Bachelor of Science in Nursing

NCMA 216 ( PHARMACOLOGY )

COURSE MODULE COURSE UNIT WEEK
2 7 8
AGENTS ACTING ON THE CARDIOVASCULAR SYSTEM

ü Read course and unit objectives

ü Read study guide prior to class attendance
ü Read required learning resources; refer to unit
terminologies for jargons
ü Proactively participate in classroom discussions
ü Participate in weekly discussion board (Canvas)
ü Answer and submit course unit tasks

1. Karch, A. M. (2019). Focus on nursing pharmacology. Lippincott Williams &

Wilkins.
2. Kee, Joyce Le Fuer and Hayer, Evelyn R., Pharmacology: A Nursing
Process Approach, 5th Edition, 2006, by Elsevier ( Singapore) PTE LTD
3. Lilley, Linda lane & Harrington, Scott, Pharmacology and the Nursing
Process, 5th Edition, by Elsevier (Singapore) PTE LTD
4. Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology 4th edition.
Cengage

At the end of the course unit (CM), learners will be able to:
Cognitive:
1. Understand and explain the physiology of the cardiovascular system.
2. Explain and understand the common disorders affecting the cardiovascular
system.
3. Identify and recognize the use of various medication for the management
and treatment of cardiovascular disorders
4. Determine appropriate pharmacological treatment and nursing
responsibilities during drug therapy for clients with problems in cardiovascular
function.
Affective:
5. Develop heightened interest in studying Nursing Pharmacology.
6. Manifest professionalism and excellence in planning for safe medication
administration.
Psychomotor:
7. Illustrate the use of various medications for the management and treatment
of cardivascular disorders
8. Determine appropriate pharmacological treatment and nursing
responsibilities during drug therapy for clients with problems in cardiovascular
dysfunctions.
9. Participate in interactive discussion concerning cardiovascular drugs and
nursing interventions.

§ Afterload
à the pressure that the heart must work against to eject blood during systole
(ventricular contraction)
§ Baroreceptors
à are mechanoreceptors located in the carotid sinus and in the aortic arch
and functions to sense pressure changes by responding to change in the tension
of the arterial wall, heart rate and contractility

 § Blood pressure
à the force exerted by the blood against the endothelial smooth muscle wall
§ Cardiac cycle
à is the period of cardiac muscle relaxation (diastole) followed by a period of
contraction (systole) in the heart
§ Cardiac output
à the amount of blood that is ejected by the heart for every minute
§ Diastole
à resting period when the veins carry blood back to the heart
§ Dysthythmia
à a disruption in cardiac rate of rhythm, also called an arrhythmia
§ Ischemia
à when blood flow to the heart is reduced, preventing the heart muscle from
receiving enough oxygen
§ Essential hypertension
à sustained blood pressure above normal limits with no discernible underlying
cause
§ Inotrope
à a drug that increases the force of cardiac contraction
§ Parasympatholytic
à drugs that block the effects of the parasympathetic nervous system
§ Parasympathomimetics
à drugs that mimic the effects of the parasympathetic nervous system
§ Peripheral vascular resistance (PVR)
à also known as systemic vascular resistance (SVR), is the pressure exerted by
the endothelial smooth muscle against the blood
§ Preload
à also known as diastolic filling pressure
à is the amount of ventricular stretch at the end of diastole
§ Renin-angiotensin-aldosterone system
à compensatory process that leads to increased blood pressure and blood
volume to ensure perfusion of the kidneys; important in the continual regulation
of blood pressure
§ Stroke volume

 à amount of blood that is ejected every contraction of the heart, important in
determining blood pressure
§ Sympathomimetics
à drugs that mimic the effects of the sympathetic nervous system
§ Systole
à contraction period when the heart pumps blood out to the arteries for
distribution to the body
§ Troponin
à a muscle protein controlling the interaction of actin and myosin

The heart, a hollow muscle with four chambers comprising two upper atria and two
lower ventricles, pumps oxygenated blood to the body’s cells and also collects waste
products from the tissues. The heart’s conduction (or stimulatory) system consists of the
SA node, the AV node, the bundle of His, the
bundle branches, and the Purkinje fibers
generate an impulse, which stimulates the
contraction of the heart. The contraction
results to a two-step process called the
cardiac cycle, namely the diastole
(relaxation) and systole (contraction). The
cardiovascular system depends on pressure
changes to circulate blood to the tissues and
back to the heart.

