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- lanoxin (digoxin)
- can be given PO of IV
- derived from the foxglove plant
- has been used for over 400 years to treat symptoms of heart failure
- a trademark for the drug digoxin
- used to treat heart failure
1. Positive inotropic action - increases stregth of myocardial contraction causing increase in COP and decrease in O2 demand.2. Negative chronotropic action - decreases HR by decreasing impulse formation is the SA node. It indirectly simulates the vagus nerve. Together these actions lead to a decrease in compensatory tachycardia (sympathetic nervous system).3. Negative dromotropic action - slowed conduction of impulses through the AV node.
CHF to treat sx of decreased COP, A-fib, A flutter
Lanoxin adverse effects
- Anorexia, N,V,D, fatigue,dizziness,visual disturbances (yellow vision, blurred vision, seeing halos around lights,double vision.)
- These are helpful in dx of toxic levels. Dose reductions may be necessary due to decreased renal function in the elderly.
- the generic name of Lanoxin
- Digoxin has a narrow therapeutic range (0.5-2.0ng/ml). Levels are drawn just prior to a dose. Doses should be given at the same time each day.
digoxin nursing measures
- Take apical pulse for a full minute prior to each dose. Hold drug and notify HCP if pulse < 60. Be aware of factors that predispose to toxicity - hypokalemia, hypercalcemia, hypoxia related to heart of lung disease, and renal or liver disease.
- Quinaglute and other antiarrhythmic drugs,calcium salts and calcium channel blockers,adrenergic drugs, and anticholinergic when given with digoxin cause increased digoxin levels.
- Digoxin may have to be decreased by 50% when given with quinidine or amidrine and 25% for calcium channel blockers.
- Antiacids, Questran (cholestyramine), laxatives, and neomycin decrease effects of oral digoxin.
- Instruct patient regarding: Take pulse before each dose,take same time each day, do not double dose if misses a dose,report adverse effects,report weight gain of more than 1lb. per day or more than 3lbs. per week.
- Antidote: Digibind
- This class of drugs alter the conduction
- of electrical impulses in the heart and are primarily used for tachydysrhythmias.
- Research has shown that patients treated for some dysrhythmias had a higher death rate than those who did not receive the therapy. These deaths were attributed to the effects of the drugs worsening existing dysrhythmias or causing new dysrhythmias.
- These studies have lead to a decrease in use of some of these class I drugs (quinidine) and higher use of class II drug (beta blockers) and class III drugs (amiodarone).
- There is now greater use of radiofrequency catheter ablation, surgically implanted cardioverter-defibrillators (ICDs).
antiarrythmic drugs uses
- Convert A-fib or flutter to NSR.
- Maintain NSR after conversion from a-fib or flutter.
- When ventricular rate is so fast that decreased COP leads to sx of decreased systemic, cerebral and coronary circulation.
- To terminate dangerous dysrhythmias that may be fatal such as ventricular tachycardia.
class 1 antidysrhythmias:class 1a
- Quinaglute (quinidine) prototype for class 1a
- Norpace (disopyramide)
- Pronestyl (procainamide)
class 1 antidysrhythmias class 1a uses
symptomatic PVCs, SVT, V tach, prevent vfib.
class 1 antidysrhythmias class 1b
Xylocaine (lidocaine) prototype for class 1b
class 1 antidysrhythmias class 1b uses
symptomatic PVCs, V tach,prevent v-fib.
Quinaglute (quinidine) adverse effects
N,V,D, hearing loss,tinnitus,visual disturbances.
Quinaglute (quinidine) Nursing Measures
Inform all HCPs that patient is taking the drug. Report adverse effects and feeling faint (V-tach or fib). Best to take on empty stomach with glass of water, but may take with food if GI sx. Avoid excessive citrus juices because they change urine pH and decrease excretion of quinidine
Similar to quinidine
Pronestyl (procainamide) Adverse
Anorexia, N, hypotension (IV), SLE like syndrome, V fib.
Pronestyl (procainamide) Contraindications
Allergy to procaine, 2nd or 3rd degree heart block, liver or renal disease.
