Health Promotion; Perfusion

I. Anticoagulants (Box 54.1 )

A. Description
1. Anticoagulants prevent the extension and formation of clots by inhibiting factors in the clotting cascade and
decreasing blood coagulability.
2. * Anticoagulants are administered when there is evidence of or likelihood of clot formation-myocardial infarction,
unstable angina, atrial fibrillation, deep vein thrombosis, pulmonary embolism, and the presence of mechanical heart
valves.
3. * Anticoagulants are contraindicated with active bleeding (except for disseminated intravascular coagulation),
bleeding disorders or blood dyscrasias, ulcers, liver and kidney disease, and hemorrhagic brain injuries ( Box 54.2 ).
B. Side and adverse effects
1. * Hemorrhage
2. Hematuria
3. Epistaxis
4. Ecchymosis
5. Bleeding gums
6. Thrombocytopenia
7. Hypotension
C. Heparin sodium
1. Description
a. Heparin prevents thrombin from converting fibrinogen to fibrin.
b. Heparin prevents thromboembolism.
c. * The therapeutic dose does not dissolve clots but prevents new thrombus formation.
2. Blood levels
a. The normal activated partial thromboplastin time (aPTT) is 30 to 40 seconds (conventional and SI units) in most
laboratories (values depend on reagent and instrumentation used).
b. * To maintain a therapeutic level of anticoagulation when the client is receiving a continuous infusion of heparin, the
aPTT should be 1.5 to 2.5 times the normal value. Some agencies use two different protocols, a high-intensity protocol
such as for acute coronary syndrome and a low-intensity protocol such as for venous thromboembolism prophylaxis,
and the dosages and recommended aPTT ranges are slightly different for the two protocols.
c. Activated partial thromboplastin time therapy should be measured every 4 to 6 hours during initial continuous
infusion therapy or until the client has been therapeutic for a specified time frame and then daily per agency policy.
d. * If the aPTT is too long, per agency procedure, the dosage should be lowered.
e. * If the aPTT is too short, per agency procedure, the dosage should be increased.
3. Interventions
a. Monitor aPTT.
b. Monitor platelet count.
c. Observe for bleeding gums, bruises, nosebleeds, hematuria, hematemesis, occult blood in the stool, and petechiae.
d. Instruct the client regarding measures to prevent bleeding.
e. * The antidote to heparin is protamine sulfate.
f. When administering heparin subcutaneously, inject into the abdomen with a ⅝-inch (16-mm) needle (25 to 28 gauge)
at a 90-degree angle and do not aspirate or rub the injection site.
g. * Continuous IV infusions must be run on an infusion pump to ensure a precise rate of delivery.
D. Enoxaparin or Rivaroxaban-low-molecular-weight heparins
1. Description: Enoxaparin and rivaroxaban have the same mechanism of action and use as heparin but are not
interchangeable with heparin; they have longer half-lives than heparin does.
2. * Interventions
a. Administer enoxaparin only to the recumbent client by subcutaneous injection into the anterolateral or posterolateral
abdominal wall; do not expel the air bubble from the prefilled syringe or aspirate during injection.
b. Rivaroxaban is taken orally, once daily.
c. Monitor results of the Anti-Xa assay. The therapeutic range for anticoagulation is 0.5 to 1.2 IU/mL (conventional and
SI units). Observe for bleeding.
d. * The antidote to low-molecular-weight heparins is protamine sulfate.
E. Warfarin sodium
1. Description
a. Warfarin suppresses coagulation by acting as an antagonist of vitamin K by inhibiting four dependent clotting factors
(X, IX, VII, and II).
b. Warfarin prolongs clotting time and is monitored by the prothrombin time (PT) and the international normalized ratio
(INR).
c. It is used for long-term anticoagulation and is used mainly to prevent thromboembolic conditions such as
thrombophlebitis, pulmonary embolism, and embolism formation caused by atrial fibrillation, thrombosis, myocardial
infarction, or heart valve damage.
2. Blood levels
a. The normal PT is 11 to 12.5 seconds (conventional and SI units).
b. * Warfarin sodium prolongs the PT; the therapeutic range is 1.5 to 2 times the control value.
3. INR
a. The normal INR is 0.81 to 1.2 (conventional and SI units).
b. The INR is determined by multiplying the observed PT ratio (the ratio of the client's PT to a control PT) by a
correction factor specific to a particular thromboplastin preparation used in the testing.
c. The treatment goal of warfarin sodium is to raise the INR to an appropriate value.
d. An INR of 2 to 3 is appropriate for standard warfarin therapy; an INR of 3 to 4.5 is appropriate for high-dose
warfarin therapy.
e. * If the PT value is longer than 30 seconds and the INR is greater than 3.0 in a client receiving standard warfarin
therapy, initiate bleeding precautions.
f. If the INR is below the recommended range, warfarin sodium dose should be increased.
g. Clients may sometimes be prescribed “bridge therapy,” whereby heparin sodium is used concurrently with warfarin
sodium until the INR reaches the recommended range. Once this occurs, the heparin is discontinued.
4. Interventions
a. Monitor PT and INR.
b. Observe for bleeding gums, bruises, nosebleeds, hematuria, hematemesis, occult blood in the stool, and petechiae.
c. Instruct the client regarding diet and measures to prevent bleeding.
d. * The antidote for warfarin is phytonadione.
F. Dabigatran etexilate
1. Description
a. Dabigatran etexilate works through direct inhibition of thrombin, preventing the conversion of fibrinogen into fibrin
and activation of factor XIII.
b. Current approved use is for clot prevention associated with nonvalvular atrial fibrillation.
c. It is administered in a fixed dose twice daily.
2. Blood levels: No blood testing is required.
3. Interventions: Same as for warfarin, except no routine monitoring is required.
II. Thrombolytic Medications (Box 54.3 )
A. Description
1. Thrombolytic medications activate plasminogen; plasminogen generates plasmin (the enzyme that dissolves clots).
2. Thrombolytic medications are used early in the course of myocardial infarction (within 4 to 6 hours of the onset of
the infarct) to restore blood flow, limit myocardial damage, preserve left ventricular function, and prevent death.
