Chapters 23,24,25 and 27

Lecture 3
•Chapters 23,24,25 and 27
Copyright © 2017, Elsevier Inc. All rights reserved. 1

Chapter 23
Antianginal Drugs
Copyright © 2017, Elsevier Inc. All rights reserved.

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.”
• Aka “chest pain”
• The heart requires a large supply of oxygen to meet
the demands placed on it.

Benefit of drug therapy for angina
through increasing oxygen supply and
decreasing oxygen demand

Drugs for Angina
• Nitrates or nitrites
• Beta blockers
• Calcium channel blockers (CCBs)

Therapeutic Objectives
• Minimize the frequency of attacks and decrease the
duration and intensity of anginal pain.
• Improve the patient’s functional capacity with as few
adverse effects as possible.
• Prevent or delay the worst possible outcome:
Myocardial Infraction (MI) aka Heart Attack.

Nitrates and Nitrites
• Available forms
• Sublingual* • Transdermal patches*
• Chewable tablets • Ointments
• Oral capsules/tablets • Translingual sprays*
• Intravenous (IV) solutions*
*Bypass the liver and the first-pass effect.

Mechanism of Action and
Drug Effects
• Cause vasodilation because of relaxation of smooth
muscles
• Potent dilating effect on coronary arteries
• Result: oxygen to ischemic myocardial tissue
• Used for prevention and treatment of angina

Nitrates and Nitrites (Cont.)
• Rapid-acting forms
• Used to treat acute anginal attacks
• Sublingual tablets; IV infusion
• Long-acting forms
• Used to PREVENT anginal episodes

Nitrates and Nitrites (Cont.)
• Nitroglycerin (both rapid and long acting)
• Isosorbide dinitrate (both rapid and long acting)
• Isosorbide mononitrate (primarily long acting)

Audience Response System Question
A patient with extremely high blood pressure (BP) is in the emergency
department. The physician will order therapy with nitroglycerin to
manage the patient’s BP. Which form of nitroglycerin is most appropriate?
A. Sublingual spray
B. Transdermal patch
C. Oral capsule
D. IV infusion

Nitrates (Cont.)
• Adverse effects
• Headaches
• Usually diminish in intensity and frequency
with continued use
• Flushing
• Reflex tachycardia
• Postural hypotension
*Tolerance may develop.

Tolerance
• Occurs in patients taking nitrates around the clock or
with long-acting forms
• Prevented by allowing a regular nitrate-free period
• i.e. Transdermal forms: remove patch at bedtime for 12
hours, then apply a new patch in the morning

Nitrates: Contraindications
• Known drug allergy
• Severe anemia
• Closed-angle glaucoma
• Hypotension
• Severe head injury
• Use of the erectile dysfunction drugs
• Sildenafil
• Tadalafil
• Vardenafil (Levitra)

Nursing Implications
• New onset of chest pain – obtain 12 lead EKG!
• Before administering, perform a complete health
history to determine presence of conditions that may
be contraindications for use or those that may call for
cautious use.
• Obtain baseline vital signs.
• Assess for drug interactions.

Nursing Implications (Cont.)
• Patients should not take any medications, including
over-the-counter medications, without checking with
their physicians.
• Patients should be encouraged to limit
caffeine intake.

• Patients should report:
• Blurred vision
• Persistent headache
• Fainting episodes
• Weight gain of 2 to 3 lb in 1 day or 5 lb in 1 week
• Dyspnea

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

• Nitroglycerin Sublingual
• Instruct patients in proper technique and guidelines for
taking sublingual nitroglycerin for anginal pain.
• Instruct patients never to chew or swallow the
sublingual form.
• Instruct patients that a burning sensation felt with sublingual
forms indicates that the drug is still potent.

• Nitroglycerin Sublingual (Cont.)
• Instruct patients to keep a fresh supply of sublingual
medication on hand; potency is lost in about 3 months after
the bottle has been opened.
• To preserve potency, medications should be stored in an
airtight, dark glass bottle with a metal cap and no cotton
filler.

