Indications: Short-term

treatment of HF in
patients who have not
responded to digitalis,
diuretics, or
vasodilators.
Actions: Blocks the enzyme
phosphodiesterase, which
leads to an increase in
myocardial cell cAMP, which
increases calcium levels in the
cell, causing a stronger
contraction and prolonged
response to sympathetic
stimulation; directly relaxes
vascular smooth muscle.
CORONARY ARTERY DISEASE
Angina
“suffocation of the
chest”pain caused by the
imbalance between
oxygen being supplied to
the heart muscle and
demand for oxygen by the
heart muscle
clenched fist sign

An indication of the pain of

angina pectoris in which an
individual presses a
clenched fist against the
chest as a means of
showing its constricting,
pressing quality.
 end result of vessel blockage
in the heart; leads to
ischemia and then necrosis
of the area cut off from the
blood supply; it can heal,
with the dead cells replaced
by scar tissue
C =

O =

I =

T =

U =

S =
 C = omfotable position

 O = one hour after taking medications

 I = intake of a light meal

 T = two/three (2 -3) flight of stairs

 U =nfamiliar partner/ place

 S= ildenafil ( VIAGRA)
 Antiarrhythmic—
Lidocaine decreases the
depolarization,
automaticity, and
excitability in the
ventricles during the
diastolic phase by a direct
action on the tissues,
especially the Purkinje
network, without
involvement of the
autonomic system
 ANTIANGINAL AGENTS

 These drugs can work

to improve blood
delivery to the heart
muscle in one of two
ways :
(1) by dilating blood
vessels = ?

Increasing blood
supply to the heart
 2) by decreasing
 the work of the heart = ?

 decreasing the demand for

oxygen)
 Drug Name Usual Dosage Usual Indications

isosorbide dinitrate 2.5–5 mg sublingual (SL);  Taken before chest pain

(Isordil)
5-mg chewable tablet; begins in situations in which
exertion or stress can be
5–20 mg PO;
anticipated for prevention of
Acute prophylaxis: 5–10 angina in adults;
mg SL or chewable
tablets q2–3h
 Taken daily for management
of chronic angina
isosorbide 2.5–5 mg SL; 5-mg  Taken before chest
mononitrate chewable tablet; pain begins in
(Imdur, Monoket) situations in which
5–20 mg PO; exertion or stress
can be anticipated
for prevention of
Acute prophylaxis: 5– angina in adults;
10 mg SL or chewable
tablets q2–3h
 Taken daily for
management of
angina
Ideally, take the
nitroglycerin before your
chest pain begins. If you
know that a certain activity
usually causes pain (e.g.,
eating a big meal, attending
a business meeting,
engaging in sexual
intercourse), take the
tablet before undertaking
that activity.
nitroglycerin (Nitro- 5 mcg/min via IV infusion pump Nitrate of choice for
Bid, Nitrostat, others) every 3–5 min; treatment of acute
angina attack;
one tablet SL every 5 min for
acute attack, up
prevention of anginal
to three tablets in 15 min;
attacks
Prevention: one tablet (0.3–0.6
mg) sublingually
5–10 min before activities that
might precipitate
an attack:

0.5 inches q8h for topical

application, up to 4–5 inches
(1 inch = 15 mg) have been used;
 The nitrates relax and dilate
veins, arteries, and
capillaries, allowing
increased blood flow through
the vessels and lowering
systemic blood pressure
because of a drop in
resistance.
 vasodilation causes blood to
pool in veins and capillaries,
decreasing preload,

 relaxation of the arteries

decreases afterload. balance.
 severe anemia because
the decrease in cardiac output
could be detrimental in a
patient who already has a
decreased ability to
deliver oxygen because of a
low red blood cell count;
head trauma or cerebral
hemorrhage because the
relaxation of cerebral
vessel could cause
intracranial bleeding;
pregnancy or lactation
because of potential
adverse effects on the
neonate and ineffective
blood flow to the fetus.
Give sublingual
preparation under the
tongue or in the buccal
pouch, and encourage the
patient not to swallow, to
ensure that therapeutic
effectiveness is achieved
Ask the patient if the tablet
“fizzles” or burns, which
indicates potency. Always
check the expiration date
on the bottle and protect
the medication from heat,
moisture, and light because
these drugs are volatile and
lose their potency.
 The tablets must
be kept in a dark
glass container.

 Check for
expiration date..
Instruct the patient that a
sublingual dose may be
repeated in 5 minutes if relief
is not felt, for a total of three
doses; if pain persists, the
patient should go to an
emergency room to ensure
proper medical support if an
MI should occur.
 Where to place the
Nitroglycerin Transdermal Patch?

Select any area of skin

on the body, EXCEPT
the extremities below
the knee or elbow.

 The chest is the

preferred site.
Rotate the sites of topical
forms to decrease the risk
of skin abrasion and
breakdown; monitor for
signs of skin breakdown
to arrange for
appropriate skin car as
needed.
 The area should be clean,

dry, and hairless. If hair is

likely to interfere with

patch adhesion or

removal, it can be clipped

but not shaved.

