Cardiovascular pharmacology
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Cardiovascular Pharmacology. A Good Resource: http://www.cvpharmacology.com/index.html. Concept Map: Selected Topics in Cardiovascular Nursing. ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation Cardiac Monitoring Lab Monitoring.

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Cardiovascular pharmacology

CardiovascularPharmacology

A Good Resource:

http://www.cvpharmacology.com/index.html


Cardiovascular pharmacology

Concept Map: Selected Topics in Cardiovascular Nursing

ASSESSMENT

Physical Assessment

Inspection

Palpation

Percussion

Auscultation

Cardiac Monitoring

Lab Monitoring

PHARMACOLOGY

Cardiac Glycosides

ACE Inhibitors

Beta Blockers

Antiarrhythmics

Catecholamines

Anticoagulants

PATHOPHYSIOLOGY

Myocardial Infarction

Acute Coronary Syndrome

Valvular Heart Disease

Pacemakers

CABG

Abdominal Aortic Aneurysm

Pericarditis

Peripheral Vasc Disease (PVD)

Fem-Pop Bypass Graft

Shock / Fluid Deficit

Raynaud’s Phenomenon

Arrhythmias / Dysrhythmias

Care Planning

Plan for client adl’s,

Monitoring, med admin.,

Patient education, more…

Nursing Interventions & Evaluation

Execute the care plan, evaluate for

Efficacy, revise as necessary


Cardiovascular pharmacology

Cardiovascular Pharmacology

Alpha

Blockers

Beta Blockers

Anti-Arrhythmics

ACE

Inhibitors

Anti-Hypertensives

Anti-Anginals

Digitalis Glycosides

Calcium Channel Blockers

Anti-Lipemics

Loop Diuretics

Potassium – Sparing / Combination Diuretics

Platelet Aggregation Inhibitors

Thiazide / Related Diuretics


Cardiovascular pharmacology

  • -pril------------------------------- ACE Inhibitor

  • -lol or –olol ------------------Beta Blocker

  • -pine --------------------- Ca Channel Blocker

  • -statin --------------- anti-lipemic

  • -nitr ------------- nitrates

  • -zosin --------------- alpha blockers

-pine

-olol

-nitr

-statin

-lol

-pril

-zosin


Cardiovascular pharmacology

atenolol (Tenormin ®)

carvedilol (Coreg ®)

metoprolol (Toprol XL ®, LoPressor ®)

propranolol HCl (Inderal ®)

  • Alpha Blockers

  • Beta Blockers

  • Ca Channel Blockers

  • ACE Inhibitors

  • Anti-Lipemic

  • Nitrates

  • -olol

  • -pril

  • -pine

  • -statin

  • -nitr-

  • -zosin

  • -lol

benazepril HCl (Lotensin ®)

captopril (Capoten®)

enalapril maleate (Vasotec®)

lisinopril (Prinivil ®, Zestril®)

amlodipine besylate (Norvasc ®)

diltiazem HCl (Cardizem ®, Dilacor ®)

nifedipine (Adalat ®, Procardia XL ®)

Verapamil HCl (Calan ®, Isoptim ®, Covera ®)

  • atorvastatin calcium (Lipitor ®)

  • lovastatin ( Mevacor ®)

  • pravastatin (Pravachol ®)

  • rosuvastatin calcium (Crestor ®)

  • simvastatin (Zocor ®)

  • isosorbide dinitrate (Isordil ®)

  • isosorbide mononitrate (Ismo®)

  • Nitroglycerin

doxazosin mesylate (Cardura®)

prazosin HCl (Minipress®)


Ace inhibitors

ACE Inhibitors

-pril

  • benazepril HCl (Lotensin ®)

  • captopril (Capoten®)

  • enalapril maleate (Vasotec®)

  • lisinopril (Prinivil ®, Zestril®)

hypertension

CHF

Diabetic

Neuropathy

Left

Ventricular

Dysfunction

After

MI

ACUTE M.I.

“The Multi-Purpose Group !”


Prototype captopril

Prototype: captopril

  • ACE Inhibitors produce desired effect by blocking production of angiotensin II, resulting in arteriolar vasodilation, excretion of sodium and retention of potassium

  • Indications: Heart failure, HTN, MI (reduce mortality, reduce heart failure), diabetic & non-diabetic nephropathy.