• Nitroglycerin (Cont.)
• If anginal pain occurs:
• Stop activity and sit or lie down and take a sublingual tablet.
• If there is no relief in 5 minutes, call 911 or emergency services
immediately and take a second sublingual tablet.
• If there is no relief in 5 minutes, take a third sublingual tablet.
• Do not try to drive to the hospital.

• Nitroglycerin Topical (Cont.)
• Instruct patients in the proper application of nitrate topical
ointments and transdermal forms, including site rotation,
picking or appropriate sites, and removal of old medication.
• To reduce tolerance, the patient may be instructed to
remove topical forms at bedtime and apply new doses in the
morning, allowing for a nitrate-free period.
• Providers are to wear gloves for application

• Instruct patients to take as-needed nitrates at the first hint
of anginal pain.
• Monitor vital signs frequently during acute exacerbations of
angina and during IV administration.
• If experiencing chest pain, the patient taking sublingual
nitroglycerin should lie down to prevent or decrease
dizziness and fainting that may occur because of
hypotension.

• IV forms of nitroglycerin must be given with special non-PVC
tubing and bags.
• Discard parenteral solution that is blue, green, or dark red.
• Follow specific manufacturer’s instructions for IV
administration.

• Antianginal drugs
• Monitor for adverse reactions: allergic reactions, headache,
lightheadedness, hypotension, dizziness.
• Monitor for therapeutic effects: relief of angina, decreased
BP, or both.

Patient Education
• Assess blood pressure
• Take at first signs of chest pain
• Maintain safety
• Long-term therapy
• Activities to avoid tolerance
• Taper off slowly
• Storage of nitroglycerin
• Change positions slowly
• Never crush or chew tablets

Patient Education
• Avoid activities that cause vasodilation
• Keep record of angina attacks

Case Study (Cont.)
A patient asks how to apply transdermal nitroglycerin.
What is the nurse’s best response?
A. “Always apply the transdermal patch over the area of your

chest where your heart is.”
B. “Keep the previous patch on for 1 full day so you always
have two patches on at a time.”
C. “Apply the patch to hairless areas of the body.”
D. “First apply Vaseline to your body; then apply the
transdermal patch.”

Break
• Activity: 2 med templates

Chapter 24
Heart Failure Drugs

Heart Failure
• Not a specific disease

• The heart is unable to pump blood in sufficient
amounts from the ventricles to meet the body’s
metabolic needs.

• https://www.youtube.com/watch?v=m4aC0-x4zWQ

Heart Failure
• Primary Treatment – cardiotonic agents

• Allows the heart muscle to contract more efficiently in an
effort to bring the system back into balance

Cardiotonic Agents
• Phophodiesterase Inhibitors
• Recommended for short term use only
• Cardiac Glycosides

Early Drug Therapy for Heart Failure (Cont.)
• B-Type Natriuretic Peptides

• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARBs)
• Beta blockers
• Diuretics
*Only after these drugs are used is digoxin added.

Phosphodiesterase Inhibitors:
Indications
• Short-term management of HF for patients in the
intensive care unit (ICU)
• AHA and ACC advise against long-term infusions

Milrinone
• Only available phosphodiesterase inhibitor

• Milrinone is available only in intravenous (IV) form.
• Adverse effects: cardiac dysrhythmias, headache,
hypokalemia, tremor, thrombocytopenia, and elevated
liver enzyme levels
• Interactions: diuretics (additive hypotensive effects)
and digoxin (additive inotropic effects)

Cardiac Glycosides
• No longer used as first-line treatment

• Not been shown to reduce mortality
• Originally obtained from Digitalis plant
• Used in HF and to control ventricular response to
atrial fibrillation

Cardiac Glycosides:
Mechanism of Action
• Increase myocardial contractility
• Change electrical conduction properties of the heart
• Decrease rate of electrical conduction
• Reduce heart rate
• Prolong the refractory period
• Allow for better filling of ventricles

