Harvard University Cardiac Medications Worksheet Please complete the attached worksheet on cardiac medication. Answers may be found in the powerpoint attac

Harvard University Cardiac Medications Worksheet Please complete the attached worksheet on cardiac medication. Answers may be found in the powerpoint attached, however some may need to be searched. Answers must be in 25 words or less if possible. Please write the answers in your own words. No plagiarizing. Cardiovascular Medications
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Answer in 25 words or less if possible.
Use your own words only.
1. Define the following terms in your own words.
Afterload
Preload
Cardiac output
Chronotropic
Conductivity
Irritability
Inotropic
Refractory
period.
Dysrhythmia
Atherosclerosis
2. What is Angina Pectoris? (In your own words please)
Fill in the table below
What is
Angina?
What causes
it?
Describe the
symptoms
3. Angina can be a recurring problem or a sudden, acute health concern. There are different types of angina. Fill
in the table below.
Stable angina
Unstable
angina
Prinzmetal’s
angina
4. Nitrate medications can be administered to patients by various routes. Fill in the table for each route.
Route
Sublingual/Spray
Advantages
Nursing Implications/Teaching
Transdermal
Intravenous
Oral Capsules
Topical
Ointment
5. Name one medication that is contraindicated with nitrates. What effect does it have if given with a nitrate?
6. Name one medical condition that is contraindicated with nitrates. What effect does nitrates have on that
particular medical condition?
7. How would you instruct a patient having an angina attack to take their sublingual nitro? Please list
instructions in order.
8. How would you instruct a client on how to use their transdermal nitro?
9. How would you instruct a client on the storage of anti-angina medications?
10. Name a drug other than a nitrate that is used to treat angina?
Hypertension Medications
11. What is Hypertension?
12. What is Arterial Hypertension?
13. What is the relationship between hypertension and fluid volume?
14. Use the table below to describe the action of each class of blood pressure medications.
Class
Action
ACE
Inhibitors
ARBS
CCB
Beta
Blockers.
Answer the following critical thinking questions.
15. The nurse is preparing medication education for a patient who has been prescribed captopril (Capoten).
Discuss the essential information that the patient should receive as part of this education.
16. State the nursing assessments needed to monitor therapeutic response and the development of common and
serious adverse effects from beta-adrenergic blocking agents and calcium channel blockers. Differentiate the
drugs according to indications of therapy.
17. What are two patient educational objectives for a patient receiving beta-adrenergic blocking agents for
treatment of hypertension?
18. Lifestyle modifications are extremely important for the treatment of hypertension, but habits can be difficult
to change for patients. Discuss education and referrals that the nurse will include.
Situation: A 64-year-old man comes to the emergency department with acute chest pain. He is holding his chest
with his fist directly over the sternum. He is diaphoretic. He is in work clothes and has been mowing the lawn.
It is 98º F outside.
19. What nursing actions would be appropriate immediately?
20. What drugs would likely be ordered if this were acute angina pectoris?
21. If a stat dose of nitroglycerin sublingual spray were ordered, what instructions would you give the patient
for administering it?
Situation: When giving morning medications in the nursing home, the nurse comes to an order to apply a 2.5mg Nitro-Dur patch to a patient. The medication administration record (MAR) indicates that the previous patch
was applied to the right scapular area, but the patch is not there.
22. How would you proceed to execute the order?
23. Summarize the actions of each major classification of drugs used to treat angina pectoris.
24. Identify pre assessment data that should be obtained before initiating drug therapy for angina.
25. Lopressor
Classification
Generic Name
Indications
Action
Therapeutic Effect
Most frequent side
effect
Nursing intervention
Descriptions
CARDIAC
Antianginal agents
• Antianginals= relieve chest pain by dilating
coronary arteries which allows more O2 –rich blood
to travel to myocardium
ANGINA
?
?
When the supply of oxygen and nutrients in
the blood is insufficient to meet the demands
of the heart, the heart muscle “aches”
The heart requires a large supply of oxygen to
meet the demands placed
Ischemia
?
Ischemia
?
?
Poor blood supply to an organ
Ischemic heart disease
?
Poor blood supply to the heart muscle
? Atherosclerosis
? Coronary artery disease
?
Myocardial infarction (MI)
?
