Perfusion and clotting: pharm exam 4

perfusion

•refers to the flow of blood through arteries and capillaries delivering nutrients and oxygen to cell

•Clotting

•physiological process in which blood is converted from a liquid to a semisolid gel

+ inotropic drugs= ??

¨increase force of myocardial contraction (treat failing heart muscle)

What can impair the clotting process

•When clotting factors are not available, patients experience excessive bleeding.

•If blood clots form when not indicated, then a thrombus (blood clot) may obstruct blood vessels and interfere with blood flow.

-inotropic drugs = ??

decrease force of contraction

+chronotropic drugs = ??

¨increased heart rate

-chronotropic drugs= ??

decrease heart rate

+dromotropic drugs= ??

accelerate conduction

-dromotropic drugs= ??

decrease conduction

What does the heart do?

¨The human heart is an organ that pumps blood throughout the body à supplies oxygen and nutrients  to all tissues and removes carbon dioxide and other wastes. If it fails to do this function, the tissues die.¨

Heart failure Meds

ACE Inhibitors

ARB’s

Beta Blockers

Aldosterone antagonists

Phosphodiesterase inhibitors

Cardiac glycosides

Coagulation Modifiers

Anticoagulants

Antiplatelets

Thrombolytics

Antifibrinolytics

what types of diuretics are there?

Loop

Osmotic

Potassium Sparing

Thiazide & Thiazide like

Carbonic anhydrase inhibitors

what is high BP in someone 60 years or older?

systolic blood pressure (SBP) of greater than 150 mm Hg or diastolic blood pressure (DBP) greater than 90 mm Hg

what is high BP in someone younger than 60 years old and those who have chronic kidney disease or diabetes?

systolic blood pressure greater than 140 and DBP greater than 90 (remember… OVER 140…OH LORDY!)

What would you use for stage 1 hypertension?

Thiazide-type diuretics for most: May consider ACE 1, ARB,  CCB, or combination

What would you use for stage 2 hypertension?

Two drug combination (usually thiazide-type diuretics and ACE 1, or  ARB, BB, CCB, or combination

Adrenergic Drugs: Adverse Effects

•Bradycardia with reflex tachycardia

•Dry mouth 

•Drowsiness, sedation 

•Constipation

•Depression

•Edema

•Sexual dysfunction

ACE Inhibitors: Mechanism of Action

¨Inhibit Angiotensin Converting Enzyme which prevents the formation of angiotensin II à which prevents the breakdown of the vasodilating substance bradykinin which à Results in decreased Systolic vascular   resistance (afterload), which leads to   vasodilation, and therefore decreased BP

what would you assess to see if a patient has decreased urinary disfunction?

edema and decreased urinary output

For heart failure – what medications also prevent water and sodium reabsorption by inhibiting aldosterone secretion?

ACE Inhibitors

What makes ACE inhibitors the cardiovascular drugs of choice for patients with diabetes?

They reduce glomerular filtration pressure and reduce proteinuria and are Standard therapy for diabetics

ACE Inhibitors: Adverse Effects

¨Fatigue 

¨Dizziness 

¨Headache 

¨Mood changes

¨Impaired taste 

¨Possible hyperkalemia 

¨Dry, nonproductive cough, which reverses when therapy is stopped

¨Angioedema: rare but potentially fatal

What are the contraindications of Ace inhibitors?

Drug Allergy, pregnancy – category C first trimester; 2^nd and 3^rd trimester Category D

What are the interactions for ACE inhibitors?

NSAIDs – decrease antihypertensive effects can lead to acute renal failure

What is the baseline potassium level?

5 mEq/L or higher

ACE Inhibitors: Adverse Effects (TOXIC)

Hypotension, renal impairment, or renal failure

What drug causes dry cough and impaired taste

ACE inhibitors

what do ARB drugs end in

“Sartan”

ARB Drugs examples

¨losartan

¨eprosartan

¨valsartan

¨irbesartan

¨candesartan

¨olmesartan

¨telmisartan

¨azilsartan

Angiotensin II Receptor Blockers Mechanism of Action

¨Block Angiotensin II from binding with the type I Angiotensin II receptors in tissuesà this blocks vasoconstriction and the secretion of aldosterone in the adrenal gland.