Pronestyl (procainamide) Nursing Measures
- Give with food, avoid hazardous activities until effects are
- known, avoid OTC drugs.
Similar to quinidine
Norpace (disopyramide) Adverse Effects
Dizziness, fatigue, HA, blurred vision, dry mouth, CHF, arrhythmias, hypotension, constipation, N, urinary retention, hypoglycemia.
Norpace (disopyramide) Contraindications
Cardiogenic shock, 2nd and 3rd degree blocks, sick sinus syndrome w/o pacemaker.
Norpace (disopyramide) Interactions
Many - cimetidine, warfarin, erythromycin, dilantin, etc.
- Local anesthetic, drug of choice for treating serious ventricular arrhythmias. Decreases myocardial irritability in the ventricles, but has little or no effect on the artria.
- Differs from quinidine in that: Always given IV, no decrease in AV conduction or cardiac contractility in therapeutic doses, rapid onset, 1to2 minutes, and short duration, 20 min, of action, it is less likely to cause heart blocks, asystole, heart failure or arrhythmias.
Lidocaine Adverse Effects:
Drowsiness, tinnitus, blurred or double vision, anaphylaxis, seizures.
Allergy to local anesthetics, heart blocks.
Lidocaine Nursing Measures:
- Ensure correct preparation and dose prior to
- administration. Monitor EKG.
- Anticoagulants prevent formation of new clots and the extension of existing clots. They do not dissolve clots, improve blood flow to tissues, or prevent damage from ischemia
- to tissues beyond the clot.
Prevention or management of thrombophlebitis, DVT, or pulmonary embolism.
Anticoagulants Adverse Effects
- Prevention and management of thromboembolic disorders, DVT, PE, and Afib with embolization.
- a blood thinner
Prevents the ultimate formation of fibrin in stage III of the clotting mechanism. Antagonizes thrombin and prevents conversion of fibrinogen to fibrin.
Heparin Adverse Effects
Bleeding – hematuria, nose bleeds, rash, alopecia, thrombocytopenia (decreased platelets, can be very severe).
Bleeding disorders, recent surgery, renal or liver disease. Pregnancy cat. C. Does not cross placenta.
Given subcutaneously or IV.
PTT and INR
PTT (partial thromboplastin time) and INR (international normalized ratio) are labs used to evaluate therapeutic effect. Dose is adjusted based on these tests.
Heparin Nursing Measures
Teach to wear or carry ID and notify all HCPs that he is taking drug. Smoking and alcohol may alter response to drug. Avoid ASA, NSAIDS, & OTC drugs w/o consulting HCP. May increase menstrual flow. Alopecia is reversible. Should be able to carry out normal activities such as shaving because it does not affect bleeding time when platelets are normal.
Coumadin (warfarin) Uses:
DVT, PE, A-fib, prosthetic valves prophylaxis.
Coumadin (warfarin) MOA:
Indirectly interferes with the hepatic synthesis of Vitamin K-dependent coagulation factors (II, VII, IX, X).
Coumadin (warfarin) Adverse Effects:
Bleeding, purple toe syndrome (microemboli to toes).
Coumadin (warfarin) Contraindications:
Pregnancy Cat. D (never use in first trimester), liver disease.
Coumadin Nursing Measures
- PT (prothrombin time) and INR are labs used to determine therapeutic effecs. Avoid IM injections while on Coumadin.
- Teach patient regarding: Purpose, dose and S/S of adverse effects. Avoid all alcohol and excessive intake of foods high in Vit. K.
- Carry ID & notify all HCPs he is taking drug.
Low molecular weight heparin.
Lovenox (enoxaparin) Uses
Prevention and management of DVT and PE. Management of unstable angina, to prevent MI.
Lovenox (enoxaparin) Adverse Effects:
- Less thrombocytopenia than standard heparin. Can be used for outpatient therapy because they do not require close monitoring of labs.
- Platelet counts should be monitored.
Lovenox (enoxaparin) antidote
- Antiplatelet effect lasts for the life of the platelet, 7-10 days.
- Aspirin is an example
Antiplatelet Drugs Uses
- Long term for prevention of MI or CVA and for patients with prosthetic heart valves.
