Introduction to clinical pharmacology chapter 38 cardiotonics and inotropic drugs
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Introduction to Clinical Pharmacology Chapter 38- Cardiotonics and Inotropic Drugs. Heart Failure. Most common symptoms associated with HF include: Left ventricular dysfunction Shortness of breath with exercise dry hacking cough or wheezing orthopnea, restlessness, edema

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Introduction to Clinical Pharmacology Chapter 38- Cardiotonics and Inotropic Drugs

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Introduction to clinical pharmacology chapter 38 cardiotonics and inotropic drugs

Introduction to Clinical PharmacologyChapter 38-Cardiotonics and Inotropic Drugs


Heart failure

Heart Failure

  • Most common symptoms associated with HF include:

    • Left ventricular dysfunction

    • Shortness of breath with exercise

    • dry hacking cough or wheezing

    • orthopnea, restlessness, edema

  • Left ventricular dysfunction

    • Pulmonary symptoms-dyspnea, moist cough with production of frothy, pink sputum

    • EF less than 40%, heart is enlarged and dilated

  • Right ventricular dysfunction

    • Peripheral edema, wt. gain


Cardiotonics actions and uses

Cardiotonics: Actions and Uses

  • Actions:

    • Increase cardiac output through positive inotropic activity; they slow the conduction velocity through the atrioventricular (AV) node in the heart and decrease the heart rate through a negative chronotropic effect

  • Uses:

    • Used to treat: Heart failure; atrial fibrillation

    • Patients with persistent symptoms, recurrent hospitalizations, or as indicated in conjunction with ACE inhibitors, loop diuretics and B blockers


Cardiotonics adverse reactions

Cardiotonics: Adverse Reactions

  • Central nervous system reaction:

    • Headache; weakness; drowsiness; visual disturbance

  • Cardiovascular and gastrointestinal reactions:

    • Arrhythmias; gastrointestinal upset; anorexia


Cardiotonics contraindications and precautions

Cardiotonics: Contraindications and Precautions

  • Contraindicated: In the presence of digitalis toxicity and in patients with known hypersensitivity, ventricular failure, ventricular tachycardia, cardiac tamponade or AV block

  • Precautions: Patients with electrolyte imbalance, severe carditis, heart block, myocardial infarction, severe pulmonary disease, acute glomerulonephritis, impaired renal or hepatic function

    • Digoxin and digoxin immune fab used cautiously during pregnancy and lactation, when the potential benefit outweighs the potential harm to the fetus


Cardiotonics interactions

Cardiotonics: Interactions


Miscellaneous inotropic drugs

Miscellaneous Inotropic Drugs

  • Inamrinone and milrinone: have inotropic actions and are used in the short-term management of severe HF that is not controlled by the digitalis preparations

  • Nurse must continuously monitor the patient’s heart rate and blood pressure with administration of either drug

  • If hypotension occurs, the drug is discontinued or the rate of administration is reduced

  • Continuous cardiac monitoring is necessary because life-threatening arrhythmias may occur


Nursing process assessment

Nursing Process: Assessment

  • Preadministration assessment:

    • The physical assessment should include:

      • Taking blood pressure, apical-radial pulse rate, respiratory rate

      • Auscultating the lungs, noting any unusual sounds during inspiration and expiration

      • Examining the extremities for edema

      • Checking the jugular veins for distention

      • Measuring weight


Nursing process assessment1

Nursing Process: Assessment

  • Preadministration assessment: (cont’d)

    • Inspecting sputum raised (if any), and noting the appearance (e.g., frothy, pink-tinged, clear, yellow)

    • Looking for evidence of other problems, such as cyanosis, shortness of breath on exertion (if the patient is allowed out of bed) or when lying flat, and mental changes

  • The primary care provider also may order laboratory and diagnostic tests


Nursing process assessment2

Nursing Process: Assessment

  • Preadministration assessment: (cont’d)

    • Because digoxin reacts with many medications, the nurse must take a careful drug history

    • Before administering each dose of a cardiotonic, the nurse takes the apical pulse rate for 60 seconds, records it in the designated area on the chart or the medication administration record

