pharm: HF and cardiac IV therapy

heart failure durgs

* diuretics
* ACE inhibitors
* ARBs
* beta adrenergic blockers

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^^FIRST LINE OF HF MANAGEMENT^^

cardiac glycoside med

digoxin (lanoxin)

cardiac glycoside patho

* @@positive inotropic@@ effect increases ^^force^^ of mycardial contractions
* improves SV, CO
* @@negative chromotrope@@
* dec HR, slows SA mode depolarization
* gives the ventricles more time to fill
* %%check apical pulse

digoxin complications

* dysrhythmias
* bradycardia
* “dig” toxicity
* normal range: 0.5-0.9 ng/mL
* narrow TI
* check digoxin levels to make sure they reached therapeutic effect
* hypo/hyperkalemia
* hypo: risk for toxicity
* hyper: dec effectiveness of digoxin
* other sympathomimetic meds can accentuate the inotropic action
* inc risk for tachyarrhythmias

digoxin toxicity assessment

* n&v: early sign
* dec feeding: early sign
* diarrhea
* anorexia
* diplopia
* yellow vision
* GI symp.
* HR: brady
* headache
* heart block

digoxin contraindications

* pts with ventricular dysrhythmias
* vtach
* vfib
* b/c it slows SA conduction which is good for afib

digoxin nursing considerations

* check pulse rate and rhythm
* administer same time daily
* monitor levels for toxicity
* monitor for signs of hypokalemia

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* ^^digibind^^: antidote for dig toxicity

adrenergic agonists patho

**alpha 1 receptors**

* vasoconstriction: ==inc BP & HR==
* dilation of pupil

**beta 1 receptors**

* ==inc HR==
* myocardial contractility
* conduction thru AV node
* release of renin

**beta 2 receptors**

* vasodilation
* bronchodilation: promotes good breathing
* relaxation of uterine smooth muscle
* glycogenolysis: mask hypoglycemia = inc glucose
* muscle contraction
* ^^don’t give to diabetic pts^^

**dopamine receptors**

* dilation of renal blood vessels
* IV: promote renal perfusion = saves kidneys

what not to give to HF pts?

CCBs

* dec contractility

adrenergic agonists catecholamines meds

* epinephrine
* dopamine
* dobutamine
* isoproterenol
* norepinephrine
* albuterol
* ephedrine

epinephrine patho

IV

* vasoconstricts


* inc HR
* myocardial contractility
* rate of AV node conduction
* CO
* improved tissue perfusion

epinephrine uses

* cardiac arrest
* shock
* HF
* anaphylaxis (subQ)

epinephrine complications

* HTN crisis
* dysrhythmias
* inc oxygen demand
* abnormal vitals

norepinephrine is a

potent vasocontrictor

albuterol is used for

* asthma
* bronchodilator

ephedrine

* sudafed: decongestant
* inc BP, chest pain, inc HR
* bad for pt w/ CV disease
* preg. risk category C: harms fetus

dopamine and dobutamine

IV infusion

* similar actions to epinephrine, only used over a %%longer period of time%%
* used for shock, HF, to ^^maintain BP, CO^^
* ^^inc HR^^
* myocardial contractility
* ==infuse thru a central line if possible: caustic to veins==

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* low or mod. dose of dopamine: maintains a good renal perfusion
* more long term potent epi version
* will inc alertness, anxiety, insomnia
* ^^blood vessels constrict^^
* cold, clammy, dec urine output, slow GI = constipation, inc BP, bounding pulses

dopamine and dobutamine complications

* dysrhythmias
* inc workload on heart
* inc oxygen demand
* necrosis
* delayed cap. refill
* pallor
* dec pulse

angina

* pain which radiates to the left shoulder, arm, jaw
* inadeq. oxygen for myocardial demand
* chronic
* managed with antiplatelet agent, cholesterol lowering agent, and ACE
* nitroglycerin, beta blockers, calcium channel blockers
* give aspirin to prevent MI

anti-angina agents

nitroglycerin (NTG) = vasodilator

* ER caps
* SL tabs
* preferred for emergency management
* translingual spray
* topical ointment
* wear gloves
* transdermal patch
* clip/shave hair
* no open wound, irritation can happen
* IV (titrating)
* HTN crisis

nitroglycerin uses

* treatment of acute angina
* prophylaxis of chronic stable angina or prinz metal angina
* caused by vasospasm

complications of nitrates (NTG)

* **headache**
* most common side effect
* **orthostatic hypotension**
* check BP before giving >90 (dias)
* **reflex tachycardia**
* **tolerance**
* start w/ small dose
* **cumulative effect w/ other cardiac meds**

contraindications of nitrates (NTG)

* **severe anemia**
* dec BP: perfusion prob.
* **closed angle glaucoma**
* inc IOP
* **TBI (traumatic brain injury)**
* and stroke
* dec perfusion in brain
* **concurrent use with PDE5 inhibitors (****ED meds****)**
* phosphodiesterase type 5 (viagra)

SL NTG

* stop activity and sit
* 1 tab SL, rest 5 mins
* no relief? → call 911 and take another tab, rest 5 mins
* no relief? → take another tab

nitrate meds used daily

* isosorbide dinitrate (isordil)
* isosorbide mononitrate (imdur)