  • Nursing Implications: orthostatic hypotension, cough, potential hyperkalemia


The pril s ace inhibitors

The –pril’s: ACE Inhibitors

  • Treatment of Hypertension

  • captopril, enalapril, lisinopril—tx of HTN, CHF, decreased L ventricular function after MI

  • Always check BP before administering—hold PRN (parameters)

  • Teach patient to change positions slowly to avoid postural hypotension

  • “cough”

C.O. = HR x SV

BP = C.O. x PVR


Alpha blockers

-zosin

Alpha Blockers

  • doxazosin mesylate (Cardura®)

  • prazosin HCl (Minipress®)


Prototype prazosin

Prototype: prazosin

  • Alpha blockers cause venous and arterial dilation, smooth muscle relaxation of prostate

  • Indications: HTN

  • Nursing Implications: monitor BP closely after initial dose; orthostatic hypotension


The zosin s alpha blockers sympatholytic

The –zosin’s: Alpha Blockerssympatholytic

Uses:

Nursing Implications

Teach patient to avoid changing positions rapidly (postural hypotension)

Check blood pressure prior to administration; hold med PRN (Parameters)

  • Treatment of HTN

  • BPH (doxazosin (Cardura®)

C.O. = HR x SV

BP = C.O. x PVR


Anti anginals

-nitr-

Anti-Anginals

  • isosorbidedinitrate(Isordil ®)

  • isosorbidemononitrate(Ismo®)

  • Nitroglycerin

  • Nitro-dur®,

  • Transderm Nitro ®

  • Nitrol ®

  • Nitrostat ®

  • Nitrotab ®


Prototype nitroglycerin

Prototype: nitroglycerin

  • Vasodilation of coronary artries increases myocardial oxygen supply; decreases myocardial oxygen demand via vasodilation and reduction of preload

  • Indications: angina treatment and/or prophylaxis;

  • Nursing Implications: hypotension, orthostatic hypotension, cough, potential hyperkalemia


The nitr s anti anginals effect vasodilation

The –”NITR’s” Anti-Anginals(effect: vasodilation)

  • nitroglycerin sl, nitropaste, nitroderm

  • Chest pain regimen: 1 tab NTG sl, q5 min X 3

  • Isosorbide dinatrate (Isordil®)

  • Treatment / Prophylaxis of angina, CHF

C.O. = HR x SV

BP = C.O. x PVR


Anti arrhythmics anti dysrhythmics

Anti-Arrhythmics( Anti-Dysrhythmics )

  • amiodarone HCl (Cordarone ®, Pacerone® )

  • lidocaine HCl (Xylocaine ®)

  • procainamide (Procanbid ®, Pronestyl ®)

  • quinidine (Quinaglute ®)


Prototype lidocaine

Prototype: lidocaine

  • Class Ibantiarrhythmic; decreases electrical conduction, decreases automaticity, increases rate of repolarization

  • Indications: short-term use for ventricular dysrhythmias; monitor respirations—respiratory arrest. Cardiac monitor—vital signs

  • Nursing Implications: CNS effects—drowsiness, altered mental status, paresthesias, seizures


Cardiovascular pharmacology

A “Slight” Side-Effect

of IV Amiodarone !


Cardiovascular pharmacology

  • Lidocaine HCl—the old reliable; used for PVC’s, ventricular ectopy, ventricular tachycardia

  • Amiodarone –Management of life-threatening ventricular arrhythmias unresponsive to less toxic meds; assess for pulmonary toxicity

  • Both of these: Infusion pumps, monitor v.s. frequently, cardiac monitor


Anti hypertensives

Anti-Hypertensives

  • clonidine (Catapres ®, Catapres Patch ®, Catapres TTS ®)

  • hydralazine HCl (Apresoline ®)

  • hydroclorothiazide / lisinopril (Prinzide ®, Zestoretic ®)

  • minoxidil (Loniten ®)


Prototype clonidine

Prototype: clonidine

  • Sympatholytic—decreases HR causes decrease in C.O., peripheral vasodilation—decreases BP

