Magno, Mae Therese B.

BSN 3-E
RLE-MEDICAL SURGUCAL WARD October 31, 2020

DRUG STUDY

Biographical Data
Name: D.H.A
Sex: M
Age: 28
Chief Complaints: severe chest pain
Diagnosis: Congestive Heart Failure
Room Number: 032800

Vital Signs
Temperature: 36.5
Pulse Rate: 104 bpm
Respiratory Rate: 24 bpm
BP: 130/90 mmHg

Captopril

Generic Name: Captopril

Brand Name: Capoten
Classification:
Therapeutic Class Pharmacologic Chemical Class Pregnancy Class
Class

 Antihypertensive  ACE inhibitors  Angiotensin-converting  Class C

s enzyme (ACE)
inhibitor

Action: Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to

the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and
other vasodilatory prostaglandins. ACE inhibitors also ↑ plasma renin levels and ↓ aldosterone
levels. Net result is systemic vasodilation.

Therapeutic Effect(s):

 Lowering of BP in patients with hypertension.

 Improved survival and reduced symptoms in patients with heart failure.
 Improved survival and reduced development of overt heart failure after myocardial infarction.
 Decreased progression of diabetic nephropathy with decreased need for transplantation or
dialysis.
Route: P.O
Onset: Within 15 min
Peak: 60-90 min
Duration: Unknown
Half-life: Less than 2 hours
Indication: For the treatment of essential or renovascular hypertension (usually administered
with other drugs, particularly thiazide diuretics). May be used to treat congestive heart failure in
combination with other drugs (e.g. cardiac glycosides, diuretics, β-adrenergic blockers). May
improve survival in patients with left ventricular dysfunction following myocardial infarction. May
be used to treat nephropathy, including diabetic nephropathy.

Dosage:
Note: Use lower doses (1/2 of those listed) in patients who are sodium and water depleted due
to diuretics.

Hypertension
PO (Adults and Adolescents): 12.5–25 mg 2–3 times daily, may be ↑ at 1–2 wk intervals up to
150 mg 3 times daily (initiate therapy with 6.25–12.5 mg 2–3 times daily in patients receiving
diuretics).

Heart Failure
-PO (Adults): 25 mg 3 times daily (6.25–12.5 mg 3 times daily in patients who have been
vigorously diuresed); titrated up to target dose of 50 mg 3 times daily (max dose = 450
mg/day).
-PO Children: 0.3–0.5 mg/kg 3 times daily, titrate up to a maximum of 6 mg/kg/day in 2–4
divided doses; Older Children: 6.25–12.5 mg every 12–24 hr, titrate up to a maximum of 6
mg/kg/day in 2–4 divided doses.
-PO Infants: 0.15–0.3 mg/kg, titrate up to a maximum of 6 mg/kg/day in 1–4 divided doses.
-PO Neonates: 0.05–0.1 mg/kg every 8–24 hr, may ↑ as needed up to 0.5 mg/kg every 6–24
hr; Premature neonates: 0.01 mg/kg/dose every 8–12 hr.

Left Ventricular Dysfunction Post-MI

PO (Adults): 6.25-mg test dose, followed by 12.5 mg 3 times daily, may be ↑ up to 50 mg 3
times daily.

Diabetic Nephropathy
PO (Adults): 25 mg 3 times daily.

Renal Impairment
PO (Adults): CCr 10–50 mL/min: Administer 75% of dose; CCr <10 mL/min: Administer 50% of
dose.

Side Effects: dizziness or lightheadedness, taste disturbances (salty or metallic taste), or

decreased ability to taste, cough, fast heartbeat, excessive tiredness
Adverse Effects:
CNS: fatigue, headache, insomnia, fainting, malaise, fever and chills, paresthesia
CV: hypotension, chest pain, palpitations, tachycardia, angina
GI: abdominal pain, anorexia, constipation, diarrhea, nausea, vomiting, dysgeusia
GU: dysuria, polyuria, nocturia, proteinuria, impaired renal function or irreversible renal failure,
nephrotic syndrome
HEMA: AGRANULOCYTOSIS, neutropenia, pancytopenia, thrombocytopenia, anemia
RESPI: bronchospasm, dyspnea, cough (dry, persistent, non-productive cough)
INTEG: ANGIOEDEMA, rash, pruritis, alopecia
METABOLIC: hyperkalemia

