a pt has HTN need to teach them s/s of ____.
Most common AE of HCTZ?
- 1. orthostatic hypotension
- 2. dizzy, lightheaded, and vertigo
- 3. anorexia, NV
- 4. polyuria & nocturia
- 5. electrolyte changes
- 6. hyperglycemia
- 7. increased uric acid levels
What teaching needs to be done for a pt who is starting HCTZ besides K foods?
how to prevent orthostatic hypotension
What are the 4 most important AE with HCTZ a thiazide diuretic?
nocturia, hypokalemia, hyperglycemia, and increased uric acid levels
What electrolyte imbalances may be caused by HCTZ, a thiazide diuretic?
hypokalemia, hyponatremia, hypochloremia, and hypercalcemia
7 things nurse should monitor with a pt taking HCTZ, a thiazide diuretic?
- 1. BP
- 2. pulse
- 3. weight
- 4. I&O
- 5. electrolyte levels, esp K
- 6. glucose levels
- 7. uric acid levels
Drug that is a loop diuretic?
3 routes of lasix admin?
PO, IV, IM
Where does lasix work at in the body?
What is its action?
loop of henle- promotes excretion of Na, Cl, K, and water
strong diuretic effect
Uses for lasix? (5)
- 1. edema from CHF
- 2. pulm edema
- 3. hepatic disease
- 4. renal disease
- 5. sometimes for HTN esp if renal disease exists
AE of lasix?
similar to thiazide drugs, but has greater loss of K+
What supplement is usually given with lasix therapy?
K+ supplements b/c it is very K wasting
Teaching for a pt taking lasix?
encourage diet high in K or give supplements prn
Can K tablets be crushed for admin?
no, there is an elixir if needed
Rate of admin of IV K?
IV by PUMP no more than 10meq/h
EX of a K sparing diuretic?
Why may triamterene/Dyrenium be given along with another diuretic?
to decrease the other diuretic's K wasting effect
Action of triamterene/Dyrenium?
promotes Na and water excretion & reabsorption of K
Triamterene/Dyrenium has a ______ diuretic effect compared to other diuretics but has a _____ effect when used with other diuretics.
What is the major electrolyte imbalance that may occur with use of triamterene/Dyrenium?
What are the increased risks ass. with older ppl taking diuretics and other BP meds?
more at risk for falls, hypotension, and K probs
What toxicity may be caused by lasix and other loop diuretics?
ototoxicity - will have hearing issues
stop med if this occurs
What type of drug is mannitol/Osmitrol?
Action of mannitol/Osmitrol?
draws water into the vascular space through osmosis -> will be filtered in the kidney but not reabsorbed = diuresis
What diuretic may not be given to a person with CHF? Why?
mannitol/Osmitrol b/c it draws fluid into the vascular space - too much volume in the BF will overwhelm the heart
3 uses for mannitol/Osmitrol an osmotic diuretic?
- 1. acute renal failure
- 2. increased intracranial pressure
- 3. increased intraocular pressure
AE of mannitol/Osmitrol?
- 1. electrolyte imbalances
- 2. may initially cause fluid overload
- 3. crystallizes easily
2 nursing interventions for crystallization of mannitol/Osmitrol?
- 1. use filtered tubing
- 2. warm drug in water before admin to dissolve crystals
What type of drug is acetazolamine/Diamox?
carbonic anhydrase inhibitor diuretic
Action of acetazolamine/Diamox, a carbonic anhydrase inhibitor diuretic?
inhibits hydrogen ion secretion in the tubule & increases loss of Na, K, bicarb, and water
also prevents formation of aqueous humor and decreases intraocular pressure
Primary use for acetazolamine/Diamox?
chronic, open angle glaucoma
may also be used in CHF
What type of drug is tolterodine/Detrol?
cholinergic muscarinic antagonist that blocks receptors in the bladder to decrease ability of bladder to contract
Use for tolterodine/Detrol? (3)
- overactive bladder
- manage urinary frequency
- urgency and urge incontinence
3 AE of tolterodine/Detrol?
- 1. dry mouth
- 2. HA
- 3. urinary retention
If a pt is taking a diuretic like lasix and not in good enough health to get up what nursing intervention should be done?
ask MD for a catheter order
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