2nd exam review

Cardiovascular Drugs - diuretics

In general, what do Diuretics do?

They accelerate the formation of urine

• results in the removal of sodium and water = “where salt goes water flows”

• Used to treat HTN, HF, edema, and renal failure

• Indirectly lower BP by producing water loss

• decrease workload of the heart

How are Diuretics classified?

• site of action in nephrons

• chemical structure

• potency of diuresis

Important actions to remember for Diuretics - general

Remember the 3 D’s!

D = decreases BP

D = diuresis - draining fluid or urination

D = dehydrate or dry the body - cardiac benefits or HF

Loop Diuretics - Mechanism of Action

they affect the Ascending loop of Henle in nephrons

• blocks the reabsorption of chloride and sodium, preventing the reabsorption of water

• significant increase in urine production + Potassium excretion

• Results in renal, cardiac, and metabolic effects

How to remember Loop Diuretics

suffix of _mide or -nide

examples include: Bumetanide, torsemide, furosemide

Furosemide - general discussion

• potent loop diuretic, used for emergencies, causes extensive diuresis even with severe renal impairment

• used for pulmonary edema, non responsive edema, uncontrolled HTN, and off label is used for hypercalcemia

Loop Diuretics Complications

• Hypotension, Hypovolemia, electrolyte imbalances

• Ototoxicity

• Hypokalemia, hyperglycemia, hyperuricemia, hypocalcemia, hypomagnesemia

Furosemide - Contraindications and Precautions

• DO NOT GIVE to pt with anuria

• TAKE CAUTION: those with liver issues, diabetes, dehydration, electrolyte depletion, hypoproteinemia (ototoxicity), and gout (hyperuricemia)

• TAKE CAUTION W/ MEDS LIKE: digoxin, lithium, ototoxic meds, NSAIDS, antihypertensives

What happens when you take a loop diuretic w/ Digoxin

drug toxicity (cardiac dysrhythmias) can occur with

hypokalemia (due to potassium excretion)

• Nursing actions: monitor potassium and digoxin levels, monitor cardiac

status (EKG), administer K+ supplements as prescribed

What happens when you take Loop Diuretics w/ Lithium

drug toxicity can occur with hyponatremia (due to sodium

excretion).

• Nursing actions: monitor lithium & Na+ levels

What happens with Loop Diuretics and NSAIDS

reduce blood flow to kidneys, which can reduce diuretic effect

What happens when you stack Loop Diuretics with Antihypertensive drugs

can have additive effect and lead to hypotension.

• Nursing actions: monitor BP, symptoms

What are some nursing implications for Loop Diuretics

• Perform thorough history and physical exam.

• Assess baseline fluid volume status, intake & output (I&O), serum

electrolytes, daily weight, and vital signs (& orthostatic BP).

• IV: must be given SLOWLY to prevent ototoxicity and abrupt

hypotension.

• Administer in the morning, if possible, to avoid interference with

sleep patterns.

• Monitor K+ and hold if <3.5 mEq/L. Monitor EKG (for cardiac

arrhythmias), notify the provider. May need K+ supplement.

• Fall precautions for elderly patients on diuretics.

• Teach patients - slow position changes, monitor BP, diet & K+

• Signs and symptoms of hypokalemia include GI symptoms, fatigue,

leg / muscle cramps, irregular pulse, dizziness

• Evaluate for effectiveness: decrease in pulmonary or peripheral

edema, BP, and increase in urinary output

Mechanism of action for Thiazide Diuretics

less potent than Loop Diuretics - work in the distal convoluted tube of the nephrons to prevent reabsorption of sodium + chloride + water. Potassium is excreted in a lesser extent

Therapeutic use of thiazide diuretics - hydrochlorothiazide

• HTN - can also be stacked w/ other anti-hypertensives

• mild to moderate HF edema

• renal failure + cirrhosis

• edema treatment

Complications of thiazide diuretics

• Dehydration and hyponatremia

• Hypokalemia + Hypochloremia

• Hyperglycemia

• Hyperuricemia + hypomagnesemia

Thiazide diuretics - Interactions

caution patients taking digoxin, lithium, NSAIDs, antihypertensive medications (same as loop diuretics)

• Thiazide diuretics do not cause hearing loss and can be combined with ototoxic medications

Thiazide Diuretics - Contraindications

• Pregnant People: use with caution, risk of jaundice and thrombocytopenia in newborns

• those w/ severe renal impairment - med will be ineffective

• Caution: CV disease, DM, hypokalemia, hyponatremia,

  hypomagnesemia, gout

Nursing implications of Thiazide Drugs

Perform a thorough history and physical exam.

