Cardiac Drugs Vasodilators Types: -Peripheral -Direct-Acting -Miscelaneous Vasodilators Peripheral Vasodilators - Decreases peripheral resistance by exerting a direct

action on the arteries or on the veins -Increases blood flow to the extemities and are used in peripheral vascular disorders of venous and arterial vessels -Most effective for disorders resulting from vasospasm (Raynauds disease) - May decrease some symptoms of cerebral vascular insufficiency Alpha-Adrenergic blockers Prazosin (Minipress) Terazosin (Hytrin) Calcium channel blockers Diltiazem (Cardizem) Nifedipine (Procardia) Verapamil (Calan, Isoptin) Hemorheological Pentoxifylline (Trental) increases microcirculation and tissue perfussion INTERVENTIONS: Monitor vital signs, CR and BP Monitor for Orthostatic Hypotension Monitor for signs of inadequate blood flow to the extremities, such as pallor, feeling cold, and pain. Instruct the client that it may take up to 3 mos. for a desired therapeutic response. Advise the client not to smoke,because smoking increases vasospasm. Instruct the client to avoid aspirin or aspirin-like compounds unless approved by the physician. Instruct client to take w/ meals if GI disturbances occurs. Instruct client to avoid alcohol because it may cause a hypotensive reaction Encourage the client to change position slowly to avoid orthostatic hypotension. Direct-Acting Arteriolar Vasodilators -Direct-acting vasodilators relax the smooth muscles of the blood vessels, mainly the arteries, causing vasodilation. -Direct-acting vasodilators promote an increase in blood flow to the brain and kidneys. -With vasodilation, the BP drops andsodium and water are retained, resulting in peripheral edema. -Diuretics may be given to decrease the edema. -Direct-acting vasodilators are used during acute hypertensive emergencies. Diazoxide (Hyperstat) Fenoldopam (Corloam) Hydralazine (Apresoline) Minoxidil (Loniten) Nitroglycerin Sodium Nitroprusside (Nitropress) SE/ AR: Hypotension Reflex tachycardia caused by vasodilation and the drop in BP Palpitations Edema Dizziness Headaches Nasal congestion GI bleeding Neurological symptoms Confusion Excess hair groth with minoxidil (Loniten)

With sodium nitroprusside, cyanide toxicity and thiocynate toxicity can occur. INTERVENTIONS: Monitor vital signs especially BP Sodium nitroprusside Monitor cyanide and thiocyanate levels Protect from light because the medication decomposes When administering, solution must be covered by a dark bag provided by the manufacturer and is stable for 24 hours. Discard if the medication is red, green or blue. Miscellaneous Vasodilator Nesiritide (Natrecor) -Recombinant version of human B-type natriuretic peptide that vasodilates arteries and veins -Used for the treatment of decompensated heart failure -SE Hypotension Confusion Dizziness dysrhythmias -Interventions Administer by continuous intravenous infusion via pump Monitor BP, cardiac rhythm, urine output, and body weight Monitor for signs of resolving heart failure

Antihypotensive Agents If BP becomes too low, vital centers in the brain and other tissues of the body may not receive sufficient oxygenated blood for functioning. Severe hypotension or shock puts the body in serious jeopardy It will constitute an acute emergency situation The first-choice of drug for treating shock is usually a sympathomimetic drug.

Sympathetic Adrenergic Agonist Sympathomimetic drugs react with sympathetic adrenergic receptors to cause a sympathetic stress response This helps to restore balance in the cardiovascular system while the underlying cause of the shock (e.g. blood loss) is treated. Dobutamine Increases myocardial force and cardiac output through stimulation of beta receptors Used in clients with heart failure and those undergoing cardiopulmonary bypass surgery Dopamine (Inotropin) Increases BP and cardiac output through positive inotropic action and increases renal blood flow through its action on alpha and beta receptors Used to treat mild renal failure caused by low cardiac output Epinephrine (Adrenalin) Used for cardiac stimulation in cardiac arrest Used for bronchodilation in asthma or allergic reactions Produces mydriasis Produces local vasoconstriction when combined with local anesthetics and prolongs anesthetic action by decreasing blood flow to the site. Isoproterenol (Isuprel) Stimulates beta receptors Used for cardiac stimulation and bronchodilation Norepinephrine (Levophed) Stimulates the heart in cardiac arrest Vasoconstricts and increases the BP in hypotension and shock