  • Indications: HTN, severe cancer pain

  • Nursing Implications: hypotension, orthostatic hypotension, administer twice daily in divided dose


Cardiovascular pharmacology

  • Hydralazine—tx of essential hypertension

  • HCTZ/Lisinopril—combination drug –essential hypertension

  • Always check BP prior to administration—hold PRN (Parameters)

  • Postural hypotension precautions


Anti lipemics

-statin

Anti-Lipemics

  • atorvastatin calcium (Lipitor ®)

  • colestipol (Colestid ®)

  • gemfibrozol (Lopid ®)

  • lovastatin ( Mevacor ®)

  • Niacin ( Niacor ®, Niaspan ®)

  • nicotinic acid (Slo-Niacin ®, Vitamin B)

  • pravastatin(Pravachol ®)

  • rosuvastatin calcium (Crestor ®)

  • simvastatin(Zocor ®)


Prototype atorvastatin

Prototype: atorvastatin


Beta blockers

-lol

Beta Blockers

-olol

  • atenolol (Tenormin ®)

  • carvedilol (Coreg ®)

  • metoprolol (Toprol XL ®, LoPressor ®)

  • propranolol HCl (Inderal ®)


Prototype metoprolol

Prototype: metoprolol

  • Remember that there are cardioselective and non-selective Beta blockers; Beta1 adrenergic blockage to reduce heart (- chronotrope) rate, decrease myocardial contractility (-inotrope), decrease rate of conduction through the AV node

  • Indications: angina, HTN, dysrhythmias, MI, Heart failure,

  • Nursing Implications: Apical pulse; monitor VS;

  • Contraindicated in AV Block, SB.


Cardiovascular pharmacology

  • Used for tx of HTN, MI, angina prophylaxis, CHF

  • Cardioselective vs nonselective B-Blockers and Respiratory

  • Nursing: Apical Pulse

C.O. = HR x SV

BP = C.O. x PVR


Calcium channel blockers

-pine

Calcium Channel Blockers

  • amlodipine besylate (Norvasc ®)

  • diltiazem HCl (Cardizem ®, Dilacor ®, Tiamate ®, Cardizem SR ®, Cardizem CD ® )

  • nifedipine (Adalat ®, Procardia XL ®)

  • Verapamil HCl (Calan ®, Isoptim ®, Covera ®)


Prototype nifedipine

Prototype: nifedipine

  • Vasodilation of peripheral arterioles; clocking of CA+ channels in heart causes decreased force of contraction, decreased heart rate, decreased pulse. (-inotrope, -chronotrope)

  • Indications: HTN, angina, selected dysrhythmias

  • Nursing Implications: hypotension, orthostatic hypotension, cardiac monitor, monitor pulse rate

  • Contraindications: AV blocks, hypotension, bradycardia, aortic stenosis, severe heart failure


Cardiovascular pharmacology

  • Treatment of HTN, vasospastic angina, angina prophylaxis, Atrial Fibrillation (sometimes) , rapid atrial dysrhythmias

  • Nursing: Check BP, hold PRN (Parameters)

  • Postural Hypotension Precautions

C.O. = HR x SV

BP = C.O. x PVR


Digitalis glycosides

Digitalis Glycosides

  • digoxin (Lanoxin ®)

  • (+) Inotrope, (-) Chronotrope

  • CHF, Atrial Tachy-arrhythmias (A-Fib, A-Flutter), Cardiogenic Shock

  • Assess Apical Pulse

  • Dig Toxicity—anorexia, fatigue, weakness, yellow-green halo’s around lights

  • Role of K+ ! (Can be Dig Toxic with therapeutic Dig levels if K+ is low!) Therapeutic Level = 0.5-2.0 ng/ml

  • Low K+: Possible U Waves on EKG


Prototype digoxin

Prototype: digoxin

  • (+) inotropic effect; (-) chronotropic effect; improves stroke volume and C.O.

