Student Name:_Jazmine Morales_______
Date:__3/12/21_____ Course: Block 4 Sim: Melody Dixon
Pathophysiology (to be done in your own words):
∙Acute Coronary Syndrome
Acute coronary syndrome is an emergency situation in which acute onset of myocardial (heart muscle) ischemia
(decreases in blood flow) results in myocardial death, if left untreated. Acute coronary syndrome is considered an
umbrella term for unstable angina, NSTEMI, and ST-segment elevation myocardial infarction (STEMI).
During unstable angina, there is reduced blood flow in a coronary artery, often due to rupture of an atherosclerotic
plaque. Then a clot begins to form on top of the coronary lesion, but the artery is not completely occluded. This results in
chest pain and other symptoms and the patient is at risk of having an MI, if left untreated.
During an MI, plaque rupture and thrombus formation result in complete occlusion of the artery, leading to inadequate
blood supply and cell death of the cardiac muscle supplied by that artery. Sudden constriction of a coronary artery,
decreased oxygen supply and increased demand for oxygen are other causes of MI.
As the cells are deprived of oxygen, ischemia develops, cellular injury occurs, and the lack of oxygen results in infarction,
or the death of cells.
NSTEMI and STEMI refers to the location of the injury to the ventricular wall (anterior, inferior, posterior, or lateral wall),
and the point in time within the process of infarction (acute, evolving, or old).
Medication: Morphine
∙Route/Onset/Peak/Duration:
Route
Onset
Peak
Duration
PO
30 min
1–2 hr
3–5 hr
PO (extended-release)
1–2 hr
3–4 hr
8–24 hr
IV
5–10 min
20 min
4–5 hr
IM
10–30 min
30–60 min
4–5 hr
∙Dosage
Moderate to severe pain
Adults: Initially, 10 mg (based on 70 kg individual) IM or 0.1 to 0.2 mg/kg IV every 4 hours p.r.n. Or, 15 to 30 mg
(immediate-release tablets) PO, or 10 to 20 mg (oral solution) PO, or 10 to 20 mg PR every 4 hours p.r.n.
In adults with severe, chronic pain, maintenance IV infusion is 0.8 to 80 mg/hour; sometimes higher doses are needed.
∙Adverse reactions:
CNS: dizziness, drowsiness, headache, euphoria, light-headedness, nightmares, sedation,
somnolence, seizures, depression, hallucinations, nervousness, physical dependence, syncope, anxiety.
CV: bradycardia, cardiac arrest, shock, HTN, hypotension, tachycardia, palpitations, peripheral circulatory collapse,
peripheral edema, chest pain, syncope.
EENT: miosis, blurred vision.
GI: constipation, nausea, vomiting, anorexia, biliary tract spasms, dry mouth, ileus, flatulence, abdominal pain.
GU: urine retention.
Hematologic: thrombocytopenia, anemia, leukopenia.
Respiratory: apnea, respiratory arrest, respiratory depression.
Skin: diaphoresis, edema, pruritus, skin flushing, pain at injection site.
∙ Interactions:
Cimetidine: May increase respiratory and CNS depression when given with morphine sulfate. Monitor patient closely.
General anesthetics, hypnotics, MAO inhibitors, other opioid analgesics, TCAs: May cause respiratory depression,
hypotension, profound sedation, or coma. Use together with caution, reduce morphine dose, and monitor patient
response.
St. John’s wort: May increase risk of serotonin syndrome. Use together cautiously and monitor patient for serotonin
syndrome.
∙ Efects on lab results
May increase amylase level. May decrease Hb level (morphine sulfate).
May decrease platelet count.
May cause abnormal LFT values (morphine sulfate).
∙ Contraindications and cautions:
Contraindicated in patients hypersensitive to drug and in those with conditions that would preclude IV administration of
opioids (acute bronchial asthma or upper airway obstruction).
∙ Nursing considerations
Assess each patient’s risk of addiction, abuse, or misuse before prescribing extended-release or long-acting forms of
morphine sulfate, and monitor all patients regularly for development of these behaviors.
Monitor patients for respiratory depression, especially during initiation of extended-release or long-acting morphine
sulfate or after a dosage increase.