3. Thrombolytics are also used in arterial thrombosis, deep vein thrombosis, occluded shunts or catheters, pulmonary
emboli, and ischemic stroke.
B. * Contraindications
1. Active internal bleeding
2. History of hemorrhagic stroke
3. Intracranial problems, including trauma
4. Intracranial or intraspinal surgery within the previous 2 months
5. Thoracic, pelvic, or abdominal surgery in the previous 10 days
6. History of hepatic or renal disease
7. Uncontrolled hypertension
8. Recent, prolonged cardiopulmonary resuscitation
9. Known allergy to the product or its preservatives
C. Side and adverse effects
1. Bleeding
2. Dysrhythmias
3. Allergic reactions
D. Interventions
1. Determine aPTT, PT, fibrinogen level, hematocrit, and platelet count.
2. Monitor vital signs.
3. Assess pulses.
4. Monitor for bleeding, and check all excretions for occult blood.
5. * Monitor for neurological changes such as slurred speech, lethargy, confusion, and hemiparesis.
6. Monitor for hypotension and tachycardia.
7. Avoid injections and venipunctures if possible.
8. Apply direct pressure over a puncture site for 20 to 30 minutes.
9. Handle the client gently and as little as possible when moving.
10. Instruct the client to use an electric razor for shaving and to brush teeth gently.
11. * Withhold the medication if bleeding develops, and notify the primary health care provider (PHCP).
12. * Antidote: Aminocaproic acid is the antidote. ** Bleeding is the primary concern for a client taking an
anticoagulant, thrombolytic, or antiplatelet medication.
III. Antiplatelet Medications (Box 54.4 )
A. Description
1. Antiplatelet medications inhibit the aggregation of platelets in the clotting process, thereby prolonging the bleeding
time.
2. Antiplatelet medications may be used with anticoagulants.
3. Used in the prophylaxis of long-term complications following myocardial infarction, coronary revascularization,
stents, and stroke
4. These medications are contraindicated in those with bleeding disorders and known sensitivity.
B. * Side and adverse effects
1. Bruising
2. Hematuria
3. Gastrointestinal bleeding
4. Tarry stools
C. Interventions
1. A blood test may be prescribed to determine the client's sensitivity to the medication before beginning
administration.
2. Monitor vital signs.
3. Instruct the client to take medication with food if gastrointestinal upset occurs.
4. Monitor bleeding time.
5. * Instruct the client to monitor for side and adverse effects and in the measures to prevent bleeding.
IV. Positive Inotropic and Cardiotonic Medications (Box 54.5 )
A. Description
1. These medications stimulate myocardial contractility and produce a positive inotropic effect.
2. These medications are used for short-term management of advanced heart failure; the increase in myocardial
contractility improves cardiac, peripheral, and kidney function by increasing cardiac output, decreasing preload,
improving blood flow to the periphery and kidneys, decreasing edema, and increasing fluid excretion. As a result, fluid
retention in the lungs and extremities is decreased (Fig. 54.1 ).
B. Side and adverse effects
1. Dysrhythmias
2. Hypotension
3. Thrombocytopenia
4. Hepatotoxicity manifested by elevated liver enzyme levels
5. Hypersensitivity manifested by wheezing, shortness of breath, pruritus, urticaria, clammy skin, and flushing
C. * Interventions
1. Positive inotropic and cardiotonic medications are administered intravenously.
a. For continuous intravenous (IV) infusion, administer with an infusion pump.
b. Stop the infusion if the client's blood pressure (BP) drops or dysrhythmias occur.
2. Monitor the apical pulse and BP.
3. Monitor for hypersensitivity.
4. Assess lung sounds for wheezing and crackles.
5. Monitor for edema.
6. Monitor for relief of heart failure as noted by reduction in edema and lessening of dyspnea, orthopnea, and fatigue.
7. Monitor electrolyte and liver enzyme levels, platelet count, and renal function studies; the medications may
decrease potassium and increase liver enzyme levels; continuous electrocardiographic monitoring is done during
administration.
V. Cardiac Glycosides
A. * Digoxin
1. Description
a. Cardiac glycosides inhibit the sodium-potassium pump, thus increasing intracellular calcium, which causes the heart
muscle fibers to contract more efficiently.
b. Cardiac glycosides produce a positive inotropic action, which increases the force of myocardial contractions.
c. Cardiac glycosides produce a negative chronotropic action, which slows the heart rate.
d. Cardiac glycosides produce a negative dromotropic action, which slows conduction velocity through the
atrioventricular (AV) node.
e. The increase in myocardial contractility increases cardiac, peripheral, and kidney function by increasing cardiac
output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and increasing fluid
excretion; as a result, fluid retention in the lungs and extremities is decreased.
f. Cardiac glycosides are a second-line medication for heart failure (medications affecting the renin-angiotensin-
aldosterone system are used more often) and cardiogenic shock, atrial tachycardia, atrial fibrillation, and atrial flutter;
they are used less frequently for rate control in atrial dysrhythmias (beta blockers and calcium channel blockers are
used more often).
g. These medications are contraindicated in those with ventricular dysrhythmias and second- or third-degree heart
block. They should be used with caution in clients with renal disease, hypothyroidism, and hypokalemia.
2. * Side and adverse effects
a. Anorexia, nausea, vomiting, diarrhea
b. Bradycardia
c. Visual disturbances: Diplopia, blurred vision, yellow vision, photophobia
d. Headache
e. Fatigue, weakness
f. Drowsiness ** Early signs of digoxin toxicity present as gastrointestinal manifestations (anorexia, nausea, vomiting,
diarrhea); then, heart rate abnormalities and visual disturbances appear.
3. * Interventions
a. Monitor for toxicity as evidenced by anorexia, nausea, vomiting, visual disturbances (blurred or yellow vision), and
dysrhythmias.
b. Monitor serum digoxin level, electrolyte levels, and renal function test results.
c. The optimal therapeutic range for digoxin is 0.5 to 2.0 ng/dL (0.63 to 2.56 nmol/L). However, a level on the low end
of normal may be preferred to avoid toxicity.
