~ Digoxin (Lanoxin)
● Normal Ranges
○ 0.125 - 0.25 mg daily
○ Onset: 30min - 2hr
○ Peak:2 - 8hr
○ Duration:3 - 4days
● Class
○ Cardiac Glycoside, antiarrhythmic
● Physiological Actions
○ Heart failure: inhibits Na/K ATPase pump in myocardial cells, promotes
Ca influx, and increases contractility
○ Supraventricular arrhythmias: suppresses AV node conduction and
decreases ventricular heart rate of atrial arrhythmias
● Indications
○ Tx of mild to moderate HF
○ Control ventricular response rate in PT with chronic atrial fib
● Contraindications
○ Hypersensitivity
○ Ventricular Fibrillation
● Cautions
○ Renal impairment
○ Sinus node disease
○ Acute MI within 6 months
○ 2nd & 3rd degree heart block
○ Concurrent use of strong inhibitors or inducers of P-glycoprotein
○ Hyperthyroidism & hypothyroidism
○ Hypokalemia
○ Hypocalcemia
● Side effects
○ Dizziness
○ Headache
○ Diarrhea
○ Rash
○ Visual disturbances (halos)
● Adverse Reactions
○ Nausea, vomiting
○ Anorexia
○ Personality changes
○ Ocular disturbances
○ Halos around bright objects
○ Yellow/green color perception
○ Sinus bradycardia
○ TOXIC LEVEL OF DIGOXIN IS OVER 2.0
● Interactions
○
Meds:
■ Amiodarone(increase toxicty)
■ Metropolol(Betw-blocker0
■ Diltiazem(Calcium-channel blocker:slow AV node conduction)
■ Furosemide(Increase toxicity due to hypokalemia)
○ Herb:
■ Licorice
● Nursing Implications
○ Take apical pulse before given if <60 hold medication
○ Monitor pulse(monitor EKG 1-2hr)
○ Monitor serum levels(Na,K,Mg,Ca)
○ Assess renal function
○ THERPEUTIC LEVEL 0.8 - 2 nanogram/ml
● Pertinent teaching criteria
○ Take pulse prior
○ Report if pulse is <60 to provider
○ Do not skip, miss, or increase doses
○ Report deccreased appetite, nausea/vomiting, diarrhea, and visual
changes
~Antidote: Digoxin immune FAB (Digibind)
~ Administration:
- Verbalize that you took apical pulse
- “What digoxin is going to do is maintain your heart’s beat. It doesn't always
happen, but if at any point you start to see halos around lights or yellow dots, use
your call light and I will come immediately.”
~Furosemide (Lasix)
● Normal Ranges
○ 20-40mg
○ Onset: 30 - 60min
○ Peak:1 - 2hr
○ Duration:6 - 8hr
● Class
○ Loop diuretic, antihypertensive
● Physiological actions
○ Inhibits reabsoprtion of NaCl in the ascending loop of Henle and
proximal/distal tubules
○ Increases excretion of H20, Na, Cl, Mg, Ca, K+
● Indications
○ Tx of edema associated with HF and renal hepatic disease
○ Acute pulmonary edema(too much fluid in lungs)
● Contraindications
○ Hypersensitivity
○ Anuria
●
●
●
●
●
●
Cautions
○ Hepatic cirrhosis
○ Hepatic coma
○ Severe electrolyte depletion
○ Systemic lupus erthematosus
○ Prostatic hyperplasia/urinary stricture
Side effects
○ Increase urinary frequency volume
○ Nausea
○ Dyspepsia
○ Abdominal cramps
○ Diarrhea/constipation
○ Electrolyte disturbances
○ Dizziness
○ Blurred vision
○ Bladder spasms
○ photosensitivity
Adverse Reactions
○ Profoun water loss, electrolyte depletion resulting in hypokalemia,
hyponatremia, and dehydration
○ Ototoxicity ( may occur in PT with severe renal impairments)
○ Can exacerbate diabetes mellitus, systemic lupus erthematosus, gout,
pancreatitis
Interactions
○ Meds:
■ Sucralfate(decrease absorption and effect)
■ Bile acid sequestration
○ Herbs:
■ Licorice
■ Yohimbe
■ Ginkgo biloba(hypertensive)
■ Garlic(hypertensive)
Nursing Implications
○ Check BP & PR for hypotension
○ Assess baseline renal fucntion
○ Serum electrolytes (Na & K+)
○ Hydration status
■ Turgor, mucus membranes
○ Assess for edema
○ Monitor weight, monitor I&O’s
○ S/S of hypokalemia and hyponatremia
Pertinent teach criteria
○ Expect increase in frequency of urination
○ Report palpitations
○
○
Signs of electrolyte imbalances
Eat food high in K
■ Whole grains, cereal, legumes, meat, bananas, apricots, orange
juice, potatoes, raisins
Stand up slowly
○
~ Adminsitration:
- Verbalize that you made sure the patient isn't dehydrated, and that you know the patient
may feel dizzy
- “What lasix is going to do is get rid of the excess fluid in your body and reduce the
swelling you may be experiencing. It’ll help you urinate that excess fluid so as soon as
you feel the need to use the bathroom, use your call light and I will come to assist you.”
