pharm: HF and cardiac IV therapy

heart failure durgs

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