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Cardiovascular and Renal Medications

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1 Cardiovascular and Renal Medications
Chapter 12 Cardiovascular and Renal Medications Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

2 6 Major Sections Anti-anginal & Vasodilators Antidysrythmics
Antihyperlipidemic Agents Cardiotonic drugs Anti-hypertensives, Diuretics, Renal Meds IV Fluids Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

3 Anti-Angina & Vasodilators
Narrowing or constriction of smooth muscle in the coronary arteries and peripheral vascular system reduces the amount of blood flow to the heart. This lack of blood supply results in diminished oxygen and nutrient flow to the heart, causing chest pain, or “angina,” and peripheral vascular disease. Arterial relaxation reduces the pressure the heart has to pump against. Venous relaxation causes blood pooling and decreases venous return to the heart.

4 Antianginals and Vasodilator
1) Nitrates: “Universal Vasodilators” Directly cause vascular smooth muscle to relax in arterial and venous circulation Decrease myocardial oxygen use Increase collateral-vessel circulation to the heart 2) Calcium Channel Blockers Dilate coronary arteries and arterioles Reduce response of electrical conduction system 3) Peripheral Vasodilators Expand or open up the arteries Relax the smooth muscles of the peripheral arterial blood vessels and leads to better circulation to the arms and legs. Narrowing or constriction of smooth muscle in the coronary arteries and peripheral vascular system reduces the amount of blood flow to the heart. This lack of blood supply results in diminished oxygen and nutrient flow to the heart, causing chest pain, or “angina,” and peripheral vascular disease. Arterial relaxation reduces the pressure the heart has to pump against. Venous relaxation causes blood pooling and decreases venous return to the heart. Nitrates are readily absorbed under the tongue, through the skin, and orally. Nitroglycerin is a nitrate. The half-life of nitroglycerin is only 1-4 minutes. Calcium is an electrolyte that helps move electrical impulses through cardiac tissue. Calcium channel blockers are drugs that help slow down the flow of calcium ions across the cell membrane, which reduces the amount of calcium available to move electrical impulses. There are many actions of these drugs. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

5 Antianginals and Peripheral Vasodilators Indication
Nitrates Acute and chronic anginal attacks Reduce the workload of the heart Calcium Channel Blockers Relief of angina pain Treat cardiac dysrhythmias Treat hypertension Peripheral Vasodilators Used to treat leg pain caused by vasoconstriction Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

6 Antianginals and Peripheral Vasodilators
Nitrates: Flushing, postural hypotension, tachycardia, confusion, dizziness, fainting, headache, lightheadedness, vertigo, weakness, drug rash, localized pruritus, skin lesions, eye and mouth edema, local burning in mouth, nausea and vomiting. Peripheral vasodilators: Headache, weakness, tachycardia, flushing, postural hypotension, dysrhythmias, confusion, severe rash, nervousness, tingling, and sweating Some nitrates contain tartrazine, a chemical that may cause an asthmatic type of allergic reaction. Peripheral vasodilating agents have a stronger action when taken with antihypertensives and alcohol. This leads to hypotension. What are the nursing implications for the LPN/LVN regarding these drugs? What patient teaching should be done for nitrates? (Storage? Expiration date?) For peripheral vasodilating agents? How should patients be taught to use nitroglycerin during an acute anginal attack? What are some drug interactions with nitrates or peripheral vasodilators? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

7 Antianginals and Peripheral Vasodilators Interactions
Nitrates Increase the effects of atropine-like drugs and tricyclic antidepressants Decrease the effects of all choline-like drugs Should not be taken with prazosin Peripheral Vasodilators Increased effect with antihypertensives and alcohol Taking alcohol, beta blockers, antihypertensives, narcotics, and vasodilators with nitrates and nitrites (especially amyl nitrite) may produce severe hypotension (low blood pressure) and cardiac collapse. A cold environment or the use of tobacco reduces the action of nitroglycerin. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

8 Nitroglycerin Rapid acting – sublingual nitro or chewable isosorbide : RELIEVE PAIN in ACUTE Long acting – topical, transdermal or transmucosal: PREVENT ANGINA when they are likely to occur (exercise). INCREASE BLOOD Supply to heart hence prevent. Tolerance (p.203) Tolerance may develop and if patient develops tolerance o one nitrate, it is likely to all.