DISORDERS OF THE HEART:

I. HYPERTENSION
à excessive high blood pressure
à Is recognized as a major risk factor for several potentially lethal cardiac
conditions, including myocardial infarction and heart failure. This can damage
the fragile inner lining of blood vessels and cause a disruption of blood flow to

 the tissues. It also puts a tremendous strain on the heart muscle, increasing
myocardial oxygen consumption and putting the heart muscle at risk.

BP = Heart rate x stroke volume x peripheral vascular resistance

BP = Cardiac output ( heart rate x stroke volume ) x peripheral vascular
resistance

A. Pathophysiology:

 B. Antihypertensive Medications:

Antihypertensive drugs are organized around a clinical indication—the need to

treat a disease—rather than a single receptor type.

a. ACE INHIBITORS ( … pril )

Captopril (P)
Enalapril
Lisinopril
Perindopril

 § Pharmacodynamics:
ü blocks angiotensin-converting enzyme (ACE) from converting
angiotensin I to angiotensin II, leading to;
o a decrease in blood pressure
o a decrease in aldosterone production
o a small increase in serum potassium levels
o sodium and fluid loss.
§ Indications:
ü hypertension
ü heart failure
ü diabetic nephropathy
ü left ventricular dysfunction after a myocardial infarction (MI).
§ Nursing Considerations:
ü encourage patient to implement lifestyle changes, including
weight loss, smoking cessation, decreased alcohol and salt in the
diet, and increased exercise
ü administer on an empty stomach 1 hour before or 2 hours after
meals
ü alert the surgeon and mark the patient’s chart prominently if the
patient is to undergo surgery
ü give the parenteral form of enalapril only if an oral form is not
feasible
ü consult with the prescriber to reduce the dose in patients with
renal failure to account for their
ü monitor patient carefully for signs of a drop in fluid volume which
may lead to hypotension and other adverse effects

b. ANGIOTENSIN II – RECEPTOR BLOCKERS ( … sartan )

Losartan (P)
Candesartan
Irbesartan
Valsartan
§ Pharmacodynamics:

 ü selectively blocks the binding of angiotensin II to specific tissue
receptors found in the vascular smooth muscle and adrenal
glands
ü blocks the vasoconstriction and release of aldosterone
associated with the renin–angiotensin–aldosterone system.
§ Indications:
ü alone or as part of combination therapy for the treatment of
hypertension
ü diabetic nephropathy with an elevated serum creatinine and
proteinuria in patients with type 2 diabetes and hypertension.
§ Nursing Considerations:
ü encourage patient to implement lifestyle changes
ü administer without regard to meals
ü alert the surgeon and mark the patient’s chart prominently if the
patient is to undergo surgery
ü ensure that the female patient is not pregnant before beginning
therapy, and suggest the use of barrier contraceptives while she
is taking these drugs
ü find an alternative method of feeding the baby if the patient is
nursing
ü monitor the patient carefully in any situation that might lead to a
drop in fluid volume

c. CALCIUM CHANNEL BLOCKERS (CCB)

Diltiazem (P)
Amlodipine
Felodipine
Nifedipine
Nicardipine
Verapamil
§ Pharmacodynamics:
ü inhibits the movement of calcium ions across the membranes of
cardiac and arterial muscle cells;
o depressing the impulse and leading to slowed conduction,
o decreased myocardial contractility

 o dilation of arterioles
ü resuts to;
o lower blood pressure
o decreases myocardial oxygen consumption.
§ Indications:
ü essential hypertension
ü angina
§ Nursing Considerations:
ü encourage lifestyle changes
ü do not cut, crush, or chew this tablet
ü give with food if GI upset occurs.
ü provide comfort and safety measures.
ü reduce dosage if patient has renal failure.
ü monitor for any situation that might lead to a drop in blood
pressure.
ü provide support and reassurance to deal with drug effects.
ü provide patient teaching regarding drug, dosage, adverse
effects, signs and symptoms of problems to report, and safety
precautions.