Contraindications:
Contraindicated in:
 Hypersensitivity
 History of angioedema with previous use of ACE inhibitors
 Concurrent use with aliskiren in patients with diabetes or moderate-to-severe renal
impairment (CCr <60 mL/min);
 Concurrent use with sacubitril/valsartan; must be a 36–hr washout period after switching
to/from sacubitril/valsartan;
 OB: Can cause injury or death of fetus – if pregnancy occurs, discontinue immediately
 Lactation: Discontinue drug or use formula.
Nursing Responsibility:
 Monitor BP and pulse frequently during initial dose adjustment and periodically during
therapy. Notify health care professional of significant changes.
 Monitor frequency of prescription refills to determine compliance.
 Assess patient for signs of angioedema (swelling of face, extremities, eyes, lips, tongue,
difficulty in swallowing or breathing); may occur at any time during therapy. Discontinue
medication and provide supportive care.
 Heart Failure: Monitor weight and assess patient routinely for resolution of fluid overload
(peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
 PO Administer 1 hr before meals or 2 hr after meals. May be crushed if patient has difficulty
swallowing. Tablets may have a sulfurous odor.
-An oral solution may be prepared by crushing a 25-mg tablet and dissolving it in 25–100 mL of
water. Shake for at least 5 min and administer within 30 min

Lab Test Considerations:

 Monitor renal function. May cause ↑ BUN and serum creatinine. If ↑ BUN or serum creatinine
concentrations occur, may require dose reduction or withdrawal.
 May cause hyperkalemia.
 Assess urine protein prior to and periodically during therapy for up to 1 yr in patients with
renal impairment or those receiving > 150 mg/day of captopril. If excessive or increasing
proteinuria occurs, re-evaluate ACE inhibitor therapy.
 May cause positive antinuclear antibody (ANA) titer.
 Monitor CBC with differential prior to initiation of therapy, every 2 wk for the first 3 mo, and
periodically for up to 1 yr in patients at risk for neutropenia (patients with renal impairment,
or collagen-vascular disease) or at first sign of infection. Discontinue therapy if neutrophil
count is <1000/mm3 .
 May cause false-positive test results for urine acetone.
 Don’t confuse captopril with carvedilol.

Health Teaching:
 Instruct patient to take captopril as directed at the same time each day, even if feeling well.
Take missed doses as soon as remembered but not if almost time for next dose. Do not
double doses. Warn patient not to discontinue ACE inhibitor therapy unless directed by
health care professional.
 Caution patient to avoid salt substitutes containing potassium or foods containing high levels
of potassium or sodium unless directed by health care professional. See food sources for
specific nutrients.
 Caution patient to change positions slowly to minimize orthostatic hypotension. Use of
alcohol, standing for long periods, exercising, and hot weather may increase orthostatic
hypotension.
 Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or
herbal products being taken and consult health care professional before taking any new
medications, especially NSAIDs and cough, cold, or allergy remedies.
 May cause dizziness. Caution patient to avoid driving and other activities requiring alertness
until response to medication is known.
 Advise patient to inform health care professional of medication regimen prior to treatment or
surgery.
 Advise patient that medication may cause impairment of taste that generally resolves within
8–12 wk, even with continued therapy.
 Instruct patient to notify health care professional if immediately rash; mouth sores; sore
throat; fever; swelling of hands or feet; irregular heart beat; chest pain; dry cough;
hoarseness; swelling of face, eyes, lips, or tongue; difficulty swallowing or breathing occurs;
or if taste impairment or skin rash persists. Persistent dry cough may occur and may not
subside until medication is discontinued. Consult health care professional if cough becomes
bothersome. Also notify health care professional if nausea, vomiting, or diarrhea occurs and
continues.
 Advise diabetic patients to monitor blood glucose closely, especially during first mo of
therapy; may cause hypoglycemia.
 Advise women of childbearing age to use contraception and notify health care professional
immediately if pregnancy is planned or suspected or if breastfeeding. If pregnancy is
detected, discontinue medication as soon as possible.
 Emphasize the importance of follow-up examinations to evaluate effectiveness of
medication.
 Hypertension: Encourage patient to comply with additional interventions for hypertension
(weight reduction, low sodium diet, discontinuation of smoking, moderation of alcohol
consumption, regular exercise, and stress management). Medication controls but does not
cure hypertension.
 Instruct patient and family on correct technique for monitoring BP. Advise them to check BP
at least weekly and to report significant changes to health care professional.

