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Florianne E. Adlawan, R.N.
The cardiovascular system includes the heart, blood vessels (arteries and veins) and blood. Blood rich in oxygen, nutrients and hormones moves through vessels called arteries, which narrow to arterioles. Capillaries transport rich nourished blood to body cells and absorb waste products such as carbon dioxide, urea, creatinine and ammonia. The deoxygenated blood returns to the circulation by the venules and veins to be eliminated by the lungs and kidneys with other waste products. The heart’s pumping action serves as the energy source that circulates blood to body cells. Blockage of vessels can inhibit blood flow. Three groups of drugs – cardiac glycosides, antianginals and antidysrhythmics are discussed in this topic. Drugs in these groups regulate heart contraction, heart rate and rhythm, and blood flow to the myocardium (heart muscle).
Cardiac Glycosides Also called digitalis glycosides, are a group of drugs that inhibit the sodium-potassium pump; thus they increase intracellular calcium, which causes the cardiac muscle fibers to contracts more efficiently. Digitalis preparations have four effects on the heart muscle: •A positive Inotropic action – increases myocardial contraction. •A negative Chronotropic action – decreases heart rate. •A negative Dromotropic action – decreases conduction of the heart cells. •Increased stroke volume. Are also used to correct atrial fibrillation (cardiac dysrhythmia with rapid uncoordinated contractions of atrial myocardium) and atrial flutter ( cardiac dyrhythmia with rapid contractions of 200 to 300 beats per minute
5 – 1 mg initially 2 divided doses (digitalization).5 mg/d IV: same as PO dose given over 5 min Elderly: 0. Renal disease.125 mg/d C: PO: 2 – 10 yr: 0. hypokalemia .012 – 0.125 – 0.04 mg/kg in divided doses Pediatrics doses are usually ordered in µg (mcg) in elixir form Contraindicatio:Ventricular dysrhthmias.DIGOXIN (Lanoxin) Drug Class: Cardiac Glycosides Trade Name: Lanoxin Pregnancy Category: C Dosage A: PO: 0. hypothyroidism. second – or third – degree heart block Caution: AMI. main: 0.
Nausea. vomiting. headache. cardiac dysrhthmias . fatigue. photophobia. visual disturbances Life – threatening: Atrioventricular block. blurred vision (yellow-green halos). flutter or fibrillation Mode of Action: Inhibits the sodium-potassium ATPase thus promoting increased force of cardiac contraction. cardiac output and tissue perfusion. diplopia. decreases ventricular rate Side Effects: Anorexia. atrial tachycardia.Therapeutic Effects/Uses: To treat CHF. confusion Adverse Reaction: Bradycardia. drowsiness.
vomiting. A low serum potassium level enhances the action of digoxin. nausea. cardiac dysrhthmias and visual disturbances. Report if a drug –drug or drug – herb interaction is probable. Apical pulse should be taken for a full minute and should be >60bpm. hypokalemia might result. o Obtain a baseline pulse rate for future comparisons.Nursing Process Assessment o Obtain a drug and herbal history. . oAssess for signs and symptoms of digitalis toxicity. bradycardia. A client taking a thiazide and/or cortisone with digoxin should take a potassium supplement. Report symptoms immediately to the health care provider. If the client is taking digoxin and a potassium – wasting diuretic or cortisone drug. causing digitalis toxicity. Common symptoms include anorexia.
Nursing Diagnosis o Decreased cardiac output o Ineffective tissue perfusion o Anxiety related to cardiac problem Planning o Checks pulse rate daily before taking digoxin. Report pulse rate <60 bpm or a marked of decline in pulse rate o Client eats food rich in potassium to maintain a desired serum potassium level .
.5mEq/L) is present.5 to 2.0 ng/mL. The normal therapeutic drug range is 0. Read the drug labels carefully. which indicate congestive heart failure o Check the serum digoxin level.3 mEq/L) and report if hypokalemia (<3. o Check the apical pulse rate before administering digoxin.0 ng/mL is indicative of digitalis toxicity.Nursing Intervention o Do not confuse digoxin with digitoxin. a serum digoxin level of >2. Do not administer if pulse rate is <60 bpm o Check the signs of peripheral and pulmonary edema.5 to 5. Digoxin has a long half – life but has a shorter half – life than digitoxin. Check serum potassium level (normal range 3.