- Immediate treatment for MI, TIA, or thrombotic CVA.
antiplatelet drugs adverse effects
- Low with therapeutic doses.
- Bleeding and hemorrhagic strokes.
antiplatelet drugs nursing measures
teach to report GI irritation or signs of bleeding
Thrombolytic Drugs Uses
To dissolve thrombi in MI, CVA, and iliofemoral thrombosis and to dissolve clots in IV catheters.
Thrombolytic Drugs MOA
Stimulate the conversion of plasminogen to plasmin, a proteolytic enzyme that breaks down fibrin which is the framework of a clot.
Thrombolytic Drugs Examples
Urokinase and streptokinase. Urokinase can be used for patients who are allergic to streptokinase.
Thrombolytic Drugs advers effects
- Relieve angina pain by reduction in myocardial O2 demand and increasing blood supply to the myocardium.
- Nitrates, beta blockers and calcium channel blockers are used.
Antianginal Drugs nitrates
Nitroglycerine (prototype), Nitro-bid, Isordil
Antianginal Drugs MOA
Reduce PVD (afterload) results in decreased systolic BP which reduces workload of the heart. Reduce venous pressure and venous return to the heart which decreases volume and pressure in the heart (preload) which reduces O2 demand. At higher doses they dilate coronary arteries and increase blood flow to the heart muscle.
Has a short half-life of 1-5 min. regardless of route. Sustained release oral or transdermal patch is used for prevention. PO – act slowly, used for prevention. Sublingual – acts within 1-3 min. and last for 30-60 min. Used for acute attacks and to prevent exercise induced angina. Transdermal - effective for 12 hours. IV is used when other agents are not effective.
Patches must be removed for 10-12 hours each night to prevent nitrate tolerance.
Nitroglycerine adverse effects
HA, dizziness, hypotension, and tachycardia.
Current use of Viagra, severe anemia.
Viagra, antihypertensives, alcohol, haldol, anticholinergics.
Nitroglycerine nursing measures
Teaching restorage, safety, use of different preparations.
Beta Blockers Examples
Inderal, Tenormin, Lopressor, Corgard
Beta Blockers MOA
Decrease sympathetic stimulation to decrease HR and myocardial contractility, especially during increased exercise decreasing need for SL nitroglycerine. Also reduce BP which decreases workload of heart and O2 demand.
Beta Blockers Uses
Angina, hypertension, etc.
Beta Blockers Contraindications
Vasospastic Angina because they may increase frequency and severity of vasospasms.
Calcium Channel Blockers Examples
Cardizem (diltiazem), Calan (verapamil)
Calcium Channel Blockers MOA
Improve blood supply to heart muscle by dilating coronary vessels and decrease the workload of the heart by dilating peripheral vessels which lowers BP. They reduce coronary artery spasm. Verapamil and Calan are the only CCBs that slow the ventricular response to A-fib, flutter and SVT.
Calcium Channel Blockers Uses
Angina, hypertension, etc.
Calcium Channel Blockers Contraindications
2nd or 3rd degree blocks, cardiogenic shock, severe bradycardia, heart failure, hypotension.
Calcium Channel Blockers
CCB can be monotherapy, but are frequently used in combination with beta blockers.
- Agents to decrease blood lipid levels. They are adjunct in antianginal therapy.
- Bile Acid Sequestering Agents
Decreases LDL levels by absorbing and combining with bile acid salts in the intestines to form an insoluble, nonabsorbable complex that is excreted in the feces.
questran adverse effects
- GI sx which usually subside by a month, increased bleeding tendency. Decreases absorption of many drugs. Long term use may result in deficiencies of
- fat soluble vitamins – A,D,E,K and Ca.
questran nursing measures
Give other meds 1 hour before or at least hours after. Dissolve in flavored liquids or semisolid foods to disguise taste. Teach S/S bleeding, need for Ca and vitamin supplements with long term use.
Fibric Acid Derivatives examples
Fibric Acid Derivatives MOA
Unclear, but decreases Triglycerides and VLDL, increases HDL, cholesterol may increase or decrease.
