Cardiovascular agents

1
Cardiovascular agents

• Chapters 21, 22, 23, 24, 27, 28

2
Heart Failure

• The heart is unable to pump blood in sufficient
  amounts from the ventricles to meet the bodys
  metabolic needs
• Symptoms depend on cardiac area affected
• Left ventricular failure
• Right ventricular failure

3
Heart Failure Causes

• Cardiac defect
• MI
• Valve deficiency
• Defect outside the heart
• Coronary artery disease
• Pulmonary hypertension
• Diabetes
• Supraventricular dysrhythmias
• Atrial fibrillation
• Atrial flutter

4
Figure 21-1 Conduction system of the heart. AV,
Atrioventricular LA, left atrium LV, left
ventricle RA, right atrium RV, right ventricle
SA, sinoatrial. (Modified from Kinney, M., et al.
(1996). Comprehensive cardiac care (8th ed.). St.
Louis, MO Mosby Lewis, S.M., Heitkemper, M.M.,
Dirksen, S.R. (2004). Medical-surgical nursing
Assessment and management of clinical problems
(6th ed.). St. Louis, MO Mosby.)
5
Positive inotropic agents

• Drugs that increase the force of myocardial
  contraction
• Used to Congestive Heart failure CHF
• Cardiac glycosides
• Digoxin (originally obtained from Digitalis
  plant, foxglove

6
Cardiac GlycosidesMechanism of Action

• Increase myocardial contractility
• Change electrical conduction properties of the
  heart
• Decrease rate of electrical conduction
• Prolong the refractory period
• Area between SA node and AV node
• digoxin

7
Drug EffectsGeneral terms

• Inotropic
• Force or energy of muscular contractions
• Chronotropic
• Rate of the heartbeat
• Dromotropic
• The conduction of electrical impulses

8
Cardiac GlycosidesDrug Effects

• Positive inotropic effect
• Increase in force and velocity of myocardial
  contraction (without an increase in oxygen
  consumption)
• Negative chronotropic effect
• Reduced heart rate
• Negative dromotropic effect
• Decreases automaticity at SA node decreases AV
  nodal conduction, and other effects

9
Cardiac GlycosidesIndications

• Heart failure
• Supraventricular dysrhythmias
• Atrial fibrillation and atrial flutter

10
Cardiac GlycosidesSide/Adverse Effects

• Digoxin
• Narrow therapeutic window
• Drug levels must be monitored
• Low potassium levels increase its toxicity
• Electrolyte levels must be monitored

11
Digoxin Toxicity

• digoxin immune Fab therapy Digibind
• (cardiac glycoside antidote)
• Life-threatening cardiac dysrhythmias
• Life-threatening digoxin overdose

12
Digoxin toxicity

• The most common side effects are related to
  digoxin toxicity and heart rhythm disturbances.
• Other side effects include abdominal pain,
  nausea, vomiting, loss of appetite, breast
  enlargement, skin rash, blurred vision, and
  mental changes.

13
Case Study

• Mr. Beaudoin is 73 years old admitted with CHF.
  He has been started on Digoxin 0.125mg.
• He will require frequent monitoring for the
  therapeutic effects of this drug. (what are
  they?)
• You will monitor for signs and symptoms of
  digoxin toxicity. (what are they?)

14
CHAPTER 22Antidysrhythmic Agents
15
Antidysrhythmics

• Dysrhythmia
• Any deviation from the normal rhythm of the heart
• Antidysrhythmics
• Drugs used for the treatment and prevention of
  disturbances in cardiac rhythm

16
Table 22-2 Vaughan Williams classification of
antidysrhythmic agents
17
Antidysrhythmics Side Effects

• ALL antidysrhythmics can cause dysrhythmias!
• Hypersensitivity reactions
• Nausea
• Vomiting
• Diarrhea
• Dizziness
• Blurred vision
• Headache

18
CHAPTER 23Anti-Anginal Agents
19
Angina Pectoris (Chest Pain)

• When the supply of oxygen and nutrients in the
  blood is insufficient to meet the demands of the
  heart, the heart muscle aches
• The heart requires a large supply of oxygen to
  meet the demands placed on it
• CAD Coronary heart disease
• IHD Ischemic heart disease

20
Types of Angina

• Chronic stable angina (also called classic or
  effort angina)
• Unstable angina
• Variant angina(also called Prinzmetals angina)

21
Figure 23-1 Benefit of drug therapy for angina
with increasing oxygen supply and decreasing
oxygen demands.
22
Antianginal Agents