  • Indications: treatment of heart failure; treatment of atrial fibrillation

  • Nursing Implications: AP, monitor dig levels, monitor K+

  • Contraindicated: Ventricular rhythm disturbances: VF, VT, 2nd -3rd degree AV block


Loop diuretics

Loop Diuretics

  • bumetanide (Bumex ®)

  • furosemide (Lasix ®)

  • Monitor serum K+ 3.5 – 5.0 mEq/L

  • Potassium rich foods


Prototype furosemide

Prototype: furosemide

  • Block reabsorption of NA and Cl, prevent reabsorption of H2O, causing extensive diuresis;

  • Indications: Pulmonary edema d/t Heart failure

  • Nursing Implications: I&O, daily weights, hypotension, diuresis (foley?), orthostatic hypotension, monitor K+, RELATE THIS MED IN RELATION TO OTHER MEDS. Dietary counseling.


Platelet aggregation inhibitors

Platelet Aggregation Inhibitors

  • clopidogrel bisulfate (Plavix ®)

  • dipyridamole (Persantine ®)

  • ticlopidine HCl (Ticlid ®)

  • Prevention of TIA’s, CVA; combined with warfarin or ASA for heart valves, MI, bypass grafts, stents.


Prototype aspirin

Prototype: aspirin

  • Prevent platelets from clumping or aggregating;

  • Indications: Primary prevention of MI; prevention of CVA (stroke);

  • Nursing Implications: bleeding , GI Upset ; use cautiously in those with anticoagulants and NSAID’s (potentiates).


Potassium sparing combination diuretics

Potassium Sparing / Combination Diuretics

  • hydrochlorothizide / triamterene

  • (Dyazide ®, Maxzide ®)

  • spironolactone (Aldactone ®)

  • Treatment of edema and hypertension

  • Avoid high K= foods (oranges, bananas, salt substitute, dried apricots, dates,

  • Weigh Daily


Prototype spironolactone

Prototype: spironolactone

  • Spironolactoneis classified as a potassium-sparing diuretic.

  • Indications:congestiveheart failure, cirrhosis of the liver, and kidney disease. It can also be used in combination with other drugs to treat elevated blood pressure.

  • Nursing Implications: Used with other diuretics; Give with meals; Avoid salt substitutes containing potassium;

  • Monitor I and O


Thiazides related diuretics

Thiazides / Related Diuretics

  • chlorthalidone

  • (Hygroton ®, Hylidone ®, Thalitone ®

  • hydrochlorothiazide [hctz] (Hydrodiuril ®)

  • indapamide (Lozol ®)

  • metolazone (Zaroxylyn ®)


Cardiovascular pharmacology

  • NOTE THAT MORE THAN ONE HYPERTENSIVE –SOMETIMES SEVERAL--MAY BE NEEDED TO CONTROL HTN; USED IN COMBINATION WITH DIURETICS; Txedema, HTN

  • Monitor for hypokalemia


Anti coagulants

Anti-Coagulants

  • Heparin

  • Enoxaparin

  • Warfarin

  • Antidotes:

  • Heparin = protamine sulfate

  • Coumadin = vitamin K

  • Digoxin = Digibind, Digifab,


Prototype heparin

Prototype: heparin

  • Inactivation of thrombin formation vis inhibition of fibrin formation,

  • Indications: DIC, stroke, prophylaxis agains post-op DVT,

  • Nursing Implications: bleeding (remember: internal & external bleeding) Heparin Induced Throbocytopenia (HIT)—stop if platelets <100,000; monitor aPTT (< 2 x baseline)

  • Antidote: Protamine sulfate


Thrombolytic medications

Thrombolytic Medications


Prototype streptokinase

Prototype: streptokinase

  • Act by dissolving clots.

  • Indications: Acute MI; DVT; Pulmonary emboli, ischemic stroke (alteplase)

  • Nursing Implications: MONITOR FOR BLEEDING; monitor VS; (see p. 310, ATI Pharm)

  • Contraindications: prior intracranial hemorrhage, active internal bleeding, significant trauma within 3 months, acute pericarditis, brain tumors.


Cardiovascular pharmacology

EMERGENCY

CARDIAC

PHARMACOLOGY


Cardiovascular pharmacology

  • Oxygen

  • Epinephrine

  • Atropine

  • Adenosine

  • Lidocaine (or amiodarone)


Oxygen

Oxygen

  • 100 % ! (during resuscitation, for all clients, including those with chronic respiratory conditions, e.g., COPD)


Cardiovascular pharmacology

Epinephrine(Adrenaline) catecholamine

  • Pharmacologic action: vasoconstriction; increased heart rate (+ chronotrope); increased rate of conduction; increased BP; increased myocardial contractility.