 Take care to avoid areas
with cuts or irritations. Do
NOT apply the patch
immediately after
showering or bathing. It is
best to wait until you are
certain the skin is
completely dry.
 Please note:

 Contact with water, as in

bathing, swimming, or
showering will not affect
the patch. In the unlikely
event that a patch falls
off, discard it and put a
new one on a different
skin site.
 Precautions:

 The most common side

effect is headache, which
often decreases as
therapy is continued, but
may require treatment
with a mild analgesic.
 Prototype Summary: Nitroglycerin

Actions:
Relaxes vascular smooth muscle
with a resultant decrease in
venous return and decrease in
arterial blood pressure, reducing
the left ventricular workload
and decreasing myocardial
oxygen consumption.
 Assignment :

 Nursing Considerations for Patients Receiving Nitrates

 Nursing Diagnoses
 Other Antianginal agents:

 Beta-Blockers

 metoprolol (Toprol,
Toprol X

 nadolol (Corgard)

 propranolol (Inderal)
 Calcium Channel Blockers

 amlodipine (Norvasc)

 diltiazem (Cardizem,
Cardizem SR)

 nicardipine (Cardene)

 nifedipine (Adalat,
Procardia)

 verapamil (Calan, Isoptin)

1. Coronary artery disease results in

a. an imbalance in cardiac muscle oxygen supply

and demand.
b. delivery of blood to the heart muscle during
systole.
c. increased pulse pressure.
d. a decreased workload on the heart.
 2. Angina

a. causes death of heart muscle cells.

b. is pain due to lack of oxygen to myocardial cells.

c. cannot occur at rest.

d. is not treatable.
3. Nitrates are commonly used antianginal drugs that
act to:

a. increase the preload on the heart.

b. increase the afterload on the heart.

c. dilate coronary vessels to increase the delivery

of oxygen through those vessels.

d. decrease venous return to the heart,

decreasing the myocardial workload.
 . The nurse is preparing to teach the client with newly
diagnosed with angina pectoris how to self- administer
nitroglycerine (NTG) tablets. What client teaching should the
nurse emphasize? Select all that apply.

a. “Stop all activities immediately and sit down if chest

pain occurs.”
b. “If the pain is unrelieved after three NTG tablets,
continue to rest and call the prescriber>”
c.“ After discharge to home, keep NTG tablets on your
bedside day and night.”
d. “Immediately after chest pain begins, notify your
personal physician”
e.“The NTG tablet should tingle when placed under the
tongue.”
 Answer = a, b, e = Since chest pain of cardiac origin is related to
inadequate coronary oxygen supply, the client needs to
decrease the oxygen demand by stopping all activities (option a).
An absence of relief from chest pain indicates that NTG is
ineffective. The client should seek emergency care if there is no
relief after taking 3 tablets (option b) . When tablets are
potent, they should sting or tangle when placed under the
tongue (option e). NTG should be kept with the client, not on
the table bedside (option 3).
The client states, “I always put on the nitroglycerin (NTG)
patch In the same place so I do not forget to take it off.”
Which of the following is the best response by the nurse?

a. “Change the patch every 24 hours.”

b. “Massage into the skin if ointment comes in contact

with your hands.”

c.“Rotate the NTG patch to a different hairless area each

day.”

d.“After removing the patch, scrub the area vigorously

with soap and water>”
 Answer – c – Nitroglycerin patched and ointments must be
rotated daily to a hairless area to reduce skin irritation
(option c). The patch should be removed after 12 hours to
decrease the risk of tolerance ((option a). Although the
client should avoid contact with NTG ointment, the question
is addressing transdermal patch, and the medication would
not come in contact with the hands with proper use. The
area should be cleansed gently after removal, but does not
require vigorous scratching (option d)
The nurse is teaching the client diagnosed with angina about
sublingual nitroglycerin (NTG), a coronary vasodilator. Which
statement indicates the client needs more medication
teaching?
a. “I will always carry my nitroglycerin in a dark-colored
bottle.”

b. “If I have chest pain, I will put a tablet underneath my

tongue.”

c. “If my pain is not relieved with one tablet, I will get

medical help.”

d. “I should expect to get a headache after taking my

nitroglycerin.”
 a. If the NTG is not kept in a dark-colored bottle, it will lose
its potency. This statement shows the client’s understanding of the
medication teaching and that more teaching on that topic is not
necessary.
b. Sublingual NTG is placed under the client’s tongue when
chest pain first occurs. The patient understands the teaching.
 c. The client should put one tablet under
the tongue every 5 minutes and, if the
chest pain is not relieved after taking
three tablets, the client should seek
medical attention. This statement indicates
the client needs more teaching
about the medication.
d. Nitroglycerin causes vasodilatation and wil
cause a headache. The client understandthis.
 READ page 788