What do ARBs primarily effect?

vascular smooth muscle and the adrenal gland

 Angiotensin II Receptor Blockers
Indications

• Hypertension

• Adjunctive drugs for the treatment of Heart failure

• May be used alone or with other drugs such as diuretics

Angiotensin II Receptor Blockers
contraindications

• Drug Allergy

• Pregnancy

• Lactation

Angiotensin II Receptor Blockers
CAUTIONS

• Elderly and patients with renal dysfunction

Angiotensin II Receptor Blockers Adverse Effects (most common)

• Chest pain

• Fatigue

• Hypoglycemia

• Diarrhea

• Urinary tract infection

• Anemia

• Weakness

• Hyperkalemia and cough are less likely to occur than with the ACE inhibitors.

Angiotensin II Receptor Blockers overdose effects

Hypotension and Tachycardia

Calcium Channel Blocker CCB Mechanism of action

•Reduce the influx of calcium into the cell

•Results in relaxation of smooth muscle & decreased BP

•Depresses automaticity and conduction velocity in smooth and/or cardiac muscle

What ways can CCBs be given?

IV, po, SL

Primary use of CCBs

treatment of hypertension, angina and Tachy dysrhythmias (known as supraventricular tachycardia)

Example CCB drugs

• verapamil

• diltiazem

• amlodipine

• nicardipine

• nefedipine

• nimodipine

what do CCB drugs end in?

“dipine” other than verapamil or diltiazem

CCB Indications

• angina

• hypertension: amlodipine

• dysrhythmias

• migraine headaches

• raynaud’s disease

• •Prevent the cerebral artery spasms after subarachnoid hemorrhage: nimodipine

What drug Prevents the cerebral artery spasms after subarachnoid hemorrhage?

nimodipine

CCB Adverse Effects

• Hypotension

• Palpitations

• Tachycardia or bradycardia

• Constipation

• Nausea

• Dyspnea

• Rash

• Flushing

• Peripheral edema

CCB Contraindications

• Drug allergy

• Acute myocardial infarction (MI)

• 2^nd and 3^rd degree AV block with out pacemaker

• Hypotension

CCB ¨Patient Education

Avoid grapefruit and grapefruit juice

Antihypertensives nursing implications

• Obtain BP and AP prior to administration

• Monitor BP

• Postural (orthostatic) hypotension

• Avoid alcohol and smoking

• Encourage weight loss

• Assess necessary labs

Antihypertensives patient Education

• Compliance with medication regimen

• Na restricted diet

what are some Methods to prevent orthostatic hypotension

• Change positions slowly

• calf pumping

• TED hose

why should antihypertensives not be stopped abruptly?

it can cause severe rebound hypertension, MI

Patient Education on none pharmacological methods to control BP

• diet – low fat

• low sodium – See DASH diet – amazing results

• Engage in regular exercise

• reduce stress

• weight loss

• avoid prolonged standing or sitting

  • Avoid heat

what are some labs needed for antihypertensives

• Serum creatinine and potassium – ACE inhibitors

• ACE inhibitors can cause renal impairment, which can be identified with serum creatinine

Why do potassium levels need to be monitored?

ACE inhibitors can also cause hyperkalemia

what drugs are first-line antihypertensives in the JNC 8 guidelines for the treatment of hypertension

diuretics

what does a decrease in plasma and extracellular fluid volume in regards to diuretics result in?

• Decreased preload 

• Decreased Cardiac Output   

• Decreased total peripheral resistance

what is the result of decreased preload, Decreased Cardiac Output, and Decreased total peripheral resistance (diuretics)

Decreased workload of the heart and decreased BP

what is the most commonly used diuretics for hypertension?

thiazide

thiazide diuretics mechanism of action

inhibit Na & Cl reabsorption in early portion of distal tubule

loop diuretics mechanism of action

inhibit Na & Cl reabsorption in ascending loop of Henle

potassium sparing diuretics mechanism of action

Block sodium reabsorption in distal tubule or inhibit action of aldosterone; Inhibit K excretion

osmotic diuretics mechanism of action

increase osmotic concentration of renal tubules – promoting water excretion

carbonic anhydrase inhibitor mechanism of action

inhibit carbonic anhydrase  - Increase excretion of bicarbonate, Na & water

example of thiazide diuretic

chlorothiazide and hydrochlorothiazide

example of loop diuretic

furosemide and bumetanide

example of potassium-sparing diuretic

spironolactone and triamterene

example of osmotic diuretic

Mannitol

example of carbonic anhydrase inhibitor

acetazolamide

what is the route of thiazide diuretics?

oral

what is the onset of thiazide diuretics?

begins 2 hours after oral dose

how route are loop diuretics taken?

orally and IV

what is the onset of loop diuretics

Po- diuresis begins in 60 minutes; IV - within 5 -10 minutes

what is used to treat glaucoma by decreasing the production of aqueous humor?

