atropine: nursing implications
- contraindicated in pts with glaucoma, tachycardia, urinary tract obstruction
- moisten mouth before administration
- wear sunglasses outdoors
- void before taking meds to avoid urinary retention
- can avoid constipation by taking a laxative and inc dietary fiber/fluids
- avoid vigorous exercise in warm environment
digoxin: class
- antidysrhythmic
- cardiac glycoside
- inotropic
dronedarone: ADRs
- liver toxicity
- in pts with severe HF or permanent atrial fibrillation, doubles risk of death
- pulmonary fibrosis, pneumonitis
- bradycardia
- heart block
- renal failure
- angioedema
adenosine: ADRs
- sinus bradycardia
- seizures
- stroke
- MI
- ventricular tachycardia
adenosine: SE
- dyspnea (from bronchoconstriction)
- hypoTN
- facial flushing (from vasodilation)
- chest comfort (from stimulation of pain receptors in the heart)
diltizem: ADRs
- bradycardia
- AV block
- heart failure
- can exacerbate heart dysfunctions
pravastatin: MOA
- decrease LDL cholesterol
-
can also slightly inc HDL cholesterol
- mechanism depends on number of LDL receptors on the liver cells
- inhibits hepatic HMG CoA reductase which is the enzyme in cholesterol synthesis
- b/c there is then dec cholesterol production, liver cells make more HMG CoA reductase, so then cholesterol synthesis is restored to pretreatment levels
- but, inhibition of cholesterol synthesis makes liver cells synthesize more LDL receptors, so it then can remove more LDLs from the blood
- mechanism depends on number of LDL receptors on the liver cells
amiodarone: class
- antidysrhythmic
- potassium channel blocker (class III)
atropine: class
- antidysrhythmic
- anticholinergic
- antimuscarinic
Adenosine: changes to EKG
- prolongs PR interval b/c of delayed AV conduction
dronedarone: SE
- diarrhea
- weakness
- nausea
- skin rxns
- sensitivity to light’
- abdominal pain
adenosine: nursing implications
- ADRs/SEs are minimal and last less than 1 minute b/c the drug is cleared rapidly from the blood
- asthma pts taking certain meds (ie. theophylline) need a larger dose of adenosine b/c those meds block adenosine Rs and even then the adenosine may not work
- short half life (<10 sec), so must give by IV bolus
- watch for orthostatic hypoTN and bronchospasm in asthmatics
- 6 second flat line
- hold arm above pt when administer
amiodarone: indications (IV)
- tx and prophylaxis of recurrent ventricular fibrillation
- hemodynamically unstable ventricular tachycardia
- unapproved uses:
- atrial fibrillation
- AV nodal reentrant tachycardia
- shock resistant ventricular fibrillation
atropine: ADRs
- elevation of intraocular pressure
- urinary retention
- tachycardia
diltizem: indications
-
atrial fibrillation w/ RVR or flutter
- b/c slow ventricular rate
- AV nodal reentrant circuit
- so terminates SVT
- essential HTN
- angina pectoris
- NOT effective against ventricular dysrhythmias
digoxin: ADRs
- cardiotoxicity: dysrhythmias
- risk inc by hypokalemia which can result from concurrent therapy with diuretics (thiazides and loop diuretics)
- risk inc by presence of heart dz
diltizem: SEs
- vasodilation–>hypoTN and peripheral edema, facial flushing, headache, dizziness
- constipation, but LESS than verapamil
- chronic eczematous rash in older adults
verapamil: class
- antidysrhythmic
- nondihydropyridine calcium channel blocker (class IV)
amiodarone: nursing implications (PO)
- contraindicated for pts w/ severe sinus node dysfunction, 2nd/3rd degree heart block, pregnant women, preexisting HF
- very toxic so only give to pts who haven’t responded to safer drugs
- toxicity can continue for weeks or months after withdrawal, so patient must be given medication guide
- baseline chest x ray and pulmonary fcn
- monitor throughout therapy
- baseline thyroid fcn
- monitor throughout therapy
- baseline liver fcn
- monitor throughout therapy
- do not give to pregnant women or women who are breast feeding b/c lipid soluble (so crosses placenta and enters breast milk)
- avoid sunlamps, wear sunscreen
- do NOT consume grapefruit juice, b/c can cause toxicity
- report any signs of changes in visual acuity
digoxin: SEs
- GI disturbances: anorexia, nausea, vomiting, discomfort
- CNS: fatigue, visual disturbances
digoxin: changes to EKG
- prolonged PR interval
- shorted QT
- depressed ST segment
- T wave is depressed or inverted
verapamil: ADRs
- bradycardia
- AV block
- heart failure
- can exacerbate heart dysfunctions
pravastatin: class
- HMG CoA Reductase inhibitor
- statin
- lipid lowering agent
pravastation: indications
- hypercholesterolemia: lower LDL
- primary and secondary prevention of CV events: MI, stroke, angina
- can reduce in ppl who have never had one: primary
- can reduce risk of second event: secondary