9 Nitroglycerin STOP DRUG: if blurred vision, dry mouth or oral tab passed in stool. PT using nitrates for a long time should not stop suddenly as it may cause more angina. FOR ACUTE angina: Sublingual Nitroglycerin as soon as pain begins, followed by up to 2 more pills every 5 minute. (Total of 3pills x 15min) Half of life of sublingual is 1-4 minutes. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

10 Nitroglycerin Store in dark glass container as dispensed.
Needs a new prescription after 3 months. Medication is active if med produces throbbing h/a. (H/A for up to 20 mins) GOAL is teach pt to avoid activity that may cause pain. PT Teaching pg. 205 Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

11 Nitrate Products isosorbide dinitrate (Isordil) nitroglcycerin (Nitrostat) ranolazine (Ranexa) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

12 Dysrhythmia Causes Symptoms MI, cardiomyopathy, CAD, HTN
Hyper or hypo thyroidism Smoking, drinking, alcohol or caffeine, drug abuse, stress Medications and supplements Diabetes Sleep apnea Genetics Fluttering, racing, slow heartbeat Chest pain SOB Lightheadedness or dizziness Sweating Fainting (syncope) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

13 Sinus Rhythm “normal” Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

14 Antidysrhythmics Four Classes
Class I: disopyramide, procainamide, quinidine Lengthen the refractory period Decrease cardiac excitability Class II: acebutolol, esmolol, propranolol (BETA) Reduce sympathetic excitation (reduce loading) Slow rate but increase contractility (stronger) Class III: amiodarone (K channel Blockers) Lengthen the time it takes for one cell to fire and recover. SLOWS the heat rate. Class IV: verapamil (Ca Channel Blockers) Blocks calcium entry into the myocardium, prolongs resting phase. (prolongs the refractory period in AV node. People with heart disease or other problems that affect the heart muscle are at risk of developing irregular heartbeats, or cardiac dysrhythmias. Dysrhythmias may be fast or slow, with an irregular or regular pattern. The most common causes of dysrhythmias are an irritation to the heart tissue after a myocardial infarction, fluid and electrolyte imbalances, diet, hypoxia, and drug reactions. Dysrhythmias vary in patients in regularity and intensity. An electrocardiogram is needed to determine the type of dysrhythmia a patient is experiencing. Halter monitors are portable ECG machines that take an ongoing tracing of the heart’s electrical function. Antidysrhythmics act on each individual cell of the heart. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

15 Antidysrhythmics Action and Uses
Quinidine and Procainamide Treat rapid and irregular dysrhythmias by decreasing the excitability of myocardial cells Bretylium Slows conduction rate in the ventricles, slows norepinephrine release in the myocardium Disopyramide Slows the depolarization of cardiac cells The exact type of irregular rhythm can only be determined by taking an ECG. It is important to find the cause of the dysrhythmia. Most dysrhythmias are caused by (1) increased sensitivity of the electrical cells in the heart, resulting in irregular or early ectopic beats and (2) electrical activity moving through abnormal conduction pathways, triggering myocardial cells to fire improperly. Depolarization is the movement of electrolytes in and out of the cell as it gets ready to send another electrical impulse. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

16 Antidysrhythmics Lidocaine**(Xylocaine)
Increases the strength of electrical impulses IV can cause ventricular dysrythmias may occur. Adenosine Stops the heart for several seconds to allow it to convert to normal sinus rhythm Beta blockers** (propranolol) Inderal Decrease the heart beta-receptor response to epinephrine and norepinephrine Many patients refuse to continue taking adenosine after experiencing its effects. Many of the antidysrhythmics are so powerful they should only be used in critical care units. What are some of the medication-specific adverse effects of these drugs? Antidysrhythmics often cause or worsen heart failure or urinary retention. Patients with a history of heart failure should be watched closely. Drug interactions: the effect of quinidine is increased by potassium and decreased by hypokalemia. The action of verapamil is stronger if the patient is taking digitalis and beta blockers. Beta blockers have many drug-specific interactions. How can the steps of the nursing process be applied here? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