d. VASODILATORS
Nitroprusside (P)
Hydralazine
Minoxidil
§ Pharmacodynamics:
ü acts directly on vascular smooth muscle to cause vasodilation
and drop of blood pressure
ü does not inhibit cardiovascular reflexes and tachycardia
ü renin release will occur.
§ Indications:
ü severe hypertension
ü maintenance of controlled hypotension during anesthesia
ü acute heart failure.
§ Nursing Considerations:
ü encourage lifestyle changes

 ü monitor BP closely during administration
ü monitor blood glucose and serum electrolytes
ü monitor for any situation that might lead to a drop in blood
pressure.
ü provide support and reassurance to deal with drug effects.
ü provide patient teaching regarding drug, dosage, adverse
effects, signs and symptoms of problems to report, and safety
precautions.

e. OTHERS:
i. DIURETICS
Hydrochlorothiazide
Indapamide
Amiloride
Spironolactone
§ Pharmacodynamics:
ü increase the excretion of sodium and water from the
kidney
ü decreases blood volume leading to decrease in BP
ü first line agent in mild hypertension
§ Indications:
ü Hypertension
• Nursing considerations:
ü monitor VS
ü monitor input and output
ü weigh the patient daily
ü monitor for adverse effects

ii. RENIN INHIBITOR

ALISKIREN (P)
§ Pharmacodynamics:
ü Inhibits renin leading to
o Decreased plasma renin activity
o Inhibits the conversion of angiotensinogen to
angiotensin I

 ü results to;
o decreased BP
o decreased aldosterone release
o decreased sodium reabsorption
§ Indications:
ü hypertension
§ Nursing Considerations:
ü avoid in the second and third trimesters of pregnancy and
used only in the first trimester if the benefit clearly out
weights the risk
ü advise to use contraceptive while on this drug
ü advise breastfeeding mothers to find another method of
feeding the baby
ü monitor serum potassium level for risk of hyperkalemia
ü monitor closely if taken with furosemide
ü advise to report any signs of difficulty in breathing or
swelling of lips, face or tongue

iii. Sympathetic Nervous System Blockers:

1. BETA BLOCKERS (…olol)
Acebutolol
Atenolol
Betaxolol
Bisoprolol
Metoprolol
§ Pharmacodynamics:
ü compete with the beta receptors ( beta-1 and
beta-1 ) of the sympathetic nervous system
ü results to;
o vasoconstriction
o decrease heart rate
o decrease cardiac muscle contraction
o increase blood flow to the kidneys
ü leading to a decrease in the release of
renin

 § Indications:
ü hypertension
o monotherapy in step 2 treatment or
combination with other antihypertensive
drugs
ü angina
ü myocardial infarction (MI)
ü prophylaxis for migraine
§ Nursing Considerations:
ü monitor vital signs especially HR and BP before
administration
ü avoid if BP is less than 90/60 mmHg
ü avoid if HR is less than 60 beats per minute
ü monitor for adverse effects
ü caution in patients with hyperglycemia
2. ALPHA- and BETA- BLOCKERS
Carvedilol
Labetalol
Guanabenz
§ Pharmacodynamics:
ü Blocks both the alpha- and beta- receptors of the
the sympathetic nervous system
§ Indications:
ü Adjunct in the treatment of hypertension
§ Nursing Considerations:
ü monitor for adverse effects complain of fatigue, loss
of libido, inability to sleep, and GI and genitourinary
disturbances
3. ALPHA-ADRENERGIC BLOCKERS
PHENTOLAMINE
PHENOXYBENZAMINE
ü Pharmacodynamics:
ü Inhibits the postsynaptic alpha1-adrenergic
receptors, preventing the feedback control of
norepinephrine release

 o results in;
§ increase in the reflex tachycardia
ü Indications:
ü diagnose and manage episodes of
pheochromocytoma
ü Nursing Considerations:
ü not recommended for essential hypertension due to
the side effects
ü monitor vital signs especially BP
ü monitor for signs of adverse effects

4. ALPHA-1 ADRENERGIC BLOCKERS

Doxazosin
Prazosin
Terazosin
• Pharmacodynamics:
ü blocks the postsynaptic alpha1-receptor sites
o results in;
o decreases vascular tone
o promotes vasodilation
§ leading to a fall in blood pressure
• Indications:
ü hypertension
ü benign prostatic hypertrophy (BPH)
• Nursing Considerations:
ü monitor vital signs
ü teach patient how to stand or move from lying
position in situation where orthostatic hypotension is
an issue