Monitor patient for signs and symptoms of adrenal insufficiency (nausea, vomiting, loss of appetite, fatigue, weakness,
dizziness, low BP). Perform diagnostic testing if adrenal insufficiency is suspected. If adrenal insufficiency is confirmed,
treat with corticosteroids and wean patient off opioids if appropriate. Discontinue corticosteroids when clinically
appropriate.
∙ Patient teaching:
Explain assessment and monitoring process to patient and family. Instruct them to immediately report difficulty
breathing or other signs or symptoms of a potential adverse opioid-related reaction.
Encourage patient to report all medications being taken, including prescription and OTC medications and supplements.
Warn patient that morphine can cause constipation.
Caution patient to immediately report signs and symptoms of serotonin syndrome, adrenal insufficiency, and decreased
sex hormone levels.
When drug is used after surgery, encourage patient to turn, cough, deep-breathe, and use incentive spirometer to
prevent lung problems.
Medication: Metformin
Decreases hepatic glucose production and intestinal absorption of glucose and improves insulin sensitivity (increases
peripheral glucose uptake and use).
∙Route/Onset/Peak/Duration:
Adults: 1 inch (2.5 cm) of ointment PR every 12 hours for up to 3 weeks.
∙Adverse reactions:
CNS: headache, dizziness, syncope, weakness.
CV: orthostatic hypotension, bradycardia, flushing, palpitations, peripheral edema.
EENT: pharyngitis, rhinitis, SL burning.
GI: nausea, vomiting, abdominal pain.
Respiratory: dyspnea.
Skin: contact dermatitis, rash.
Other: hypersensitivity reactions.
∙ Interactions:
Antihypertensives: May increase hypotensive effect. Monitor BP closely.
Ergotamine, ergot derivatives: May diminish vasodilatory effect of nitroglycerin. Avoid combination.
Heparin: IV nitroglycerin may interfere with anticoagulant effect of heparin. Monitor PTT.
∙ Efects on lab results:
May falsely decrease values in cholesterol determination tests using the Zlatkis-Zak color reaction.
∙ Contraindications and cautions:
Contraindicated in patients hypersensitive to drug.
Contraindicated in patients with early MI (oral and sublingual), severe anemia, increased ICP, angle-closure glaucoma,
orthostatic hypotension, allergy to adhesives (transdermal), or hypersensitivity to nitrates.
IV nitroglycerin is contraindicated in patients hypersensitive to IV form and in those with cardiac tamponade, restrictive
cardiomyopathy, or constrictive pericarditis.
Use cautiously in patients with hypotension or volume depletion.
∙ Nursing considerations:
Closely monitor vital signs, particularly BP, during infusion, especially in patient with an MI. Excessive hypotension can
worsen ischemia.
Monitor BP and intensity and duration of drug response.
Drug may cause headaches, especially at beginning of therapy. Dosage may be reduced temporarily, but tolerance usually
develops. Treat headache with aspirin or acetaminophen.
Tolerance to drug can be minimized with a 10- to 12-hour nitrate-free interval.
Wipe off nitroglycerin paste or remove patch before defibrillation to avoid patient burns.
∙ Patient teaching:
Caution patient to take nitroglycerin regularly, as prescribed, and to have it accessible at all times.
Alert: Advise patient that stopping drug abruptly may cause coronary artery spasm.
Teach patient how to give the prescribed form of nitroglycerin.
Tell patient to take SL tablet at first sign of attack. Patient should wet the tablet with saliva, place it under the tongue
until absorbed, and then sit down and rest. Patient may repeat dose every 5 minutes for a maximum of three doses. If
drug doesn’t provide relief, patient should obtain medical help promptly.
Advise patient who complains of a tingling sensation with SL drug to try holding tablet in cheek.
Tell patient not to use more than 3 packets of SL powder in a 15-minute period and to obtain medical help promptly if
drug doesn’t provide relief. Advise patient not to swallow or spit for 5 minutes after taking each packet.
Tell patient to take oral tablets on an empty stomach either 30 minutes before or 1 to 2 hours after meals, to swallow
oral tablets whole, and not to chew tablets.
