Cardiotonic Drugs

Treatment for CHF

 Vasoldilators
 Diuretics
 Beta-Adrenergics Agonists
 Cardiotonic Drugs
 Cardiotonic (inotropic)
– Increases heart muscle contractility
 Cardiac Glycosides
 Cardiac Glycosides
ACTION: makes heart beat slower but stronger
 improves pumping ability of heart
 increases force of heart's contraction ( +
inotropic)
 decreases rate of contraction ( - chronotropic)
 increases cardiac output
 Decreases electrical conduction ( - dromotropic)
USES
 congestive heart failure
 atrial flutter
 atrial fibrillation
Cardiac Glycosides
examples
 digitoxin (Crystodigin)
 digoxin (Lanoxin)
 Cardiac Glycosides
CONTRAINDICATIONS
 ventricular tachycardia
 ventricular fibrillation
 second and third degree heart block
ADVERSE EFFECTS
 gastrointestinal effects such as nausea and vomiting,
diarrhea, and anorexia
 bradycardia
 xanthopsia (visual disturbance - yellow halo)
 muscle weakness
 dysrhythmia
– Antidote: Digoxin Immune Fab (Digibind, Digifab)
 Cardiac Glycosides
– CAUTIONS
 Diuretics
 Tetrcyclines
 Amiodarone
 erythromycin
 Cardiac Glycosides
nursing interventions
 before giving glycoside, check apical pulse and heart
rhythm. Report if < 60 bpm
 establish baseline data such as vital signs,
electrolytes, clinical symptoms, creatinine clearance
test
 monitor for drug toxicity
 in children - cardiac arrhythmias
 Cardiac Glycosides
nursing interventions
 in adults - visual disturbances, nausea
and vomiting, anorexia
 older clients more prone to toxicity
 monitor drug levels
 therapeutic range 0.8 to 2.0 ng/ml, toxic
range > 2 ng/ml
 diuretics may increase chance of toxicity
 monitor intake and output
 Cardiac Glycosides
–client teaching
 take medication as prescribed
 teach client how to take and record pulse
daily
 identify and report signs of toxicity
 for atrial fibrillation: take pulse and report if
below 60 or above 100 or changes in rhythm
 daily weights: report two pound increase
Antiarrthmic Agents
Antianginal Drugs
 Nitrates
– Amyl nitrate
– Isosorbide dinitrate (isordil)
– Isosorbide mononitrate (Imdur)
– Nitroglycerin (nitrostat) during
attack
 Beta-Blockers
– “olols”
 Calcium Channel Blockers
 Nitrates
– Action:
 Relaxes smooth muscle
 Decreases arterial pressure (decreases afterload)
 Reduce cardiac workload
 Decreases myocardial oxygen consumption
 Nitroglycerin
CONTRAINDICATIONS:
 Hypersensitive clients
 Severe anemia
 Acute myocardial infarction, cardiomyopathy
 Head trauma, cerebral hemorrhage
SIDE EFECTS:
 Orthostatic hypotension
 Dry mouth, blurred vision
 Tachycardia, headaches
 Nitroglycerin
NURSING IMPLICATIONS:
 Client with angina pectoris should carry nitrates
with them at all times
 Teach proper storage for freshness (tingling,
fizzle sensation under tongue
 Avoid alcoholic beverages during nitrate therapy
 Avoid swallowing or chewing sustained release
tablets to help the drug reach the
gastrointestinal system. Rotate transdermal
patches
ANTICOAGULANTS
 Heparin
 ACTION:
 Exerts effect on blood coagulation by enhancing the
inhibitory actions of antithrombin III on several factors
essential to normal blood clotting, thereby blocking the
conversion of prothrombin to thrombin and fibrinogen to
fibrin
 Does not cross the placenta & doe not enter breast milk
 USES:
 Prevention and treatment of deep vein thrombosis,
pulmonary embolism, and emboli in atrial fibrillation
 Heparin
CONTRAINDICATIONS:
 Bleeding tendencies
 Thrombocytopenia
 Uncontrollable bleeding
 Postoperative patients
SIDE EFECTS:
 Injection site reactions
 Transient thrombocytopenia
 Large doses may suppress renal function
 Spontaneous bleeding at mucous membranes
ANTIDOTE: Protamine Sulfate
 Heparin
NURSING IMPLICATIONS:
 Monitor the partial thromboplastin time and
activated PTT (aPTT) should be 1 1/2 to 2
times the normal range; watch for bleeding
 Protamine sulfate is the antidote
 Low-molecular weight heparins (e.g.
enoxaparin [Lovenox]) do not require PTT
or aPTT monitoring
 Warfarin Sodium
(Coumadin)
ACTION:
 Suppresses the production of fibrin which
disrupts the coagulation cascade
USES:
 Prevention of venous thrombosis and
thromboembolism associated with atrial
fibrillation and prosthetic heart valves
 Decreases risk of recurrent transient ischemic
attack (TIA), cerebrovascular accident (stroke),
and myocardial infarction
ANTIDOTE: Vitamin K
 Thrombolytics
 ACTION:
 Works by activating plasminogen to
plasmin, an enzyme that acts to digest the
fibrin matrix of clots, which breaks down
fibrin threads in a clot to dissolve clot
 USES:
 Treatment of acute myocardial infarction,
massive pulmonary embolism, thrombotic
strokes, and deep vein thrombosis
 Thrombolytics
IMPORTANT DRUGS:
 streptokinase (Streptase)
 urokinase (Abbokinase)
 Thrombolytics
 CONTRAINDICATIONS:
 Cerebrovascular disease and pregnancy
 Active bleeding, aortic dissection, pericarditis
 History of intracranial hemorrhage