17 Antidysrhythmics digoxin (Lanoxin) verapamil (Calan)
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

18 Antidysrhythmics Adverse Reactions
May cause cardiac dysrhythmias, hypotension, diarrhea, tinnitus, headache, vertigo, confusion, delirium, disturbances in vision, and abdominal pain. Some nitrates contain tartrazine, a chemical that may cause an asthmatic type of allergic reaction. Peripheral vasodilating agents have a stronger action when taken with antihypertensives and alcohol. This leads to hypotension. All patients receiving these drugs should have their heart carefully monitored by ECG for any change. All patients receiving these drugs should have their heart carefully monitored by ECG for any change. It may cause cardiac dysrhythmias, hypotension, diarrhea, tinnitus, headache, vertigo, confusion, delirium, disturbances in vision, and abdominal pain. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

19 Hyperlipidemia High levels of lipoproteins leads to CHD
Types lipoproteins Chylomicrons Very low-density lipoproteins (VLDLs) Low-density lipoproteins (LDLs) BAD High-density lipoproteins (HDLs) GOOD Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

20 Hyperlipidemia Recommended serum levels Total Cholesterol >200
LDL >100 HDL Triglcerides >120 Lipoproteins are described by how thick or dense they are. Chylomicrons are usually present for 1 to 8 hours in the plasma after the last meal. Nearly all the triglycerides in plasma that are not in chylomicrons are considered to be VLDLs. About 75% of plasma cholesterol is moved in the form of LDLs. High LDL levels indicate cholesterol levels that are higher than the body needs. Patients are at high risk for developing atherosclerosis. HDLs block the uptake of LDL cholesterol by the vascular smooth muscle cells and may prevent atherosclerotic activity. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

21 Antihyperlipidemics STATINS
Highly effective for lowering LDL levels atorvastatin (Lipitor) fluvastatin (Lescol) lovastatin (Mevacor) pravastatin (Pravachol) rosuvastatin (Crestor) simvastatin (Zocor ) Research suggests high LDL levels can lead to coronary artery disease. Evaluation of LDL and HDL levels is of primary importance, because research has shown that lowering serum lipids or cholesterol can reduce the risk of atherosclerotic heart disease. HMG-CoA reductase inhibitors (statins) are extremely costly but highly effective. Liver function tests should be closely monitored when taking these drugs. Fibric acid derivatives are not as effective as HMG-CoA reductase inhibitors in lowering LDL levels. Gemfibrozil and fenofibrate are well-tolerated but can cause liver toxicity and gallstones. The liver uses cholesterol to replace the bile excreted by bile acid sequestrants. These drugs increase triglyceride levels. Adverse GI side effects include constipation, nausea, and bloating. Niacin is highly effective. Its use is limited by the side effect of flushing in the face and neck. What are some significant points for the LPN/LVN to include in patient teaching? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

22 Antihyperlipidemics Fibric Acid Derivatives Lopid (gemfibrozil) Bile Acid Sequestrants Questran (Cholestyramine) may increase anticoagulants effect, monitor symptoms of vitamin deficiency (ADEK). Monitor liver function Niacin (Niaspan) may cause flushing (give with apple) Selective Cholesterol Absorption Inhibitor Ezetimibe (Zetia) Research suggests high LDL levels can lead to coronary artery disease. Evaluation of LDL and HDL levels is of primary importance, because research has shown that lowering serum lipids or cholesterol can reduce the risk of atherosclerotic heart disease. HMG-CoA reductase inhibitors (statins) are extremely costly but highly effective. Liver function tests should be closely monitored when taking these drugs. Fibric acid derivatives are not as effective as HMG-CoA reductase inhibitors in lowering LDL levels. Gemfibrozil and fenofibrate are well-tolerated but can cause liver toxicity and gallstones. The liver uses cholesterol to replace the bile excreted by bile acid sequestrants. These drugs increase triglyceride levels. Adverse GI side effects include constipation, nausea, and bloating. Niacin is highly effective. Its use is limited by the side effect of flushing in the face and neck. What are some significant points for the LPN/LVN to include in patient teaching? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

23 Cardiotonics Powerful and can be toxic to the heart.
The symptoms of digitalis toxicity may begin slowly and are easy to overlook; however, toxicity can occur quickly, especially in the elderly. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