~Potassium Chloride (KCI, Micro-K, Klor-Chon)
● Normal Ranges
○ 10 - 40 mEq daily
● Class
○ Electrolyte supplement
● Physiological actions
○ Necessary for multiple cellular metabolic processes
○ Primary action is intracellular, required for nerve impulse conduction
○ Contraction of cardiac, skeletal, and smooth muscle
○ Maintains normal renal function an dacid-base balance
● Indications
○ Tx/prevention of hypokalemia
● Contraindications
○ Renal failure
○ Hyperkalemia
○ Conditions in which K retention is present
● Cautions
○ Cardiac disease
○ Acid base disorders
○ K altering disorders
○ Digitized patienst and renal impairment
● Side effects
○ Nausea, vomiting, flatulence
○ Abdominal discomfort with distension
○ Rash
● Adverse Reactions
○ Hyperkalemia manifested as paresthesia
○ Motor weakness
○ Cold skin
○ Hypotension
○ Confusion
○ Irritability
○ Paralysis
○ Cardiac arrhythmias
○ Cramping
● Interactions
○ Meds:
■ ACE inhibitors(lisinopril)
■ K-sparring diuretics
■ Salt substitues
● Pertinent teach criteria
○ Report symptoms of high K levels
○ Irregular heart beats
○ Muscle weakness
○ Nausea
○ Numbness and tingling
~ Administration:
- Know that it's usually administered with lasix
- “Potassium will be given as a supplement because it is an electrolyte that the
heart needs to continue beating normally. It doesn't always happen, but if you
start to feel tingling or numbness at the tips of your fingers or weakness, use your
call light and I will come immediately.”
~Lisinopril (Zestril)
● Normal Ranges
○ 10 - 40mg daily
○ Onset: 1hr
○ Peak: 6hr
○ Duration: 24hr
● Class
○ ACE inhibitor, antihypertensive
● Physiological actions
○ Inhibits angiotensin-converting enzymes, prevents angiotensin 1 from
convetring to angiotensin 2 (Doesn’t allow vasoconstriction, lowers BP)
○ Decrease plasma angiotensin 2 which increase plasma renin activity
which decrease aldosterone secretion which in turn reduces blood
pressure
○ Potent vasodilator
● Indications
○ Tx of hypertension in adults
○ Adjunctive therapy to reduce signs and symptoms of systolic HF
○ Tx of acute MI within 24hrs in stable hemodynamic pt (pt with stable vital
signs)
● Contraindications
○ Hypersensitivity
■ As well as to other ACE inhibitors
○
●
●
●
●
●
History of angioedema from treatment of ACE inhibitors (swelling of
lips/tongue)
Cautions
○ Renal impairment
○ Volume depletion
○ Ischemic heart disease
○ Severe aortic stenosis
○ Hypertrophic cadriomyopathy
○ Heart Failure
○ Systolic BP <100 ( under 100 hold med)
○ Dialysis
○ Hyponatremia
Side effects
○ Headache
○ Dizziness
○ Postural Hypotension
○ Chest discomfort
○ Fatigue
○ Rash
○ Abdominal pain
○ Nausea
○ Diarrhea
○ Dry mouth
○ Cough(dry)
Adverse Reactions
○ Excessive hypotension
○ Severe salt/volume depletion
○ Angioedema
○ Swelling of the face and lips
○ Hyperkalemia
Interactions
○ Meds:
■ Lasartan(angiotension blocker; increase adverse effects)