Carbonic Anhydrase Inhibitor

what do diuretics treat?

edema, fluid volume excess, and hypertension

diuretics: side/ adverse effects

• hypotension

• dehydration

• electrolyte imbalance - especially hypokalemia

• ECG changes, dysrhythmias

• anorexia, N, V, decrease peristalsis

• skeletal muscle weakness

• metabolic alkalosis - from chloride depletion

• ototoxicity

• hyperglycemia, hyperuricemia

• Vertigo, dizziness

diuretics: drug interactions

• Aminoglycosides which increase ototoxicity

• antihypertensive which decrease BP

General Nursing Implications of diuretics

• Monitor I & O, daily weight, BP

• Monitor electrolytes - especially K (can cause dysrhythmias, muscle weakness & cramps)

• Give early in the day to prevent nocturia

• Diet – if potassium losing diuretic ( can cause high potassium, low sodium diet of citrus fruit, bananas, fish, etc.)

Vasodilators mechanism of action

Directly relax arteriolar or venous smooth muscle (or both)

which results in:

• Decreased Systolic Vascular Resistance

• Decreased afterload

• Peripheral vasodilation

Vasodilator drugs

• diazoxide

• hydralazine

• minoxidil

• nitroprusside (Nitropress)

Vasodilators Indications

• Treatment of hypertension

• May be used in combination with other drugs

what vasodilators would be administered during a hypertensive emergency?

• Sodium nitroprusside

• and IV diazoxide

adverse effects of vasodilators: hydralazine

• dizziness

• headache

• anxiety

• Tachycardia

• edema

• Dyspnea

• nausea, vomiting, diarrhea,

• hepatitis

• systemic lupus erythematosus

• vitamin B₆ deficiency

• rash

adverse effects of vasodilators: sodium nitroprusside

• bradycardia

• decreased platelet aggregation

• rash

• hypothyroidism

• Hypotension

• methemoglobinemia,

• (rarely) cyanide toxicity

adverse effects of vasodilators: minoxidil

• ECG changes

• pericardial effusion or tamponade

• angina

• breast tenderness

• rash

• thrombocytopenia

what treats angina

antianginal

what is angina?

Imbalance of oxygen supply and oxygen demand

what is one Chronic angina medication

ranolazine (given orally)

what are the therapeutic objectives of antianginals?

1. Minimize the frequency of attacks and decrease the duration and intensity of angina pain.

2. Improve the patient’s functional capacity with as few adverse effects as possible.

3. Prevent or delay the worst possible outcome -> myocardial infarction

Mechanism of Action: Nitrates and nitrites

Dilate blood vessels.

what is the use of Nitrates and nitrites?

Prophylaxis and treatment of angina and other heart problems

examples of Nitrates and nitrites

• Nitroglycerine

• Isorbide dinitrate

• Isorbide mononitrate

Contraindications for Nitrates and nitrites

• Drug allergy

• Severe anemia

• Closed angle glaucoma

• Hypotension

• Severe head injury

• Erectile dysfunction drugs (sildenafil, tadalafil, vardenafil)

Nitrates Nursing Implications for Sublingual / Spray

• Store tablets in dark, airtight container

• Take 1 every 5 minutes x 3

• Replace supply every 3 months

• spray against oral mucosa

• do not inhale spray

Nitrates Nursing Implications for Topicals

• rotate sites

• apply in thin layer to hairless area, cover with plastic

Nitrates Nursing Implications for IV

• must be administered in glass bottle, use special tubing

• Monitor BP, pulse

• Instruct patients to avoid nicotine

Nitrates Adverse effects

• headache

• postural hypotension

• reflex tachycardia

• dizziness

• weakness

• Syncope

• palpitations

when does Reflex tachycardia occur?

occurs in vasodilation (occurs rapidly & overcompensates and increases heart rate)

when does Tolerance and cross tolerance occur?

when using more than 1 nitrate form

Duration of Action for NTG: Intravenous infusion

¨Onset of action 1 to 2 minutes (fastest of all dosage forms), peak action not applicable, duration of action 3 to 5 minutes