d. An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, or
hypothyroidism.
e. Note that older clients are more sensitive to digoxin toxicity.
f. Monitor the potassium level; if hypokalemia occurs (potassium lower than 3.5 mEq/L [3.5 mmol/L]), notify the
PHCP.
g. Monitor the client taking a potassium-losing diuretic or corticosteroids closely for hypokalemia, because the
hypokalemia can cause digoxin toxicity.
h. Instruct the client to avoid over-the-counter medications.
i. Advise the client to eat foods high in potassium, such as fresh and dried fruits, fruit juices, vegetables, and potatoes.
j. Monitor the apical pulse for 1 full minute; if the apical pulse rate is lower than 60 beats per minute, the medication
should be withheld and the PHCP notified.
k. Teach the client how to measure the pulse and to notify the PHCP if the pulse rate is lower than 60 or more than 100
beats per minute.
l. Teach the client the signs and symptoms of toxicity.
m. Antidote: Digoxin immune Fab is used in extreme toxicity.
VI. Antihypertensive Medications: Diuretics (Box 54.6 )
A. Thiazide diuretics (Box 54.7 )
1. Description
a. Thiazide diuretics increase sodium and water excretion by inhibiting sodium reabsorption in the distal tubule of the
kidney.
b. Used for hypertension and peripheral edema
c. Not effective for immediate diuresis
d. Used in clients with normal renal function (contraindicated in clients with renal failure)
e. Thiazide diuretics should be used with caution in the client taking lithium, because lithium toxicity can occur, and in
the client taking digoxin, corticosteroids, or hypoglycemic medications.
2. * Side and adverse effects
a. Hypercalcemia, hyperglycemia, hyperuricemia
b. Hypokalemia, hyponatremia
c. Hypovolemia
d. Hypotension
e. Rashes
f. Photosensitivity
g. Dehydration
3. * Interventions
a. Monitor vital signs.
b. Monitor weight.
c. Monitor urine output.
d. Monitor electrolytes, glucose, calcium, blood urea nitrogen (BUN), creatinine, and uric acid levels.
e. Check peripheral extremities for edema.
f. Monitor for signs of digoxin or lithium toxicity if the client is taking these medications.
g. Instruct the client to take the medication in the morning to avoid nocturia and sleep interruption.
h. Instruct the client in how to record the BP.
i. Instruct the client to eat foods high in potassium.
j. Instruct the client in how to take potassium supplements if prescribed.
k. Instruct the client to take medication with food to avoid gastrointestinal upset.
l. Instruct the client to change positions slowly to prevent orthostatic hypotension.
m. Instruct the client to use sunscreen when in direct sunlight because of increased photosensitivity.
n. Instruct the client with diabetes mellitus to have the blood glucose level checked periodically.
B. * Loop diuretics (Box 54.8 )
1. Description
a. Loop diuretics inhibit sodium and chloride reabsorption from the loop of Henle and the distal tubule.
b. Loop diuretics have little effect on the blood glucose level; however, they cause depletion of water and electrolytes,
increased uric acid levels, and the excretion of calcium.
c. Loop diuretics are more potent than thiazide diuretics, causing rapid diuresis, thus decreasing vascular fluid volume,
cardiac output, and BP.
d. Used for hypertension, pulmonary edema, edema associated with heart failure, hypercalcemia, and renal disease
e. Use loop diuretics with caution in the client taking digoxin or lithium and in the client taking aminoglycosides,
anticoagulants, corticosteroids, or amphotericin B.
2. * Side and adverse effects
a. Hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia
b. Thrombocytopenia
c. Hyperuricemia
d. Orthostatic hypotension
e. Rash
f. Ototoxicity and deafness
g. Thiamine deficiency
h. Dehydration
3. * Interventions: See section VI, A, 3 (Interventions for thiazide diuretics).
a. Monitor electrolytes, calcium, magnesium, BUN, creatinine, and uric acid levels.
b. Administer IV furosemide slowly over 1 to 2 minutes, because hearing loss can occur if injected rapidly.
C. Aldosterone antagonists (osmotic diuretics): See Chapter 60.
D. * Potassium-sparing diuretics (Box 54.9 )
1. Description
a. Potassium-sparing diuretics act on the distal tubule to promote sodium and water excretion and potassium retention.
b. Used for edema and hypertension, to increase urine output, and to treat fluid retention and overload associated with
heart failure, ascites resulting from cirrhosis or nephrotic syndrome, and diuretic-induced hypokalemia
c. Potassium-sparing diuretics are contraindicated in severe kidney or hepatic disease and in severe hyperkalemia.
d. Potassium-sparing diuretics should be used with caution in clients with diabetes mellitus, clients taking
antihypertensives or lithium, or clients taking angiotensin-converting enzyme inhibitors or potassium supplements
because hyperkalemia can result. ** The primary concern with administering potassium- sparing diuretics is
hyperkalemia.
2. * Side and adverse effects
a. Hyperkalemia
b. Nausea, vomiting, diarrhea
c. Rash
d. Dizziness, weakness
e. Headache
f. Dry mouth
g. Photosensitivity
h. Anemia
i. Thrombocytopenia
3. Interventions
a. Monitor vital signs.
b. Monitor urine output.
c. Monitor for signs and symptoms of hyperkalemia such as nausea; diarrhea; abdominal cramps; tachycardia followed
by bradycardia; tall, peaked T waves on the electrocardiogram; and oliguria.
d. Monitor for a potassium level greater than 5.0 mEq/L (5.0 mmol/L), which indicates hyperkalemia.
e. Instruct the client to avoid foods high in potassium.
f. Instruct the client to avoid exposure to direct sunlight.
g. Instruct the client to monitor for signs of hyperkalemia.
h. Instruct the client to avoid salt substitutes because they contain potassium.
i. Instruct the client to take the medication with or after meals to decrease gastrointestinal irritation.
VII. Peripherally Acting α-Adrenergic Blockers (Box 54.10 )
A. Description
1. These medications decrease sympathetic vasoconstriction by reducing the effects of norepinephrine at peripheral
nerve endings, resulting in vasodilation and decreased BP.
2. These medications are used to treat hypertension and maintain renal blood flow.
B. Side and adverse effects
1. Orthostatic hypotension