• Nitrates/nitrites
• Beta-blockers
• Calcium channel blockers

23
Therapeutic Objectives

• Increase blood flow to ischemic heart muscle
• and/or
• Decrease myocardial oxygen demand

24
Therapeutic Objectives (contd)

• Minimize the frequency of attacks and decrease
  the duration and intensity of anginal pain
• Improve the clients functional capacity with as
  few side effects as possible
• Prevent or delay the worst possible outcome,
  MI.destruction of cardiac cells

25
Nitrates

• Available forms
• Sublingual, tablets, spray
• Oral capsules/tablets
• Intravenous solutions
• Ointments
• Transdermal patches, NTG patches (transdermal)
  varying doses 0.2-0.4-0.6-0.8mg/hr on/off 12
  hours to reduce tolerance
• Buccal

26
Nitrates (contd)

• Cause vasodilation due to relaxation of smooth
  muscles
• Potent dilating effect on coronary arteries
• Used for prevention and treatment of angina

27
Nitrates (contd)

• Vasodilation results in reduced myocardial oxygen
  demand
• Nitrates cause dilation of both large and small
  coronary vessels
• Result oxygen to ischemic myocardial tissue
• Nitrates alleviate coronary artery spasms

28
Nitrates (contd)

• Nitroglycerin
• Large first-pass effect with oral forms
• Used for symptomatic treatment of ischemic heart
  conditions (angina)
• IV form used for BP control in perioperative
  hypertension, treatment of HF, ischemic pain,
  pulmonary edema associated with acute MI, and
  hypertensive emergencies

29
Nitrates

• isosorbide dinitrate, Isordil
• Used for
• Acute relief of angina
• Prophylaxis in situations that may provoke angina
• Long-term prophylaxis of angina

30
Nitrates (contd)Isordil

• Side effects
• Headache
• Usually diminish in intensity and frequency with
  continued use
• Tachycardia, postural hypotension
• Tolerance may develop

31
Nitroglycerin

• Nursing implications
• Instruct clients in proper technique and
  guidelines for taking sublingual NTG for anginal
  pain
• Instruct clients never to chew or swallow the SL
  form
• Instruct clients that a burning sensation felt
  with SL forms indicates that the drug is still
  potent

32
Nitroglycerin (contd)

• Nursing implications
• Instruct clients to keep a fresh supply of NTG on
  hand potency is lost in about 3 months after the
  bottle has been opened
• Medications should be stored in an airtight, dark
  glass bottle with a metal cap and no cotton
  filler to preserve potency

33
Nitroglycerin (contd)

• Nursing implications
• Instruct clients in the proper application of
  nitrate topical ointments and transdermal forms,
  including site rotation and removal of old
  medication
• To reduce tolerance, the client may be instructed
  to remove topical forms at bedtime, and apply new
  doses in the morning, allowing for a nitrate-free
  period

34
Nitroglycerin (contd)

• Nursing implications
• Instruct clients to take prn nitrates at the
  first hint of anginal pain
• If experiencing chest pain, the client taking SL
  NTG should be lying down to prevent or decrease
  dizziness and fainting that may occur due to
  hypotension. May repeat 3 times, then call 911,
  should NOT drive.
• Monitor VS frequently during acute exacerbations
  of angina and during IV administration

35
Anti-Anginal Agents Nursing Implications

• Monitor for adverse reactions
• Allergic reactions, headache, lightheadedness,
  hypotension, dizziness
• Monitor for therapeutic effects
• Relief of angina, decreased BP, or both

36
Nursing Implications (contd)

• Clients should not take any medications,
  including OTC medications, without checking with
  the physician
• Clients should report blurred vision, persistent
  headache, dry mouth, dizziness, edema, fainting
  episodes, weight gain of 1 kg in 1 day or 2.5 kg
  in 1 week, pulse rates less than 60, and any
  dyspnea

37
Nursing Implications (contd)

• Alcohol consumption and hot baths or spending
  time in whirlpools, hot tubs, or saunas will
  result in vasodilation, hypotension, and the
  possibility of fainting
• Teach clients to change positions slowly to avoid
  postural BP changes
• Encourage clients to keep a record of anginal
  attacks, including precipitating factors, number
  of pills taken, and therapeutic effects

38
Nitroglycerin IV

• Nursing implications
• IV forms of NTG must be contained in glass IV
  bottles and must be given with infusion pumps
• IV pump
• Nitro IV tubing (PVC free)
• Follow the institutions policy

39
Case Study

• Mrs. Jarvis is 82 years old was admitted to
  hospital 4 days ago with angina. She is
  discharged today with NTG spray and a transdermal
  NTG patch 0.2 mg/hr.
• What will be your discharge teaching in regards
  to both these meds?