 SIDE EFECTS:
 Hemorrhage and anemia
 Hypotension and fever
 Bronchospasm, anaphylaxis
 Periorbital swelling
 Itching, urticaria, headache
 Thrombolytics
NURSING IMPLICATIONS:
 Administer immediately after the event for better
outcome, preferably within 6 hours
 Monitor intake and output and hematocrit during
treatment
 Monitor patients for anaphylactic reactions and
bleeding
 While receiving the medication, maintain the
client on bed rest
 Monitor signs of blood loss ( petechiae, bleeding
gums, dark-colored stools)
 Antithrombolytics
ACTION:
 reverse fibrinolysis, prevent activation of
plasminogen, and inhibit formation of plasmin

USES:
 Treatment of excessive bleeding from
hyperfibrinolysis
 Prevention of bleeding in hemophilia
Important drugs:
– Aminocaproic acid ( Amicar)
– Tranexamic acid (Hemostan)
 Antithrombolytics
CONTRAINDICATIONS:
 Disseminated intravascular coagulation
 Evidence of active intravascular clotting
problems
 Pregnancy

SIDE EFECTS:
 Nausea, diarrhea, cramps
 Hypotension, dysrhythmias
 Headaches, decreased urine output
 Antithrombolytics
NURSING IMPLICATIONS:
 Monitor intake and output
 Monitor client for bleeding dyscrasias
 Use antithrombolytic medications as an
antidote for streptokinase
 ANTIPLATELET DRUGS
 ACTION: inhibits platelet adhesion &
aggregation by blocking receptor sites on
the platelet membrane
 USES :
– MI
– Thromboembolitic stroke
 Important Drugs
– Cilostazol (Plital)
– Clopidogrel (Plavix)
– Dipyridamole (persantine)
– Ticlopidine (Ticlid)
 ANTIPLATELET DRUGS
 CONTRAINDICATIONS
– Bleeding disorder, recent surgery
 SIDE EFFECTS
– Headache, weakness, dizziness
 ANTIPLATELET DRUGS
 NURSING IMPLICATIONS
Diuretic Agents
 Diuretic Agents
 Drugs that accelerate the rate of urine
formation.
 Result: removal of sodium and water
 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, and 3%
in collecting ducts.
 If it is not absorbed, it is excreted with
the urine.
 Classes:
– Thiazide & Thiazide-like diuretics
– Loop diuretics
– Carbonic Anhydrase inhibitors
– Potassium-sparing diuretics
– Osmotic diuretics
 Thiazide & Thiazide-like diuretics
– Action:
 Belongs to sulfonamide class
 acts primarily on the distal tubules, inhibiting Na
and Cl reabsorption