2. Reflex tachycardia
3. Sodium and water retention
4. Edema
5. Weight gain
6. Gastrointestinal disturbances
7. Drowsiness
8. Nasal congestion
C. * Interventions
1. Monitor vital signs.
2. Monitor for fluid retention and edema.
3. Instruct the client to change positions slowly to prevent orthostatic hypotension.
4. Instruct the client in how to monitor the BP.
5. Instruct the client to monitor for edema.
6. Instruct the client to decrease salt intake.
7. Instruct the client to avoid over-the-counter medications.
VIII. Centrally Acting Sympatholytics (Adrenergic Blockers) (Box 54.11 )
A. Description
1. Centrally acting sympatholytics stimulate α-receptors in the central nervous system to inhibit vasoconstriction, thus
reducing peripheral resistance.
2. Used to treat hypertension
3. Contraindicated in impaired liver function
B. Side and adverse effects
1. Sodium and water retention
2. Edema
3. Drowsiness, dizziness
4. Dry mouth
5. Hypotension
6. Bradycardia
7. Impotence
8. Depression
C. * Interventions
1. Monitor vital signs.
2. Instruct the client not to discontinue medication, because abrupt withdrawal can cause severe rebound hypertension.
3. Monitor liver function tests.
IX. Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs) ( Box 54.12 )
A. Description
1. ACE inhibitors prevent peripheral vasoconstriction by blocking conversion of angiotensin I to angiotensin II (AII).
2. ARBs prevent peripheral vasoconstriction and secretion of aldosterone and block the binding of AII to type 1 AII
receptors.
3. These medications are used to treat hypertension and heart failure; also, ACE inhibitors are administered for their
cardioprotective effect after myocardial infarction.
4. Avoid use with potassium supplements and potassium-retaining (sparing) diuretics.
B. * Side and adverse effects
1. Nausea, vomiting, diarrhea
2. Persistent dry cough (ACE inhibitors)
3. Hypotension
4. Hyperkalemia
5. Tachycardia
6. Headache
7. Dizziness, fatigue
8. Insomnia
9. Hypoglycemic reaction in the client with diabetes mellitus
10. Bruising, petechiae, bleeding
11. Diminished taste (ACE inhibitors) * A persistent dry cough is common for those taking an ACE inhibitor, but this
often subsides after a few weeks. Instruct the client to contact the PHCP if this occurs and persists.
C. * Interventions
1. Monitor vital signs.
2. Monitor white blood cells, and protein, albumin, BUN, creatinine, and potassium levels.
3. Monitor for hypoglycemic reactions in the client with diabetes mellitus.
4. If captopril is prescribed, instruct the client to take the medication 20 to 60 minutes before a meal.
5. Monitor for bruising, petechiae, or bleeding with captopril.
6. Instruct the client not to discontinue medications, because rebound hypertension can occur.
7. Instruct the client not to take over-the-counter medications.
8. Instruct the client in how to take the BP.
9. Inform the client that the taste of food may be diminished during the first month of therapy.
10. Instruct the client to report adverse effects to the PHCP.
X. * Antianginal Medications (Box 54.13 )
A. Nitrates (see Clinical Judgment: Take Action Box)
1. Description
a. Nitrates produce vasodilation, decrease preload and afterload, and reduce myocardial oxygen consumption.
b. Contraindicated in the client with significant hypotension, increased intracranial pressure, or severe anemia and in
those taking medication to treat erectile dysfunction
c. Should be used with caution with severe renal or hepatic disease
d. Avoid abrupt withdrawal of long-acting preparations to prevent the rebound effect of severe pain from myocardial
ischemia.
2. Side and adverse effects
a. Headache
b. Orthostatic hypotension
c. Dizziness, weakness
d. Faintness
e. Flushing or pallor
f. Dry mouth
g. Reflex tachycardia
3. * Sublingual medications
a. Monitor vital signs.
b. Offer sips of water before giving, because dryness may inhibit medication absorption.
c. Instruct the client to sit down before taking the medication because of the potential for dizziness and risk of falling.
d. Instruct the client to place under the tongue and leave until fully dissolved.
e. Instruct the client not to swallow the medication.
f. Instruct the at-home client to take 1 tablet for pain and to immediately contact emergency medical services if pain is
not relieved; in the hospitalized client, 1 tablet is administered every 5 minutes for a total of three doses, and the PHCP
is notified immediately if pain is not relieved following the three doses (the BP is checked before each administration).
g. Inform the client that a stinging or burning sensation may indicate that the tablet is fresh.
h. Instruct the client to store medication in a dark, tightly closed bottle.
i. Instruct the client to take acetaminophen for a headache. * Instruct the client using nitroglycerin tablets to check the
expiration date on the medication bottle, because expiration may occur within 6 months of obtaining the medication.
The tablets will not relieve chest pain if they have expired.
4. Translingual medications (spray)
a. Instruct the client to direct the spray against the oral mucosa.
b. Instruct the client to avoid inhaling the spray.
5. Sustained-released medications: Instruct the client to swallow and not to chew or crush the medication.
6. Transdermal patch
a. Instruct the client to apply the patch to a hairless area, using a new patch and different site each day.
b. * As prescribed, instruct the client to remove the patch after 12 to 14 hours, allowing 10 to 12 “patch-free” hours
each day to prevent tolerance.
7. Topical ointments
a. Instruct the client to remove the ointment on the skin from the previous dose.
b. Instruct the client to squeeze a ribbon of ointment of the prescribed length onto the applicator or dose-measuring
paper.
c. Instruct the client to spread the ointment over a 2.5- by 3.5-inch (6.5 by 9 cm) area and cover with plastic wrap,
using the chest, back, abdomen, upper arm, or anterior thigh (avoid hairy areas).
d. * Instruct the client to rotate sites and to avoid touching the ointment when applying.
8. Patches and ointments
a. Wear gloves when applying.
b. Do not apply on the chest in the area of defibrillator-cardioverter pad placement, because skin burns can result if the
pads need to be used.