40
Beta-Blockers

• Beta adrenergic receptors in the heart are
  predominantly beta1-adrenergic receptors.They are
  responsible for the conduction effects of the
  conduction system.
• When blocked, by beta-blockers, the SA node fires
  less decrease heart rate

41
Beta-Blockers (contd)

• Mechanism of action
• Decrease the HR, resulting in decreased
  myocardial oxygen demand and increased oxygen
  delivery to the heart
• Decrease myocardial contractility, helping to
  conserve energy or decrease demand

42
Beta-Blockers (contd)

• Indications
• Angina
• Antihypertensive
• Cardioprotective effects, especially after MI
• Some used for migraine headaches
• Contraindications asthma, serious conduction
  disturbances

43
Beta-Blockers (contd)

• Side effects
• Body System Effects
• Cardiovascular Bradycardia, hypotension second-
  or third-degree heart block heart failure
• Metabolic Altered glucose and lipid metabolism

44
Beta-Blockers (contd)

• Side effects (contd)
• Body System Effects
• CNS Dizziness, fatigue, mental depression,
  lethargy, drowsiness, unusual dreams
• Other Impotence, wheezing, dyspnea

45
Beta-Blockers (contd)

• Nursing implications
• These medications should never be abruptly
  discontinued due to risk of rebound hypertensive
  crisis
• Inform clients that these medications are for
  long-term prevention of angina, not for
  immediate relief

46
Beta-Blockers

• Nursing implications
• Clients taking beta-blockers should monitor pulse
  rate daily and report any rate lower than 60
  beats per minute
• Dizziness or fainting should also be reported
• Constipation is a common problem instruct
  clients to take in adequate fluids and eat
  high-fibre foods

47
Calcium Channel Blockers

• Verapamil (Isoptin)
• Diltiazem (Cardizem)
• Nifedipine (Adalat)
• Calcium plays an important role in the
  exctation/contraction of the heart
• When blocked, prevents contraction and results in
  relaxation, increasing blood flow and O2 supply
  to the heart

48
Calcium Channel Blockers (contd)

• Mechanism of action
• Cause peripheral arterial vasodilation
• Reduce myocardial contractility (negative
  inotropic action)
• Result decreased myocardial oxygen demand

49
Calcium Channel Blockers (contd)

• Indications
• First-line agents for treatment of angina,
  hypertension, and supraventricular tachycardia
• Short-term management of atrial fibrillation and
  flutter
• Several other uses

50
Calcium Channel Blockers (contd)

• Side effects
• May cause hypotension, palpitations, tachycardia
  or bradycardia, constipation, nausea, dyspnea

51
CHAPTER 24Antihypertensive Agents
52
Optimal BP level

• Hypertension silent killer
• lt 140/90 for general population
• lt130/80 for clients with renal disease and
  diabetes

53
Indications

• Post-MI
• High cardiovascular risk
• Heart failure
• Diabetes mellitus
• Chronic kidney disease
• Cerebrovascular disease

54
Cultural Considerations

• Beta-blockers and ACE inhibitors have been found
  to be more effective in white clients than black
  clients
• CCBs and diuretics have been shown to be more
  effective in geriatric and black clients than in
  white clients

55
Antihypertensive Agents Categories

• Adrenergic agents Beta Blockers
• Angiotensin converting enzyme (ACE) inhibitors
• Angiotensin II receptor blockers (ARBs)
• Calcium channel blockers (CCBs)
• Diuretics
• Vasodilators

56
Adrenergic Agents

• Centrally acting alpha2-receptor agonists
• Peripherally acting alpha1-receptor agonists

57
Adrenergic Agents Centrally Acting
Alpha2-Receptor Agonists

• clonidine
• methyldopa
• Drug of choice for hypertension in pregnancy

58
Adrenergic Agents (cont'd)

• Indications (cont'd)
• Peripherally acting alpha1-receptor agonists 
• Treatment of hypertension
• Relief of symptoms of BPH
• Management of severe HF when used with cardiac
  glycosides and diuretics
• doxazosin
• prazosin
• terazosin

59
Adrenergic Agents

• Side Effects
• Most common Dry mouth Drowsiness Sedation Consti
  pation
• Other Headaches Sleep disturbances Nausea Rash
  Cardiac disturbances (palpitations)
• HIGH INCIDENCE OF
• ORTHOSTATIC HYPOTENSION