Fibric Acid Derivatives uses
Decrease triglycerides, decrease LDL is secondary effect.
Fibric Acid Derivatives adverse effects
- Myalgias, impaired liver function, gall stones, abd. pain, N, D.
- Less hyperglycemic effect, best for diabetics.
Fibric Acid Derivatives teach:
- Restrict alcohol, fats, chol, and
HMG-CoA Reductase Inhibitors (statins) examples
Zocor, Mevacor, Lipitor, Pravachol
HMG-CoA Reductase Inhibitors (statins) MOA
Inhibit HMG-CoA reductase, an enzyme essential in synthesis of cholesterol. Lower LDL and VLDL and triglycerides, and increase HDL. Many health benefits unrelated to lipids.
HMG-CoA Reductase Inhibitors (statins) uses
Decrease LDL in hypercholesterolemia/hypertriglyceridemia
HMG-CoA Reductase Inhibitors (statins) adverse effects
Myalgias, liver damage, HA, rash, GI sx.
HMG-CoA Reductase Inhibitors (statins) nursing measures
Monitor labs, give in evening, teach compliance with diet and sx to report.
- Review: Pathophysiology of hypertension
- Antihypertensives work in three basic ways to decrease BP.
- 1. Decrease fluid volume, diuresis.
- 2. Decrease HR
- 3. Decrease PVR
- There are different classes that work in different ways. They may be used alone or in combinations.
Central Sympatholytic (Central Acting Adrenergic Inhibitors) example
Central Sympatholytic (Central Acting Adrenergic Inhibitors) MOA
Stimulates alpha receptors in brain to inhibit peripheral sympathetic activity resulting in vasodilatation (decreased PVR) and decreased BP. Reduces HR.
Central Sympatholytic (Central Acting Adrenergic Inhibitors) uses
Hypertension. Off-label: Migraine prophylaxis, drug withdrawal sx.
Central Sympatholytic (Central Acting Adrenergic Inhibitors) adverse effects
- Avoid alcohol & CNS depressants, gradual withdrawal to prevent rebound hypertension.
Alpha-Adrenergic Blockers example
Hytrin (terazosin) Minipress (prazosin)
Alpha-Adrenergic Blockers MOA
Decreases PVR and lowers BP by selectively blocking the alpha 1 adrenergic receptors in vascular smooth muscle.
Alpha-Adrenergic Blockers uses
Hypertension. Off-label: Urinary flow obstruction in BPH.
Alpha-Adrenergic Blockers adverse effects
Severe orthostasis, especially first dose – give at bedtime.
Alpha-Adrenergic Blockers nursing measures
Beta Adrenergic Blockers examples
Tenormin (atenolol), Inderal (propanolol), Lopressor (metoprolol)
Beta Adrenergic Blockers MOA
Non-selective blockers of beta 1 and beta 2 receptors by competing with epinephrine and NE for available beta receptor sites. Lower COP and BP by decreasing HR, force of contraction and renin release from the kidneys.
Beta Adrenergic Blockers uses
Hypertension, angina, prevent 2nd MI, tachyarrythmias. Off-label: Migraine prophylaxis, antianxiety, acute panic sx.
Beta Adrenergic Blockers contraindications
CHF, COPD, Asthma (may cause bronchospasms), heart block > 1st degree. Caution: Diabetes (blocks sx of hypoglycemia).
Beta Adrenergic Blockers nursing measures
Teach that abrupt withdrawal may lead to angina, MI or death.
ACE Inhibitors examples
Quinipril (accupril), Capoten (captopril), Vasotec (enalapril), Lotensin (benaepril)
ACE Inhibitors MOA
Block the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor by specific inhibition of the angiotensin converting enzyme. This results in decreased PVR.
ACE Inhibitors uses
Hypertension, Used after MI if ejection fraction < 40, protects diabetics from renal failure.
ACE Inhibitors adverse effects
Dry cough, angioneurotic edema, hyperkalemia, ARF.
ACE Inhibitors contraindications
Pregnancy – renal failure in infants, renal impairment.