* Clinical Judgment: Take Action

The nurse is caring for a hospitalized client with coronary artery disease. The client calls the nurse and reports
substernal crushing chest pain that radiates to the left arm. The nurse takes the following actions:

▪ Quickly assesses the client, specifically characteristics of pain, heart rate and rhythm, and blood pressure (BP)
▪ Administers a nitroglycerin tablet sublingually
▪ Stays with the client
▪ Reassesses the client in 5 minutes
▪ Administers another nitroglycerin tablet sublingually if pain is not relieved and the BP is stable
▪ Reassesses the client in 5 minutes
▪ Administers a third nitroglycerin tablet sublingually if pain is not relieved and the BP is stable
▪ Reassesses in 5 minutes; contacts the PHCP if the third nitroglycerin tablet does not relieve the pain
▪ Documents the event, actions taken, and the client's response to treatment
XI. β-Adrenergic Blockers (Box 54.14 )
A. Description
1. β-Adrenergic blockers inhibit response to β-adrenergic stimulation, thus decreasing cardiac output.
2. They block the release of catecholamines, epinephrine, and norepinephrine, thus decreasing the heart rate and BP;
they also decrease the workload of the heart and decrease oxygen demands.
3. Used for angina, dysrhythmias, hypertension, migraine headaches, prevention of myocardial infarction, and
glaucoma
4. β-Adrenergic blockers are contraindicated in the client with asthma, bradycardia, heart failure (with exceptions),
severe renal or hepatic disease, hyperthyroidism, or stroke; carvedilol, metoprolol, and bisoprolol have been approved
for use in heart failure once the client has been stabilized by ACE inhibitor and diuretic therapy.
5. β-Adrenergic blockers should be used with caution in the client with diabetes mellitus, because the medication may
mask symptoms of hypoglycemia.
6. β-Adrenergic blockers should be used with caution in the client taking antihypertensive medications.
B. * Side and adverse effects
1. Bradycardia
2. Bronchospasm
3. Hypotension
4. Weakness, fatigue
5. Nausea, vomiting
6. Dizziness
7. Hyperglycemia
8. Agranulocytosis
9. Behavioral or psychotic response
10. Depression
11. Nightmares
C. Interventions
1. Monitor vital signs.
2. Withhold the medication if the pulse or BP is not within the prescribed parameters.
3. Monitor for signs of heart failure or worsening heart failure.
4. Assess for respiratory distress and for signs of wheezing and dyspnea.
5. Instruct the client to report dizziness, light-headedness, or nasal congestion.
6. Instruct the client not to stop the medication, because rebound hypertension, rebound tachycardia, or an anginal
attack can occur.
7. Advise the client taking insulin that the β-adrenergic blocker can mask early signs of hypoglycemia, such as
tachycardia and nervousness.
8. Instruct the client taking insulin to monitor the blood glucose level.
9. Instruct the client in how to take pulse and BP.
10. Instruct the client to change positions slowly to prevent orthostatic hypotension.
11. Instruct the client to avoid over-the-counter medications, especially cold medications and nasal decongestants.
XII. Calcium Channel Blockers (Box 54.15 )
A. * Description
1. Calcium channel blockers decrease cardiac contractility (negative inotropic effect by relaxing smooth muscle) and
the workload of the heart, thus decreasing the need for oxygen.
2. Calcium channel blockers promote vasodilation of the coronary and peripheral vessels.
3. Used for angina, dysrhythmias, or hypertension
4. Used with caution in the client with heart failure, bradycardia, or atrioventricular block
B. Side and adverse effects
1. Bradycardia
2. Hypotension
3. Reflex tachycardia as a result of hypotension
4. Headache
5. Dizziness, light-headedness
6. Fatigue
7. Peripheral edema
8. Constipation
9. Flushing of the skin
10. Changes in liver and kidney function
C. * Interventions
1. Monitor vital signs.
2. Monitor for signs of heart failure.
3. Monitor liver enzyme levels.
4. Monitor kidney function tests.
5. Instruct the client not to discontinue the medication.
6. Instruct the client in how to take the pulse.
7. Instruct the client to notify the PHCP if dizziness or fainting occurs.
8. Instruct the client not to crush or chew sustained-release tablets.
XIII. Peripheral Vasodilators (Box 54.16 )
A. Description
1. Peripheral vasodilators decrease peripheral resistance by exerting a direct action on the arteries or on the arteries and
the veins.
2. These medications increase blood flow to the extremities and are used in peripheral vascular disorders of venous and
arterial vessels.
3. Peripheral vasodilators are most effective for disorders resulting from vasospasm (Raynaud's disease).
4. These medications may decrease some symptoms of cerebral vascular insufficiency.
B. Side and adverse effects
1. Light-headedness, dizziness
2. Orthostatic hypotension
3. Tachycardia
4. Palpitations
5. Flushing
6. Gastrointestinal distress
C. * Interventions
1. Monitor vital signs, especially the BP and the heart rate.
2. Monitor for orthostatic hypotension and tachycardia.
3. Monitor for signs of inadequate blood flow to the extremities, such as pallor, pain, or feeling cold.
4. Instruct the client that it may take up to 3 months for a desired therapeutic response.