SE Dysrhythmias Tachycardia Angina Restlessness Urgency or urinary incontinence

Interventions Monitor vital signs Monitor lung sounds Monitor urinary output Monitor ECG Administer the medication through a large vein

Midodrine Used to treat orthostatic hypotension that interferes with a persons ability to function and has not responded to any other therapy. Action: interferes with alpha-receptors in arteries and veins to produce increased vascular tone and BP. AE: piloerection, chills and rash hypertension and bradycardia dizziness, vision changes , vertigo, headache changes in urination Drug to Drug Caution: increased effects and toxicity of cardiac glycosides, betablockers, alpha-adrenergic agents, and corticosteroids Interventions: Monitor BP Do not administer the drug to patients who are bedridden, but only to patients who are up and mobile, to ensure therapeutic effects and decrease the risk of severe hypertension. Monitor HR closely. Bradycardia usually occurs at the beginning of therapy, if it persists, discontinue drug Monitor patients with known visual problems. Provide comfort measures to help patient tolerate drug effects, including small, freq. meals, access to bathroom, safety precautions if CNS effects occur, environment controls, and analgesics as needed. Cardiotonic Agents Positive Inotropic and Cardiotonic Drugs Stimulates myocardial contractility and produce a positive inotropic effect Used for short-term management of advanced heart failure; increased myocardial contractility improves cardiac, peripheral, and kidney function by increasing cardiac output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and increasing fluid excretion. Thus, fluid retention of the lungs and extremities is decreased

Milirinone (Primacor) Used for short-term management of congestive heart failure A second class of drugs that acts as cardiotonic (phosphodiesterase inhibitor) May be given before heart transplantation SE Dysrhythmias Hypotension Thrombocytopenia Toxic and adverse reactions Hepatotoxicity manifested by elevated liver enzyme levels Hypersensitivity manifested by wheezing, shortness of breath, puritus, urticaria, clammy skin, and flushing Interventions: Positive inotropic and cardiotonic meds are for IV administration Do not dilute with dextrose-containing solutions For continuous IV infusion, give through IV pump Stop infusion if BP drops or dysrhythmias occur. Monitor apical pulse and BP Monitor for hypersensitivity Assess lung sounds for wheezing and crackles Monitor for edema Monitor for relief of heart failure as noted by reduction of edema, lessening of dyspnea, orthopnea, and fatigue Monitor electrolyte and liver enzyme levels, platelet count, and renal studies; these drugs may decrease K and increase liver enzyme levels, continuous ECG monitoring is done during administration Milrinone (Primacor) SE Headache Hypotension Angina Toxic and AR Dysrhythmias Intervention For IV injection of a loading dose, administer slowly over 10 minutes For continuous infusion, use an IV pump Monitor apical pulse and BP Stop infusion if BP drops or dysrhythmias occur Assess lung sounds Monitor for edema Monitor for relief of heart failure

Dopamine Used as short-term rescue measure for clients with severe, acute cardiac failure Increases myocardial contractility, thereby improving cardiac performance Dilates renal blood vessels and increases renal blood flow and urine output Dobutamine Used for short-term management of heart failure Increases myocardial contractility, thereby improving cardiac performance Inamirinone lactate Used for short-term management congestive heart failure in those who have not responded adequately to cardiac glycosides, diuretics and vasodilators A second class of drugs that acts as cardiotonic (phosphodiesterase inhibitor) -

Cardiac Glycosides Derived from the fox-glove or digitalis plant Inhibit the sodium-potassium pump, thus increasing intracellular calcium, which causes the heart muscle fibers to contract more efficiently Produces a positive inotropic action, w/c increases the force of myocardial contractions Produces a negative dromotropic action that slows conduction velocity through the AV node Increases myocardial contractility, thus increasing cardiac output Used for heart failure and cardiogenic shock, atrial fibrillation, and atrial flutter CI in clients w/ ventricular dysrhythmias and second- or third degree heart blocks and should be used w/ caution in clients w/ renal disease, hypothyroidism, and hypokalemia