- post MI therapy: begin as soon as patient is stabilized
- diabetes: anyone over 40 yo and with LDL greater than 100
atropine: MOA
- competitive blockade of muscarinic Rs
- no direct effects of its own, but all result from preventing receptor activation by endogenous acetylcholine
- heart: inc HR
- exocrine glands: dec secretion
- smooth muscle: relaxation of bronchi, dec tone of GI tract
- eyes: mydriasis (dilation)
- CNS: excitation
verapamil: indications
- atrial fibrillation w/ RVR or flutter
- b/c slow ventricular rate
- AV nodal reentrant circuit
- so terminates SVT–more long term than adenosine
- essential HTN
- angina pectoris
- NOT effective against ventricular dysrhythmias
adenosine: class
- antidysrhythmic
- naturally occurring nucleotide
digoxin: MOA
- positive inotropic actions: their ability to inc myocardial contractile force
- can inc CO
- works by inhibiting Na/K ATPase, so inhibits the uptake of K into the cell which inhibits Na moving out, so w/ each action potential, intracellular K declines, Na inc, and Ca inc, so promotes Ca accumulation in myocytes
- dec conduction thru AV node by:
- direct depressant effect on AV node
- acting on CNS to inc parasympathetic impulses to AV node
- dec automaticity of SA node by :
- inc parasympathetic traffic to node
- dec sympathetic traffic
atropine: SEs
- dry mouth (xerostomia)
- can cause infections, impede swallowing
- blurred vision and photophobia
- drowsiness
- constipation
- anhidrosis
- asthma
dronedarone: class
- antidysrythmic
- potassium channel blocker (class III)
metoprolol: MOA
-
selective blockade of beta 1 receptors in the heart
- only binds to beta 2 with a large dose
- reduces HR
- reduces force of contraction
- reduces conduction velocity through AV node
- reduces secretion of renin by kidney
- lowers BP
dronedarone: changes to EKG
- PR and QT prolongation
- widening of QRS complex
pravastatin: nursing implications
- contraindicated in pts with viral or alcoholic hepatitis and pregnant women
- do not give to a pt with a liver problem, b/c this drug works in the liver
- category X
- take in the evening
- Liver fcn tests should be done before tx and during tx
- if muscle pain develops, look at thyroid fcn
- measure creatinine kinase levels
- have lactic acid levels checked
dronedarone: nursing implications
- teach pts signs of liver toxicity: anorexia, nausea, vomiting, malaise, fatigue, itching, jaundice, dark urine
- cannot use in pregnancy b/c proven teratogen
- category X
- do NOT consume grapefruit juice
amiodarone: indications (PO)
- long term therapy of recurrent ventricular fibrillation
- recurrent hemodynamic unstable ventricular tachycardia
- atrial fibrillation
- most effective drug for this even though not approved for this use
metoprolol: ADRs
- bradycardia
- HF
- pulmonary edema
- AV heart block
- rebound cardiac excitement with abrupt withdrawal
dronedarone: Indications
- atrial flutter, fibrillation
- also give to pts in sinus rhythm with a history of paroxysmal or persistent afib
metoprolol: SEs
- reduced cardiac output
- fatigue
- weakness
diltizem: MOA
- blocks Ca channel blockers in the heart and blood vessels
- slowing of SA nodal automaticity
- delay of AV nodal conduction
- reduction of myocardial contractility
- blockade of peripheral arterioles which causes dilation and reduces arterial pressure
- blockade of arteries and arterioles which inc coronary perfusion
- vasodilation
digoxin: nursing implications
-
watch K+ levels especially in pts taking thiazide or loop diuretics
- must be w/in normal ranges: 3.5-5.0 mEq/L
- need to monitor these–digoxin toxicity
-
narrow therapeutic range, so need to keep range b/w 0.5-0.8 ng/mL
- half life is 36-48 hours
- make sure pts don’t double up on doses to compensate for missed dose
- limit salt intake to 1500 mg/day
- pts should avoid excess fluid
- if drink alcohol, consume no more than 1 drink/day
- help pts establish appropriate regular, mild exercise
- teach pt to monitor pulse
- HR must be over 60 bpm before administration
- teach pt to monitor for signs of hypokalemia (muscle weakness)–inform doctor
digoxin: indications
- HF
- control of dysrhythmias
- SVT
- atrial fibrillation/flutter: can slow ventricular rate by reducing atrial impulses thru AV node
- ineffective against ventricular dysrhythmias
adenosine: Indication
- termination of paroxysmal SVT–more emergent use
- including Wolff Parkinson White Syndrome
- test drug during stress test in cardiac cath lab
verapamil: changes to EKG
- prolong PR interval
- reflect delayed AV nodal conduction
metoprolol: indications
- HTN–primary use for metoprolol
- angina pectoris
- HF
- MI and post MI
amiodarone: SE (PO)
- dyspnea
- cough
- corneal microdeposits
- photosensitivity