– Uses:
 Edema, associated with CHF, renal or liver disease
& hypertension
 Thiazide & Thiazide-like diuretics
– Contraindications:
 Allergy to thiazides or sulfonamides
 Fluid or electrolyte imbalances
 Renal & liver disease
 DM
 Systemic Lupus erythematous (SLE)
 Pregnancy & lactation
 Thiazide & Thiazide-like diuretics
– Adverse Effects:
 Hypokalemia
 Hyperurecemia
 hyperglycemia
– Cautions:
 digoxin
– Important Drugs:
 Hydrochlorthiazide, chlorothiazide,
 Loop Diuretics
– Action:
 Also referrred as “Highceiling diuresis”
 Decreases reabsorption of Na & Cl
– Uses:
 CHF, acute pulmonary edema, HPN
– Contraindications:
 Allergy, electrolyte depletion, anuria, severe renal
failure, hepatic coma, pregnancy & lactation
 Loop Diuretics
– Adverse Effects:
 Hypokalemia, Alkalosis (a drop in serum pH),
hypocalcemia, tetany, hypotension, dizziness,
hearing loss
– Cautions:
 Aminoglycoside, cisplatin, anticoagulants, NSAIDS
 Loop Diuretics
– Important Drugs:
 Furosimide (Lasix), bumetanide (Bumex)
 Carbonic Anhydrase Inhibitor
– Action:
 Inhibits carbonic anhydrase resulting to decrease
secretion of aqueous humor of the eye
– Uses:
 glaucoma
– Important Drugs:
 Acetazolamine (Diamox), methezolamide
 Loop Diuretics
– Adverse Effects:
 Matabolic acidosis, hypokalemia, paresthesias
(tingling of the extremities), confusion &
drowsiness
 Potassium-Sparing Diuretics
– Action:
 Has a direct effect on the distal tubules in the kidney.
Spironolactone competes with aldosterone for cell receptor sites in
the distal tubules while inducing urinary excretion of sodium and
reducing excretion of potassium and hydrogen ions
– Uses:
 Drug of choice for hyperaldosteronism
 Reduces edema in clients with congestive heart failure, with
dysrhythmias, and on digoxin therapy
 Prevention, treatment of oliguric phase of acute renal failure
 Reduces increased intracranial pressure due to cerebral edema;
decreases edema of injured spinal cord
 Decreases intraocular pressure due to acute glaucoma
 Promotes excretion of toxic substances

– Important Drugs:
 Spironolactone (aldactone)
 Potassium-Sparing Diuretics
CONTRAINDICATIONS
– Hypersensitivity or renal failure
– Anuria
– Hyperkalemia

SIDE EFECTS
 Hyperkalemia
 Weakness
 Tinnitus
 Hyperglycemia
 gynecomastia
 Osmotic Diuretic
– Action:
 Increases the osmotic pressure of the glomerular
filtrate. The higher the concentration of mannitol
in the filtrate, the more diuresis occurs
– Uses:
 Increases the osmotic pressure of the glomerular
filtrate. The higher the concentration of mannitol
in the filtrate, the more diuresis occurs
– Important Drugs:
 Mannitol (Resectisol, Osmitrol)
 Osmotic Diuretic
– CONTRAINDICATIONS
 Severe renal disease, dehydration, intracranial
bleeding, severe pulmonary edema
– SIDE EFFECTS
 Blurred vision, dizziness, hypotension/
hypertension, tachycardia
 Headache, nausea and vomiting, backache
 Diuretic Agents:
Nursing Implications
 Perform a thorough patient history and physical
examination.

 Assess baseline fluid volume status, intake and

output, serum electrolyte values, weight, and
vital signs.

 Assess for disorders that may contraindicate the

use of, or necessitate cautious use of, these
agents.
 Diuretic Agents:
Nursing Implications
 Instruct patients to take in the morning as much
as possible to avoid interference with sleep
patterns.

 Monitor serum potassium levels during therapy.

 Potassium supplements are usually not

recommended when potassium levels exceed
3.0 mEq/L.
 Diuretic Agents:
Nursing Implications
 Teach patients to maintain proper nutritional
and fluid volume status.

 Teach patients 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.
 Diuretic Agents:
Nursing Implications
 Patients taking diuretics along with a digitalis
preparation should be taught to monitor for
digitalis toxicity.

 Diabetic patients who are taking thiazide and/or

loop diuretics should be told to monitor blood
glucose and watch for elevated levels.
 Diuretic Agents:
Nursing Implications
 Teach patients to change positions slowly, and
to rise slowly after sitting or lying to prevent
dizziness and possible fainting related to
orthostatic hypotension.