Digoxin (Lanoxicaps, Lanoxin, Digitek) Lanoxin vs Lanoxicaps Both provide digoxin but bioavailability differ Digoxin has a small margin of safety, the room for error is smaller with Lanoxicaps SE and Toxic effects Anorexia, nausea, vomiting, diarrhea Headache

Visual disturbances: diplopia, blurred vision, yellow-green halos, photophobia Drowsiness Bradycardia Fatigue, weakness Interventions Monitor for toxicity: Anorexia, N/V Visual disturbances Premature ventricular contractions (PVCs) Tachydysrhythmias Monitor serum digoxin level, electrolytes , and renal function test results Therapeutic dogoxin range is 0.5 to 2 ng/mL; above 2 is toxic. Increased risk for toxicity exists in clients w/ hypercalcemia, hypokalemia, hypomagnesemia, or hypothyroidism Monitor potassium level Instruct patient to avoid OTC Monitor client taking a potassium-wasting diuretic or corticosteroids closely for hypokalemia for this condition can cause digoxin toxicity. Note that older clients are more sensitive to toxicity Advise the client to eat foods high in potassium such as fresh and dried fruits, fruit juices, vegetables and potatoes Monitor apical pulse. If lower than 60 bpm or higher than 100 bpm, hold dose and notify the physician Teach client S/S of toxicity ANTIDOTE: DIGOXIN IMMUNE FAB (Digibind)

instruct the client not to swallow the drug Instruct client to take one tablet for pain and repeat every 5 min.,for a total of three doses. Instruct client to seek medical help immediately if pain is not relieved in 15 minutes, after the 3 doses Inform the client that a stinging or burning sensation may indicate that the tablet is fresh Instruct client to store drug in a dark, tightly closed container Instruct client to check the expiration date on the bottle because expiration may occur within 6 mos. of obtaining medication Instruct client to take acetaminophen for a headache

Translingual preparation (spray) Instruct the client to direct the spray against the oral mucosa Instruct client to avoid inhaling the spray Sustained release preparation Instruct the client to swallow and not to chew or crush the medication Transmucosal-buccal Instruct client to place the medication between the upper lip and gum or in the buccal area between the cheek and gum Inform client that the medication will adhere to the oral mucosa and slowly dissolve Transdermal patch Apply patch to a hairless area, rotate sites Topical ointments Instruct the client to remove the ointment on the skin from previous dose before applying new one Use prescribed applicator paper and spread evenly Avoid touching the ointment when applying. Use gloves. Avoid using areas where paddles of defibrillator is used. May cause burns.

Antianginal Drugs Nitrates produce vasodilation Nitrates decrease preload and afterload and reduce myocardial oxygen consumption CI in client w/ significant hypotension, ICP, or severe anemia Use w/ caution in clients w/ severe renal or hepatic disease Avoid abrupt withdrawal of long-acting preparations to prevent rebound effect of severe pain from myocardial ishcemia

Antidysrhythmic Drugs Suppress dysrhythmias by inhibiting abnormal pathways of electrical conduction through the heart CLASS I antidysrhythmics are sodium channel blockers CLASS IA Disopyramide (Norpace) Procanamide (Procanbid) Quinidine sulfate CLASS IB Lidocaine (Xylocaine) Mexiletine hydrochloride (Mexitil) Phenytoin (Dilantin) CLASS IC Flecainide acetate (Tambocor) Propafenone hydrochloride (Rythmol) Moricizine (Ethomozine) SE: hypotension heart failure worsened or new dysrhythmias nausea, vomiting, or diarrhea CLASS II Acebutolol (Sectral) Esmolol (Brevibloc) Propanolol (Inderal) SE: Dizziness Fatigue Hypotension Bradycardia Heart Failure

Antianginal Medications (organic nitrates) Amyl nitrate inhalant Isosorbide dinitrate (Isordil Titradose) Isosorbide mononitrate (Nitrostat, NitroQuick, Nitrotab) Nitroglycerin, translingual (Nitrolingual pumpspray) Nitroglycerin, transmucosal Nitroglycerin, transdermal patches (Minitran, Nitro-Dur, Nitrek, Transderm-Nitro) Nitroglycerin, ointment (Nitro-Bid) SE Headache Orthostatic hypotension Dizziness, weakness Faintness N/V Flushing or pallor Confusion Rash Dry mouth Reflex tachycardia Interventions: Sublingual preparation Monitor VS Offer sips of water before giving because dryness may inhibit drug absorption Instruct client to place under the tongue and leave until fully dissolved