  • Indication: Cardiac arrest; ventricular fibrillation

  • Administration: IV, IV push

  • Dose: 1 mg IV pushq3-5min

  • Nursing Implications: Monitor blood pressure, peripheral pulses, urinary outputUse infusion pump


Atropine sympathomimetics

Atropine sympathomimetics

  • Pharmacologic Action:

  • Indication:SYMPTOMATIC BRADYCARDIA

  • Administration: IV

  • Nursing Considerations: weigh the risks to increased myocardial oxygen demand in CV patient

  • 1 mg rapid IV. Repeat q3-5 minutes up to maximum total dose of 0.04 mg/kg.


Adenosine class v antiarrhythmic

Adenosineclass V antiarrhythmic

  • Pharmacologic Action: Class V anti-arrhythmic; causes transient heart block in the AV node

  • Indication: SVT & WPW

  • Administration: IV Bolus

  • Nursing Considerations: after IV bolus, causes a transientasystole

  • 6 mg rapid IV, followed by saline flush. If no response in 1-2 minutes give 12 mg rapid IV. May repeat in 1-2 minutes if needed.


Lidocaine anti arrhythmic

Lidocaineanti-arrhythmic

  • Indications: ventricular fibrillation, ventricular tachycardia

  • Pharmacologic Actions: anti-arrhythmic

  • Administration: IV

  • Nursing Considerations: monitor the patient! If received bolus, needs to receive a continuous infusion afterwards; CNS effects—drowsiness, altered mental status, seizures

  • 1 to 1.5 mg/kg q3-5min. Maximum total: 3 mg/kg.


Amiodarone anti arrhythmic

Amiodaroneanti-arrhythmic

  • Indications:

  • Pharmacologic Actions:

  • Administration:

  • Nursing Considerations:


Matching

Matching

C

J

S

V

Column A

Column B

A. isosorbidedinitrate (Isordil ®)

B. digoxin (Lanoxin ® )

C. prazosinHCl (Minipres ®)

D. amiodaroneHCl (Cordarone®, Pacerone ® )

E. hydralazineHCl (Apresoline ®)

F. dipyridamole (Persantine ®)

G. nitroglycerin (Nitrostat ®)

H. lidocaineHCl (Xylocaine ®)

I. simvastatin (Zocor ®)

J. doxazosinmesylate(Cardura®)

K. quinidine (Quinaglute ®)

L. clonidine (Catapres ®)

M. atorvastatin calcium (Lipitor ®)

N. gemfibrozol (Lopid ®)

O. lovastatin ( Mevacor ®)

P. spironolactone (Aldactone ®)

Q. hydrochlorothiazide [hctz] (Hydrodiuril ®)

R. clopidogrel bisulfate (Plavix ®)

S. carvedilol (Coreg ®)

T. furosemide (Lasix ®)

U. colestipol (Colestid ®)

V. propranololHCl (Inderal ®)

W. nifedipine (Adalat ®, Procardia XL ®)

X. ticlopidineHCl (Ticlid®)

Y. verapamilHCl (Calan ®)

Z. bumetanide (Bumex ®)

ACE Inhibitors

  • Alpha Blocker

  • Beta Blocker

  • Calcium Channel Blocker

  • Anti-Anginal

  • Anti-Arrhythmic

  • Anti-Hypertensive

  • Anti-Lipemic

  • Digitalis Glycosides

  • Loop Diuretics

  • Platelet Aggregation Inhibitors

  • Potassium Sparing / Combination Diuretics

  • Thiazide Diuretics

A

G

D

H

K

Y

E

L

I

M

N

O

U

B

T

F

R

X

P

Z

W

Q


Appendix electrolytes imbalances related to cardiac effects

Appendix: Electrolytes & Imbalancesrelated to: Cardiac Effects

Sodium (Na+)

Effects:

>DecreasedHypotension, headache, nausea, vomiting, abdominal cramps, muscle tremors, twitching, fatigue, headache, nausea, vomiting, diarrhea, abdominal cramps, muscle tremors, twitching, weakness, confusion, seizures, and coma

<IncreasedLethargy, irritability, muscle twitching, tremors, dry skin and mucous membranes, fever, hypotension, disorientation, delirium, cerebral hemorrhage, coma 

  • Normal level =

  • 135 to 145 mEq/L (adult)

  • Required in acid-base and osmotic pressure balance, nerve function and water equilibrium. 