A visiting nurse may ensure that the medications are properly taken. Request childproof bottles. o Keep drugs out of reach of small children. o Instruct the client or parent of child to check pulse rate before administering the drug . o Advise the client not to take over – the – counter (OTC) drugs without first consulting the health care provider to avoid adverse reactions.Client Teaching General o Explain to the client the importance of compliance with the drug therapy.
. fruit juices and vegetables including potatoes. vomiting. and visual disturbances including diplopia.Self – administration o Instruct the client how to check the pulse rate before taking digoxin and to call the health care provider for pulse rate <60bpm or irregular pulse Side Effects o Instruct the client to report side effects such as pulse rate <60bpm. Diet o Advise the client to eat foods rich in potassium such as fresh and dried fruits. nausea. headache.
decreased chest rales) and the absence of side effects. diuretics and potassium supplements for heart failure do not miss drug doses of their medication. The client should be fully aware of adverse effects and readily report them to the health care provider. Continue monitoring the pulse rate. Evaluation o Evaluate the effectiveness of digoxin by noting the client’s responses to the drug (decreased heart rate.Cultural Considerations o It is essential that clients from various cultural backgrounds taking digoxin. .
Referred pain felt in the neck and left arm commonly occurs with severe angina pectoris. With decreased blood flow. Angina pain is frequently described by the client as tightness. . This is a condition of acute cardiac pain cause by inadequate blood flow to the myocardium resulting from either plaque occlusions within or spasms of the coronary arteries. Anginal attacks may lead to myocardial infarction (MI). there is a decrease in oxygen to the myocardium results in pain. or heart attack.Specific Drugs Antianginal Drugs Antianginal drugs are used to treat angina pectoris. Anginal pain usually lasts for only a few minutes. and pain radiating down the left arm. pressure in the center of the chest.
The frequency of angina pain depends on many factors. There are three types of angina: • Classis (stable) – occurs with stress or exertion • Unstable (preinfarction) – occurs frequently over the course of a day with progressive severity • Variant (Prinzmmetal. They cause generalized vascular and coronary vasodilation thus increasing blood flow to the through the coronary arteries to the myocardial cells. Vasopastic) – occurs during rest Types of antianginal drugs: •Nitrates – affects the blood vessles in the venous circulation and coronary arteries. including the type of angina. . This group of drugs reduces myocardial ischemia but can cause hypotension.
. increasing the workload of the heart and the need for more oxygen.• Beta-blockers – decrease the effects of the sympathetic nervous system by blocking the release of the catecholamines eipinephrine and norepinephrine thereby decreasing the heart rate and blood pressure. Are effective as antianginal because by decreasing the heart rate and myocardial contractility. they reduce the need for oxygen consumption and consequently they reduce angina pain. Calcium blockers decrease cardiac contractility (negative intropic effect that relaxes smooth muscle) and the workload of the heart thus decreasing the need for oxygen. • Calcium Channel Blockers – calcium activates myocardial contraction.
6 mg repeat q 5 minutes x 3 doses as needed SR: 2. Transderm – Nitro patch.5 – 26 mg. Nitrogard SR. NTG.NITROGLYCERIN Drug Class: Antianginal Trade Name: Nitrostat.3. 0. 2 – 4 x d IV: Initially: 5 µg/min. dose may be increased Oint: 2% 1 – 2 inch to chest or thigh area Patch: 2. Nitro – Bid. Nitrol Nitrate Pregnancy Category: C Dosage: A: PO/SL: 0.5 – 11 mg/d to chest or thigh area . 0.4.
early MI Therapeutic Effects/Uses: To control angina pectoris (angina pain) Mode of Action: Decrease myocardial demand for oxygen.Contraindications: Marked hypotension. increased intracranial pressure. AMI. vomiting. flush. weakness. dry mouth Adverse Reaction: Hypotension. Side Effects: Nausea. paradoxical bradycardia Life – threatening: Circulatory collapse . rash. reflex tachycardia. dizziness. decreases preload by dilating veins thus indirectly decreasing afterload. pallor. confusion. syncope. headache. severe anemia Caution: Severe renal or hepatic disease.
Nursing Process Assessment o Obtain baseline vital signs for future comaparisons. Nitroglycerins is contraindicated for marked hypotension or acute myocardial infarction (AMI) Nursing Diagnosis o Decreased Cardiac output o Anxiety related to cardiac problems o Acute pain o Activity intolerance . o Obtain health and drug histories.