5. ALPHA-2 ADRENERGIC AGONIST

Clonicine
Guanfacine
Methyldopa
• Pharmacodynamics:

 ü stimulates the alpha2-adrenergic receptors in the
CNS and inhibit the cardiovascular centers
ü results in;
o decrease in sympathetic outflow from the
CNS
o decrease in norepinephrine release
o weakening the sympathetic nervous system
effects
ü results in;
o increase in the reflex tachycardia
• Indications:
ü hypertension
• Nursing considerations:
ü monitor for signs of reflex hypertension

 Site of action of
ANTIHYPERTENSIVE DRUGS

Variety of adverse effects and

toxicities associated with
ANTIHYPERTENSIVE DRUGS

II. ANGINA
à refers to a strangling or pressure-like pain caused by cardiac ischemia. The pain
is usually located substernally, sometimes with radiation to the neck, shoulder and
arm, or epigastrium. Drugs used in angina exploit two main strategies: reduction of
oxygen demand and increase of oxygen delivery to the myocardium.

A. Pathophysiology of Angina:
• spasm / obstruction of coronary arteries

• myocardial ischemia

• reduced O2 supply to myocardium

• chest pain : angina pectoris

B. Drugs used for Angina:

a. NITRATES
Nitroglycerine (P)
Isosorbide dinitrate
Isosorbide mononitrate
• Pharmacodynamics:
ü 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
ü drug of choice for treating an acute anginal attack.
• Indications:
ü treatment of acute angina
ü prophylaxis of angina

 ü intravenous treatment of angina unresponsive to beta-blockers
or organic nitrates
ü perioperative hypertension
ü heart failure associated with acute MI
ü to produce controlled hypotension during surgery
• Nursing considerations:
ü give sublingual preparations under the tongue or in the buccal
pouch, and encourage the patient not to swallow
ü ask the patient if the tablet “fizzles” or burns, which indicates
potency
ü always check the expiration date on the bottle and protect the
medication from heat and light
ü 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
ü give sustained-release forms with water, and caution the patient
not to chew or crush them.
ü 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 care as needed.
ü make sure that translingual spray is used under the tongue and
not inhaled
ü break an amyl nitrate capsule and wave it under the nose of the
angina patient to provide rapid relief using the inhalation form of
the drug; this may be repeated with another capsule in 3 to 5
minutes if needed.
ü keep a record of the number of sprays used if a trans- lingual
spray form is used to prevent running out of medication and
episodes of untreated angina.
ü have emergency life support equipment readily available in
case of severe reaction to the drug or myocardial infarction.
ü taper the dose gradually (over 4 to 6 weeks) after long-term
therapy

 b. BETA-BLOCKERS
Metoprolol (P)
Nadolol
Propranolol
• Pharmacodynamics:
ü competitively blocks beta-adrenergic receptors in the heart and
kidneys, decreasing the influence of the sympathetic nervous
system on these tissues and the excitability of the heart;
decreases cardiac output, which results in a lowered blood
pressure and decreased cardiac workload.
• Indications:
ü treatment of stable angina pectoris
ü treatment of hypertension
ü prevention of reinfarction in myocardial infarction patients
ü treatment of stable, symptomatic heart failure (HF)
• Nursing considerations:
ü see nursing considerations of beta blockers in Hypertension

c. CALCIUM CHANNEL BLOCKERS (CCB)

Diltiazem (P)
• Pharmacodynamics:
ü inhibits the movement of calcium ions across the membranes of
myocardial and arterial muscle cells
o altering the action potential and blocking muscle cell
contraction
o depresses myocardial contractility
o slows cardiac impulse formation in the conductive tissues,
and relaxes and dilates arteries
o fall in BP and a decrease in venous return
o decreases the workload of the heart and myocardial
oxygen consumption
ü relieves the vasospasm of the coronary artery
ü increasing blood flow to the muscle cells (Prinzmetal angina).
• Indications:
ü treatment of Prinzmetal angina, effort- associated angina, and
chronic stable angina

