1. PYRAMID POINTS CHAPTER 60: CARDIOVASCULAR MEDICATIONS

2. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-2 PYRAMID POINTS I. Anticoagulants  Description Prevent extension and formation of clots by inhibiting factors in clotting cascade and decreasing blood coagulability Prevent extension and formation of clots by inhibiting factors in clotting cascade and decreasing blood coagulability  Side effects Bleeding Bleeding  Heparin sodium Normal activated partial thromboplastin time (aPTT) Normal activated partial thromboplastin time (aPTT) 20 to 30 seconds Antidote is protamine sulfate Antidote is protamine sulfate  Enoxaprin (Lovenox)  Warfarin sodium (Coumadin) Normal PT is 11 to 12.5 seconds Normal PT is 11 to 12.5 seconds Normal INR is 0.7 to 1.8 Normal INR is 0.7 to 1.8 Antidote is vitamin K (phytonadione [AquaMEPHYTON]) Antidote is vitamin K (phytonadione [AquaMEPHYTON])

3. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-3 PYRAMID POINTS II. Thrombolytic Medications  Description Dissolve clots Dissolve clots  Contraindications Active bleeding, stroke or other intracranial problems, surgical client, hepatic or renal disease, uncontrolled hypertension, recent cardiopulmonary resuscitation, or hypersensitivity Active bleeding, stroke or other intracranial problems, surgical client, hepatic or renal disease, uncontrolled hypertension, recent cardiopulmonary resuscitation, or hypersensitivity  Side effects Bleeding Bleeding  Interventions Monitor for bleeding Monitor for bleeding Implement bleeding precautions Implement bleeding precautions  Antidote Aminocaproic acid (Amicar) is antidote for streptokinase Aminocaproic acid (Amicar) is antidote for streptokinase

4. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-4 PYRAMID POINTS III. Antiplatelet Medications  Description Inhibit aggregation of platelets and prolong bleeding time Inhibit aggregation of platelets and prolong bleeding time  Side effects Bleeding Bleeding  Interventions Monitor for bleeding Monitor for bleeding Implement bleeding precautions Implement bleeding precautions

5. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-5 PYRAMID POINTS IV. Positive Inotropic-Cardiotonic Medications  Description Stimulate myocardial contractility Stimulate myocardial contractility  Side effects Dysrythmias, hypotension, thrombocytopenia Dysrythmias, hypotension, thrombocytopenia  Toxic, adverse reactions Hepatotoxocity, hypersensitivity Hepatotoxocity, hypersensitivity  Interventions Monitor for side effects and adverse effects Monitor for side effects and adverse effects Monitor pulse and blood pressure closely Monitor pulse and blood pressure closely

6. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-6 PYRAMID POINTS V. Cardiac Glycosides  Description Increases the force of myocardial contraction and slows the heart rate Increases the force of myocardial contraction and slows the heart rate  Side effects, toxic effects Gastrointestinal disturbances (anorexia, nausea, vomiting, diarrhea) Gastrointestinal disturbances (anorexia, nausea, vomiting, diarrhea) Visual disturbances Visual disturbances Bradycardia Bradycardia  Interventions Monitor for toxicity; digoxin level above 2 ng/mL Monitor for toxicity; digoxin level above 2 ng/mL Monitor potassium level for hypokalemia Monitor potassium level for hypokalemia Monitor apical pulse; if less than 60/min, hold medication, notify physician Monitor apical pulse; if less than 60/min, hold medication, notify physician

7. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-7 PYRAMID POINTS VI. Antihypertensive Medications  Thiazide diuretics Side effects include hypercalcemia, hyperglycemia, hyperuricemia, hypokalemia, hyponatremia, hypovolemia Side effects include hypercalcemia, hyperglycemia, hyperuricemia, hypokalemia, hyponatremia, hypovolemia Interventions include monitoring vital signs, appropriate laboratory values, intake and output (I&O); intake of potassium- containing foods Interventions include monitoring vital signs, appropriate laboratory values, intake and output (I&O); intake of potassium- containing foods  Loop diuretics Side effects include hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, orthostatic hypotension Side effects include hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, orthostatic hypotension Interventions include monitoring vital signs, appropriate laboratory values, I&O; intake of potassium-containing foods Interventions include monitoring vital signs, appropriate laboratory values, I&O; intake of potassium-containing foods

8. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-8 PYRAMID POINTS VI. Antihypertensive Medications (continued)  Osmotic diuretics  Carbonic anhydrase inhibitors  Potassium-sparing diuretics Side effects include hyperkalemia Side effects include hyperkalemia Interventions include monitoring potassium blood level Interventions include monitoring potassium blood level

9. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-9 PYRAMID POINTS VII. Peripherally Acting  -Adrenergic Blockers  Description Cause vasodilation and decrease the blood pressure Cause vasodilation and decrease the blood pressure Used to treat hypertension and maintain renal blood flow Used to treat hypertension and maintain renal blood flow  Side effects Hypotension Hypotension Tachycardia Tachycardia Sodium and water retention Sodium and water retention Gastrointestinal disturbances Gastrointestinal disturbances  Interventions Monitor blood pressure and apical heart rate Monitor blood pressure and apical heart rate Monitor for fluid retention and edema Monitor for fluid retention and edema

10. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-10 PYRAMID POINTS VIII. Centrally Acting Sympatholytics (Adrenergic Blockers)  Description Inhibit vasoconstriction and reduce peripheral resistance Inhibit vasoconstriction and reduce peripheral resistance Used to treat hypertension Used to treat hypertension  Side effects Sodium and water retention Sodium and water retention Bradycardia Bradycardia Hypotension Hypotension  Interventions Monitor blood pressure and apical heart rate Monitor blood pressure and apical heart rate Monitor for fluid retention and edema Monitor for fluid retention and edema Instruct client that abrupt withdrawal can cause rebound hypertension Instruct client that abrupt withdrawal can cause rebound hypertension

11. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-11 PYRAMID POINTS IX. Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotension II Receptor Blockers (ARB)  Description Prevent peripheral vasoconstriction Prevent peripheral vasoconstriction Used to treat hypertension and heart failure Used to treat hypertension and heart failure  Side effects Persistent dry cough Persistent dry cough Hypotension Hypotension Tachycardia Tachycardia Hyperkalemia Hyperkalemia Hypoglycemia in diabetic client Hypoglycemia in diabetic client

12. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-12 PYRAMID POINTS continued …  Interventions Avoid use with potassium supplements and potassium- sparing diuretics Avoid use with potassium supplements and potassium- sparing diuretics Monitor vital signs and for signs of hyperkalemia Monitor vital signs and for signs of hyperkalemia Instruct diabetic client about the risk for hypoglycemia Instruct diabetic client about the risk for hypoglycemia Instruct client to report persistent dry cough Instruct client to report persistent dry cough

13. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-13 PYRAMID POINTS X. Antianginal Medications  Nitrates Side effects Side effects Sublingual medications Sublingual medications Translingual medications (spray) Translingual medications (spray) Sustained-release medications Sustained-release medications Transmucosal-buccal medications Transmucosal-buccal medications Transdermal patch Transdermal patch Topical ointments Topical ointments Client education Client education

14. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-14 PYRAMID POINTS XI.  -Adrenergic Blockers  Description Decrease the workload of the heart and decrease myocardial oxygen demands Decrease the workload of the heart and decrease myocardial oxygen demands Decrease heart rate and blood pressure Decrease heart rate and blood pressure May mask symptoms of hypoglycemia in diabetic client May mask symptoms of hypoglycemia in diabetic client  Side effects Bradycardia Bradycardia Hypotension Hypotension Bronchospasm Bronchospasm  Interventions Monitor apical pulse rate and blood pressure Monitor apical pulse rate and blood pressure Monitor for respiratory distress Monitor for respiratory distress Instruct the diabetic client to monitor for signs of hypoglycemia Instruct the diabetic client to monitor for signs of hypoglycemia

15. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-15 PYRAMID POINTS XII. Calcium Channel Blockers  Description Decrease the workload of the heart and decrease myocardial oxygen demands Decrease the workload of the heart and decrease myocardial oxygen demands Promote vasodilation of coronary and peripheral vessels Promote vasodilation of coronary and peripheral vessels Used to treat angina, dysrythmias, and hypertension Used to treat angina, dysrythmias, and hypertension Used with caution in heart failure, bradycardia, or atrioventricular block Used with caution in heart failure, bradycardia, or atrioventricular block  Side effects Bradycardia Bradycardia Hypotension Hypotension Reflex tachycardia Reflex tachycardia

16. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-16 PYRAMID POINTS continued …  Interventions Monitor apical heart rate and blood pressure Monitor apical heart rate and blood pressure Monitor for signs of heart failure Monitor for signs of heart failure Instruct the client to report dizziness or fainting Instruct the client to report dizziness or fainting

17. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-17 PYRAMID POINTS XIII. Peripheral Vasodilators  Description Decrease peripheral resistance Decrease peripheral resistance Increase blood flow to extremities Increase blood flow to extremities Used to treat peripheral vascular disorders and cerebral vascular insufficiency Used to treat peripheral vascular disorders and cerebral vascular insufficiency  Side effects Hypotension Hypotension Tachycardia Tachycardia Flushing Flushing  Interventions Monitor apical heart rate and blood pressure Monitor apical heart rate and blood pressure Monitor for signs of inadequate blood flow to extremities Monitor for signs of inadequate blood flow to extremities Instruct client to change positions slowly Instruct client to change positions slowly

18. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-18 PYRAMID POINTS XIV. Direct-Acting Arteriolar Vasodilators  Description Relax smooth muscles of blood vessels, resulting in vasodilation Relax smooth muscles of blood vessels, resulting in vasodilation Promote an increase in blood flow to the brain and kidneys Promote an increase in blood flow to the brain and kidneys Used to treat hypertension Used to treat hypertension  Side effects Hypotension Hypotension Reflex tachycardia Reflex tachycardia Edema Edema

19. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-19 PYRAMID POINTS continued …  Interventions Monitor apical heart rate and blood pressure Monitor apical heart rate and blood pressure Monitor for fluid retention and edema Monitor for fluid retention and edema Sodium nitroprusside Sodium nitroprusside  Monitor cyanide and thiocyanide for signs of toxicity

20. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-20 PYRAMID POINTS XV. Miscellaneous Vasodilators  Description Nesiritide (Natrecor) dilates arteries and veins and is used to treat decompensated heart failure Nesiritide (Natrecor) dilates arteries and veins and is used to treat decompensated heart failure  Side effects Hypotension Hypotension Dysrhythmias Dysrhythmias  Interventions Monitor apical heart rate and blood pressure, urine output, and body weight Monitor apical heart rate and blood pressure, urine output, and body weight Monitor for signs of resolving heart failure Monitor for signs of resolving heart failure

21. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-21 PYRAMID POINTS XVI. Antidysrhythmic Medications  Description Suppress dysrhythmias by inhibiting abnormal pathways of electrical conduction through the heart Suppress dysrhythmias by inhibiting abnormal pathways of electrical conduction through the heart Classifications Classifications  Class I: sodium channel blockers  Class II: beta blockers  Class III: potassium channel blockers  Class IV: calcium channel blockers  Interventions for antidysrhythmics Monitor heart rate, respiratory rate, and blood pressure Monitor heart rate, respiratory rate, and blood pressure Provide continuous cardiac monitoring Provide continuous cardiac monitoring Administer intravenous antidysrhythmics via an infusion pump Administer intravenous antidysrhythmics via an infusion pump Monitor for signs of fluid retention Monitor for signs of fluid retention Monitor for effective response Monitor for effective response

22. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-22 PYRAMID POINTS XVII. Adrenergic Agonists  Dobutamine hydrochloride Increases myocardial force and cardiac output Increases myocardial force and cardiac output  Dopamine hydrochloride Increases blood pressure (BP), cardiac output, and renal blood flow Increases blood pressure (BP), cardiac output, and renal blood flow  Epinephrine Used for cardiac stimulation in cardiac arrest Used for cardiac stimulation in cardiac arrest  Isoproterenol hydrochloride (Isuprel) Used for cardiac stimulation and bronchodilation Used for cardiac stimulation and bronchodilation  Norepinephrine bitartrate (Levophed) Stimulates the heart in cardiac arrest and vasoconstricts and increases the BP in hypotension and shock Stimulates the heart in cardiac arrest and vasoconstricts and increases the BP in hypotension and shock

23. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-23 PYRAMID POINTS XVII. Adrenergic Agonists (continued)  Side effects Dysrhythmias Dysrhythmias Angina Angina Restlessness Restlessness Urgency or urinary incontinence Urgency or urinary incontinence  Interventions Monitor vital signs Monitor vital signs Monitor urinary output Monitor urinary output Monitor electrocardiogram Monitor electrocardiogram

24. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-24 PYRAMID POINTS XVIII. Antilipemic Medications  Description Reduce cholesterol, triglyceride, or low-density lipoprotein levels Reduce cholesterol, triglyceride, or low-density lipoprotein levels  Bile sequestrants Side effects Side effects  Constipation Interventions Interventions  Increase fluid intake and high fiber diet  HMG-CoA reductase inhibitors Side effects Side effects  Gastrointestinal disturbances, visual disturbances, elevated serum liver enzyme levels

25. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-25 PYRAMID POINTS continued … Interventions Interventions  Instruct client to report visual problems or gastrointestinal disturbances

26. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-26 PYRAMID POINTS XVIII. Antilipemic Medications (continued)  General interventions Monitor serum cholesterol and triglyceride levels Monitor serum cholesterol and triglyceride levels Instruct client about foods low in fat and cholesterol Instruct client about foods low in fat and cholesterol Instruct client to follow an exercise program Instruct client to follow an exercise program

27. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-27 The nurse has reinforced discharge instructions to a client being placed on long-term anticoagulant therapy with warfarin sodium (Coumadin). The nurse reminds the client to do which of the following? 1.Avoid taking products containing acetylsalicylic acid (aspirin). 2.Reduce alcohol intake to 12 oz daily. 3.Take any over-the-counter medications as needed. 4.Alternate the timing of the daily dose.

28. ADULT HEALTH: Cardiovascular Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.60-28 The nurse has an order to give a client a scheduled dose of digoxin (Lanoxin). Prior to administering the medication, the nurse routinely screens for which of the following manifestations that could indicate digoxin toxicity? 1. Dyspnea, edema, and palpitations 2. Chest pain, hypotension, and paresthesias 3. Constipation, dry mouth, and sleep disorder 4. Double vision, loss of appetite, and nausea