Medication: Aspirin
Route/Onset/Peak/Duration:
Route
Onset
Peak
Duration
PO (buffered)
5–30 min
1–2 hr
1–4 hr
PO (enteric-coated)
5–30 min
Variable
1–4 hr
PO (tablet)
5–30 min
25–40 min
1–4 hr
PO (extended-release)
Unknown
2 hr
4–8 hr
∙Dosage:
Suspected acute MI
Adults: Initial dose of 160 to 325 mg PO (non-enteric-coated) chewed or crushed as soon as MI is suspected. Continue
maintenance dose of 160 to 325 mg PO daily for 30 days after infarction.
To reduce risk of MI in patients with previous MI, unstable angina, and chronic stable angina pectoris
Adults: 75 to 325 mg PO daily. Or, 162.5 mg extended-release capsule PO daily.
To reduce risk of recurrent TIAs and stroke or death in patients at risk
Adults: 50 to 325 mg PO daily. Or, 162.5 mg extended-release capsule PO daily.
Acute ischemic stroke
Adults: 50 to 325 mg PO daily, started within 48 hours of stroke onset; continue indefinitely.
CABG
Adults: 325 mg PO daily starting 6 hours postprocedure.
∙Adverse reactions:
CNS: agitation, cerebral edema, coma, confusion, dizziness, headache, lethargy, seizures, subdural or intracranial
hemorrhage.
CV: arrhythmias, hypotension, tachycardia.
EENT: tinnitus, hearing loss.
GI: nausea, GI bleeding, dyspepsia, GI distress, occult bleeding, pancreatitis, vomiting.
GU: antepartum and postpartum bleeding, interstitial nephritis, papillary necrosis, prolonged pregnancy and labor,
proteinuria, renal insufficiency, renal failure.
Hematologic: prolonged bleeding time, leukopenia, thrombocytopenia, coagulopathy, DIC.
Hepatic: hepatitis.
Metabolic: dehydration, hyperkalemia, hyperglycemia; hypoglycemia (children), metabolic acidosis, respiratory alkalosis.
Skin: rash, bruising, urticaria, hives.
Other: angioedema, Reye syndrome, hypersensitivity reactions, low birth weight (infants), stillbirth.
∙ Interactions:
ACE inhibitors: May decrease antihypertensive effects. Monitor BP closely.
Antacids in high doses and other urine alkalinizers: May decrease levels of aspirin products. Watch for decreased aspirin
effect.
Beta blockers: May decrease antihypertensive effect. Avoid long-term aspirin use if patient is taking antihypertensives.
Diuretics: May decrease effectiveness of diuretics in patients with underlying renal or CV disease. Monitor patient for
effectiveness.
Heparin: May increase risk of bleeding. Monitor coagulation studies and patient closely if used together.
Ibuprofen, other NSAIDs: May negate the antiplatelet effect of low-dose aspirin therapy.
∙ Efects on lab results:
May increase LFT values, BUN, creatinine, and potassium levels.
May decrease platelet and WBC counts.
May falsely decrease protein-bound iodine level.
May interfere with urine glucose analysis with Diastix, Chemstrip uG, Clinitest, and Benedict solution; with urinary 5hydroxyindoleacetic acid and vanillylmandelic acid tests; and with Gerhardt test for urine acetoacetic acid.
∙ Contraindications and cautions:
Contraindicated in patients hypersensitive to drug and in those with NSAID-induced sensitivity reactions, G6PD
deficiency, or bleeding disorders, such as hemophilia, von Willebrand disease, telangiectasia, bleeding ulcers, and
hemorrhagic states.
Use cautiously in patients with GI lesions, impaired renal function, hypoprothrombinemia, vitamin K deficiency,
thrombocytopenia, or thrombotic thrombocytopenic purpura.
Avoid use in patients with severe hepatic impairment or history of active peptic ulcer disease.
∙ Nursing considerations
For inflammatory conditions, rheumatic fever, and thrombosis, give aspirin on a schedule rather than as needed.