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* slow onset, long duration

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DO NOT CRUSH OR CHEW

adjunct angina meds

ranolazine (ranexa)

ranolazine patho

* ==lowers cardiac oxygen demand== thereby improves exercise tolerance and decreases pain
* used w/ cc blocker, beta blocker or a nitrate
* ^^for maintenance for unstable angina^^

anti- lipemic agents

* use with regular exercise, proper diet, weight control
* lower LDL cholesterol, possibly VLDL (very low density lipids)
* raise HDL cholesterol

anti- lipemic initial labs

* total cholesterol
* LDL
* HDL
* triglycerides
* liver & kidney function

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main assessment: LFTs, kidney function, hepatotoxicity

cholesterol lab values

* total


* less than 200 mg/dL


* LDL (“lazy”)
* greater than 50 but less than 100 mg/dL
* HDL (“happy”)
* higher than 40 mg/dL (male)
* higher than 50 mg/dL (female)
* cardioprotective: above 50 mg/dL
* triglycerides
* less than 150 mg/dL

anti-lipemic classifications

* HMG-CoA reductase inhibitors (statins)
* produce cholesterol
* ==most common==
* cholesterol absorption inhibitors
* inhibit absorption in GI
* bile-acid sequestrants
* nicotinic acid
* fibrates

statins

* decrease LDL, VLDL
* improves lipid profile
* inhibits cholesterol synthesis in liver
* inc HDL
* promotes vasodilation
* hypotension
* decrease in plaque site inflammation
* thromboembolism
* risk of afib

statin uses

* hypercholesteremia
* protection against MI, stroke
* primary prevention

statin meds

* simvastatin (zocor)
* pravastatin (pravachol)
* rosuvastatin (crestor)
* simvstatin & ezetimibe
* simvastatin & niacin
* lovastatin & niacin
* atorvastatin
* ==most common==

statins complications

* hepatotoxicity
* inc AST, ALT
* monitor LFTs after 12 wks, then q6months
* observe for liver dysfunction
* avoid alcohol
* myopathy (muscle aches, pain, tenderness)
* can progress to rhabdomyolysis
* protein bkdn → leg pain, muscle wkns
* take in evening
* same time
* sleep inc cholesterol
* ^^no grapefruit or grapefruit juice^^
* tylenol hepatotoxic
* only 4g

cholesterol absorption inhibitor med

ezetimibe (zetia)

cholesterol absorption inhibitor patho

* inhibits absorption of cholesterol secreted in the bile and from food
* lowers LDL
* used alone or in combination

cholesterol absorption inhibitor complicaitons

* hepatitis
* myopathy

bile acid sequestrants meds

* colesevelam
* colestipol

bile acid sequestrants patho

* dec LDL
* used alone or with a statin
* advise high fiber food and oral fluids
* cautiously with pt with biliary disorders

nicotinic acid med

niacin (vit. b3)

nicotinic acid patho

* dec LDL and triglyceride levels
* dosage is ==much larger== than dosage in a vitamin supplement
* if flushing, take aspirin 30 mins before dose

nicotinic acid complications

* hepatotoxicity
* hyperglycemia
* hyperuricemia
* allopurinol: dec uric acid, gout med

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caution with diabetics and gout

fibrates meds

* gemfibrozil
* fenofibrate

fibrates patho

dec in triglycerides

fibrates complications

* gallstones
* myopathy
* hepatotoxicity

intravenous therapy

* administer ==fluids, meds, electrolytes== or nutrients (TPN, PPN)
* cont., bolus, intermittent
* bolus: of fluid or meds
* fast drip
* meds: emergency- blood loss, hypotension
* prescribed by the provider
* ==rate/total time, total amt==

advantages of IV therapy

* rapid effects
* precise amts
* no discomfort from administration
* some can cause irritation, burn: dilute med
* can cause necrosis, vessel injury
* constant therapeutic blood levels

IV therapy are at risk for

* fluid overload
* HF
* kidney failure
* liver failure
* in neonates, old people

proper ways of infusing

* antibiotics: intermittently
* give @ exact time interval, if delay microbes will grow
* infusing for a short period, on a particular schedule
* “piggyback” meds
* IV push or IV bolus
* never push potassium!
* will cause cardiac arrest
* push > 10 meq/hr
* monitor urine output
* IV push: consider compatibility
* IV bolus: consider compatibility and how fast to push
* peripheral vein
* central venous access
* PICC
* pneumothorax: SOB, tachy, can’t breathe, punctured vein
* IJ or subclavian vein
* #1 infection site
* port-a-cath

SAFE IV administration

* use an ^^infusion pump^^
* some meds require their own line
* know how many access they have
* check for ^^compatibility^^ if piggyback
* never administer meds thru blood products
* separate lines
* ==nutraviolet bag (meds sensitive to UV)==
* extra care with pts on ^^anticoag^^.
* high alert meds: anticancer, insulin IV
* standard precautions for starting an IV
* change IV sites according to protocol
* %%q4 days (96 hrs), immunocompromised (72 hrs)%%
* replace tubing according to protocol

Scrub the Hub! FROG it!

* 15 secs


* chlorhexidine or alcohol infused caps

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* F riction
* R ubs
* O uts
* G erms

IV solutions

* 0.9 NaCl
* lactated ringers
* D5W
* 0.9 Macl with 20 meq KCL
* D5W/NS
* D5W/0.45 NS

**hypo**tonic solutions

* 0.45 NS
* 0.33 NS
* 0.22 NS

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push fluid to cells, rehydrate cells

hypotonic solutions indication

diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia nonketotic syndrome (HHNS)

* initially isotonic (NS) then hypotonic
* %%maintenance%%

**hyper**tomic solutions

* 3%, 5% NS
* 10% dextrose
* D5W/0.9% NS
* D5W/0.45% NS
* D5W/LR

hypertonic solutions indications

* hyponatremia
* dec Na
* cerebral edema
* swelling will dec, dec ICP
* ICU setting

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* inc blood volume = inc BP
* risk for fluid overload = crackles, edema

**iso**tonic solutions

* 0.9% NS
* D5W
* D5W/0.22% NS
* LR

isotonic solution indications

* %%initially for DKA%%
* blood loss
* dehydration
* surgery