Cardiac Glycosides:
Adverse Effects
• digoxin
• Very narrow therapeutic window
• Drug levels must be monitored.
• 0.5 to 2 ng/mL
• Hypokalemia increases the risk of digoxin toxicity
• 3.5-5 mmol/L
• Drug-to-drug: potassium losing diuretics
• Electrolyte levels must be monitored.
• Monitor renal function

Cardiac Glycosides:
Adverse Effects (Cont.)
• digoxin
• Cardiovascular:
• dysrhythmias
• bradycardia
• Central nervous system
• Headaches
• Fatigue
• Confusion
• Convulsions

Cardiac Glycosides:
Adverse Effects (Cont.)
• digoxin
• Eyes:
• colored vision (seeing green, yellow, purple)
• halo vision
• Gastrointestinal:
• Anorexia
• Nausea and vomiting
• Diarrhea

Digoxin Toxicity
• Signs and symptoms

• Arrhythmias
• Visual changes
• GI upset
• digoxin immune Fab (Digibind) therapy
• Hyperkalemia (serum potassium greater than
5 mEq/L) in a digitalis-toxic patient
• Life-threatening cardiac dysrhythmias
• Life-threatening digoxin overdose

Heart Failure Drugs:
• Assess history, drug allergies, and contraindications.
• Assess clinical parameters, including:
• BP
• Apical pulse for 1 full minute
• Hold if < 60 bpm adults, <90 bpm infants
• Heart sounds, breath sounds

• Assess clinical parameters (Cont.)
• Daily Weights
• Educate clients on how to obtain accurately
• Input and output measures
• Electrocardiogram
• Serum labs:
• Potassium
• Renal

• Hold dose and notify prescriber if the patient
experiences signs or symptoms of toxicity.
• Anorexia, nausea, vomiting, diarrhea
• Visual disturbances (blurred vision, seeing green or yellow
halos around objects)
• Arrythmias

• Check dosage forms carefully and follow instructions
for administering.
• If administer IV dose – give slowly – over at least 5 min
• Monitor heart rhythm
• Avoid giving digoxin with high-fiber foods (fiber binds
with digitalis).
• Patients should immediately report a weight gain of 2
to 3 lb or more in 1 day or 5 lb or more in 1 week.

• Monitor for therapeutic effects:
• Increased urinary output
• Decreased edema, shortness of breath, dyspnea, crackles,
fatigue
• Improved peripheral pulses, skin color, temperature
• Monitor for adverse effects.

Patient Education
• Take medication exactly as prescribed

• Never skip doses, and never try to “catch up” on missed
dose
• Learn to take own pulse
• Monitor weight
• Dizziness, drowsiness, and HA can occur
• Avoid driving or performing hazardous tasks at the time
• Encourage foods high in potassium

Patient Education
• Take small frequent meals for N, GI upset, and loss of

appetite
• Report vision changes
• Report the following s/s to MD
• Slow or irregular pulse, rapid weight gain, yellow vision,
difficulty breathing, swelling of ankles, legs, or fingers
• Consider wearing medical alert bracelet
• Schedule regular check-ups to monitor drug levels

BREAK
• Activity: Disease process, med, outcomes map.

Chapter 25
Antidysrhytmic Drugs

What is a Dysrhythmia?
• Any deviation from Normal Sinus Rhythm
• Important rythms: Atrial Flutter, Atrial Fibrillation,

Ventricular Tachycardia, Supraventricular Tachycardia
• Goals: Identify the rhythm and pair with medication.