5. Advise the client not to smoke, because smoking increases vasospasm.
6. Instruct the client to avoid aspirin or aspirin-like compounds unless approved by the PHCP.
7. Instruct the client to take the medication with meals if gastrointestinal disturbances occur.
8. Instruct the client to avoid alcohol, because it may cause a hypotensive reaction.
9. Encourage the client to change positions slowly to avoid orthostatic hypotension.
XIV. Direct-Acting Arteriolar Vasodilators (Box 54.17 )
A. Description
1. Direct-acting vasodilators relax the smooth muscles of the blood vessels, mainly the arteries, causing vasodilation;
with vasodilation, the BP drops and sodium and water are retained, resulting in peripheral edema (diuretics may be
given to decrease the edema).
2. Direct-acting vasodilators promote an increase in blood flow to the brain and kidneys.
3. These medications are used in the client with moderate to severe hypertension and for acute hypertensive
emergencies.
B. * Side and adverse effects
1. Hypotension
2. Reflex tachycardia caused by vasodilation and the drop in BP
3. Palpitations
4. Edema
5. Dizziness
6. Headaches
7. Nasal congestion
8. Gastrointestinal bleeding
9. Neurological symptoms
10. Confusion
11. With sodium nitroprusside, cyanide toxicity and thiocyanate toxicity can occur.
C. * Interventions
1. Monitor vital signs, especially BP.
2. Sodium nitroprusside
a. Monitor cyanide and thiocyanate levels.
b. Protect from light because the medication decomposes.
c. When administering, solution must be covered by a dark bag provided by the manufacturer and is stable for 24 hours.
d. Discard if the medication is red, green, or blue. ** Vasodilators cause orthostatic hypotension. Instruct the client
about safety measures when taking these medications, such as when rising from a lying to a sitting or standing position
slowly.
XV. Miscellaneous Vasodilator
A. Description
1. Nesiritide
a. Recombinant version of human B-type natriuretic peptide that vasodilates arteries and veins
b. Used for the treatment of decompensated heart failure
2. Side and adverse effects
a. Hypotension
b. Confusion
c. Dizziness
d. Dysrhythmias
3. Interventions
a. Administer via continuous IV infusion device.
b. Monitor BP, cardiac rhythm, urine output, and body weight.
c. Monitor for signs of resolving heart failure.
XVI. Antidysrhythmic Medications
A. Description: Antidysrhythmic medications suppress dysrhythmias by inhibiting abnormal pathways of electrical
conduction through the heart.
B. Class I antidysrhythmics are sodium channel blockers, class II are beta blockers, class III are potassium channel
blockers (medications that delay repolarization), and class IV are calcium channel blockers.
C. Class IA antidysrhythmics
1. Disopyramide
2. Procainamide
3. Quinidine sulfate
D. Class IB antidysrhythmics
1. Lidocaine
2. Mexiletine hydrochloride
3. Phenytoin
E. Class IC antidysrhythmics
1. Flecainide acetate
2. Propafenone hydrochloride
3. * Side and adverse effects: Class I antidysrhythmics
a. Hypotension
b. Heart failure
c. Worsened or new dysrhythmias
d. Nausea, vomiting, or diarrhea
F. Class II antidysrhythmics
1. Acebutolol
2. Esmolol
3. Propranolol
4. Metoprolol
5. Nadolol
6. Atenolol
7. * Side and adverse effects: Class II antidysrhythmics
a. Dizziness
b. Fatigue
c. Hypotension
d. Bradycardia
e. Heart failure
f. Dysrhythmias
g. Heart block
h. Bronchospasms
i. Gastrointestinal distress
G. Class III antidysrhythmics
1. Amiodarone
2. Dofetilide
3. Ibutilide
4. Sotalol
5. * Side and adverse effects: Class III antidysrhythmics
a. Hypotension
b. Bradycardia
c. Nausea, vomiting
d. Amiodarone hydrochloride may cause pulmonary fibrosis, photosensitivity, bluish skin discoloration, corneal
deposits, peripheral neuropathy, tremor, poor coordination, abnormal gait, and hypothyroidism.
e. The electrocardiogram should be monitored for clients receiving amiodarone or dofetilide, because they may prolong
the QT interval, potentially leading to torsades de pointes (a ventricular tachycardia that occurs in the setting of long
QT interval).
H. Class IV antidysrhythmics
1. Verapamil
2. Diltiazem
3. * Side and adverse effects: Class IV antidysrhythmics
a. Dizziness
b. Hypotension
c. Bradycardia
d. Edema
e. Constipation
I. Other antidysrhythmics
1. Adenosine
2. Digoxin
J. * Interventions for antidysrhythmics
1. Monitor heart rate, respiratory rate, and BP.
2. Monitor electrocardiogram.
3. Provide continuous cardiac monitoring.
4. Maintain therapeutic serum medication levels.
5. Before administering lidocaine, always check the vial label to prevent administering a form that contains epinephrine
or preservatives, because these solutions are used for local anesthesia only.
6. Do not administer antidysrhythmics with food, because food may affect absorption.
7. Mexiletine may be administered with food or antacids to reduce gastrointestinal distress.
8. Always administer IV antidysrhythmics via an infusion pump.
9. Monitor for signs of fluid retention such as weight gain, peripheral edema, or shortness of breath.
10. Advise the client to limit fluid and salt intake to minimize fluid retention.
11. Monitor respiratory, thyroid, and neurological functions.