- CNS effects: ataxia, dizziness, tremor, hallucinations, mood alterations
- GI disturbances: nausea, vomiting, anorexia
difference b/w dronedarone and amiodarone
- dronedarone is less toxic but also less effective than amiodarone
- dronedarone doubles the risk of death in patients with permanent atrial fibrillation or HF
- dronedarone has shorter half life so ADRs resolve more quickly
- dronedarone DOES NOT cause thyroid, pulmonary, or ocular toxicity
diltizem: nursing implications
- contraindications: severe hypoTN, sick sinus syndrome, 2nd/3rd degree AV heart block
- check BP, pulse, liver & kidney fcn before starting
- need to watch pts that are receiving diltizem with digoxin or a beta blocker
- can be given PO or IV, but PO undergoes extensive metabolism on first pass thru liver
- do NOT consume grapefruit juice
- monitor BP–b/c this drug will dec BP
- inform pts about signs of cardiac effects and edema
- tell pts that constipation can be minimized by inc fluids and fiber
atropine: indication
- preanesthetic medication:
- sometimes procedures that stimulate baroreceptors will cause bradycardia, but since muscarinic Rs on heart, we can prevent this dangerous reduction in HR
- disorders of eye: by blocking muscarinic Rs, it can cause mydriasis and paralysis of ciliary M
- bradycardia: will accelerate HR in pts with bradycardia, b/c blockade of muscarinic Rs reverses parasympathetic slowing of heart
- intestinal hypertonicity and hypermotility
- muscarinic agonist poisoning
- treats AV heart block
amiodarone: changes to EKG (PO)
- widen QRS complex
- prolong PR interval
amiodarone: ADRs (PO)
- lung damage (biggest concern)
- hypersensitivity pneumonitis
- interstitial/alveolar pneumonitis
- pulmonary fibrosis
- paradoxical inc in dysrhythmic activity
- sinus bradycardia
- AV block
- HF
- hypo/hyperthyroidism
- liver injury: malaise, dark urine, fatigue, jaundice
- optic neuropathy
- neuritis
verapamil: MOA
- slowing of SA nodal automaticity
- delay of AV nodal conduction
- reduction of myocardial contractility
- blockade of peripheral arterioles which causes dilation and reduces arterial pressure
- blockade of arteries and arterioles which inc coronary perfusion
- vasodilation
diltizem: class
- antidysrhythmic
- nondihydropyridine calcium channel blocker (class IV)
pravastatin: ADRs
- myopathy/rhabdomyolysis
- can cause muscles to deteriorate
- hepatotoxicity
- new onset diabetes
- cataracts
verapamil: nursing implications
- contraindications: severe hypoTN, sick sinus syndrome, 2nd/3rd degree AV heart block
- check BP, pulse, liver & kidney fcn before starting
- can inc risk of digoxin toxicity–so watch K+ levels
- if combine with beta blocker, it will inc risk of bradycardia, AV block, HF
- can be given PO or IV, but PO undergoes extensive metabolism on first pass thru liver
- do NOT consume grapefruit juice
- monitor BP
- inform pts about signs of cardiac effects and edema
- tell pts that constipation can be minimized by inc fluids and fiber
pravastatin: SEs
- headache
- rash
- GI: cramps, dyspepsia, flatulence, constipation, pain
dronedarone: MOA
- blocks cardiac potassium channels so delays repolarization
- can block Na channels, beta adrenergic receptors, and calcium channels
metoprolol: class
- anti HTN
- beta blocker–only acts on the heart
amiodarone: MOA (PO)
- delays repolarization so prolongs action potential and ERP
- effects may be due to blockage of potassium channels
- reduced automaticity of SA node
- reduced contractility
- reduced conduction velocity of AV node, ventricles, His Purkinje fibers
- promote dilation in coronary and peripheral blood vessels
verapamil: SEs
- vasodilation–>hypoTN and peripheral edema, facial flushing, headache, dizziness
- constipation
metoprolol: nursing implications
- contraindicated in pts with bradycardia and AV block greater than 1st degree
- be careful in pts with HF
- masks signs of hypoglycemia so watch for hunger, fatigue, poor concentration
- caution in pts with asthma, bronchospasm, diabetes
- do not d/c abruptly
- warn pt about signs of orthostatic hypoTN
dronedarone: contraindications
- class IV HF OR class II or III HF with recent decompensation requiring hospitalization
- liver/lung toxicity
- permanent atrial fibrillation
- 2nd/3rd degree AV block or sick sinus syndrome (unless pt has pacemaker)
- bradycardia
- PR interval greater than 280 msec
- QT interval greater than 500 msec
- use of drugs or supplements that prolong QT interval
- use of strong inhibitors of CYP34A
- pregnancy
- breast feeding
- severe liver impairment
adenosine: MOA
- decreases automaticity of SA node and slows conduction thru AV node
- inhibits cyclic AMP induced calcium influx, so suppresses calcium dependent action potentials in the SA and AV nodes