• Assess baseline fluid volume status, intake and output (I&O), serum

electrolytes, daily weight, and vital signs (including orthostatic BP).

• Instruct patients to take in the morning, to avoid interference with

sleep patterns.

• Monitor K+ and hold if <3.5 mEq/L. Monitor EKG (cardiac

arrhythmias), notify the provider. May need K+ supplement.

• Fall precautions for elderly patients on diuretics.

• Teach patients - slow position changes, monitor BP at home.

• Signs and symptoms of hypokalemia include GI symptoms, muscle

weakness, fatigue, leg cramps, irregular pulse, dizziness

• Evaluate for effectiveness: decrease in BP, edema, and increase in

urinary output

Patient education when on K+ wasting diuretics

• fluid status is important - diuretics should be taken in the AM

• weight daily in morning and report changes

• patients could eat K+ rich foods when they take meds that deplete K+ —→ foods like bananas, legumes, oranges, dates, apricots, raisins, broccoli, green beans, potatoes, meat, and fish

• if K+ supplement is ordered - DONT CRUSH IT and take it with a full glass of water

Mechanism of Action for K+ Sparing Diuretics

Include: spironolactone, amiloride, triamterene

Mechanism of Action: Work in collecting ducts and distal convoluted tubules. Competitively bind to aldosterone receptors. Blocks the action of aldosterone which prevents the reabsorption of sodium and water, resulting in the excretion of sodium and water, and the retention of potassium.

Therapeutic Uses - Spironolactone

• HTN + HF

• K+ sparing and K+ wasting diuretics are combined to treat HTN and edema

• treats hyperaldosteronism by blocking the aldosterone receptors and inhibiting their action - ex treatment of PCOS

K+ Sparing Diuretics Adverse Effects

• Hyperkalemia - K+ level > 5.0 mEq/L

• Endocrine effects – deepened voice, impotence, gynecomastia, irregular menses (females), hirsutism

• Drowsiness or Metabolic Acidosis - restlessness, tired

Contraindications and Precautions for K+ Sparing Diuretics

WARNING: pregnant people

• don’t give to someone w/ hyperkalemia

• do not admin to someone w/ severe kidney failure or anuria

• CAUTION: those w/ hepatic or kidney disease, electrolyte imbalance, metabolic acidosis

K+ Sparing Diuretics Interactions

Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor

blocker (ARB) = increases risk of hyperkalemia. Avoid concurrent use!

• Do not take potassium supplements OR salt substitutes = increases

risk of hyperkalemia. Do not take with another K+ sparing diuretic.

• NSAIDs = reduce effect of diuretic and may worsen kidney function

• Digoxin = increased risk of digoxin toxicity

• Lithium = increased risk of lithium toxicity

Nursing Implications for K+ Sparing Diuretics

• Collect patient history and physical examination.

• Assess baseline fluid volume status, intake and output, daily weight,

and vital signs.

• Monitor for hyperkalemia with potassium-sparing diuretics

• Complications of high potassium = Cardiac dysrhythmias

• Hold medication and call provider for high/critical values

• Instruct patients to take the medication in the morning, to avoid

interference with sleep patterns.

• Advise the patient to avoid salt substitutes (Ex. Ms. Dash). Do not

take potassium supplements.

ACE inhibitors - name some

• Prototype: Captopril (short acting, dose 2 – 3 times a day)

• Lisinopril (dose once a day, most prescribed)

• Enalapril

• Benazepril

• Fosinopril

• Moexipril

• Perindopril

• Quinapril

• Ramipril

• Trandolapril

• Enalaprilat (only ACE inhibitor that is IV)

Mechanism of Action for ACE Inhibitors

inhibits angiotensin-converting enzyme that converts angiotensin 1 to angiotensin 2 and allows blood vessels to remain dilated, thus keeping BP managed

ACE Inhibitors also prevent the secretion of aldosterone, that prevents the body from holding onto water and sodium, thus keeping BP managed

What does Angiotensin 2 do? What abt Aldosterone

Angiotensin ll: constricts blood vessels which increases BP

Aldosterone: causes our bodies to retain water and sodium which increases BP

Primary Effects of ACE inhibitors/Indications

• cardiovascular and renal protective ( in pt’s w/ diabetic and nondiabetic nephropathy)

• lowers BP (HTN)