Dysrhythmias, Heart Block Bronchospasms Gastrointestinal distress CLASS III Amiodarone (Cordarone, Pacerone) Bretylium Dofetilide (Tikosyn) Ibutilide (Corvert) Sotalol (Betapace) SE: Hypotension Bradycardia Nausea, vomiting amiodarone hydrochloride may cause pulmonary fibrosis, photosensitivity, bluish skin discoloration, corneal deposits, peripheral neuropathy, tremor, poor coordination, abnormal gait, and hypothyroidism bretylium may cause vertigo, syncope and dizziness CLASS IV Verapamil (Isoptin Sr, Calan, Verelan) Diltiazem (Cardizem) SE: Dizziness Hypotension Bradycardia Edema Constipation OTHER ANTIDYSRHYTHMICS Adenosine (Adenocard) Digoxin (Lanoxin) INTERVENTIONS: Monitor HR, RR, Bp Monitor ECG Provide continuous cardiac monitoring Maintain therapeutic serum drug levels Before administering lidocaine, always check the vial label to prevent administering a form that contains epinephrine or preservatives because these solutions are used for local anesthesia only Do not administer antidysrhythmics with food because food may affect absorption Mexiletine may be administered with food or antacids to reduce GI distress Always administer IV antidysrhythmics via an infusion pump Monitor for signs of fluid retention such as weight gain, peripheral Edema, or shortness of breath Advise the client to limit fluid and salt intake to minimize fluid retention Monitor respiratory, thyroid, and neurological functions After administering bretylium, keep the patient supine and monitor for hypotension Instruct the client to change position slowly to minimize orthostatic hypotension Instruct the client taking amiodarone to use sunscreen and protective clothing to prevent photosensitivity reactions Encourage the client to increase fiber intake to prevent constipation

Hema Drugs Anticoagulants Increase the amount of time it takes for blood to form a clot. Sometimes referred to as blood thinners. Action: prevents blood clot formation or extension by acting on one or more of the hemostatic processes responsible for clot formation. Anticoagulants do not dissolve existing clots; they work by preventing extension of existing clots and formation of new ones. Indication: anticoagulants are given as prophylaxis to prevent embolization in any condition in which normal blood viscosity could possibly cause clot formation. Contraindication: contraindicated in any condition in which the threat of bleeding is present. Adverse effect: GI upset; granulocytosis, leukopenia, eosinophilia, increased bleeding, petechiae and purpura. Nursing Management Before therapy begins, assess the clients coagulation profiles. Be sure that a thorough and complete history and physical examination are documented. Note any bleeding or clotting problems in the past or present illness. Monitor prothrombin time (protime, PT). Teach the client and family to recognize signs signifying possible thrombocytopenia, such as bleeding gums, black tarry stools, cloudy or dark urine, abdominal or back pain, headache, or blurred vision. Instruct the client to avoid foods rich in vitamin K because these will interfere with the effectiveness of the medication. These include: green, leafy vegetables, cheese, egg yolks, liver, tomatoes. Heparin (Lipo-Hepin, Liquemin) Natural anticoagulant found in the liver and lungs. Action: It accelerates hepatic production of antithrombin III, thereby blocking conversion of fibrinogen to fibrin. Impairs activation of fibrinstabilizing factor and reduces platelet adhesion, making it more difficult for clots to form from platelets sticking together. Indication: Prevention of extension of existing clots. Prevention of thrombus formation in at-risk clients. It is the drug of choice when immediate action is required. Heparin does not dissolve existing clots. Side effects: Spontaneous bleeding, hemorrhagic complications, early and delayed thrombocytopenia, heparin-induced platelet aggregation. Nursing Management Mix heparin in normal saline for IV infusion. When giving the drug SC, inject heparin deep into the fat in the abdominal area around the umbilicus. Rotate injection sites and use a fine-gauge needle, with no aspiration after injection. Avoid rubbing the injection site when giving heparin or bruising will occur. Monitor thrombocytes because thrombocytopenia can indicate dangerous allergic hypersensitivity. Enoxaparin -