■ Valsartan(angiotension blocker; increase adverse effects)
■ Aliskiren(renin inhibitor)
■ K-sparring diuretics(keeps K+ high)
○ Herbs:
■ Licorice
■ Garlic
■ Yohimbe
Pertinent teach criteria
○ Go from lying to standing slowly
○ Limit alcohol intake
○ Report vomiting, diarrhea
○
○
○
○
Diaphoresis
Swelling of face, lips, and tongue
Difficulty breathing
Limit K rich food
~ Angioedema
Chronic cough
Elevated K+
~Administration:
- “What lisinopril is going to do is help maintain you blood pressure. It’s important that you
change positions slowly after taking this medication. It doesn’t always happen but if you
start to have any swelling in your face or beign to cough, use your call light and i will
come immediately”
~Carvedilol (Coreg)
● Normal Ranges
○ Immediate release: 3.125 - 25mg
○ Extended release: 10 - 80mg
○ Onset: 30min
○ Peak: 1 - 2hr
○ Duration: 24hr
● Class
○ Antihypertensive, beta-adrenergic blocker
● Physiological actions
○ Non selective beta blocking and alpha adrenergic blocking activity
○ Causes vasodilation hypotension (easier for heart to pump blood, widens
blood vessels)
● Indications
○ Tx for mild to severe HF
○ Left ventriculkar dysfunction following MI
○ Hypertension
● Contraindications
○ Hypersensitivity
○ Bronchial asthma/related bronchospastic conditions (betablocker work in
lungs)
○ Severe hepatic impairment
○ 2nd & 3rd AV block (special slow heartbeat; bradycardio rythm)
○ Severe bradycardia (less than 60)
○ Sick sinus sydnrome ( slow HR)
■ Except in pt with pacemaker
● Cautions
○ Diabetes
○ Mild to moderate hepatic impairment
● Side effects
○ Fatigue
●
●
●
●
○ Dizziness
○ Diarrhea
○ Bradycardia
○ Rhinitis
○ Back pain
○ Postural hypertension
Adverse Reactions
○ Bradycardia
○ Hypotension
○ Bronchospasms
○ Cardiac insufficiency
○ Cardiogenic shock
○ Cardiac arrest
○ May mask symptoms of hypoglcemia (casued by betablocker; cold &
clamy)
Interactions
○ Meds:
■ Diltiazem(calcium-channel blocker)
■ Digoxin
■ Albuterol
■ Amiodarane
○ Herbs:
■ Licorice
■ Yohimbe
■ Garlic
Nursing Implications
○ Assess BP and apical PR before
■ Hold if pulse is <60 or systolic <90
○ Monitor respirations for dyspnea
○ ECG: cardiac arrhythmias
○ I&O’s
Pertinent teach criteria
○ Take with food
○ Abruptly stopping tx or missing multiple doses may cause beta blocker
withdrawal syndrome
■ Fast HR, High BP, palpitations, sweating, tremors
○ Take as prescribed
○ Monitor BP and pulse before taking med
○ Restroct salt & alcohol intake
~ 5 B’s
Bronchospasm
Bradycardia
Blue (depression
Blood sugar lowers
BP lowering (hypotension)
~ Adminstration:
- Make sure the patient has food especially if they have HF
- “What carvedilol is going to do is help maintain your blood pressure and it’s important
that this medication is taken with food. It does usually happen, but if you notice your
heart rate slows down <60 bpm or start to experience breathing problems, use your call
light and I will come immediately.”