60
Angiotensin Converting Enzyme Inhibitors (ACE
inhibitors)

• Large group of safe and effective drugs
• Often used as first-line agents for CHF and
  hypertension
• May be combined with a thiazide diuretic or
  calcium channel blocker

61
ACE InhibitorsMechanism of Action

• RAAS renin angiotensin-aldosterone system
• When the enzyme angiotensin I is converted to
  angiotensin II, the result is potent
  vasoconstriction and stimulation of aldosterone
• Result of vasoconstriction increased systemic
  vascular resistance and increased afterload
• Result increased BP

62
ACE InhibitorsMechanism of Action (cont'd)

• Aldosterone stimulates water and sodium
  resorption
• Result increased blood volume, increased
  preload, and increased BP

63
ACE InhibitorsMechanism of Action (cont'd)

• ACE inhibitors block the angiotensin converting
  enzyme, thus preventing the formation of
  angiotensin II
• Angiotensin II is a potent vasoconstrictor and
  stimulator of adolsterone from the adrenal glands
• Result decreased systemic vascular resistance
  (afterload), vasodilation, and therefore
  decreased blood pressure

64
ACE InhibitorsIndications

• Hypertension
• CHF (either alone or in combination with
  diuretics or other agents)
• Slows progression of left ventricular hypertrophy
  after an MI
• Renal protective effects in clients with diabetes
• Drugs of choice in hypertensive clients with CHF
• Captopril, lisinorpril, ramipril

65
ACE InhibitorsSide Effects

• Fatigue Dizziness
• Headache Mood changes
• Impaired taste Possible hyperkalemia
• Dry, nonproductive cough, which reverses when
  therapy is stopped
• NOTE First-dose hypotensive effect may occur!

66
Angiotensin II Receptor Blockers

• (A II blockers, or ARBs)
• Newer class
• Well tolerated, clinically as effective as ACE
  inhibitors
• Do not cause a dry cough
• Losartan, Valsartan

67
Angiotensin II Receptor Blockers Mechanism of
Action

• Allow angiotensin I to be converted to
  angiotensin II, but block the receptors that
  receive angiotensin II
• Block vasoconstriction and release of aldosterone

68
Angiotensin II Receptor Blockers Indications

• Hypertension
• Adjunctive agents for the treatment of HF
• May be used alone or with other agents such as
  diuretics
• Used primarily in clients who cannot tolerate ACE
  inhibitors

69
Calcium Channel BlockersMechanism of Action

• Cause smooth muscle relaxation by blocking the
  binding of calcium to its receptors, preventing
  muscle contraction
• This causes decreased peripheral smooth muscle
  tone and decreased systemic vascular resistance
• Result decreased blood pressure

70
Calcium Channel Blockers (cont'd)

• Indications
• Angina
• Hypertension
• Dysrhythmias
• Migraine headaches
• Raynauds disease

71
Diuretics

• Decrease the plasma and extracellular fluid
  volumes
• Results Decreased preload Decreased cardiac
  output Decreased total peripheral resistance
• Overall effect Decreased workload of heart,
  and decreased pressure

72
VasodilatorsMechanism of Action

• Directly relax arteriolar smooth muscle
• Result decreased systemic vascular response,
  decreased afterload, and peripheral vasodilation

73
Antihypertensive AgentsVasodilators

• diazoxide
• hydralazine HCl (Apresoline)
• sodium nitroprusside

74
Vasodilators Indications

• Treatment of hypertension
• May be used in combination with other agents
• Intravenous sodium nitroprusside and diazoxide
  are reserved for the management of hypertensive
  emergencies

75
Vasodilators Side Effects

• Hydralazine
• Dizziness, headache, anxiety, tachycardia, nausea
  and vomiting, diarrhea, anemia, dyspnea, edema,
  nasal congestion
• Sodium nitroprusside
• Bradycardia, hypotension, possible cyanide
  toxicity

76
Nursing Implications HPT

• Educate clients about the importance of not
  missing a dose and taking the medications exactly
  as prescribed
• Clients should never double up on doses if a dose
  is missed check with physician for instructions
  on what to do if a dose is missed
• Monitor BP during therapy instruct clients to
  keep a journal of regular BP checks

77
Nursing Implications HPT

• Instruct clients that these drugs should not be
  stopped abruptly because this may cause a rebound
  hypertensive crisis, and perhaps lead to stroke
• Oral forms should be given with meals so that
  absorption is more gradual and effective
• Administer IV forms with extreme caution and use
  an IV pump

78
Nursing Implications HPT (cont'd)

• Remind clients that medication is only part of
  therapy. Encourage clients to watch their diet,
  stress level, weight, and alcohol intake
• Clients should avoid smoking and eating foods
  high in sodium
• Encourage supervised exercise