Because enteric-coated tablets are slowly absorbed, they aren’t suitable for rapid relief of acute pain, fever, or
inflammation. They cause less GI bleeding and may be better suited for long-term therapy, such as for arthritis.
For patients who can’t tolerate oral drugs, ask prescriber about using aspirin rectal suppositories. Watch for rectal
mucosal irritation or bleeding.
During prolonged therapy, assess hematocrit, Hb level, PT, INR, and renal function periodically.
∙ Patient teaching:
Tell patient who’s allergic to tartrazine to avoid aspirin.
Advise patient on a low-salt diet that 1 tablet of buffered aspirin contains 553 mg of sodium.
Advise patient to take drug with food, milk, antacid, or large glass of water to reduce GI reactions.
Tell patient not to crush or chew enteric-coated or extended-release forms but to swallow them whole.
Advise patient to take extended-release capsules at same time each day.
Warn patient not to drink alcohol 2 hours before or 1 hour after taking extended-release capsule and not to take extra
capsule to make up for a missed dose.
Remind patient taking drug for a chronic condition not to stop drug without first discussing with prescriber.
Instruct patient to discard aspirin tablets that have a strong vinegar-like odor.
Medication: Heparin
Accelerates formation of antithrombin III–thrombin complex and deactivates thrombin, preventing conversion of
fibrinogen to fibrin.
∙Route/Onset/Peak/Duration:
Route
Onset
Peak
Duration
IV
Immediate
Immediate
Variable
Subcut
20–30 min
2–4 hr
Variable
∙Dosage:
Thromboprophylaxis
Adults: 5,000 units subcut every 8 to 12 hours for a minimum of 7 days or for 10 to 14 days for patients undergoing total
hip arthroplasty, total knee arthroplasty, or hip fracture surgery
Full-dose continuous IV infusion therapy for DVT or PE
Adults: Initially, 5,000 units (or 80 units/kg) by IV bolus; then 20,000 to 40,000 units/day (or 18 units/kg/hour) by IV
infusion with pump. Titrate hourly rate based on aPTT results
Full-dose subcut therapy for DVT or PE
Adults: Initially, 5,000 units IV bolus and 10,000 to 20,000 units in a concentrated solution subcut;
Full-dose intermittent anticoagulation IV therapy for DVT or PE
Adults: Initially, 10,000 units by IV bolus; then 5,000 to 10,000 units (or 50 to 70 units/kg) IV every 4 to 6 hours titrated
according to aPTT.
∙Adverse reactions:
CNS: fever.
EENT: rhinitis.
Hematologic: hemorrhage, overly prolonged clotting time, thrombocytopenia, white clot syndrome.
Metabolic: hyperkalemia, hypoaldosteronism.
Musculoskeletal: osteoporosis.
Skin: irritation, mild pain, hematoma, ulceration, cutaneous or subcutaneous necrosis, pruritus, urticaria,
transient alopecia.
Other: hypersensitivity reactions, including chills; anaphylactoid reactions.
∙ Interactions:
Antihistamines, nitrates: May decrease heparin effect. Monitor coagulation tests.
Antiplatelet drugs, salicylates: May increase anticoagulant effect. Use together cautiously. Monitor coagulation studies
and patient closely.
Nitroglycerin: May decrease effects of heparin. Monitor patient closely.
Oral anticoagulants: May increase additive anticoagulation. Monitor PT, INR, and PTT. Avoid combination.
Thrombolytics: May increase risk of hemorrhage. Monitor patient closely.
∙ Efects on lab results
May increase ALT, AST, and potassium levels.
May increase INR and prolong PT and aPTT. May decrease platelet count.
Drug may cause false elevations in some tests for thyroxine level.
∙ Contraindications and cautions:
in patients hypersensitive to drug or pork products.
Conditionally contraindicated in patients with active bleeding, blood dyscrasia, or bleeding tendencies, such as
hemophilia, thrombocytopenia, history of heparin-induced thrombocytopenia (HIT), or hepatic disease with
hypoprothrombinemia; suspected intracranial hemorrhage; suppurative thrombophlebitis; inaccessible ulcerative lesions
(especially of GI tract) and open ulcerative wounds; extensive denudation of skin; ascorbic acid deficiency; and other
conditions that cause increased capillary permeability.