• HF and post MI

ACE inhibitors adverse effects

• First-dose orthostatic hypotension

• Dizziness, headache, hypotension

• Rash and impaired taste (metallic)

• Neutropenia (rare but serious)

• Hyperkalemia – monitor K+

• Dry, nonproductive cough

• Angioedema

ACE Inhibitors Contraindications and Precautions

• Pregnancy or breastfeeding – teratogenic effects

• Angioedema or known allergy to ACE inhibitors

• Hypotension

• Liver disease or elevated LFTs

• Decreased renal function

• Immunosuppressed or bone marrow depression

• Autoimmune disorders (i.e. rheumatoid arthritis)

• Cardiovascular disease, cerebral vascular disease, heart failure

• Hyperkalemia, hyponatremia

• Older adults

• Less effective in African Americans

Drug Interactions ACE Inhibitors

• Potassium-sparing diuretics or potassium

supplements – increased risk for hyperkalemia

• Other antihypertensive meds, diuretics, &

nitrates – increased risk of hypotension

• NSAIDs – may decrease ACE inhibitor

effectiveness

• May potentiate lithium toxicity

ACE Inhibitors Nursing Admin

• Monitor BP before & after each dose

• In case of angioedema —> epinephrine

• Monitor for dry cough, potassium levels

• Monitor WBC with differential every 2 weeks for 1st 3 months

of therapy then periodically

• Limit NSAID use – may decrease ACE inhibitor effectiveness

• Captopril – food decreases absorption

• May contribute to lithium toxicity

Angiotensin 2 Receptor Blockers - Name some

These are ARBS - well tolerated and do NOT cause dry cough that is common w/ ACE inhibitors

• Prototype: Losartan

• Valsartan

• Irbesartan

• Candesartan

• Olmesartan

• Telmisartan

• Azilsartan

Mechanism of Action for ARBs

• ARBs affect primarily vascular smooth muscle and the adrenal gland.

• Selectively block the binding of Angiotensin II to the type 1 Angiotensin II receptors in these tissues, thereby blocking the action of angiotensin II

ARB’s result in

• Vasodilation (arterioles and veins)

• Excretion of water and sodium (by preventing the release of aldosterone)

ARBs indications

• HTN

• HF

• Post MI

• Diabetic Nephropathy

• Stroke Prevention (in high risk patients)

• in situations when an ACE inhibitor was indicated but not tolerated to protect against CVD

Adverse Effects of ARBs

• Most common adverse effects of ARBs:

• Headache, dizziness, orthostatic hypotension

• Fatigue, muscle weakness

• Diarrhea

• Back or leg pain, muscle cramps

• Rare, but serious:

• Hyperkalemia less likely than with ACE inhibitors

• Angioedema

• Acute renal failure (history of KD or HF)

ARBs Contraindications and Precautions

• Pregnant, planning to becoming pregnant, or breastfeeding d/t teratogenic effects

• Known allergy to ARBs

• Children < 6 years old or those with very low creatinine clearance

• Caution with concurrent diuretic use, hyperkalemia, liver or renal disorders

ARBs interactions

• When given concurrently with other antihypertensive meds, there is an increased risk of hypotension

• NSAIDs —> decrease ARB effectiveness & potentiates risk of renal complications

• Potassium sparing diuretics (i.e.Spirolactone/ Aldactone)

• (mechanism: ARBs block aldosterone/excrete less potassium —> builds up K+ in the blood)

Nursing Implications for Losartan

obtain a thorough health history and head-to-toe physical examination.

• Assess for contraindications to specific antihypertensive drugs. Do not take in pregnancy.

• Assess for conditions that require cautious use of these drugs. Use caution with renal disease, monitor labs (CR and BUN).

Memory Trick for ACE Inhibitors

captopril, lisinopril, enalapril, benazepril, quinapril (suffix "pril)

A= angioedema

C = cough (dry, hacking)

E = electrolyte imbalance (hyperkalemia0

ARB’s memory trick (Angiotensin II Receptor Blockers)

losartan, valsartan, irbesartan (suffix "sartan")

A = angioedema

R = renal function changes

B = BP too low (hypotension)

S = slight increase K+ (hyperkalemia)

Alpha and Beta Blockers like Carvedilol and Labetalol are contraindicated in

• pt’s w/ asthma, bronchospasm, and bradycardia

• caution w/ liver or kidney disease

• Labetalol: is unique as it can be used in pregnancy or lactating mothers

Beta Blockers Mechanism of Action

Blocks Beta 1 receptors of the heart - sympathetic system or fight or flight response, this leads to….