Report angina that persists . o Have the client sit or lie down when taking a nitrate for the first time. Have the client rise slowly to a standing position.Planning o Client takes nitroglycerin or other antianginals and angina pain is controlled Nursing Intervention o Monitor vital signs. dryness may inhibit drug absorption. Hypotension is associated with most angina drugs. o Offer sips of water before giving sublinguals (SL) nitrates. After administration. o Monitor effects of intravenous (IV) nitroglycerin. check the vital signs while client is lying down and then sitting up.
Do not give more than three tablets. weakness. use a tongue blade or gloves. immediate medical help is necessary. If the chest pain persists >15 minutes.o Apply Nitro – Bid ointments to the designated mark on paper. Explosion and skin burns may results. Client Teaching General o A SL nitroglycerin tablet is used if chest pain occurs. and faintness. Do not use fingers because the drug can be absorbed. o Tolerance to nitroglycerin can occur. If the client’s chest pain is not completely alleviated. Repeat in 5 minutes if the pain has not subsided and again in another 5 minutes if it persists. For the Transderm – Nirto patch in any area on the chest in the vicinity of defibrillator – cardioverter paddle placement. Call 911 o Instruct the client not to ingest alcohol while taking nitroglycerin to avoid hypotension. the client should notify the health care provider. .
amber glass bottle. A stinging or biting sensation may indicate the tablet is fresh. the thighs and arms are. which can easily reduce the potency of the tablets. Usually the patch is applied to the chest wall. Apply once a day. o Instruct the client about the Transderm – Nitro patch. however.Beta – blockers and Calcium blockers o Instruct the client not to discontinue these drugs without the health care provider’s approval. Avoid hairy areas. usually in the morning. the biting sensation may not be present. . The tablet is placed under the tongue for quick absorption. The bottle is stored away from light and kept dry. Rotation of skin is necessary. The amber color of the glass provides light protection and the screw – cap closure protects from moisture in the air. Keep in original screw-up. With the newer SL nitroglycerin. Self – Administration o Instruct the client about SL nitroglycerin tablets. Withdrawal symptoms such as reflex tachycardia and pain may be severe.
Acetaminophen is suggested for relief. Advise the client to call the health care provider if dizziness or faintness occurs. o If hypotension results from SL nitroglycerin. place the client in supine position with legs elevated (Trendelenburg Position). .Side Effects o Headaches commonly occur when first taking nitroglycerin products and last about 30 minutes. Beta – blockers and Calcium Blockers o Instruct the client how to take a pulse rate. this may indicate hypotension.
As interpreter may be necessary to ensure the client’s compliance with drug and diet regimens. Note headache.Cultural Considerations o Ascertain from African – American. . o Discuss with clients from various cultures the importance of the drug regimen. and obese clients their understanding of foods common to people from their culture that may contribute to cardiac conditions. Hispanic. dizziness and faintness. Evaluation o Evaluate the client’s response to nitrate product for relieving angina pain.
Antidysrhythmic Drugs A cardiac dysrhythmias (arrhythmia) is defined as any deviation from the normal rate or pattern of the heartbeat. too fast (tachycardia). this includes heart rates that are too slow (bradycardia). The terms dysrhythmia (disturbed heart rhythm. and arrhythmia (absence of rhythm) are used interchangeably. The ECG identifies the type of dysrhythmia. despite the slight difference in meaning. or irregular. .
3. mexiletine HCL). Indication: Life – threatening. Indication: Atrial and Ventricular dysrhythmias. (Quinidine. IB – Actions: Slows conduction and shortens repolarization. (Encainide. ventricular dysrhythmias . Indications: Acute ventricular dysrhythmias. Disopyramide). IC – Actions: Prolongs conduction with little to no effect on repolarization. suppressions of the automaticity that decreases the likelihood of ectopic foci. and increased recovery time (repolarization or refractory period). paroxysmal atrial tachycardia (PAT). Flecainide). Procainamide. The drug response is decreased conduction velocity in the cardiac tissues. (Lidocaine. There are three subgroups: 1.Types of antidhsrhythmic drugs: • Class I: Fast (Sodium) Channel Blockers – decrease the fast sodium influx to the cardiac cells. supraventricular dysrhythmias 2. IA – Actions: Slows conduction and prolongs repolarization.