~Docusate Sodium (Colace)
● Normal Ranges
○ 50 - 400mg
○ Onset: 12 - 72hr
● Class
○ Laxative, Stool Softener
● Physiological actions
○ Acts in small/large intestine
○ Hydrates/softens stool by surfactant action
○ Facilitates penetartion of fat and water in the stool
○ Pulls everythng in to soften the stool
● Indications
○ Tx of constipation due to hard stool
○ Those with painful anal-rectal conditions
○ Those who need to avoid straining
■ Post op
■ Labor and delivery
■ Episiotomy
■ MI cardiac pt (to prevent straining pressure)
■ Hemmorrhoids
■ Hernias
● Contraindications/Cautions
○ Hypersensitivity
○ Diarrhea
● Side effects
○ Mild nausea
○ Cramping
○ Irritating of throat ( for drinkable froms)
● Adverse Reactions
○ Severe diarrhea
● Interactions
○ Meds:
■ Mineral oil
● Nursing Implications
○ Assess for anbdominal distension
○ Assess presence of bowel sounds
○ Assess usual pattern of bowel function
○ Color
○ Consistency
○ Amount
● Pertinent teach criteria
○ Not a long-term med
○ Increase fiber
○ 6-8 glasses of water a day
○ Increase mobility
○ Tell cardiac pt not to strain
○ Do not take docusate within 2hrs of another laxative
~Administration:
- “What colace is going to do is help you have a bowel movement. This is not a long term
medication and it is important that after taking this medication you still allow yourself to
have a bowel movement naturally, so no straining. Drinking plenty of water and
increasing your fiber intake is important while you take this as well. It usually doesn’t
happen, but if you start to feel nauseous, use your call light and I will come immediately.”
~Nitroglycerine Transdermal
● Normal Ranges
○ Transdermal patch: 0.2 - 0.8mg/hr, nitrate free for 10-12hrs
■ Onset: 40 - 60min
■ Peak: 60 - 180min
■ Duration
○ Ointment: 2% 1 - 2in Q6hrs, pt nitrate free 10-12hrs
■ Onset: 15 - 60min
■ Peak: 30 - 120min
■ Duration: 2 - 12hr
○ Sublingual: 0.3 - 0.6mg Q5min, max 3 tabs/15min
■ Onset: 1 - 3min
■ Peak: 4 - 8min
■ Duration: 30 - 60min
● Class
○ Nitrate, antianginal, antihypertensive, coronary vasodilator
● Physiological actions
○ Produces vasodilation on peripheral veins/arteries
○ Decreases myocardial oxygen deman by decreasing preload
○ Improves collateral flow to sichemic areas
● Indications
○ Tx/prevention of angina pectorales
○ Extended release and topical release is used for prophlaxis of long term
angina management
○ IV is used to treat HF and acute MI
● Contraindications
○ Hypersensitivity
○ Allergies to adhesives
○ Concurrent use of PDE5 inhibitors(viagra)(makes BP to low)
● Cautions
○ Blood volume depletion
○ Systolic blood pressure of <90 mmHg and bradycardia HR of <50 bpm
● Side effects
○ Headache
○ Flushing of face or neck
○ Dizziness, weakness, orthostatic hypotension
○ Ointment can cause erythema
○ Transdermal patch can cause contact dermatitis
● Adverse Reactions
○ Discontinue if blurred vision, dry mouth, (sinkable episode) faint
○ Severe orthostatic hypotension
● Interactions
○ Meds:
■ Alcohol
■ Lisinopril(antihypertensive)
■ Valsartan(antihypertensive)
■ Vasodilaters
■ PDE5 inhibitors(sildenafil, tadalafil, vardenfil; produce
hypertension)
● Nursing Implications
○ Check BP before
○ Assess for angina
○ Monitor BP & HR
○ Assess for flushing(color red/pink)
○ Take BP and apical before giving drug
○ Transdermal patch: change sites
● Pertinent teach criteria
○ Go from lying to standing slowly
○ Take it as the first sign of angina attack(chest pain)
○ Avoid alcohol (intensifies hypotensive effects)
○ Do not take within 48hrs of taking PDE5 inhibitors(viagra)
~Administration:
- Know the different considerations of each administration route
- “What nitroglycerin is going to do is help relieve the sudden heart pains so it’s important
that you take this drug at the first sign of heart pains. It’s not common, but if you
experience any flushing or paleness in your face and neck or dizziness, use your call
light and I will come immediately.”