Action: It is a vitamin K antagonist and therefore inhibits synthesis of clotting factors II, VII, IX, and X, thus prolonging clotting time. Indication: Long-term prevention or treatment of venous thromboembolic disorders. Prevention of extension of existing blood clots and complications secondary to thromboembolism. Pharmacokinetics: Warfarin becomes effective only once each vitamin K dependent coagulation factor is reduced sufficiently. Peak effect: 1 and 3 days. Warfarin is metabolized in the liver and excreted in feces and urine. The drug crosses the placenta and also enters breast milk. Side effects: bleeding episodes, GI upset Nursing Management Know that PO preparations are given once a day and that doses are in milligrams. Instruct client to avoid foods rich in vitamin K. Foods rich in Vit. K: spinach, Brussels sprouts, broccoli, asparagus, Lettuce Okra, malunggay

Low-molecular-weight heparin Same mechanism of action and use as heparin but not interchangeable; has a longer half-life Given SQ Action and Indication: same as with Heparin Intervention: Administer by SQ injection only to the recumbent client in the anterolateral or posterolateral abdominal wall Do not expel air bubbl from the prefilled syringe or aspirate during injection Monitor same laboratory values as for heparin ANTIDOTE: PROTAMINE SULFATE -

Thrombolytic Drugs Thrombolytic medications activate plasminogen; plasminogen generates plasmin (enyme that dissolves clots) Used early in the course of MI (within 4-6 hours of the onset of the infarct) to restore blood flow, limit myocardial damage, preserve left ventricular function, and prevent death Used in arterial thrombosis, deep vein thrombosis, occluded shunts or catheters, and pulmonary emboli Ateplase (Activase , tPA) Reteplase (Retavase) Streptokinase (Streptase) Tenecteplase (TNKase) Urokinase (Abbokinase) CI Active internal bleeding History of hemorrhagic brain attack (Stroke) Intracranial problems including trauma Intracranial or intraspinal surgery w/in 2 mos. History of thoracic, pelvic, or abdominal surgery w/in the last 10 days History of renal or hepatic disease Uncontrolled hypertension Recent CPR Known allergy to product or preservatives SE Bleeding Dysrhythmias Fever Allergic reactions Interventions Determine aPTT, PT, fibrinogen level, hematocrit, and platelet count Monitor VS Monitor for bleeding Monitor all excretions for occult blood Monitor for neurological changes such as slurred speech, lethargy, confusion, and hemiparesis Monitor for hypotension and tachycardia Avoid injections if possible Apply direct pressure over a puncture site for 20-30 min. Handle the client as little as possible when moving Instruct the client to use an electric razor for shaving and brush teeth gently w/hold drug if bleeding occurs ANTIDOTE: AMINOCAPROIC ACID (Amicar) for streptokinase Use only in life-threatening conditions

Warfarin sodium (Coumadin, Panwarfarin, Sofarin) Oral anticoagulant derived from coumarin. Although the drug may prevent new blood clots from forming, it does not dissolve existing clots -

Antiplatelet Drugs Inhibits the aggregation of platelet in the clotting process, thereby prolonging the bleeding time May be used with anticoagulants Used in the prophylaxis of long-term complications following MI, coronary vasularization, stents, and stroke CI in those with bleeding disorders and known allergy

SE: GI bleeding Bruising Hematuria Tarry stools Abciximab (ReoPro) Aspirin (acetylsalicylic Acid, ASA) Cilostazol (Pletal) Clopidogrel (Plavix) Dipyridamole (Persantine) Eptifibatide (Integrilin) Tidopidine (Ticlid) Tirofiban (Affrastat) Interventions: Determine sensitivity before administration Monitor VS Instruct to give with food if w/ GI upset Monitor bleeding time Monitor for bleeding Instruct client on measures to prevent bleeding -

within 12 to 16 hours. With oral preparation, absorption occurs in the GI tract. Bile must be present for GI absorption. Side effects: anaphylaxis, pain at the injection site, dizziness, and diaphoresis. Nursing Management same with Protamine sulfate

Anemia Ferrous sulfate, Ferrous gluconate, ferrous fumarate Classification: Anti-anemic Action: Iron is absorbed from the GI tract through the mucosal cells where it combines with the protein transferrin. Indication: Prophylaxis and treatment of iron-deficiency anemia. Contraindication: Peptic ulcer, ulcerative colitis, haemolytic anemia, and cirrhosis of the liver. Side effects: GI: constipation, gastric irritation, nausea, abdominal cramps, anorexia, vomiting, and diarrhea. Nursing Management Take with meals to reduce gastric irritation. Taking preparations with citrus juices enhances iron absorption. May cause indigestion, change in stool color, and GI upset. Increase intake of fruit, fiber, and fluids to minimize constipating effects. Dilute liquid preparations well with water or fruit juice and use a straw to minimize teeth staining.