• decreased HR

• decreased BP

• decreased myocardial contractility

• decreased conduction through AV node

Indications for BB’s

treatment of cardiovascular diseases

• angina, HTN, dysrhythmias, MI, HF

• May also be used in migraine prophylaxis, anxiety/tremors, glaucoma, hyperthyroidism/thyroid storm

Adverse Effects of Beta Blockers

• Cardiovascular: bradycardia, orthostatic hypotension, AV block, worsening of HF

• Metabolic (Nonselective Beta Blockers): hyperglycemia, hyperlipidemia, masking of hypoglycemia (lowers HR)

• CNS: fatigue, depression, lethargy, dizziness, hypotension, fainting

• other: bronchoconstriction (wheezing) - caution w/ asthmatics (use beta 1 blockers), impotence

Contraindications of Beta Blockers

acute or unstable HF

AV block and sinus bradycardia

nonselective beta blockers: not for pt'‘s w/ asthma, bronchospasm, HF

CAUTION: pregnancy, lactation, diabetes PADS, depression, older adults, allergies

Beta Blockers - Drug Interactions

 Calcium channel blockers and other antihypertensives can intensify the effects of beta blockers

 Monitor EKG (telemetry), HR and BP

 Nonselective beta blocker (propranolol): use can mask the hypoglycemic effect of insulin

 Monitor blood glucose levels in diabetics

Nursing Actions - Beta Blockers

B = bradycardia and AV block risk, monitor HR and EKG

B = breathing problems (astma, COPD)

B = blood glucose, monitor sugars

B = bad for acute HF pt’s

B = BP LOW, check before e/ dose

baseline EKG and telemetry, check vitals before e/ dose, no effect on K"+

Beta Blockers = patient ed

 Patients should monitor their pulse rates and BP daily, report symptoms of bradycardia or hypotension.

 Instruct patients to sit or lie down with dizziness, change positions slowly & notify provider of fainting.

 These medications should never be abruptly discontinued (must be tapered slowly).

 These medications are used for long-term prevention of angina, not for immediate relief of chest pain. Go to ED or call 911 for acute

chest pain not relieved by rest or nitroglycerine.

Patients should report what w/ Beta Blockers

• Fainting, dizziness or lightheadedness

• Weight gain of 2 lb in 1 day or 5 lb in 1

week

• Edema

• Pulse rate less than 60 beats/min (hold

dose)

• Systolic BP < 90 mmHg (hold dose)

• Dyspnea, wheezing

Calcium Channel Blockers - Mech of Action

Binds to receptors on myocardial and smooth muscle cells, Blocks calcium channels in the blood vessels, leads to

vasodilation of peripheral arterioles and coronary arteries/arterioles. Veins not significantly impacted

CCB’s Indications

• angina

• HTN

• Diltiazem and verapamil: SVT, afib and a flutter

• amlodipine: HTN, stable angina

CCB Adverse Effects

• Peripheral edema, orthostatic hypotension, constipation

• dysrhythmias, reflex tachycardia, bradycardia, nausea, dyspnea

CCB Contraindications

• severe hypotension

• acute MI

• Verapamil & Diltiazem: heart block - can worsen this, severe HF

• older adults, liver and kidney disorders

CCB Interactions

• Concomitant use w/ beta blockers: increased risk of bradycardia, AV block, worsening HF

• Use w/ grapefruit juice

• Use w/ digoxin

CCB Patient Ed

 Constipation is a common problem: instruct to take in adequate fluids and eat high-fiber foods.

 Avoid grapefruit juice with CCBs.

 Monitor for peripheral edema = swelling of feet, advise patient to raise feet while at rest. Notify provider of sudden weight changes.

 Orthostatic hypotension: change positions slowly, sit or lay down if dizziness, lightheadedness occurs.

 Check vitals signs, hold dose if SBP < 90 mmHg and HR < 60 BPM

 Do not crush or chew sustained-release tablets.

CCB patients should report

 Fainting, dizziness or near syncope

 Edema or swelling

 Weight gain of 2 lb in 1 day or 5 lb in 1 week

 Pulse rate less than 60 beats/min (hold dose)

 Systolic BP < 90 mmHg (hold dose)

 With angina symptoms: record pain frequency, intensity, duration and location. Notify provider of any increases in frequency, intensity, duration. Call 911 for acute angina not relieved by rest & NTG.