Cardiovascular pharmacology

Potassium (K+)

Effects:

> Decreased Cardiac arrhythmia, depressed S-T segment,flattened/inverted T wave, U wave, confusion, lethargy, muscle weakness, paralysis, abdominal distention, constipation, paralytic ileus, thirst, frequent voiding

< Increased Muscle weakness, paralysis, numbness and tingling, ventricular fibrillation, cardiac arrest, tall tented T waves

  • Normal level =

  • 3.5 to 5 mEq/L (adult)

  • Major factor in carbohydrate metabolism, osmotic pressure balance, acid-base balance and normal muscle contraction. 

!


Cardiovascular pharmacology

Calcium (Ca++)

Effects

>DecreasedFrequent hives, chronic fatigue, canker and cold sores, muscle cramps (Charlie Horses), and itchy skin dementia, depression, psychosis, tetany (Chvostek's and Trousseau's signs), laryngospasm, or generalized convulsions, cardiac arrhythmias with lengthened QT segments

<Increased Muscle weakness, bone fragility, kidney stones, loss of appetite, thirst, frequent urination, lethargy, fatigue, joint pains, memory loss, depression, constipation, anorexia, nausea and vomiting, abdominal pain, ileus, polyuria, nocturia, and polydipsia, emotional lability, confusion, delirium, psychosis, stupor, coma, cardiac arrhythmias with shortened QT segment

  • Normal level =

  • 8.5 to 10 mg/dL

  • Involved in bone and tooth formation, blood coagulation, nerve function, muscle contraction. 


Cardiovascular pharmacology

Magnesium (Mg2+)

>Decreased Muscle weakness, fatigue, confusion, restlessness, hyperexcitability, vertigo, seizures, muscle tremors, nystagmus, tachycardia, hypotension, PAC, PVC, Toursades de Pointes arrhythmia, anorexia, nausea, vomiting, personality change, tetany (eg, positive Trousseau's or Chvostek's sign or spontaneous carpopedal spasm), and tremor and muscle fasciculations

<Increased Muscle weakness, drowsiness, lethargy, hypotension, paralysis, coma, cardiac and respiratory problems

  • Normal level =

  • 1.3 to 2.1 mEq/L

  • Required for activation of an enzyme necessary for energy metabolism and bone formation. 


Blood glucose

Blood Glucose

Hypoglycemia

Hyperglycemia

Diabetic Ketoacidosis · Fatigue · Flushed, dry skin· Dry mouth · Increased thirst · Increased urination· Blurry vision · Headache· Nausea and Vomiting· Dehydration· Weak, rapid pulse· Hypotension· High blood glucose levels (>240 mg/dL).· Ketones in urine· Increased thirst and urination · Nausea, vomiting, and/or stomach pain· Changes in or difficulty breathing (Kussmaul’s respirations)· Acid or fruity smell on breath (Acetone breath)· Flushing · Dehydration · Fatigue · Stupor and coma

Restlessness· Irritability· Confusion· Trembling· Slurred speech · Headache · Tingling lips · Paresthesia· Diaphoresis (cool skin) · Pallor· Tachycardia· Shallow respirations· Hypertension· Weakness · Hunger · Coma · Tremors 


Cardiovascular pharmacology

Hypokalemia: ST depression, decreased or inverted T waves, U waves²         Hyperkalemia: peaked T waves, decreased P waves, short QT, widened QRS, sine wave²         Hypocalcemia: prolonged QT, flat or inverted T waves²         Hypercalcemia: short or absent ST, decreased QTc interval²         Hypomagnesemia: prolonged QT, flat T waves, prolonged PR, aFib, torsade²         Hypermagnesemia: short PR, heart block, peaked T waves, widened QRS0²         Digitalis toxicity: ST depression (scoop), flat T waves²         Quinidine: prolonged QT, widened QRS²        Pericarditis: diffuse ST elevation with PR interval depression