Conditionally contraindicated during or after brain, eye, or spinal cord surgery; during spinal tap or spinal anesthesia;
during continuous tube drainage of stomach or small intestine; and in subacute bacterial endocarditis, shock, advanced
renal disease, threatened abortion, or severe HTN.
May reduce bone mineral density with prolonged use (longer than 6 months).
Use cautiously in women older than age 60 because of an increased risk of bleeding.
∙ Nursing considerations
Although heparin use is clearly hazardous in certain conditions, its risks and benefits must be evaluated.
Alert: Some commercially available heparin injections contain benzyl alcohol.
Drug requirements are higher in early phases of thrombogenic diseases and febrile states; they are lower when patient’s
condition stabilizes.
Elderly patients should usually start at lower dosage.
Monitor patients for hyperkalemia during therapy.
Alert: Check order and vial carefully; heparin comes in various concentrations. It’s now required that the label clearly
state the strength of the entire container followed by how much medication is in 1 mL.
Alert: USP and international units aren’t equivalent for heparin.
Alert: Heparin, low-molecular-weight heparins, and danaparoid aren’t interchangeable.
∙ Patient teaching:
Instruct patient and family to report all adverse reactions.
Advise patient and family to watch for signs and symptoms of bleeding or bruising and to notify prescriber immediately if
any occur.
Tell patient to avoid OTC drugs containing aspirin, other salicylates, or drugs that may interact with heparin unless
ordered by prescriber.
Advise patient to consult prescriber before starting herbal therapy; many herbs have anticoagulant, antiplatelet, or
fibrinolytic properties.
Medication: Zofran (ondansetron)
∙Route/Onset/Peak/Duration:
Route
Onset
Peak
Duration
PO
30 min
1–2 hr
Unknown
IV
Immediate
Unknown
Unknown
IM
Unknown
Unknown
Unknown
∙Dosage
To prevent nausea and vomiting from highly emetogenic chemotherapy
Adults: Administer in combination with neurokinin 1 receptor antagonist and dexamethasone, with or without
olanzapine. Give 24 mg PO as a single dose or 8 mg PO b.i.d. for two doses 30 minutes before chemotherapy
To prevent postoperative nausea and vomiting
Adults: 4 mg undiluted solution for injection IM or IV over 2 to 5 minutes at end of surgery. Or, 8 mg ODT or oral soluble
film PO as a single dose 30 to 60 minutes before surgery.
∙Adverse reactions:
CNS: dizziness, fatigue, headache, malaise, sedation, extrapyramidal syndrome, fever, agitation, anxiety, pain.
CV: arrhythmias, chest pain.
GI: constipation, diarrhea.
GU: gynecologic disorders, urine retention.
Respiratory: hypoxia.
Skin: pruritus, rash.
Other: chills, injection-site reaction.
∙ Interactions:
Alert: Apomorphine: May cause profound hypotension and loss of consciousness. Use together is contraindicated.
Drugs (such as cimetidine) that alter hepatic drug-metabolizing enzymes, phenobarbital, rifampin: May change
pharmacokinetics of ondansetron, but there is no need to adjust dosage based on clinical data.
Drugs that prolong QTc interval (antiarrhythmics, antipsychotics, antidepressants): May result in ventricular arrhythmias.
Use cautiously and avoid combination with drugs at highest risk for QTc-interval prolongation.
SSNRIs, SSRIs: May result in serotonin syndrome. Use cautiously and monitor patient for mental status changes,
tachycardia, sweating, flushing, nausea, vomiting, tremors, and muscle rigidity.
∙ Efects on lab results
May increase ALT and AST levels.
∙ Contraindications and cautions:
Contraindicated in patients hypersensitive to drug.
ECG changes, including prolonged QT interval and torsades de pointes, have been reported. Avoid use in patients with
congenital long QT syndrome. Monitor patient carefully.
Use cautiously in patients with hepatic impairment.
∙ Nursing considerations:
Drug may increase the risk of prolonged QT interval and torsades de pointes (a potentially fatal heart rhythm). Monitor
ECG in patients with congenital long QT syndrome, in those with HF or bradyarrhythmias, and in those taking other
medications that can prolong the QT interval.