Necrosis, or death, of cardiac tissue
? Disabling or fatal
Ischemia
?
?
?
Chronic stable angina
(also called classic or effort angina)
-occurs with activity or stress
Unstable angina
(also called preinfarction or crescendo angina)
-unexpected chest pain, usually occurring with
rest; progressively becomes worse and may lead
to MI
Vasospastic angina
(also called Prinzmetal’s or variant angina)
-spasms in coronary artery restrict blood flow
causing chest pain, usually occurring while at rest
Antianginal agents
? Type: Nitrates
Nitrates produce vasodilation, decrease preload and
afterload, and reduce myocardial oxygen
consumption.
a. action: arterial, venous, and capillary vasodilation by
relaxing vascular smooth muscle
i.
decreases myocardial oxygen consumption
ii.
decreases preload with venous pooling
iii.
decreases afterload by decreasing peripheral vascular
resistance
Drugs for Angina
? Nitrates/nitrites
? Beta-blockers
? Calcium channel blockers
Therapeutic Objectives
?
?
?
Minimize the frequency of attacks and decrease
the duration and intensity of anginal pain
Improve the patient’s functional capacity with as
few adverse effects as possible
Prevent or delay the worst possible outcome: MI
Nitrates/Nitrites
?
?
?
?
?
Sublingual*
Buccal*
Chewable tablets
Oral capsules/tablets
Intravenous solutions*
*Bypass the liver and the firstpass effect
?
?
?
Transdermal patches*
Ointments*
Translingual sprays*
Nitrates/Nitrites
?
Rapid-acting forms
?
?
?
Used to treat acute anginal attacks
Sublingual tablets; intravenous infusion
Long-acting forms
?
Used to PREVENT anginal episodes
Nitrates/Nitrites
?
?
?
?
?
?
?
Cause vasodilation because of relaxation of
smooth muscles
Potent dilating effect on coronary arteries
Used for prevention and treatment
of angina
Vasodilation results in reduced myocardial oxygen
demand
Nitrates cause dilation of both large and small
coronary vessels
Result: oxygen to ischemic myocardial tissue
Nitrates alleviate coronary artery spasms
Nitroglycerin
a.
Nitroglycerin
?
Prototypical nitrate
? Large first-pass effect with oral forms
? Used for symptomatic treatment of ischemic heart conditions (angina)
? IV form used for BP control in perioperative hypertension, treatment of
HF, ischemic pain, pulmonary edema associated with acute MI, and
hypertensive emergencies
i.
(Nitro-Bid) IV (titrate according to blood pressure)
ii.
(Nitro-Dur) 1 transdermal patch daily
iii.
(Nitrostat) one 0.4 mg sublingual tablet under the tongue; may repeat
every 5 minutes up to 3 tablets
Route
Use
Sublingual tablet Treat acute
and translingual attack
spray
• Prophylaxis of acute attack
• Rapid onset
• Short duration
Transmucosal
• Rapid onset
• Long duration
Sustainedrelease
oral capsules
• Slow onset
• Long duration
Treat acute
attack
• Prophylaxis of acute attack
• Long-term prophylaxis
against anginal
attacks
Long-term prophylaxis against
anginal
attacks
Nursing Intervention
• Use this rapid-acting nitrate at the first sign of chest pain. Do not
wait until pain is severe.
• Use prior to activity that is known to cause chest pain, such as
climbing a flight of stairs.
For sublingual tablet:
?Place the tablet under the tongue and allow it to dissolve.
?Tablets should be stored in original
bottles, and in a cool, dark place.
?Discard tablets after 24 months unless indicated on the package.
• Translingual spray should be sprayed against oral mucosa and not
inhaled.
• Use this rapid-acting nitrate at the first sign of chest pain. Do not
wait until pain is severe.
• Use prior to activity that is known to cause chest pain, such as
climbing a flight of stairs.
• Do not chew the tablet, but place the tablet between the upper
lip and gum, or between the cheek and gum to be dissolved.
Swallow capsules without crushing or chewing.
Route
Use
Nursing Intervention
Transdermal
• Slow onset
• Long duration
Long-term prophylaxis
against anginal attacks
• To ensure appropriate dose, patches should not be cut.