24 Cardiotonics AKA cardiac glycosides
Treatment of CHF and rapid or irregular heartbeats (atrial fibrillation, atrial flutter, frequent PVCs, or paroxysmal atrial tachycardia) Lanoxin digoxin** Action: slow and stronger heartbeat Apical pulse for one FULL minute (hold >60 BPM), monitor K+ levels Serum level = ng/ml Toxicity= anorexia, N=V, visual disturbances Life threatening dysrhythmias may follow Antidote= Digibind Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

25 Hypertension (HTN) Hypertension is a disorder in which the patient’s blood pressure is elevated above normal limits for age. Blood pressures above 150/90 mm Hg are associated with accelerated vascular damage of the heart, brain, and kidneys, which leads to increased risk of death. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

26 Hypertension (HTN) Primary hypertension affects 80% to 90% of people with high blood pressure; the cause is unknown. The other 10% to 20% have secondary hypertension, in which elevated blood pressure is the result of another disease process or problem. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

27 Antihypertensives 5 Categories Diuretics Adrenergic Blockers Vasodilators Calcium Channel Blockers Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

28 Diuretics Thiazide diuretics hydrochlorothiazide
Replaces calcium to bone (reabsorption) Elderly osteoporosis (low calcium in bone) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

29 Diuretics Loop diuretics Potassium-depleting block the active transport of chloride, sodium, and potassium in the thick ascending loop of Henle. These drugs work well in patients with impaired renal function. Lasix (furosemide) Demadex (torsemide) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

30 Diuretics Potassium-sparing diuretics increase the excretion of water and sodium by saving potassium. These drugs are used in patients with kidney disease or who are at risk for potassium imbalance. alactone (Spironolactone) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

31 Adrenergic Inhibitors
5 Categories Beta-adrenergic blockers Central adrenergic inhibitors Peripheral adrenergic antagonists Alpha –adrenergic Blockers Combo Meds Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

32 Beta Blockers 2 groups (selective/noselective)
Actions: >HR, prevent renin release, slow sympathetic system Assess AP, HOLD for HR >60 No orange or grapefruit juice (absorbtion) Orthostatic hypotension Tenormin atenolol Lopressor metoprolol **Inderal propanolol Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

33 Central Peripheral Adrenergic Inhibitors
2. Central adrenergic inhibitors stimulate peripheral alpha-adrenergic receptors, causing brief vasoconstriction, and then stimulate alpha2-adrenergic receptors in the brainstem that coordinate cardiac function. clonidine Catapress methyldopa Aldomet Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

34 Central Peripheral Adrenergic Inhibitors
3. Peripheral adrenergic antagonists* decrease total peripheral resistance to blood flow by relaxing smooth muscle. Most of these medications are no longer available in the United States.* Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

35 adrenergic inhibitors
4. Alpha Blockers Cardura Doxazosin Minipress Prazosin 5. Combination Medications Coreg Carvedilol Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

36 Renin-angiotensin mechanism vasoconstrictive reaction
ACE inhibitors (angiotensin-converting enzyme inhibitors) inhibit conversion/reaction Captopril capoten ** Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

37 Renin-angiotensin mechanism vasoconstrictive reaction
Angiotensin II receptor antagonists interfere with angiotensin II acting on the adrenal cortex to increase aldosterone secretion. ARB’s atacand candesartan Avapro irbestartan Cozaar losartan Diovan valsartan Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

38 Renin-angiotensin mechanism vasoconstrictive reaction
Vasodilators reduce systolic and diastolic blood pressure by direct relaxation of smooth muscle, which lowers vascular resistance. Rogaine minoxidil Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

39 Calcium Channel Blockers
limit the passage of extracellular calcium ions through specific ion channels of the cell membrane in cardiac, vascular, and smooth muscle cells. This lowers peripheral resistance and decreases blood pressure. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

40 Calcium Channel Blockers
Amlodipine (Norvasc) Diltiazem (Cardizem) Felodipine Isradipine Nicardipine (Cardene) Nifedipine (Procardia)** Nisoldipine (Sular) Verapamil (Calan)** Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