12. Instruct the client to change positions slowly to minimize orthostatic hypotension.
13. Instruct the client taking amiodarone to use sunscreen and protective clothing to prevent photosensitivity reactions.
14. Encourage the client to increase fiber intake to prevent constipation.
XVII. Adrenergic Agonists (Box 54.18 )
A. Dobutamine
1. Increases myocardial force and cardiac output through stimulation of β-receptors
2. Used in clients with heart failure and for clients undergoing cardiopulmonary bypass surgery
B. * Dopamine
1. Increases BP and cardiac output through positive inotropic action and increases renal blood flow through its action
on α- and β-receptors
2. Used to treat mild kidney failure caused by low cardiac output
C. Epinephrine
1. Used for cardiac stimulation in cardiac arrest
2. Used for bronchodilation in asthma or allergic reactions
3. Produces mydriasis
4. Produces local vasoconstriction when combined with local anesthetics and prolongs anesthetic action by decreasing
blood flow to the site
D. Norepinephrine
1. Stimulates the heart in cardiac arrest
2. Vasoconstricts and increases the BP in hypotension and shock
E. * Side and adverse effects
1. Dysrhythmias
2. Tachycardia
3. Angina
4. Restlessness
5. Urgency or urinary incontinence
F. * Interventions
1. Monitor vital signs.
2. Monitor lung sounds.
3. Monitor urinary output.
4. Monitor electrocardiogram.
5. Administer the medication through a large vein.
XVIII. Antilipemic Medications
A. Description
1. Antilipemic medications reduce serum levels of cholesterol, triglycerides, or low-density lipoprotein.
2. When cholesterol, triglyceride, and low-density lipoprotein levels are elevated, the client is at increased risk for
coronary artery disease.
3. In many cases, diet alone will not lower blood lipid levels; therefore, antilipemic medications will be prescribed.
B. Bile sequestrants (see Chapter 50)
1. Description
a. Bind with acids in the intestines, which prevents reabsorption of cholesterol
b. Should not be used as the only therapy in clients with elevated triglyceride levels because they may raise triglyceride
levels
2. * Side and adverse effects
a. Constipation
b. Gastrointestinal disturbances: Heartburn, nausea, belching, bloating
3. * Interventions
a. Cholestyramine comes in a gritty powder that must be mixed thoroughly in juice or water before administration.
b. Monitor the client for early signs of peptic ulcer such as nausea and abdominal discomfort followed by abdominal
pain and distention.
c. Instruct the client that the medication must be taken with and followed by sufficient fluids.
C. HMG-CoA reductase inhibitors (Box 54.19 )
1. Description
a. Lovastatin is highly protein-bound and should not be administered with anticoagulants.
b. Lovastatin should not be administered with gemfibrozil.
c. Administer lovastatin with caution to the client taking immunosuppressive medications.
2. Side and adverse effects
a. Nausea
b. Diarrhea or constipation
c. Abdominal pain or cramps
d. Flatulence
e. Dizziness
f. Headache
g. Blurred vision
h. Rash
i. Pruritus
j. Elevated liver enzyme levels
k. Muscle cramps and fatigue
3. * Interventions
a. Monitor serum liver enzyme levels.
b. Instruct the client to have an annual eye examination, because the medications can cause cataract formation.
c. If lovastatin is not effective in lowering the lipid level after 3 months, it should be discontinued. ** Instruct the client
who is taking an antilipemic medication to report any unexplained muscular pain to the PHCP immediately.
D. Other antilipemic medications (Box 54.20 )
1. Description
a. Gemfibrozil should not be taken with anticoagulants, because they compete for protein sites; if the client is taking an
anticoagulant, the anticoagulant dose should be reduced during antilipemic therapy and the INR should be monitored
closely.
b. Do not administer gemfibrozil with HMG-CoA reductase inhibitors, because it increases the risk for myositis,
myalgias, and rhabdomyolysis.
c. Fish oil supplements have been associated with a decreased risk for cardiovascular heart disease; plant stanol and
sterol esters and cholestin have been associated with reducing cholesterol levels.
2. * Interventions
a. Monitor vital signs.
b. Monitor liver enzyme levels.
c. Monitor serum cholesterol and triglyceride levels.
d. Instruct the client that it will take several weeks before the lipid level declines.
e. Instruct the client to restrict intake of fats, cholesterol, carbohydrates, and alcohol.
f. Instruct the client to follow an exercise program.
g. Instruct the client to have an annual eye examination and to report changes in vision.
h. Instruct the client with diabetes mellitus who is taking gemfibrozil to monitor blood glucose levels regularly.
i. Instruct the client to increase fluid intake.
j. Nicotinic acid has numerous side and adverse effects, including gastrointestinal disturbances, flushing of the skin,
elevated liver enzyme levels, hyperglycemia, and hyperuricemia.
k. Instruct the client that taking aspirin or nonsteroidal antiinflammatory drugs 30 minutes before nicotinic acid may
assist in reducing the side effect of cutaneous flushing.
l. Instruct the client to take nicotinic acid with meals to reduce gastrointestinal discomfort.
TABLE