    • Pulse rate below 60bpm and above 100bpm in adults: withhold the drug and inform the primary health care provider, PEDS-notify PCP if AP <70 bpm or below 90 bpm in infant


Nursing process assessment3

Nursing Process: Assessment

  • Ongoing assessment: (con’td)

    • Weighs patients receiving a cardiotonic drug daily, or as ordered

    • I and O, especially in the presence of edema or HF

    • Assess the patient for peripheral edema and auscultates the lungs for rales or crackles throughout therapy


Nursing process planning

Nursing Process: Planning

  • The expected outcomes of the patient depend on the specific reason for administering the drug, but may include:

    • Optimal response to therapy

    • Support of patient needs related to the management of adverse reactions

    • Understanding of and compliance with the prescribed drug regimen


Nursing process implementation

Nursing Process: Implementation

  • Promoting an optimal response to therapy

    • The nurse should carefully check the primary care provider’s order and the drug container

    • Digitalization

      • Maybe accomplished by two general methods: Rapid digitalization and gradual digitalization

      • Involves giving a series of doses until the drug begins to exert a full therapeutic effect, additional freactions of the digitalis dose are administered at 6-8 hour intervals


Nursing process implementation1

Nursing Process: Implementation

  • Promoting an optimal response to therapy (cont’d)

    • Digitalization (cont’d)

      • During digitalization, the nurse takes the blood pressure, pulse, and respiratory rate every 2 to 4 hours or as ordered by the primary care provider

      • Periodic electrocardiograms, serum electrolytes, hepatic and renal function tests, and other laboratory studies also may be ordered


Nursing alert

Nursing Alert

  • Plasma digoxin levels are monitored closely

  • Plasma levels should be drawn immediately before the next dose or 6-8 hours after the last dose regardless of route

  • Plasma dig. Levels greater than 2 nanograms/ml are toxic are must be reported to PCP

  • Hypokalemia makes heart muscle more sensitive to digitalis, increasing the possibility of developing digitalis toxicity


Nursing process implementation2

Nursing Process: Implementation

  • Promoting an optimal response to therapy (cont’d)

    • Parenteral administration:

      • The nurse may give a cardiotonic orally, IV, or intramuscularly (IM)

      • When a cardiotonic drug is given IV, it is administered slowly and the administration site is assessed for redness or infiltration

      • When giving a cardiotonic drug IM, the nurse should rotate the injection sites


Nursing process implementation3

Nursing Process: Implementation

  • Promoting an optimal response to therapy (cont’d)

    • Oral Administration:

      • Nurse can administer oral preparations without regard to meals

  • Monitoring and managing patient needs

    • Risk of imbalanced nutrition: Less than body requires

      • Observe the patient for adverse reactions, such as anorexia, vomiting, nausea (symptoms of toxicity)


Nursing process implementation4

Nursing Process: Implementation

  • Monitoring and managing patient needs (con’td)

    • Potential complication: Digital toxicity

      • Observe for signs of digitalis toxicity- 2-4 hours during digitalization and 1-2 times a day

      • Digoxin toxicity can be successfully treated by simply withdrawing the drug; severe life-threatening toxicity is treated with digoxin immune fab

      • Nurse should be alert for the possibility of worsening HF, low cardiac output, hypokalemia, or atrial fibrillation

      • Give atropine if bradycardia develops!!


Nursing process implementation5

Nursing Process: Implementation

  • Educating the patient and family:

    • If HR falls below 60 bpm in adult, 70 bpm in child-instruct them to call PCP

    • The patient and family must understand that the prescribed drug must be taken exactly as directed by the primary care provider-do not miss or double a dose

    • Show the patient or a family member the correct technique for taking the pulse


Nursing process evaluation

Nursing Process: Evaluation

  • The therapeutic effect is achieved

  • The patient maintains an adequate nutritional status

  • The patient is able to carry out activities of daily living

  • Adverse reactions are identified, reported to the primary care provider, and managed using appropriate nursing interventions

  • The patient verbalizes the importance of continued follow-up care


Nursing process evaluation cont d

Nursing Process: Evaluation (cont’d)

  • The patient verbalizes the importance of complying with the prescribed therapeutic regimen

  • The patient and family demonstrate an understanding of the drug regimen

  • The patient complies with the prescribed drug regimen


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