79
Nursing Implications HPT(cont'd)

• Instruct clients to change positions slowly to
  avoid syncope from postural hypotension
• Clients should report unusual shortness of
  breath difficulty breathing swelling of the
  feet, ankles, face, or around the eyes weight
  gain or loss chest pain palpitations or
  excessive fatigue

80
Nursing Implications (cont'd)

• Men taking these agents may not be aware that
  impotence is an expected effect. This may
  influence compliance with drug therapy
• If clients are experiencing serious side effects,
  or believe that the dose or medication needs to
  be changed, they should contact their physician
  immediately

81
Nursing Implications (cont'd)

• Educate about lifestyle changes that may be
  needed
• Weight loss
• Stress management
• Supervised exercise

82
Nursing Implications (cont'd)

• Monitor for side/adverse effects (dizziness,
  orthostatic hypotension, fatigue) and for toxic
  effects
• Monitor for therapeutic effects
• Blood pressure should be maintained at less than
  140/90 mm Hg
• If a client with hypertension also has diabetes
  or renal disease, the BP goal is lt130/80 mm Hg

83
Case Study HPT

• Mrs Castiglione is 95 years old, although she
  tells everyone she is 88. She is independent and
  wants to do everything herself. She is admitted
  with a hypertensive crisis, is now being
  discharged on HCTZ 25mg OD and Metropolol 25mb
  BID.
• What will be your discharge instructions?

84
Diuretic Agents

• Drugs that accelerate the rate of urine formation
• Result removal of sodium and water

85
Sodium

• Where sodium goes, water follows
• 20 to 25 of all sodium is reabsorbed into the
  bloodstream in the loop of Henle
• 5 to 10 in the distal tubules
• 3 in collecting ducts
• If water is not absorbed, it is excreted as urine

86
Figure 25-1 The nephron and diuretic sites of
action. ADH, Antidiuretic hormone.
87
Diuretic Agents

• Carbonic anhydrase inhibitors
• Loop diuretics(most common, most potent)
• Osmotic diuretics
• Potassium-sparing diuretics
• Thiazide and thiazide-like diuretics

88
Loop Diuretics

• Furosemide, Lasix
• Others
• bumetanide
• ethacrynic acid

89
Loop Diuretics Mechanism of Action

• Act directly on the ascending limb of the loop
  of Henle to inhibit sodium and chloride
  reabsorption
• Increase renal prostaglandins, resulting in the
  dilation of blood vessels and reduced peripheral
  vascular resistance

90
Loop Diuretics Drug Effects

• Potent diuresis and subsequent loss of fluid
• Decreased fluid volume causes
• Reduced BP
• Reduced pulmonary vascular resistance
• Reduced systemic vascular resistance
• Reduced central venous pressure
• Reduced left ventricular end-diastolic pressure
• Potassium depletion

91
Loop DiureticsIndications

• Edema associated with CHF or hepatic or renal
  disease
• Control of hypertension
• Increase renal excretion of calcium in clients
  with hypercalcemia

92
Loop Diuretics Side Effects

• Body System Effect
• CNS Dizziness, headache, tinnitus, blurred
  vision
• GI Nausea, vomiting, diarrhea
• Metabolic Hypokalemia, hyperglycemia, hyperuric
  emia

93
Osmotic Diuretics IndicationsOsmolol

• Used in the treatment of clients in the early,
  oliguric phase of ARF
• To promote the excretion of toxic substances
• Reduction of intracranial pressure
• Treatment of cerebral edema

94
Potassium-Sparing Diuretics Mechanism of Action

• Work in collecting ducts and distal convoluted
  tubules
• Interfere with sodium-potassium exchange
• Competitively bind to aldosterone receptors
• Block the resorption of sodium and water usually
  induced by aldosterone
• amiloride
• Spironolactone, Aldactone

95
Potassium-Sparing Diuretics Drug Effects

• Prevent potassium from being pumped into the
  tubule, thus preventing its secretion
• Competitively block the aldosterone receptors and
  inhibit its action
• The excretion of sodium and water is promoted

96
Potassium-Sparing Diuretics Indications

• spironolactone
• Hyperaldosteronism
• Hypertension
• Reversing the potassium loss caused by
  potassium-losing drugs
• amiloride
• Treatment of CHF

97
Potassium-Sparing Diuretics Side Effects

• Body System Effect
• CNS Dizziness, headache
• GI Cramps, nausea, vomiting, diarrhea
• Other Urinary frequency, weakness hyperkalemia
  