Hypomagnesemia: prolonged QT, flat T waves, prolonged PR, aFib, torsade²         Hypermagnesemia: short PR, heart block, peaked T waves, widened QRS0²         Digitalis toxicity: ST depression (scoop), flat T waves


Appendix a med surg nurses description of cardiac care things to think about with patient care

Appendix: A Med-SurgNurses description of cardiac care—things to think about with patient care

If the physician prescribes a digitalis glycoside, take your patient's apical pulse for a full minute before administering the drug. Withhold the drug if his apical pulse is less than 60 beats per minute.

  • Monitor your patient's response to drug therapy by assessing his blood pressure, heart rate, heart sounds, ECG results, breath sounds, urine output, and weight. Also, assess him for peripheral edema.


Cardiovascular pharmacology

If he's also receiving a thiazide or loop diuretic, monitor his serum potassium level; a low potassium level can lead to digitalis toxicity.

  • Begin digitalis glycoside therapy by administering a loading dose (AS ORDERED) to achieve a therapeutic level more quickly. Monitor your patient's serum digoxin level to ensure that it remains in the therapeutic range of 1 to 2 ng/ml. Also, assess him for signs and symptoms of digitalis toxicity.


Cardiovascular pharmacology

If your patient is receiving one of these drugs during digitalis glycoside therapy, monitor his heart rate and rhythm and assess for signs of digitalis toxicity, such as gastrointestinal, neurologic, or vision disturbances. If he shows evidence of toxicity, HOLD THE MEDICATION & NOTIFY THE PYSICIAN--the digitalis glycoside will most likely be on hold until his level returns to the therapeutic range.

  • Other drugs that increase the risk of digitalis toxicity include beta-blockers, anticholinergics, quinidine, verapamil, nifedipine, amiodarone, and propafenone.


Cardiovascular pharmacology

After therapy, your patient may be referred to an occupational therapist to learn how to conserve oxygen and energy while performing daily activities. The therapist also may help your patient modify his environment to reduce cardiac workload. For ex­ample, the therapist may suggest moving bed­room furniture to the first floor and obtaining a bedside commode.

  • During therapy, reduce your patient's cardiac workload by restricting his activity. Provide oxygen through a face mask or nasal cannula, as prescribed, to support his heart's oxygen demands


Cardiovascular pharmacology

Tell him to withhold the dose and call the physician if his pulse is lower than 60 beats per minute. Also, teach him the signs and symptoms of digitalis toxicity, such as nausea, vomiting, diarrhea, fatigue, vision changes, and an abnormally slow pulse rate; hypokalemia, such as weakness, fatigue, nausea, abdominal cramps, and diarrhea; and hyperkalemia, such as muscle tenderness, fatigue, and constipation.

  • Teach your patient and his family about his prescribed drug therapy. If a digitalis glycoside has been prescribed, instruct him to take his pulse before taking the drug. Tell your patient that he may need potassium supplements with diuretic and digitalis glycoside therapy.


Cardiovascular pharmacology

If your patient is taking more than one drug, help him devise a dosage schedule that accommodates his lifestyle. For example, advise him to take twice-daily drugs before breakfast and dinner (if not contraindicated) to avoid forgetting to take them during a busy workday.

  • Tell your patient that he may need potassium supplements with diuretic and digitalis glycoside therapy.


Cardiovascular pharmacology

Tell him to conserve his energy by resting frequently. Explain how to obtain and use supplemental oxygen, if prescribed.

  • Instruct the patient to follow a low-sodium diet. If necessary, refer him to a dietitian. Tell him to record his daily weights in a log and to report a weight gain greater than 3 pounds over 2 days or less.


Cardiovascular pharmacology

The home health nurse will also instruct him and his family about using home oxygen therapy, if prescribed.

  • Most patients with heart failure benefit from a home care referral. If your patient will have a home care nurse, tell him that the nurse will perform a complete assessment of his cardiac and respiratory status. And the nurse will answer questions about his drug regimen and monitor his compliance with the drug regimen and dietary restrictions.


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