 ü to treat essential hypertension
ü to treat paroxysmal supraventricular tachycardia.
• Nursing considerations:
ü see nursing consideration of CCB used in hypertension

d. PIPERAZINEACETAMIDE
Ranolazine
• Pharmacodynamics:
ü mechanism of action is not understood
ü it does prolong the QT interval, it does not decrease heart rate or
blood pressure, but it does decrease myocardial workload,
bringing the supply and demand for oxygen back into balance.
• Indications:
ü approved as a first-line treatment for angina or for use in
combination with nitrates, beta-blockers, or amlodipine.
• Nursing considerations
ü contraindicated for use with any known sensitivity to the drug
with preexisting prolonged QT interval or in combination with
drugs that would prolong QT intervals; and with hepatic
impairment and lactation
ü caution should be used with pregnancy or renal impairment.
ü Drug–drug interactions can occur with;
o ketoconazole, diltiazem, verapamil, macrolide antibiotics,
and HIV protease inhibitors;
o Digoxin levels may become high if the two drugs are
combined; if this combination is needed, the digoxin dose
will need to be decreased
o Tricyclic antidepressants and antipsychotic drug levels
may increase if these agents are combined with ranola-
zine; if they are combined, the dose of these drugs may
need to be decreased.
ü Grapefruit juice should be avoided while taking this drug.
ü dizziness, headache, nausea, and constipation are the most
commonly experienced adverse effects
ü patients must be cautioned not to cut, crush, or chew the
tablets, which need to be swallowed whole.
ü safety precautions may be needed if dizziness is an issue.

III. ARRHYTHMIA
à a problem with the rate or rhythm of the heart
A. Pathophysiology:
à involves changes to the automaticity or conductivity of the heart cells
resulting from several factors, including;
a. electrolyte imbalances that alter the action potential
b. decreased oxygen delivery to cells that changes their action potential
c. structural damage that changes the conduction pathway
d. acidosis or waste product accumulation that alters the action potential
e. drugs that alter the action potential or cardiac conduction.

B. Drugs used for Arrhythmia:

à affect the action potential of the cardiac cells by altering their
automaticity, conductivity, or both. Because of this effect, antiarrhythmic
drugs can also produce new arrhythmias—that is, they are proarrhythmic.
à are used in emergency situations when the hemodynamics arising from
the patient’s arrhythmia are severe and could potentially be fatal.

a. CLASS I ANTIARRHYTHMIC DRUGS

• Class Ia:
Procainamide
Quinidine
• Class Ic

 Flecainide
Propafenone
• Class Ib
Lidocaine (P)
Mexiletine

• Pharmacodynamics:
ü blocks phase 0, blocks sodium channels
ü decreases depolarization, decreasing automaticity of the
ventricular cells
ü increases ventricular fibrillation threshold
• Indications:
ü management of acute ventricular arrhythmias during
cardiac surgery or MI
• Adverse effects:
ü dizziness, light-headedness, fatigue, arrhythmias, cardiac
arrest, nausea, vomiting, anaphylactoid reactions,
hypotension, vasodilation
• Nursing considerations:
ü Titrate the dose to the smallest amount needed to
achieve control of the arrhythmia
ü continually monitor cardiac rhythm when initiating or
changing dose
ü ensure that emergency life support equipment is readily
available
ü administer parenteral forms as ordered only if the oral form
is not feasible; expect to switch to the oral form as soon as
possible
ü consult with the prescriber to reduce the dose in patients
with renal or hepatic dysfunction
ü offer support and encouragement to help the patient
deal with the diagnosis and the drug regimen.
ü provide thorough patient teaching
ü establish safety precautions, including side rails, lighting,
and noise control, if CNS effects occur to ensure patient
safety
ü arrange for periodic monitoring of cardiac rhythm when
the patient is receiving long-term therapy