References:

 Nursing 2020 Drug Handbook (Philippine Edition). (2020). Philadelphia, PA, USA: Lippincott
Williams & Wilkins Company.
 Mosby's Drug guide for Nurses (Seventh Edition). (2008). 11830 Westline Industrial Drive
St. Louis, Missouri 63146; Linda Skidmore-Roth
 Nursing Central Unbound Medicine. Davis's Drug Guide Captopril.. 2020. Retrived October
31, 2020 from
https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/109012/all/captopril
 Rxlist. CAPTOPRIL August 8, 2020. Retrieved October 31, 2020 from
https://www.rxlist.com/capoten-drug.htm
 DRUG STUDY

Biographical Data
Name: T.G
Sex: M
Age: 25
Chief Complaints: Edema
Diagnosis: Chronic Kidney Failure
Room Number: 87000

Vital Signs
Temperature: 36.2
Pulse Rate: 99 bpm
Respiratory Rate: 19 bpm
BP: 120/70 mmHg

Warfarin

Generic Name: Warfarin

Brand Name: Coumadin, Jantoven
Classification:
Therapeutic Class Pharmacologic Class Chemical Class Pregnancy Class

 Anticoagulants  Coumarin   Class X

derivatives
Action: Interferes with hepatic synthesis of vitamin K-dependent clotting factors (II, VII, IX, and
X). Also inhibits anticoagulant proteins C and S.
Therapeutic Effect:
Prevention of thromboembolic events.

Route: PO
Onset: within 24 hours
Peak: 4 hr
Duration: 2-5 days
Half-life: 20-60 hours

Indication:
Prophylaxis and treatment of:
 Venous thrombosis,
 Pulmonary embolism,
 Atrial fibrillation with embolization.

Management of myocardial infarction:

 Decreases risk of death,
 Decreases risk of subsequent MI,
 Decreases risk of future thromboembolic events.
Prevention of thrombus formation and embolization after prosthetic valve placement.

Dosage:
 PO (Adults): 2–5 mg/day for 2–4 days; then adjust daily dose by results of INR. Initiate therapy
with lower doses in geriatric or debilitated patients or in   Asian patients or those with
CYP2C9*2 and/or CYP2C9*3 alleles or VKORC1 AA genotype.

PO (Children >1 mo):   Initial loading dose– 0.2 mg/kg (maximum dose: 10 mg) for 2–4 days
then adjust daily dose by results of INR, use 0.1 mg/kg if liver dysfunction is
present.   Maintenance dose range– 0.05–0.34 mg/kg/day.
.
Side Effects:

 sudden headache, feeling very weak or dizzy;

 swelling, pain, unusual bruising;
 bleeding gums, nosebleeds
 bleeding from wounds or needle injections that will not stop;
 heavy menstrual periods or abnormal vaginal bleeding;
 blood in your urine, bloody or tarry stools

Adverse Effects:
CNS: fever
GI: abdominal pain, cramps, nausea, diarrhea, vomiting, anorexia, stomatitis, hepatitis
GU: hematuria
HEMA: bleeding, hemorrhage
RESPI: tracheal calcification
INTEG: rash, dermatitis, urticaria, alopecia, pruritus
Others: hypersensitivity or allergic reactions, anaphylactic reactions

Contraindications:
Contraindicated in:
 Uncontrolled bleeding;
 Open wounds;
 Active ulcer disease;
 Recent brain, eye, or spinal cord injury or surgery;
 Severe liver or kidney disease;
 Uncontrolled hypertension;
 OB: Crosses placenta and may cause fatal hemorrhage in the fetus. May also cause
congenital malformation.