 Encourage patients to keep a log of their

daily weight.

 Encourage patients to return for follow-up visits

and lab work.
 Diuretic Agents: Nursing
Implications
 Patients who have been ill with nausea,
vomiting, and/or diarrhea should notify their
physician as fluid loss may be dangerous.

 Signs and symptoms of hypokalemia include

muscle weakness, constipation, irregular pulse
rate, and overall feeling of lethargy.
 Diuretic Agents:
Nursing Implications
 Instruct patients to notify the physician
immediately if they experience rapid heart rates
or syncope (reflects hypotension or fluid loss).

 A weight gain of 2 or more pounds a day

or 5 or more pounds a week should be
reported immediately.
 Diuretic Agents:
Nursing Implications
Monitor for adverse effects:
 metabolic alkalosis, drowsiness, lethargy,
hypokalemia, tachycardia, hypotension, leg
cramps, restlessness, decreased mental
alertness
 Diuretic Agents:
Nursing Implications
 Monitor for therapeutic effects:
– Reduction in edema, fluid volume overload,
CHF
– Reduction of hypertension
– Return to normal intraocular pressures
 DIURETICS
ACTION
 Loop diuretics inhibit sodium (Na) and chloride
(Cl) reabsorption through direct action primarily
in the ascending loop of Henle but also in the
proximal and distal tubules. Thiazide diuretics
act primarily on the distal tubules, inhibiting Na
and Cl reabsorption

USES
 Treat edema that involves fluid volume excess
resulting from a number of disorders of the
heart, liver, kidney & eye
 DIURETICS
CONTRAINDICATIONS
 Hypersensitivity to sulfonamides
 Severe adrenocortical impairment, anuria,
progressive oliguria
 Fluid and electrolyte depletion

SIDE EFFECTS
 Unusual tiredness, weakness, dizziness
 Irregular heart beat, weak pulse, orthostatic
hypotension
 Tinnitus, hearing loss (Lasix)
 DIURETICS
NURSING IMPLICATIONS
 Monitor for adequate intake and output
and potassium loss
 Monitor the client’s weight and vital signs
 Monitor for signs and symptoms of
hearing loss, which may last from 1 to 24
hours
 MANNITOL
ACTION
 Increases the osmotic pressure of the glomerular filtrate.
The higher the concentration of mannitol in the filtrate,
the more diuresis occurs

USES
 Prevention, treatment of oliguric phase of acute renal
failure
 Reduces increased intracranial pressure due to cerebral
edema; decreases edema of injured spinal cord
 Decreases intraocular pressure due to acute glaucoma
 Promotes excretion of toxic substances
 MANNITOL
 CONTRAINDICATIONS
 Severe renal disease, dehydration,
intracranial bleeding, severe pulmonary
edema

 SIDE EFFECTS
 Blurred vision, dizziness, hypotension/
hypertension, tachycardia
 Headache, nausea and vomiting, backache
 MANNITOL
 NURSING IMPLICATIONS
 Check vital signs before administering the
dose. Assess urinary output, hydration
status, electrolytes (hypokalemia), blood
urea nitrogen, and renal and hepatic
panels
 Evaluate for symptoms of congestive heart
failure and pulmonary edema
SPIRONOLACTONE (ALDACTONE)
 CLASSIFICATION
 Potassium-sparing diuretic
 ACTION
 Has a direct effect on the distal tubules in the kidney.
Spironolactone competes with aldosterone for cell
receptor sitees in the distal tubules while inducing
urinary excretion of sodium and reducing excretion of
potassium and hydrogen ions
 USES
 Preventing or treating diuretic-induced hypokalemia with
heart, liver, kidney, and hypertension
 Reduces edema in clients with congestive heart failure,
with dysrhythmias, and on digoxin therapy
 SPIRONOLACTONE (ALDACTONE)
CONTRAINDICATIONS
 Hypersensitivity or renal failure
 Anuria
 Hyperkalemia
SIDE EFECTS
 Hyperkalemia
 Weakness
 Tinnitus
 Hyperglycemia
 Impotence
SPIRONOLACTONE (ALDACTONE)

NURSING IMPLICATIONS
 Monitor intake and output, and watch for
cardiac arrhythmias
 Monitor levels of electrolytes (potassium,
sodium, etc.)
 Teach the client to report cramps,
weakness, fatigue, or nausea