Atrial Flutter Atrial Fibrillation
• Treatments
• Calcium Channel Blockers
• Diltiazem
• Verpamil
• Class III’s
• Amidodorone
• Sotolol

Ventricular Supraventricular
Tachycardia Tachycardia
• Flecainide
• Beta blockers
• Class III’s

Calcium channel blockers
• Class IV, prolongs AV refractory period
• Verapamil: 80 ‐120 mg TID to QID
• Diltiazem: 30 ‐420 mg, varies due to different formulations
• Side effects general to drug class: bradycardia, AV

block, hypotension, constipation
• Monitor: BUN/Cr, LFTs

Class III’s
Amiodarone Sotalol
• Prolongs action potential • beta‐1/beta‐2 antagonist,
• 200‐600 mg daily prolongs action potential
• Adverse effects: bradycardia, AV • 80‐160 Q 12 hrs
block, pulmonary tox, thyroid • Adverse effects: CHF,
tox, pancreatitis, etc… bradycardia, bronchospasm,
• Monitor: LFT, TFT, PFT, ECG dyspnea, fatigue, headache
• Monitor: renal function, adjust
dose, EKG

Flecainide
• Class IC, depresses action potential
• 50‐300 mg daily, divided doses
• Side effects: arrhythmias, CHF, heart block,
hematologic, dyspnea, headache, nausea, fatigue
• Monitor: Cr, electrolytes, ECG • Allow cardiology to
manage

Beta blockers
• Class II, beta‐1 antagonist
• Atenolol: 50‐100mg daily
• Metoprolol: 20‐200 mg daily
• Side effects general to drug class: bradycardia,

hypotension, fatigue, dizziness, bronchospasm
• No lab monitoring

Conclusion
• Know the dysrhythmia
• Know the drug
• Know the side effects

Break
• Activity: Do 2 med cards

Chapter 27
Antilipemic Drugs

Cholesterol and Coronary Heart Disease
• The risk of coronary heart disease in patients with cholesterol levels

of 300 mg/dL is three to four times greater than that in patients with
levels less than 200 mg/dL.

Hyperlipidemias Treatment and Guidelines
(Cont.)
• All reasonable nondrug means of controlling blood cholesterol levels

(e.g., diet, exercise) should be tried for at least 6 months and found
to fail before drug therapy is considered.

Unmodifiable Risk Factors for CAD
• Genetic Predisposition
• Age
• Gender
Modifiable Risk Factors for CAD
• High fat diet

• Smoking
• Sedentary lifestyle
• Obesity
• Hypertension
• High stress
Treatment
• Decrease dietary fats

• Increase exercise
• Weight loss
• Eliminate smoking
Lipid Blood Level Classification
Desirable or Normal serum concentration levels

• Total cholesterol
• <200
• Low-Density Lipoproteins (LDL) – “bad cholesterol”
• 100-129
• High-Density Lipoproteins (HDL) – “good cholesterol”
• > 60 is considered protected from heart disease
• The lower the number the higher risk for heart disease
• Triglycerides – fats and oils we consume through diet
• < 150
Treatment of Dyslipidemias
• Statins: HMG–CoA reductase inhibitors

• Bile acid sequestrants
• B vitamin niacin (vitamin B3; also known as nicotinic acid)
• Fibric acid derivatives (fibrates).

Antilipemics: HMG-CoA Reductase Inhibitors
(Statins)
• First-line drug therapy for hypercholesterolemia
• Most potent LDL reducers
• lovostatin
• pravastatin
• simvastatin
• atorvastatin
• fluvastatin
• rosuvastatin
• pitavastatin

Contraindications
• Active liver disease

• Pregnancy and lactation
• Avoid grapefruit juice

HMG-CoA Reductase Inhibitors: Adverse
Effects
• Gastrointestinal (GI) disturbances – most common

• Rash
• Headache
• Myopathy (muscle pain), possibly leading to the serious condition
rhabdomyolysis
• Elevations in liver enzymes or liver disease
• Cataract development

Rhabdomyloysis
• Breakdown of muscle protein
• Myoglobinuria: urinary elimination of the muscle protein myoglobin
• Can lead to acute renal failure and even death
• When recognized reasonably early, rhabdomyolysis is usually reversible
with discontinuation of the statin drug.
• Instruct patients to immediately report any signs of toxicity, including
muscle soreness or changes in urine color.