• Place the patch on a hairless area of skin (chest, back, or abdomen) and
rotate sites to prevent skin irritation.
• Wash skin with soap and water and dry thoroughly before applying new
patch.
• Remove the patch at night to reduce the risk of developing tolerance to
nitroglycerin. Be medication-free a minimum of 8 hr each day.
Topical Ointment
• Slow onset
• Long duration
Long-term prophylaxis
against anginal attacks
• Remove the prior dose before a new dose is applied. Measure
specific dose with applicator paper and spread over 2.5 to 3.5
inches of the paper.
• Apply to a clean, hairless area of the body, and cover with clear
plastic wrap.
• Follow same guidelines for site selection as for transdermal
patch.
• Avoid touching ointment with the hands.
Intravenous
Control of angina
not responding to
other medications
• Control of BP
or induced
hypotension
during surgery
• Heart failure
resulting from
acute MI
• Administer with IV tubing supplied by manufacturer using a glass IV
bottle.
• Administer continuously due to short duration of action.
• Start at a slow rate, usually 5 mcg/min, and titrate gradually until desired
response is achieved.
• Provide continuous cardiac monitoring during administration.
SIDE EFFECTS
NURSING INTERVENTIONS
Headache
• Instruct clients to use aspirin or acetaminophen to relieve
pain.
• Clients should notify the provider if symptoms do not resolve
in a few weeks. Dosage may need to be reduced.
Orthostatic
hypotension
• Advise clients to sit or lie down if experiencing dizziness or
faintness.
• Clients should avoid sudden changes of position and rise
slowly.
• Monitor the client’s vital signs.
• Administer a beta-blocker such as metoprolol (Lopressor) if
symptoms occur.
Reflex tachycardia
(increased pulse
due to specific
stimulus)
Tolerance
• Use lowest dose needed to achieve effect.
• All long-acting forms of nitroglycerin should be taken with a
medication-free period each day (usually 8 hr).
Use of alcohol can contribute
to the hypotensive effect of
nitroglycerin
Antihypertensive
medications, such as
betablockers,calcium channel
blockers, and diuretics can
contribute to hypotensive
effect
Use of sildenafil (Viagra) and
nitroglycerin can result in lifethreatening hypotension
Advise clients to avoid use of
alcohol.
Use nitroglycerin cautiously
in clients receiving these
medications.
Instruct clients not to take
sildenafil if prescribed
nitroglycerin
SIDE EFFECTS
i.
Life-threatening: sudden, severe refractory hypotension
when taken with sildenafil citrate (Viagra) or tadalafil
(Cialis), methemoglobinemia:high amt of
methemoglobin(type of hemoglobin) contact dermatitis
ii.
Most common: headache, nausea, vomiting, dizziness,
reflex tachycardia, postural hypotension
iii.
OTHER
iv. Dizziness,
Weakness, Flushing or Pallor, Paradoxical
bradycardia are possible.
Contraindications
i.
Severe anemia, cardiac tamponade
ii.
Cerebral hemorrhage or trauma
iii.
Hypovolemia, hypotension, shock
iv.
Nitroglycerin is Pregnancy Risk Category C.
v.
This medication is contraindicated in clients with hypersensitivity
to nitrates.
vi.
Nitroglycerin is contraindicated in clients with traumatic head
injury because the medication can increase intracranial pressure.
vii.
Nitrates are contraindicated in the client with increased
intracranial pressure
viii. Use
cautiously in clients taking antihypertensive medications and
clients who have renal or liver dysfunction.
Treatment of Anginal Attack
? Instruct the client to stop activity.
? The client should take a dose of rapid-acting nitroglycerin
immediately.
? If pain is unrelieved in 5 min, the client should call 9-1-1 or be
driven to an emergency department.
? The client can take up to two more doses at 5 min intervals.
? Advise clients not to stop taking long-acting nitroglycerin abruptly
and follow the provider’s instructions.
Advise clients who have angina to record pain frequency, intensity,
duration, and location.
? The provider should be notified if attacks increase in frequency,
intensity, and/or duration.
?