 b. CLASS II ANTIARRHYTHMIC DRUGS
Acebutolol
Esmolol
Propranolol (P)
• Pharmacodynamics:
ü competitively blocks beta-adrenergic receptors in the
heart and kidney, has a membrane-stabilizing effect, and
decreases the influence of the sympathetic nervous
system
• Indications:
ü treatment of cardiac arrhythmias, especially
supraventricular tachycardia;
ü treatment of ventricular tachycardia induced by digitalis
or catecholamines
• Adverse effects:
ü bradycardia, heart failure, cardiac arrhythmias, heart
blocks, cerebrovascular accident, pulmonary edema,
gastric pain, flatulence, nausea, vomiting, diarrhea,
impotence, decreased exercise tolerance, antinuclear
antibody development
• Nursing consideration: please refer Class I agents

c. CLASS III ANTIARRHYTHMIC DRUGS

Amiodarone (P)
Dofetilide
• Pharmacodynamics:
ü acts directly on heart muscle cells to prolong
repolarization and the refractory period, increasing the
threshold for ventricular fibrillation; also acts on peripheral
smooth muscle to decrease peripheral resistance.
• Indications:
ü Treatment of life-threatening ventricular arrhythmias
• Adverse effects:
ü malaise, fatigue, dizziness, heart failure, cardiac
arrhythmias, cardiac arrest, constipation, nausea,

 vomiting, hepatotoxicity, pulmonary toxicity, corneal
microdeposits, and vision changes.
• Nursing consideration: please refer Class I agents

d. CLASS IV ANTIARRHYTHMIC DRUGS

Diltiazem (P)
Verapamil
• Pharmacodynamics:
ü blocks the movement of calcium ions across the cell
membrane, depressing the generation of action
potentials, delaying phases 1 and 2 of repolarization, and
slowing conduction through the AV node.
• Indications:
ü Treatment of paroxysmal supraventricular tachycardia
ü atrial fibrillation
ü atrial flutter.
• Adverse effects:
ü dizziness, light-headedness, headache, asthenia,
peripheral edema, bradycardia, AV block, flushing,
nausea, hepatic injury.
• Nursing consideration: please refer Class I agents

IV. HEART FAILURE (HF):

Muscle physiology:
allows actin
calcium and myosin to
enters the inactivates form
muscle fibers muscle
the troponin actomyosin slide together contraction
cell
bridges

Heart Failure
à a condition where the heart is not pumping effectively and blood backs up so
the system becomes congested
A. Pathophysiology:
à involves dysfunction of the cardiac muscle, of which the sarcomere is
the basic unit, containing two contractile proteins, actin and myosin
can occur with any of the disorders that damage or overwork the heart
muscle

 o Coronary artery disease (CAD)
o Cardiomyopathy
o Hypertension
o Valvular heart disease

C. Signs and Symptoms:

 D. Agents used for Heart Failure :
a. CARDITONIC DRUGS ( INOTROPIC DRUGS )
à drugs that affect the intracellular calcium levels in the heart muscle
à results in;
ü increased contractility
ü increase in contraction
ü increased cardiac output
ü increased renal blood flow
ü increased urine production
o decreases renin release
o interfering with the effects of the renin–
angiotensin–aldosterone system
o increases urine output
o decreased blood volume
ü decrease in the heart’s workload
ü relief of HF

i. CARDIAC GLYCOSIDES
Digoxin ( Lanoxin )
à derived from digitalis plant
à most often used drug to treat HF
ü Pharmacodynamics:
ü increases intracellular calcium and allows more calcium to
enter myocardial cells during depolarization
ü results in;
o a positive inotropic effect
o increased cardiac output and renal perfusion
o a negative chronotropic effect
o decreased conduction velocity through the
atrioventricular (AV) node
ü decrease in the heart’s workload
ü relief of HF
• Nursing considerations:
ü consult with the prescriber about the need for a loading
dose when beginning therapy to achieve desired results as
soon as possible.