Implementation – Nursing Interventions
• Administer the drug at bedtime
• Monitor lab values
• Cholesterol
• Liver function tests
• Educate on barrier contraception for women of child-bearing age
• Risk of severe fetal abnormalities
Patient Education
• Can take with meals to prevent GI upset
• Small frequent meals assist with upset as well
• Low cholesterol diet
• Exercise
• Take medication at night
• Monitor cholesterol levels
• Eye exams for potential cataract development
• Call physician if muscle pain occurs
Bile Acid Sequestrants
• cholestyramine
• colestipol
• colesevelam

Bile Acid Sequestrants: Mechanism of Action
• Prevent resorption of bile acids from small intestine

• Bile acids are necessary for absorption
of cholesterol.

Contraindications
• Biliary obstruction
• Abnormal intestinal function
• Pregnancy and lactation

Bile Acid Sequestrants:
Adverse Effects
• Constipation
• Heartburn, nausea, belching, bloating
• These adverse effects tend to disappear over time.
• Increasing dietary fiber as well as increasing fluid intake, may relieve
constipation and bloating.
• Increased bleeding times

Bile Acid Sequestrants:
Considerations
• Overdose can cause obstruction because the bile acid sequestrants

are not absorbed.
• Treatment of overdose includes restoring gut motility.
• Drug interactions
• All drugs must be taken at least 1 hour before or 4 to 6 hours after the
administration of bile acid sequestrants.

Implementation – Nursing Interventions
• Do not give powdered agents in dry form

• Mix with water or beverage
• Take tablet whole
• Give medication before meals
• Administer other oral medications 1 hour before or 4-6 hours after
bile sequestrant
• Avoid drug to drug interaction
• Monitor for signs and symptoms of bleeding
Patient Education
• Method of administration
• Powders to mix
• Some require 8 oz of fluid
• Tablets don’t crush
• Take on empty stomach
• Avoid taking with other oral medications
• Need to monitor cholesterol and lipid levels
Patient Education
• Monitor for s/s bleeding

• Safety measures
• Dizziness or fatigue
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 drugs

Niacin: Adverse Effects
• Flushing (caused by histamine release)

• Pruritus
• GI distress
*To minimize effects, start with low dose and then increase gradually.

Fibric Acid Derivatives
• Also known as fibrates

• gemfibrozil
• fenofibrate

Fibric Acid Derivatives: Contraindications
• Known drug allergy

• Severe liver or kidney disease
• Cirrhosis
• Gallbladder disease

Fibric Acid Derivatives:
Adverse Effects
• Abdominal discomfort, diarrhea, nausea

• Blurred vision, headache
• Increased risk of gallstones
• Increased bleeding times
• Liver studies may show increased enzyme levels

Fibric Acid Derivatives:
Interactions
• Statins
• Risk for myositis, myalgias, and rhabdomyolysis is increased

Cholesterol Absorption Inhibitor
• Ezetimibe
• Inhibits absorption of cholesterol and related sterols from the small intestine
• Results in reduced total cholesterol, LDL, and triglyceride levels
• Also increases HDL levels
• Often combined with a statin drug
• Can be used as monotherapy

Herbal Products
• Garlic
• Flax
• Omega 3 Fatty Acids
*Educate client to report ALL herbal and alternative

therapy
*Monitor for adverse effects and drug-to-drug
interactions – i.e. anticoagulants

• Before beginning therapy, obtain a thorough health and medication
history.
• Assess dietary patterns, exercise level, weight, height, vital signs,
tobacco and alcohol use, and family history.
• Assess for contraindications, conditions that require cautious use, and
drug interactions.
• Educate client that medications can take weeks to become therapeutic
• Monitor lab values
• Assess for liver dysfunction

•Questions
•Review

Chapters 23,24,25 and 27

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Chapters 23,24,25 and 27

Hochgeladen von

Copyright:

Verfügbare Formate

Lecture 3

•Chapters 23,24,25 and 27

Copyright © 2017, Elsevier Inc. All rights reserved. 1

Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. 3

Copyright © 2017, Elsevier Inc. All rights reserved. 4

Copyright © 2017, Elsevier Inc. All rights reserved. 6

Copyright © 2017, Elsevier Inc. All rights reserved. 7

*Bypass the liver and the first-pass effect.