98
Thiazide and Thiazide-like Diuretics

• Thiazide diuretics
• hydrochlorothiazide (HCTZ)
• trichlormethiazide
• Thiazide-like diuretics
• chlorthalidone
• metolazone

99
Thiazide and Thiazide-like Diuretics Mechanism
of Action

• Inhibit tubular reasorption of sodium and
  chloride ions
• Action primarily in the ascending loop of Henle
  and early distal tubule
• Result water, sodium, and chloride are excreted
• Potassium is also excreted to a lesser extent
• Dilate the arterioles by direct relaxation

100
Thiazide and Thiazide-like Diuretics Drug Effects

• Lowered peripheral vascular resistance
• Depletion of sodium and water

101
Thiazide and Thiazide-like Diuretics Side Effects

• Body System Effect
• CNS Dizziness, headache, blurred vision,
  paresthesias, decreased libido
• GI Anorexia, nausea, vomiting, diarrhea
• Metabolic Hypokalemia

102
Nursing Implications

• Assess baseline fluid volume status, intake and
  output, serum electrolyte values, weight, and
  vital signsespecially postural BPs
• Instruct clients to take in the morning as much
  as possible to avoid interference with sleep
  patterns
• Monitor serum potassium levels during therapy

103
Nursing Implications (contd)

• Teach clients to maintain proper nutritional and
  fluid volume status
• Teach clients to eat more potassium-rich foods
  when taking any but the potassium-sparing agents
• Foods high in potassium include bananas, oranges,
  dates, raisins, plums, fresh vegetables,
  potatoes, meat, and fish

104
Nursing Implications (contd)

• Clients taking diuretics along with a digitalis
  preparation should be taught to monitor for
  digitalis toxicity
• Diabetic clients who are taking thiazide and/or
  loop diuretics should be told to monitor blood
  glucose and watch for elevated levels

105
Nursing Implications (contd)

• Teach clients to change positions slowly, and to
  rise slowly after sitting or lying to prevent
  dizziness and possible fainting related to
  orthostatic hypotension
• Encourage clients to keep a log of their daily
  weight
• Encourage clients to return for follow-up visits
  and laboratory work

106
Nursing Implications (contd)

• Clients who have been ill with nausea, vomiting,
  and/or diarrhea should notify their physician
  because fluid loss may be dangerous
• Signs and symptoms of hypokalemia include muscle
  weakness, constipation, irregular pulse rate, and
  overall feeling of lethargy

107
Nursing Implications (contd)

• Instruct clients to notify the physician
  immediately if they experience rapid heart rates
  or syncope (reflects hypotension or fluid loss)
• A weight gain of 1 kg or more a day or 2.5 or
  more a week should be reported immediately

108
Nursing Implications (contd)

• Monitor for therapeutic effects
• Reduction in edema, fluid volume overload, HF
• Reduction of hypertension
• Return to normal intraocular pressures
• Excessive consumption of licorice can lead to an
  additive hypokalemia in clients taking thiazides

109
Case Study Diuretics

• Mr. Poe is 78 and is being discharge to his
  apartment, where he lives alone. He is being
  discharged on
• Spironoloactone 25 mg OD. This drug is new to
  him, please provide discharge instructions

110
Coagulator modifying Agents

• Anticoagulants
• Inhibit the action or formation of clotting
  factors
• Prevent clot formation
• Antiplatelet drugs
• Inhibit platelet aggregation
• Prevent platelet plugs
• Thrombolytic drugs
• Lyse (break down) existing clots
• Hemostatic agents
• Promote blood coagulation

111
Anticoagulants

• Have no direct effect on a blood clot that is
  already formed
• Used prophylactically to prevent
• Clot formation (thrombus)
• An embolus (dislodged clot)

112
Coagulation System

• Cascade
• Each activated factor serves as a catalyst that
  amplifies the next reaction
• Result is fibrin, a clot-forming substance
• Intrinsic pathway and extrinsic pathway

113
Figure 27-1 Coagulation pathway and factors
extrinsic pathway. Plt, Platelets.
114
AnticoagulantsMechanism of Action

• Vary, depending on agent
• Drugs that prevent the formation of a clot by
  inhibiting certain clotting factors
• Work on different points of the clotting cascade
• Do not lyse existing clots

115
AnticoagulantsMechanism of Action (contd)

• All ultimately prevent clot formation
• heparin
• Low-molecular-weight heparins
• warfarin

116
Anticoagulants

• Prevention of clot formation also prevents
• CVA
• Myocardial infarction
• Deep vein thrombosis (DVT)
• Pulmonary embolism (PE)