Box 54.1 Anticoagulants

Oral

▪ Apixaban
▪ Dabigatran etexilate mesylate
▪ Edoxaban
▪ Rivaroxaban
▪ Warfarin sodium

Parenteral

▪ Argatroban
▪ Bivalirudin
▪ Dalteparin
▪ Desirudin
▪ Enoxaparin
▪ Fondaparinux
▪ Heparin sodium

Box 54.2 Substances to Avoid with Anticoagulants

▪ Allopurinol
▪ Cimetidine
▪ Corticosteroids
▪ Fluoroquinolones
▪ Ginkgo and ginseng (herbs)
▪ Green, leafy vegetables and other foods high in vitamin K
▪ Macrolide antibiotics
▪ Nonsteroidal antiinflammatory drugs
▪ Oral hypoglycemic agents
▪ Phenytoin
▪ Salicylates
▪ Sulfonamides

Box 54.3 Thrombolytic Medications

▪ Alteplase
▪ Reteplase
▪ Tenecteplase

Box 54.4 Antiplatelet Medications

Oral

▪ Acetylsalicylic acid
▪ Anagrelide
▪ Cilostazol
▪ Clopidogrel
▪ Dipyridamole
▪ Ticagrelor
▪ Ticlopidine

Parenteral

▪ Abciximab
▪ Eptifibatide
▪ Tirofiban

Box 54.5 Positive Inotropic and Cardiotonic Medications

Dobutamine

▪ Used for short-term management of heart failure

▪ Increases myocardial contractility, thereby improving cardiac performance

Dopamine

▪ Used as a short-term rescue measure for clients with severe, acute heart failure
▪ Increases myocardial contractility, thereby improving cardiac performance
▪ Dilates renal blood vessels and increases renal blood flow and urine output
Milrinone Lactate

▪ Used for short-term management of heart failure; may be given before heart transplantation
Fig. 54.1 The vicious cycle of maladaptive compensatory responses to a failing heart.

Box 54.6 Classifications of Diuretics

▪ Aldosterone antagonists
▪ Loop diuretics
▪ Potassium-sparing diuretics
▪ Thiazide diuretics

Box 54.7 Thiazide and Thiazide-Like Diuretics

▪ Chlorothiazide
▪ Chlorthalidone
▪ Hydrochlorothiazide
▪ Indapamide
▪ Metolazone

Box 54.8 Loop Diuretics

▪ Bumetanide
▪ Ethacrynic acid
▪ Furosemide
▪ Torsemide
Box 54.9 Potassium-Sparing Diuretics

▪ Amiloride hydrochloride
▪ Eplerenone
▪ Spironolactone
▪ Triamterene

Box 54.10 Peripherally Acting α-Adrenergic Blockers

▪ Doxazosin
▪ Prazosin
▪ Terazosin

Box 54.11 Centrally Acting Sympatholytics (Adrenergic Blockers)

▪ Clonidine
▪ Guanfacine
▪ Methyldopa

Box 54.12 Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers

Angiotensin-Converting Enzyme Inhibitors

▪ Benazepril
▪ Captopril
▪ Enalapril
▪ Fosinopril
▪ Lisinopril
▪ Moexipril
▪ Perindopril
▪ Quinapril
▪ Ramipril
▪ Trandolapril

Angiotensin II Receptor Blockers

▪ Azilsartan
▪ Candesartan
▪ Eprosartan
▪ Irbesartan
▪ Losartan
▪ Olmesartan
▪ Telmisartan
▪ Valsartan

Box 54.13 Antianginal Medications (Organic Nitrates)

▪ Isosorbide dinitrate
▪ Isosorbide mononitrate
▪ Nitroglycerin, sublingual
▪ Nitroglycerin, translingual
▪ Nitroglycerin, transdermal patches
▪ Nitroglycerin ointment
▪ Intravenous nitroglycerin

Box 54.14 β-Adrenergic Blockers

Nonselective (Block β 1 and β2)

▪ Carvedilol
▪ Labetalol
▪ Nadolol
▪ Pindolol
▪ Propranolol
▪ Sotalol

Cardioselective (Block β 1)

▪ Acebutolol
▪ Atenolol
▪ Betaxolol
▪ Bisoprolol
▪ Esmolol
▪ Metoprolol
▪ Nebivolol

Box 54.15 Calcium Channel Blockers

▪ Amlodipine
▪ Clevidipine
▪ Diltiazem
▪ Felodipine
▪ Isradipine
▪ Levamlodipine
▪ Nicardipine
▪ Nifedipine
▪ Nimodipine
▪ Nisoldipine
▪ Verapamil

Box 54.16 Peripheral Vasodilators

α-Adrenergic Blockers

▪ Doxazosin
▪ Prazosin
▪ Terazosin

Calcium Channel Blockers

▪ Diltiazem
▪ Nifedipine
▪ Nimodipine
▪ Verapamil

Hemorheological

▪ Pentoxifylline (increases microcirculation and tissue perfusion)

Box 54.17 Direct-Acting Arteriolar Vasodilators

▪ Diazoxide
▪ Fenoldopam
▪ Hydralazine
▪ Nitroglycerin
▪ Sodium nitroprusside
Box 54.18 Adrenergic Agonists

▪ Dobutamine
▪ Dopamine
▪ Epinephrine
▪ Norepinephrine

Box 54.19 HMG-CoA Reductase Inhibitors

▪ Atorvastatin
▪ Fluvastatin
▪ Lovastatin
▪ Pitavastatin
▪ Pravastatin
▪ Rosuvastatin
▪ Simvastatin

Box 54.20 Other Antilipemic Medications

▪ Cholestyramine
▪ Colesevelam
▪ Colestipol
▪ Ezetimibe
▪ Fenofibrate
▪ Gemfibrozil
▪ Icosapent
▪ Lomitapide
▪ Nicotinic acid
▪ Omega-3-acid ethyl esters