Copyright © 2017, Elsevier Inc. All rights reserved. 8

Copyright © 2017, Elsevier Inc. All rights reserved. 9

Copyright © 2017, Elsevier Inc. All rights reserved. 10

Copyright © 2017, Elsevier Inc. All rights reserved. 11

Copyright © 2017, Elsevier Inc. All rights reserved. 12

Copyright © 2017, Elsevier Inc. All rights reserved. 13

Copyright © 2017, Elsevier Inc. All rights reserved. 14

Copyright © 2017, Elsevier Inc. All rights reserved. 15

Copyright © 2017, Elsevier Inc. All rights reserved. 16

Copyright © 2017, Elsevier Inc. All rights reserved. 17

Copyright © 2017, Elsevier Inc. All rights reserved. 18

Copyright © 2017, Elsevier Inc. All rights reserved. 19

Copyright © 2017, Elsevier Inc. All rights reserved. 20

Copyright © 2017, Elsevier Inc. All rights reserved. 21

Copyright © 2017, Elsevier Inc. All rights reserved. 22

Copyright © 2017, Elsevier Inc. All rights reserved. 23

Copyright © 2017, Elsevier Inc. All rights reserved. 24

Copyright © 2017, Elsevier Inc. All rights reserved. 25

Copyright © 2017, Elsevier Inc. All rights reserved. 26

Copyright © 2017, Elsevier Inc. All rights reserved. 27

Copyright © 2017, Elsevier Inc. All rights reserved. 28

A. “Always apply the transdermal patch over the area of your

Copyright © 2017, Elsevier Inc. All rights reserved. 29

Copyright © 2017, Elsevier Inc. All rights reserved. 30

Heart Failure Drugs

Copyright © 2017, Elsevier Inc. All rights reserved.

• Not a specific disease

Copyright © 2017, Elsevier Inc. All rights reserved. 32

Copyright © 2017, Elsevier Inc. All rights reserved. 33

• Primary Treatment – cardiotonic agents

Copyright © 2017, Elsevier Inc. All rights reserved. 34

Copyright © 2017, Elsevier Inc. All rights reserved. 35

• B-Type Natriuretic Peptides

*Only after these drugs are used is digoxin added.

Copyright © 2017, Elsevier Inc. All rights reserved. 36

Copyright © 2017, Elsevier Inc. All rights reserved. 37

• Only available phosphodiesterase inhibitor

Copyright © 2017, Elsevier Inc. All rights reserved. 38

• No longer used as first-line treatment

Copyright © 2017, Elsevier Inc. All rights reserved. 39

Copyright © 2017, Elsevier Inc. All rights reserved. 40

Copyright © 2017, Elsevier Inc. All rights reserved. 41

Copyright © 2017, Elsevier Inc. All rights reserved. 42

Copyright © 2017, Elsevier Inc. All rights reserved. 43

• Signs and symptoms

Copyright © 2017, Elsevier Inc. All rights reserved. 44

Copyright © 2017, Elsevier Inc. All rights reserved. 45

Copyright © 2017, Elsevier Inc. All rights reserved. 46

Copyright © 2017, Elsevier Inc. All rights reserved. 47

Copyright © 2017, Elsevier Inc. All rights reserved. 48

Copyright © 2017, Elsevier Inc. All rights reserved. 49

• Take medication exactly as prescribed

Copyright © 2017, Elsevier Inc. All rights reserved. 50

• Take small frequent meals for N, GI upset, and loss of