Hemostatic agents Used to control bleeding. Action: Act to terminate bleeding. They may be topical or systemic. Action varies with the agent. Indication: Treatment of bleeding as a side effect of anticoagulation therapy. Treatment of bleeding that result from hyperfibrinolysis, overdoses of thrombolytic drugs.

Aminocaproic acid (Amicar) A systemic hemostatic drug used to stop bleeding episodes. Action: Inhibits plasminogen activators. It prevents plasmin binding to fibrin, thus inhibiting fibrinolysis Indication: Treatment of overdose of fibrinolytic drug. Treatment of bleeding associated with hyperfibrinolysis, which may occur with open heart surgery, cancer, abruption placentae, severe trauma, and shock. Treatment of urinary fibrinolysis, usually associated with prostatectomy, or renal malignancies. Prevention of recurrence of subarachnoid hemorrhage. Aminocaproic acid should only be administered in lifethreatening hemorrhage caused by fibrinolysis. Pharmacokinetics: Onset of action is immediate with IV delivery, rapid with the PO preparation. Contraindications: Contraindicated during pregnancy and in clients with active intravascular clotting with active fibrinolysis and bleeding. Reduce dose in clients with renal, hepatic, or cardiac conditions. Side effects: acute renal failure, hyperkalemia, Nursing Management: Monitor vital signs, hemodynamic parameters, and coagulation profiles very closely. Assess for embolic complications such as chest pain, cyanosis, and shortness of breath. Protamine sulfate Heparin antagonist. Action: Protamine combines chemically with heparin and this combination neutralizes heparins anticoagulant effect. Indications: Used when anticoagulation needs to be reversed as in heparin overdose or in case of hemorrhage. Nursing Management Administer the drug slowly. Continue to monitor coagulation studies and be alert for signs of coagulation (chest pain, cyanosis, shortness of breath). Assessment is the same as for anticoagulants. Vitamin K (AquaMEPHYTON, Konakion Neutralizes the anticoagulant effect of warfarin. Action: Vitamin K promotes hepatic synthesis of clotting factors II, VII, IX, X and reverses the prothrombin depression induced by an anticoagulant medication. Pharmacokinetics: Onset of action occurs within 6 to 10 hours with PO, 1 to 2 hours with IM, and 15 minutes with IV administration. Normal PT levels may be achieved -

Megaloblastic Anemia Folic Acid (Folvite) Classification: Vitamin B complex Action: Folic acid is necessary for normal production of RBCs and for synthesis of nucleoproteins. Indication: Treatment of megaloblastic anemias due to folic acid deficiency Side effects: GI: nausea, abdominal distention, flatulence, bitter or bad taste Health Teaching: Document baseline CBC, reticulocytes, serum folate and B12 levels. Given PO; if there is severe malabsorption, give either IV or SC. Dietary sources of folic acid include dark green leafy vegetables, beans, fortified breads, and cereals. Drug may discolour urine a deep yellow Cyanocobalamin (Vitamin B12) It is a cobalt-containing vitamin, can be isolated from liver and is identical to that of the anti-anemic factor of liver. Required for hematopoiesis, cell reproduction, nucleoprotein myelin synthesis. Intrinsic factor is required for adequate absorption of PO vitamin B12 and in pernicious anemia and malabsorption diseases intrinsic factor is administered simultaneously. Rapidly absorbed following IM or SC administration. Following absorption, vitamin B12 is carried by plasma proteins to the liver where it is stored until required for various metabolic functions. Side effects: urticaria, itching, exanthema. Health Teaching: Monitor CBC, potassium, and B12 levels if being treated for megaloblastic anemia. With pernicious anemia, vitamin B12 replacement must be taken for life. The stinging, burning sensation that may occur after injection is transitory. If vitamin B12 therapy is the result of dietary deficiency, identify foods high in B12 and review diet. Avoid alcohol; interferes with absorption. Report any symptoms of urticaria, itching, and evidence of anaphylaxis immediately. If diarrhea occurs, record the frequency, quantity, and consistency of stools. If severe or persists, a change in drug may be required.