Correct electrolyte abnormalities (hypokalemia or hypomagnesemia) before infusing drug.
Monitor LFT results. Don’t exceed 8 mg in patients with hepatic impairment.
Monitor patient for signs and symptoms of serotonin syndrome.
Look alike-sound alike: Don’t confuse Zofran with Zosyn, Zantac, or Zoloft.
∙ Patient teaching:
Alert: Caution patient to contact health care provider immediately for signs and symptoms of abnormal HR or rhythm,
such as palpitations, dyspnea, or dizziness.
Tell patient that an ECG may be necessary to monitor HR and rhythm.
Instruct patient to immediately report difficulty breathing after drug administration.
Tell patient receiving drug IV to report discomfort at insertion site.
Tell patient taking ODTs to open blister just before use by peeling backing off and not by pushing through foil blister and
that taking ODT with liquid isn’t required.
Teach patient to place ODTs or film on tongue, allow to dissolve, then swallow with saliva.
Normal Lab values
∙ CBC
Hemoglobin: 13-17 g/dL (men), 12-15 g/dL (women)
Hematocrit 40%-52% (men), 36%-47%
Glycosylated hemoglobin 4%-6%
Mean corpuscular volume (MCV): 80-100 fL
Red blood cell distribution width (RDW): 11.5%-14.5%
Mean corpuscular hemoglobin (MCH): 0.4-0.5 fmol/cell
Mean corpuscular hemoglobin concentration (MCHC): 30-35 g/dL
Reticulocytes 0.5%-1.5%
White blood cells (WBC) 4-10 x 10^9/L
Neutrophils: 2-8 x 10^9/L
Bands: < 1 x 10^9/L
Lymphocytes: 1-4 x 10^9/L
Monocytes: 0.2-0.8 x 10^9/L
Eosinophils: < 0.5 x 10^9/L
Platelets: 150-400 x 10^9/L
Fibrinogen: 1.8-4 g/L
Bleeding time: 2-9 min
∙ CMP
Albumin: 35-50 g/L
Alkaline phosphatase: 50-100 U/L
Alanine aminotransferase (ALT): 5-30 U/L
Amylase: 30-125 U/L
Aspartate aminotransferase (AST): 5-30 U/L
Direct bilirubin: 0-6 µmol/L
Gamma glutamyl transferase: 6-50 U/L
Lipase: 10-150 U/L
Total bilirubin: 2-20 µmol/L
Total protein: 60-80 g/L
∙ PT/INR
Prothrombin time: 11-14 sec
International normalized ratio (INR): 0.9-1.2
∙ PTT
Activated partial thromboplastin time (aPTT): 20-40 sec
∙ CPKMB
Creatine kinase: 25-200 U/L
Creatine kinase MB (CKMB): 0-4 ng/mL
∙Troponin
Troponin: 0-0.4 ng/mL
∙ HDL/LDL Triglycerides
Triglycerides: 50-150 mg/dL
Total cholesterol: 3-5.5 mmol/L
High-density lipoprotein (HDL): 40-80 mg/dL
Low-density lipoprotein (LDL): 85-125 mg/dL
Priority interventions with rationale:
∙ RELIEVING PAIN AND OTHER SIGNS AND SYMPTOMS OF ISCHEMIA
∙ IMPROVING RESPIRATORY FUNCTION
∙ PROMOTING ADEQUATE TISSUE PERFUSION
Priority teaching topics:
Avoid any activity that produces chest pain, extreme dyspnea, or undue fatigue.
Avoid extremes of heat and cold and walking against the wind.
Lose weight, if indicated.
Stop smoking and the use of tobacco; avoid secondhand smoke.
Develop heart-healthy eating patterns, and avoid large meals and hurrying while eating.
Call 911 if chest pressure or pain (or prodromal symptoms) is not relieved in 15 minutes by taking 3 nitroglycerin tablets
at 5-minute intervals.
Contact the primary provider if any of the following occur: shortness of breath, fainting, slow or rapid heartbeat, swelling
of feet and ankles.