heart failure durgs
diuretics
ACE inhibitors
ARBs
beta adrenergic blockers
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 <60 bpm
2ND LINE OF HF MANAGEMENT
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
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
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)
slow onset, long duration
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
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
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
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
hypotonic solutions
0.45 NS
0.33 NS
0.22 NS
push fluid to cells, rehydrate cells
hypotonic solutions indication
diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia nonketotic syndrome (HHNS)
initially isotonic (NS) then hypotonic
maintenance
hypertomic 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
inc blood volume = inc BP
risk for fluid overload = crackles, edema
isotonic solutions
0.9% NS
D5W
D5W/0.22% NS
LR
isotonic solution indications
initially for DKA
blood loss
dehydration
surgery