Nursing care
i.
establish baseline data and monitor during acute angina or
IV administration: blood pressure, heart rate, EKG, chest
pain
ii.
may decrease effectiveness of heparin
iii.
withdraw treatment gradually to avoid angina
iv.
toxicity: central nervous system changes, hypotension,
flushing, nausea
v.
buccal area must be moist for sublingual absorption
vi.
may induce alcohol intoxication (without alcohol intake)
vii. maintain
a 6 to 8 hour nitrate-free period every 24 hours after
acute episode to avoid tolerance
Nursing Evaluation of Medication Effectiveness
? Depending on therapeutic intent, effectiveness may be
evidenced by:
? Prevention of acute anginal attacks
? Long-term management of stable angina
? Control of perioperative blood pressure
? Control of heart failure following acute MI
Nitrates
TYPE: ISOSORBIDE (ISOSORBIDE DINITRATE
AND ISOSORBIDE MONONITRATE
i.
Action: vasodilation by relaxing arterial and venous
smooth muscle; decreases preload with venous pooling,
peripheral vascular resistance, and myocardial oxygen
consumption
?
?
Isosorbide dinitrate
(Isordil, Sorbitrate, Dilatrate SR)
Isosorbide mononitrate
(Imdur, Monoket, ISMO)
a. sublingual (adults)
a. acute attack of angina pectoris: 2.5-5 mg; may be repeated every 5 to 10
minutes for 3 doses in 15 to 30 minutes
b. prophylaxis of angina pectoris: 2.5-5 mg given 15 minutes prior to
activities known to provide angina
b.
oral (adults)
a. prophylaxis of angina pectoris: 5-20 mg, 2 to 3 times daily
b. usual maintenance dose: 10-40 mg every 6 hours (immediate-release) or
40-80 mg every 8 to 12 hours (sustained-release)
•
isosorbide mononitrate (Imdur, Monoket): used for prevention of angina pectoris
a.
Imdur: 30-60 mg by mouth once daily; may increase to 120 mg once daily
(maximum 240 mg/day)
b.
Monoket: 5-20 mg twice daily with the 2 doses given 7 hours apart
Isosorbide
? Used
for:
• Acute relief of angina
• Prophylaxis in situations that may
provoke angina
• Long-term prophylaxis of angina
Tolerance
?
?
Occurs in patients taking nitrates around the clock
or with long-acting forms
Prevented by allowing a regular nitrate-free period
to allow enzyme pathways to replenish
?
Transdermal forms: remove patch at bedtime for 8
hours, then apply a new patch in the morning
Adverse effects
?
?
?
Headaches
? Usually diminish in intensity and frequency
with continued use
Tachycardia, postural hypotension
Tolerance may develop
ANTIANGINAL AGENT
Antianginal Agent
? Medication: ranolazine (Ranexa)
Purpose
? Lowers cardiac oxygen demand and thereby improves
exercise tolerance and decreases pain
Therapeutic Uses
? Chronic stable angina in combination with amlodipine
(Norvasc), a beta adrenergic blocker or an organic nitrate
Complications
Side/Adverse Effects Nursing Interventions/Client Education
? QT prolongation – Monitor ECG
? Elevated blood pressure – Monitor blood pressure
Contraindications/Precautions
?
Ranolazine is contraindicated in clients who have QT
prolongation or in clients taking other medications that
can result in QT prolongation.
? This medication is contraindicated in clients who have
liver dysfunction.
? Use cautiously in older adult clients.
Medication/Food Interactions
Nursing Interventions/Client
Education
Inhibitors of CYP3A4(enzyme that
metabolizes most drugs) can increase levels
of ranolazine and lead to torsades de
pointes(sudden ventricular tachycardia).
Agents include grapefruit juice, HIV
protease inhibitors, macrolide antibiotics,
azole antifungals and verapamil.
Quinidine and sotalol (Betapace) can
further increase QT interval
Concurrent use of digoxin (Lanoxin) and
simvastatin (Zocor) increases serum levels
of digoxin and simvastatin.
• Avoid concurrent use
• Avoid concurrent use.
• Monitor digoxin level.
• Instruct client to report muscle
weakness.
Nursing Administration
Administer as an extended release oral tablet, twice daily.
Obtain baseline and monitor ECG for QT prolongation.
? Obtain baseline and monitor digoxin level with concurrent
use.
? Nursing Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be
evidenced by:
Prevention of acute anginal attacks
Long-term management of stable angina
?
?
?
?
?

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