Anemia in Renal Disease Erythropoietin (Epoetin alfa) Epogen, Eprex Classification: Recombinant human erythropoietin Action: Epoetin alfa is a 165-amino-acid glycoprotein made by recombinant DNA technology; it has the identical amino acid sequence and same biologic effects as endogenous erythropoietin (which is normally synthesized in the kidney and stimulates RBC production). Epoetin alfa will elevate or maintain the RBC level, decreasing the need for blood transfusions Indication: Treatment of anemia associated with chronic renal failure. Side effects: Due to CRF: hypertension, tachycardia, edema; headache, fatigue; N&V, diarrhea. Due to Cancers: fatigue, pyrexia; N&V; trunk pain. Health Teachings: Determine CBC and iron stores. Monitor renal function studies, electrolytes, phosphorus and uric acid levels; especially with chronic renal failure. Supplemental iron is administered to enhance the effects of epoetin alfa. Report as scheduled for lab studies as drug dose is adjusted based on these results. Must continue to follow prescribed dietary and dialysis recommendations; schedule activities to permit rest periods. Do not perform any tasks that require mental alertness until drug effects realized.

If lovastatin is not effective in decreasing lipid level after 3 mos, it should be discontiued Instruct to report unexplained S/S immediately Lovastatin (Mevacor) highly protein-bound and should not be administered with anticoagulants Should not be administered with gemfibrozil (Lopid) Administer lovastatin with caution to the client taking immunosuppressive medications Atorvastatin (Lipitor) Fluvastatin (Lescol) Pravastatin (Pravachol) Rosuvastatin (Crestor) Simvastatin (Zocor)

Other antilepemic drugs Ezetimabe (Zetia) Ezetimabe, simvastatin (Vytotin) Fenofibrate Gemfibrozil (Lopid) Nicotinic acid (Niacin) Probuccol Gemfibrozil should not be taken with anticoagulants. Monitor INR closely Do not administer gemfirozil with HMG-CoA reductase inhiitors because it increases risk for myalgias and rhabdomyolysis Interventions: Monitor VS Monitor liver enzyme levels Monitor serum cholesterol and triglyceride levels Instruct the client to restrict intake of fats, chol., carohydrates, and alcohol Instruct client to follow exercise program Instruct client that it will take several weeks before the lipid level declines Instruct client to have annual eye exam. Instruct client w/ DM2 who is taking gemfibrozil to monitor blood glucose levels regularly Instruct client to increase fluid intake Note that nicotinic acid has numerous s/e Taking aspirin or NSAIDs may assist in reducing the SE of cutaneous flushing from nicotinic acid and take with meals to reduce GI discomfort

Lipids Antilipemic Drugs Antilipemic medications reduce serum levels of cholesterol, triglycerides, or low-density lipoproteins (LDL) When cholesterol, triglycerides and LDL are elevated, client is at increased risk for coronary artery disease When diet alone, will not lower blood lipid levels, antilipemics will be prescribed

Bile sequestrants Colesevelam (WelChol) Colestipol (Colestid) Bind with acids in the intestines, which prevents reabsorption of cholesterol Should not be used as the only therapy in clients with elevated triglyceride levels SE: constipation GI disturbances: heartburn, nausea, belching, bloating Cholestyramine (Questran) comes in a gritty powder that must be mixed thoroughly in juice or water monitor client for early signs of peptic ulcer such as nausea and abdominal discomfort followed by abdominal pain and distention instruct client that drug must be taken w/ sufficient fluids HMG-CoA reductase inhibitor Early rate-limiting step in the synthesis of cellular cholesterol involving the enzyme HMG-CoS reductace, if blocked, lowers cholesterol level and LDL levels SE: Nausea, diarrhea or constipation Abdominal pain or cramps Flatulence Dizziness Headache, blurred vision, Rash, pruritis Elevated liver enzyme levels Muscle cramps and fatigue Interventions: monitor serum liver enzyme levels Instruct client to receive regular eye examinationbecause the medications can cause cataract formation