117
Anticoagulants Indications

• Used to prevent clot formation in certain
  settings
• Myocardial infarction
• Unstable angina
• Atrial fibrillation
• Indwelling devices, such as mechanical heart
  valves
• Major orthopedic surgery

118
AnticoagulantsSide/Adverse Effects

• Bleeding
• Risk increases with increased dosages
• May also cause
• Nausea, vomiting, abdominal cramps,
  thrombocytopenia, others

119
Anticoagulants

• Heparin
• Monitored by activated partial thromboplastin
  times (APTTs)
• Parenteral
• Short half-life (1 to 2 hours)
• Effects reversed by protamine sulfate

120
Heparin Nursing Implications

• Ensure that SC doses are given SC, not IM
• SC doses should be given in areas of deep
  subcutaneous fat, and sites rotated
• Do not give SC doses within 2 inches of
• The umbilicus, abdominal incisions, or unhealed
  wounds
• Do not aspirate SC injections (may cause hematoma
  formation)
• Do not massage SC injection sites

121
Heparin Nursing Implications (contd)

• IV doses may be given by bolus or IV infusions
• Anticoagulant effects seen immediately
• Laboratory values are done daily to monitor
  coagulation effects (APTT)
• Protamine sulfate can be given as an antidote in
  case of excessive anticoagulation

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Anticoagulants (contd)

• Low-molecular-weight heparins
• enoxaparin and dalteparin
• More predictable anticoagulant response
• Do not require frequent laboratory monitoring
• Given subcutaneously in the abdomen
• Rotate injection sites

123
Anticoagulants (contd)

• Warfarin sodium
• Given orally only
• Monitored by INR
• Vitamin K can be given if toxicity occurs

124
INR

• What is INR and why is it so important?
• International Normalization Ratio, is the
  standard unit for reporting the clotting time of
  blood.
• A common target INR level for a person taking
  anticoagulants is 2.0 to 3.0, though it can vary
  from one individual to another, and should be
  determined by a physician.

125
Warfarin SodiumNursing Implications

• May be started while the client is still on
  heparin until prothrombin times indicate adequate
  anticoagulation
• Full therapeutic effect takes several days
• Monitor INR regularly
• Antidote is vitamin K (IM, IV, or PO)

126
Antiplatelet Agents

• Prevent platelet adhesion
• aspirin, dipyridamole (Aggrenox)
• Pentoxifylline (Trental)
• Clopidogre(Plavix)
• Ticlopidine (Ticlid)

127
Antiplatelet Agents (contd)

• Indications
• Antithrombotic effects
• Reduce risk of fatal and nonfatal strokes
• Side effects/adverse effects
• Vary according to agent

128
Antiplatelet DrugsNursing Implications

• Concerns and teaching tips same as for
  anticoagulants
• Nicotine causes vasoconstriction, which alters
  the effectiveness of antiplatelet agents
• Monitoring for abnormal bleeding

129
Thrombolytic Agents

• Agents that break down, or lyse, preformed clots
• Older agents
• streptokinase and urokinase
• Newer agents
• Tissue plasminogen activator
• Anisoylated plasminogen-streptokinase activator
  complex (APSAC)

130
Thrombolytic Agents (contd)

• streptokinase
• APSAC
• alteplase TPA
• reteplase
• tenecteplase

131
Thrombolytic Agents Mechanism of Action

• Activate the fibrinolytic system to break down
  the clot in the blood vessel quickly
• Activate plasminogen and convert it to plasmin,
  which can digest fibrin
• Re-establishes blood flow to the heart muscle via
  coronary arteries, preventing tissue destruction

132
Thrombolytic Agents Indications

• Acute MI
• Arterial thrombolysis
• DVT
• Occlusion of shunts or catheters
• Pulmonary embolus

133
Thrombolytic Agents Side Effects/Adverse Effects

• BLEEDING
• Internal
• Intracranial
• Superficial
• Other effects
• Nausea, vomiting, hypotension, anaphylactoid
  reactions
• Dysrhythmias

134
Thrombolytic AgentsNursing Implications

• Follow strict manufacturers guidelines for
  preparation and administration
• Monitor IV sites for bleeding, redness, pain
• Monitor for bleeding from gums, mucous membranes,
  nose
• Observe for signs of internal bleeding (decreased
  BP, restlessness, increased pulse)