 ü monitor apical pulse for 1 full minute before administering
the drug to monitor for adverse effects.
ü hold the dose if the pulse is less than 60 beats/min in an
adult or less than 90 beats/min in an infant; retake the
pulse in 1 hour. If the pulse remains low, document it,
withhold the drug, and notify the prescriber because the
pulse rate could indicate digoxin toxicity
ü monitor the pulse for any change in quality or rhythm to
detect arrhythmias or early signs of toxicity.
ü check the dose and preparation carefully because
digoxin has a very small margin of safety
ü check pediatric dose with extreme care
ü have the dose double-checked by another nurse before
administration
ü follow dilution instructions carefully for intravenous use; use
promptly to avoid drug degradation.
ü administer intravenous doses very slowly over at least 5
minutes to avoid cardiac arrhythmias and adverse effects.
ü avoid IM administration
ü arrange for the patient to be weighed at the same time
each day, in the same clothes
ü avoid administering the oral drug with food or antacids
ü maintain emergency equipment on standby:
o potassium salts
o lidocaine (for treatment of arrhythmias)
o phenytoin (for treatment of seizures)
o atropine (to increase heart rate)
o a cardiac monitor, in case severe toxicity
ü Obtain digoxin level as ordered
ü monitor the patient for therapeutic digoxin level (0.5–2
ng/mL)
ü monitor for adverse effects (vision changes, arrhythmias,
HF, headache, dizziness, drowsiness, GI upset, nausea
ü Patient teaching on the antidote in case of toxicity
(Digoxin immune Fab)

ii. PHOSPHODIESTERASE INHIBITORS

Milrinone
ü Pharmacodynamics:
ü blocks the enzyme phosphodiesterase

 ü results in;
o an increase in myocardial cell cAMP
o increases calcium levels in the cell
o stronger contraction
o prolonged response to sympathetic stimulation
o directly relaxes vascular smooth muscle.
ü decrease in the heart’s workload
ü relief of HF
• Indication:
ü short-term treatment of HF in patients who have not
responded to digitalis, diuretics, or vasodilators
• Nursing considerations:
ü protect the drug from light to prevent drug degradation
ü ensure that patient has a patent intravenous access site
available to allow for intravenous administration of the
drug
ü monitor pulse and BP frequently
ü monitor input and output and record daily weight
ü monitor platelet counts before and regularly during
therapy
ü inspect the skin for bruising or petechiae
ü consult with the prescriber about the need to decrease
the dose at the first sign of thrombocytopenia.
ü monitor IV injection sites and provide comfort measures
ü provide life support equipment on standby in case of
severe reaction to the drug or development of ventricular
arrhythmias.
ü provide comfort measures

b. VASODILATORS
i. ACE Inhibitors ( …pril )
ü Captopril
ü Enalapril
ii. Nitrates
ü Nitroglycerine
• Pharmacodynamics:
ü relax vascular smooth muscle
ü results in;

 o a decrease afterload
o a venous pooling
§ a decrease preload of the heart
§ decrease workload
§ (+) inotropic effect
• Indications:
ü Hypertension
ü heart failure
ü diabetic nephropathy
ü left ventricular dysfunction after a myocardial infarction
(MI).

iii. DIURETICS
§ Pharmacodynamics:
ü Increase urine output to reduce blood volume
ü results in;
o a decrease afterload
o a decrease preload of the heart
o a decrease cardiac workload
§ (+) inotropic effect
Indications:
ü hypertension
ü heart failure

iv. BETA-ADRENERGIC AGONISTS

§ Pharmacodynamics:
ü stimulate the beta receptors in the sympathetic nervous
system
ü results in;
o increase calcium flow into the myocardial cell
o (+) inotropic effect
§ Indications:
ü Heart failure

 Site of action of drugs
used in HEART FAILURE

Variety of adverse effects

and toxicities with
CARDIOTONIC AGENTS

 1. Karch, A. M. (2019). Focus on nursing pharmacology. Lippincott Williams &
Wilkins.
3. Kee, Joyce Le Fuer and Hayer, Evelyn R., Pharmacology: A Nursing
Process Approach, 5th Edition, 2006, by Elsevier ( Singapore) PTE LTD
4. Lilley, Linda lane & Harrington, Scott, Pharmacology and the Nursing
Process, 5th Edition, by Elsevier (Singapore) PTE LTD
5. Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology 4th edition.
Cengage

Lilley, Linda lane & Harrington, Scott, Pharmacology and the Nursing Process, 5th Edition, by
Elsevier (Singapore) PTE LTD

Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology 4th edition. Cengage

1. Make a drug study for each drug class using the format below.

CLASSIFICATION DRUGS PHARMACODYNAMICS PHARMACOKINETICS INDICATIONS SIDE EFFECTS / NURSING
INTERACTIONS CONSIDERATIONS

II. Give the rationale for each of the nursing considerations mentioned for each class.