Nursing Responsibility:
 Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising;
tarry, black stools; hematuria; fall in hematocrit or BP; guaiac-positive stools, urine, or
nasogastric aspirate).
 Assess for evidence of additional or increased thrombosis. Symptoms depend on area of
involvement.
Lab Test Considerations:
 Monitor PT, INR and other clotting factors frequently during therapy; monitor more frequently
in patients with renal impairment.
-Geri: Patients over 60 yr exhibit greater than expected PT/INR response. Monitor for side
effects at lower therapeutic ranges
-Pedi: Achieving and maintaining therapeutic PT/INR ranges may be more difficult in pediatric
patients. Assess PT/INR levels more frequently
 Monitor hepatic function and CBC before and periodically throughout therapy.
 Monitor stool and urine for occult blood before and periodically during therapy.
 High Alert: Do not confuse Coumadin (warfarin) with Avandia (rosiglitazone) or Cardura
(doxazosin). Do not confuse Jantoven (warfarin) with Janumet (sitagliptin/metformin) or
Januvia (sitagliptin).
 Because of the large number of medications capable of significantly altering warfarin's
effects, careful monitoring is recommended when new agents are started or other agents
are discontinued. Interactive potential should be evaluated for all new medications (Rx,
OTC, and herbal products).
 PO Administer medication at same time each day. Medication requires 3–5 days to reach
effective levels; usually begun while patient is still on heparin.
 Do not interchange brands; potencies may not be equivalent.
Toxicity Overdose:
Withholding 1 or more doses of warfarin is usually sufficient if INR is excessively elevated or
if minor bleeding occurs. If overdose occurs or anticoagulation needs to be immediately
reversed, the antidote is vitamin K (phytonadione, Aquamephyton). Administration of whole blood
or plasma also may be required in severe bleeding because of the delayed onset of vitamin K.

Health Teaching:
 Instruct patient to take medication as directed. Take missed doses as soon as
remembered that day; do not double doses. Inform health care professional of
missed doses at time of checkup or lab tests. Inform patients that anticoagulant
effect may persist for 2–5 days following discontinuation. Advise patient to read
Medication Guide before starting therapy and with each Rx refill in case of
changes.
 Review foods high in vitamin K (see food sources for specific nutrients). Patient
should have consistent limited intake of these foods, as vitamin K is the antidote
for warfarin, and alternating intake of these foods will cause PT levels to
fluctuate. Advise patient to avoid cranberry juice or products during therapy.
 Caution patient to avoid IM injections and activities leading to injury. Instruct
patient to use a soft toothbrush, not to floss, and to shave with an electric razor
during warfarin therapy. Advise patient that venipunctures and injection sites
require application of pressure to prevent bleeding or hematoma formation.
 Advise patient to report any symptoms of unusual bleeding or bruising (bleeding
gums; nosebleed; black, tarry stools; hematuria; excessive menstrual flow) and
pain, color, or temperature change to any area of your body to health care
professional immediately. Genetic implication Patients with a deficiency in
protein C and/or S mediated anticoagulant response may be at greater risk for
tissue necrosis.
 Instruct patient not to drink alcohol or take other Rx, OTC, or herbal products,
especially those containing aspirin or NSAIDs, or to start or stop any new
medications during warfarin therapy without advice of health care professional.
 Advise patient to notify health care professional if pregnancy is planned or
suspected or if breast feeding.
 Instruct patient to carry identification describing medication regimen at all times
and to inform all health care personnel caring for patient on anticoagulant
therapy before lab tests, treatment, or surgery.
 Emphasize the importance of frequent lab tests to monitor coagulation factors.

References

 Nursing 2020 Drug Handbook (Philippine Edition). (2020). Philadelphia, PA,

USA: Lippincott Williams & Wilkins Company.
 Mosby's Drug guide for Nurses (Seventh Edition). (2008). 11830 Westline
Industrial Drive St. Louis, Missouri 63146; Linda Skidmore-Roth
 Nursing Central Unbound Medicine. Davis's Drug Guide Warfarin. 2020. Retrived October
31, 2020 from
https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51797/all/warfarin
 Rxlist.WARFARIN August 8, 2020. Retrieved October 31, 2020 from
https://www.rxlist.com/coumadin-drug.htm#side_effects