135
AnticoagulantsClient Education

• Education should include
• Importance of regular lab testing
• Signs of abnormal bleeding
• Measures to prevent bruising, bleeding, or tissue
  injury
• Monitor for signs of excessive bleeding
• Bleeding of gums while brushing teeth,
  unexplained nosebleeds, heavier menstrual
  bleeding, bloody or tarry stools, bloody urine or
  sputum, abdominal pain, vomiting blood

136
AnticoagulantsClient Education (contd)

• Education should include (contd)
• Wearing a medical alert bracelet
• Avoiding foods high in vitamin K (tomatoes, dark
  leafy green vegetables, bananas, fish)
• Consulting physician before taking other meds or
  OTC products, including natural health/herbal
  products

137
Case Study Warfarin

• Mr. Jamison is 64, he was admitted with atrial
  fibrillation and is now being discharged on
  Coumadin 5mg po, with weekly INRs.
• Please give him discharge instructions in regards
  to his diet, s/e of Coumadin and the rational and
  importance for INRs

138
Antilipemics

• Drugs used to lower lipid levels

139
Triglycerides and Cholesterol

• Two primary forms of lipids in the blood
• Water-insoluble fats that must be bound to
  apolipoproteins, specialized lipid-carrying
  proteins
• Lipoprotein is the combination of triglyceride or
  cholesterol with apolipoprotein

140
Lipoproteins

• Very-low-density lipoprotein (VLDL)
• Produced by the liver
• Transports endogenous lipids to the cells
• Low-density lipoprotein (LDL)
• High-density lipoprotein (HDL)
• Responsible for recycling of cholesterol
• Also known as good cholesterol

141
Coronary Heart Disease

• The risk of CHD in clients with cholesterol
  levels of 5.2 mmol/L is three to four times
  greater than that in clients with levels less
  than 4.0 mmol/L

142
Antilipemics

• HMG-CoA reductase inhibitors (HMGs, or statins)
• Bile acid sequestrants
• Niacin (nicotinic acid)
• Fibric acid derivatives

143
Antilipemics HMG-CoA Reductase Inhibitors
(statins)

• Most potent LDL reducers
• Lovastatin (Mevacor)
• pravastatin (Pravachol)
• simvastatin (Zocor)
• Atorvastatin(Lipitor)

144
HMG-CoA Reductase Inhibitors (contd)

• Mechanism of action
• Inhibit HMG-CoA reductase, which is used by the
  liver to produce cholesterol
• Lower the rate of cholesterol production

145
HMG-CoA Reductase Inhibitors (contd)

• Side effects
• Mild, transient GI disturbances
• Rash
• Headache
• Myopathy (muscle pain)
• Elevations in liver enzymes or liver disease

146
Bile Acid Sequestrants

• cholestyramine
• colestipol hydrochloride
• Also called bile acidbinding resins and
  ion-exchange resins

147
Bile Acid Sequestrants (contd)

• Mechanism of action
• Prevent reasorption of bile acids from small
  intestine
• Bile acids are necessary for absorption of
  cholesterol

148
Bile Acid Sequestrants (contd)

• Side effects
• Constipation
• Heartburn, nausea, belching, bloating
• These adverse effects tend to disappear over time

149
Niacin (Nicotinic Acid)

• Vitamin B3
• Lipid-lowering properties require much higher
  doses than when used as a vitamin
• Effective, inexpensive, often used in combination
  with other lipid-lowering agents

150
Fibric Acid Derivatives

• clofibrate
• gemfibrozil
• fenofibrate (Lipidil)
• bezafibrate

151
Fibric Acid Derivatives (contd)

• Mechanism of action
• Believed to work by activating lipase, which
  breaks down cholesterol
• Also suppress release of free fatty acid from the
  adipose tissue, inhibit synthesis of
  triglycerides in the liver, and increase the
  secretion of cholesterol in the bile

152
Fibric Acid Derivatives (contd)

• Side effects
• Abdominal discomfort
• Diarrhea
• Nausea
• Blurred vision
• Increased risk of gallstones
• Prolonged prothrombin time
• Liver studies may show increased function

153
Nursing Implications (contd)

• Assess dietary patterns, exercise level, weight,
  height, VS, tobacco and alcohol use, family
  history
• Contraindications include biliary obstruction,
  liver dysfunction, active liver disease
• Obtain baseline liver function studies
• Clients on long-term therapy may need
  supplemental fat-soluble vitamins (A, D, K)
• Take with meals to decrease GI upset

154
Nursing Implications (contd)

• Powder forms must be taken with a liquid, mixed
  thoroughly but not stirred, and NEVER taken dry
• Other medications should be taken 1 hour before
  or 4 to 6 hours after meals to avoid interference
  with absorption