It increases the refractory period of the AV node. amiodarone (Cordarone). automaticity and recovery time (refractory period).• Class II: Beta – blockers – decreases conduction velocity. which decreases ventricular resposes. bretylium (Bretylol). Verapamil is a slow (calcium) channel blockers that blocks calcium influx thereby decreasing the excitability and contractility (negative inotropic) of the myocardium. • Class IV: Calcium Channel Blockers – consist of verapamil (Calan. Examples are propranolol (Inderal) and acebutolol (Sectral). Verapamil is contraindicated for clients with AV block or congestive heart failure. . increase the refractory period (recovery time) and prolong the action potential duration (cardiac cell activity). These drugs. Isoptin) and diltiazem (Cardizem). • Class III: Prolonged Repolarization – are uses in emergency treatment of ventricular dsrhythmias when other antidhysrhythmics are ineffective.
Pronestyl Pregnancy Category: C Dosage: A: PO: 250 – 500 mg q 3 – 4hour.PROCAINAMIDE HCL Drug Class: Fast (sodium) channel blockers I Trade Name: Procan. SR: 250 mg – 1 g q 12 hour or q 6 hour IM: 50 mg/kg/d in 4 divided doses IV: Inf: 20 mg/min for 25 – 30 minutes (500 – 600mg) C: PO: 40 – 60 mg/kg/d in 4 divided doses Max: 100 mg/dose TDM: 4 – 8 µg/mL .
Agranulocytosis. bundle of His. renal and hepatic insufficiency. weakness. headache. and ventricle to decrease cardiac dysrhythmias. Adverse Reaction: Life – threatening: Atrioventricular block. Therapeutic Effects/Uses: To control cardiac ventricular contractions.Contraindication: Hypersensitivity to procaine. myasthenia gravis. ventricular tachycardia). Thrombocytopenia. pleural effusion. lupuslike syndrome with rash. diarrhea. vomiting. rush. dysrhythmias (premature Mode of Action: Depression of myocardial excitability by slowing conduction of cardiac tissue through atrium. cardiovascular collapse. Caution: Hypotension. . nausea. flush. heart block. cardiogenic shock. MI. ventricular tachycardia/fibrillation. CHF. dizziness. Side Effects: Anorexia.
o Obtain baseline vital signs and electrocardiogram (ECG) for future comparisons. previous angina or cardiac dysrhythmias and drugs that the client currently takes. creatinine phosphokinase) to compare with future laboratory results.Nursing Process Assessment o Obtain health and drug histories. duration and severity). coughing. o Check early cardiac enzyme results (aspartate aminotransferase. lactate dehydrogenase. The history may include shortness of breath (SOB). . heart palpitations. chest pain (type.
administer it over a period of 2 – 3 minutes or as prescribed. increased PR ad QT intervals. oMonitor ECG for abnormal patterns and report findings. . and/or widening of the QRS complex.Nursing Diagnosis oDecrease cardiac output oAnxiety related to irregular heartbeat oRisk activity intolerance Planning oClient will no longer experience abnormal sinus rhythm oClient will comply with the antidysrhythmic drug regimen Nursing Intervention oMonitor vital signs. oWhen the drug is ordered intravenously push obolus. Hypotensions can occur. such as premature ventricular cpntrations (PVCs).
g.. oAdvise the client to avoid alcohol. Alcohol can intensify the hypotensive reaction. Drug compliance is essential. These can include dizziness. nausea and vomiting. oProvide specific instructions for each drug (e. faintness. caffeine and tobacco. and tobacco promotes vasoconstriction. photosensitivity for amiodarone). . caffeine increases the catecholamines level.Client Teaching General oInstruct the client to take the prescribed drug as ordered. Side Effects oInstruct the client to report side effects and adverse reactions to the health care provider.
As interpreter may be necessary to ensure the client’s compliance with drug and diet regimen. o Discuss with clients from various cultures the importance of the drug regimen. which may require discontinuation of the drug. Evalation o Evaluate the effectiveness of the prescribing antidysrhythmic by comparing heart rates with the baseline heart rate and assessing the client’s response to drug. Hispanic and obese clients their understanding of foods common to people from their culture that may contribute to cardiac conditions.Cultural Considerations o Ascertain from African – American. The drug regimen may need to be adjusted. . A proarrhythmic effect may occur. Report side effects and adverse reactions.
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