41 Calcium Channel Blockers
Monitor for dizziness, weakness, falls (lifespan alert-elderly) Nicotine reduces effectiveness Avoid alcohol DO NOT suddenly stop (rebound angina) Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

42 Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Stage I: Lifestyle Changes Stage II: Drug Therapy Adverse Reactions Drug-specific Drug Interactions What lifestyle changes may help a patient reduce hypertension risk factors? (Losing weight; increased physical activity; reduction of fat, salt, and calories in the diet; smoking cessation; and reducing alcohol intake) What are some of the nursing implications and patient teaching issues for these medications? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

43 Urinary Drugs Urinary incontinence Oxybutynin Ditropan
Treatment: anticholinergics/antispasmodics, alpha- adrenergic agonists, estrogens, cholinergic agonists, and alpha-adrenergic antagonists Oxybutynin Ditropan Tolterodine Detrol LA There are a variety of drugs used to treat urinary symptoms related to incontinence, benign prostatic hyperplasia (BPH), and urinary tract pain secondary to infections. Anticholinergic agents used for urinary incontinence stop bladder contraction and decrease the response of some bladder muscles. Antispasmodic drugs directly cause smooth muscle relaxation. Estrogens may help restore urethral mucosa and increase vascularity, tone, and the ability of the urethral muscle to respond. Benign prostatic hyperplasia (BPH) is a noncancerous growth of the prostate gland that can cause voiding problems. Tamsulosin (Flomax) and finasteride are two drugs specifically used for this problem. What are some of the nursing implications and patient teaching issues for these medications? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

44 Urinary Drugs Benign prostatic hyperplasia (BPH) Finasteride Proscar
Treatment: alpha1-adrenergic receptor blockers Finasteride Proscar Tamsulosin Flomax There are a variety of drugs used to treat urinary symptoms related to incontinence, benign prostatic hyperplasia (BPH), and urinary tract pain secondary to infections. Anticholinergic agents used for urinary incontinence stop bladder contraction and decrease the response of some bladder muscles. Antispasmodic drugs directly cause smooth muscle relaxation. Estrogens may help restore urethral mucosa and increase vascularity, tone, and the ability of the urethral muscle to respond. Benign prostatic hyperplasia (BPH) is a noncancerous growth of the prostate gland that can cause voiding problems. Tamsulosin (Flomax) and finasteride are two drugs specifically used for this problem. What are some of the nursing implications and patient teaching issues for these medications? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

45 Urinary Drugs Analgesia Phenazopyridine AZO
There are a variety of drugs used to treat urinary symptoms related to incontinence, benign prostatic hyperplasia (BPH), and urinary tract pain secondary to infections. Anticholinergic agents used for urinary incontinence stop bladder contraction and decrease the response of some bladder muscles. Antispasmodic drugs directly cause smooth muscle relaxation. Estrogens may help restore urethral mucosa and increase vascularity, tone, and the ability of the urethral muscle to respond. Benign prostatic hyperplasia (BPH) is a noncancerous growth of the prostate gland that can cause voiding problems. Tamsulosin (Flomax) and finasteride are two drugs specifically used for this problem. What are some of the nursing implications and patient teaching issues for these medications? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

46 Fluid and Electrolytes
Many fluid and electrolyte solutions are given when oral food intake has been stopped or to prevent dehydration. NS D5 Ringers Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

47 Fluid and Electrolytes
Causes of dehydration include vomiting, bowel obstruction (which causes a pooling of fluid and electrolytes), diarrhea, and fever (which increases the use of fluid and electrolytes). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

48 Fluid and Electrolytes
Patients taking diuretics should avoid caffeinated beverages as the diuretic effect of caffeine plus their medications may cause them to become dehydrated. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

49 Fluid and Electrolytes
Dehydration: dry skin/mucus membranes, low BP, tachy Fluid Overload: edema, crackles, JVD Many fluid and electrolyte solutions are given when oral food intake has been stopped or to prevent dehydration. Patients taking diuretics should avoid caffeinated beverages as the diuretic effect of caffeine plus their medications may cause them to become dehydrated. Causes of dehydration include vomiting, bowel obstruction (which causes a pooling of fluid and electrolytes), diarrhea, and fever (which increases the use of fluid and electrolytes). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.


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