ACE Inhibitors nursing measures
Instruct regarding need for return to have K drawn.
Apresoline (hydralazine), Nipride (nitroprusside), Nitroglycerine.
Vasodilators cause a direct relaxation of vascular smooth muscle to decrease PVR and lower BP. There are two types: arteriolar dilators and venous dilators.
- Hypertension, angina
- They are usually given with a beta blocker to prevent hypotension-induced compensatory mechanisms of tachycardia and fluid retention that raise BP.
Calcium Channel Blockers examples
Cardizem (diltiazam), Calan (verapamil), Procardia (nifedipine)
Calcium Channel Blockers MOA
- Selectively block Ca ions from crossing cell membranes in cardiac and vascular smooth muscles without affecting serum Ca levels. They relax and prevent coronary artery spasm and reduce myocardial O2 use and may reduce HR by slowing conduction through SA & AV nodes. Cause vasodilatation of
- coronary and peripheral vessels.
Calcium Channel Blockers uses
- Hypertension, Angina (verapamil and diltiazem), SVT, cerebral spasm in SAH (nimodipine). Off-label: Migraine prophylaxis
- Most effective in blacks and elderly.
Agents for Anemia
- Iron deficiency anemia is a symptom, not a disease. The cause should always be investigated, especially in men.
- 80% of iron in the plasma goes to the bone marrow for use in erythropoesis – manufacture of RBC.
- When iron stores are low, iron absorption increases by 20-30%. When iron stores are high the rate of absorption is 5-10%.
- It is the gold standard.
- Cheapest, just as effective as any.
Ferrous Sulfate MOA
Corrects erythropoetic abnormalities caused by iron deficiency. Does not stimulate erythropoesis.
Ferrous Sulfate uses
iron deficiency anemia
Ferrous Sulfate adverse effects
Generally mild in therapeutic doses. N, heartburn, constipation or diarrhea.
Ferrous Sulfate contraindications
Ferrous Sulfate absorption
Better absorption on empty stomach – give with food for GI sx. Stains teeth. Milk, eggs and caffeine decrease absorption. Vit.C ncreases absorption.
Imferon (iron dextran)
Given IV or IM by Z tract.
Imferon (iron dextran) uses
Severe iron deficiency anemia
Imferon (iron dextran) adverse effects
- Anaphylaxis, stains tissues
- Builds iron stores faster, but does not correct anemia any faster than oral iron.
Imferon (iron dextran) nursing measures
Skin test prior to IV dose. Test dose prior to IM. Give in dorsolateral. Change needle after drawing up med., use air lock. Monitor for adverse effects for 24 hr.
Vitamin B 12 (cyanocobalamin) MOA
Activates folic acid enzymes that are necessary for synthesis of RBC.
Vitamin B 12 (cyanocobalamin) uses
Pernicious anemia (IM). Arrests disease, does not reverse it.
Vitamin B 12 (cyanocobalamin) nutritional supplement
Must have intrinsic factor to absorb PO.
Vitamin B 12 (cyanocobalamin) adverse effects
Transient itching and pain at site, optic nerve atrophy, CHF.
Overview of Four ACLS Algorithm Protocols
IV Push, intravenous infusion, endotracheal administration, and use of algorithms
- Route of most medications used
- Fast onset of action
- Immediate bioavailability
Intravenous Infusion: Medications for continuous infusion only
- P – procainamide
- I – isoproterenol
- N – norepinephrine
- D – dopamine
Intravenous Infusion: Medications given IV push or infusion
- A – amiodarone
- L – lidocaine
- E – epinephrine
- Tracheal administration of medications:
- L – lidocaine (2-4 mg/kg)
- E – epinephrine (2-2.5 mg)
- A – atropine (2-3 mg)
- N – naloxone (0.8-1.6 mg)
- Doses usually 2-2.5 times those given IVP
- Follow each dose with 10 ml NS; flush down tracheal tube if not diluted to that volume for administration
Use of Algorithms
- Meant to treat broadest range possible of patients
- Meant to be good memory aids
- Meant to be used “wisely,” not blindly
- Not meant to replace clinical judgment