NSG 251 Exam 5 Blueprint

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May 24, 2024

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NSG 251: Pharmacology and Dosage with Lab Exam 5: Test Blueprint FALL 2022 Exam 5 40 questions worth 2 points each Testing Date Exam 5 is scheduled for Week 11. See Communication Course Calendar Module 7 Outcomes: Drugs Acting on the Cardiovascular System After completing this module, you will be able to: Antihypertensive Drugs  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for patients receiving antihypertensive medications: o alpha 2 agonists o beta blockers o ACE/ARBs o calcium channel blockers o vasodilators  hydralazine Diuretic Drugs  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for patients receiving diuretic medications: o loop o thiazide o potassium sparing  Develop a nursing plan of care using nursing process for patients receiving diuretic therapy. Drugs to Treat Angina  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for patients receiving anti-anginal medications: o nitrates o beta blockers o calcium channel blockers  Develop a nursing plan of care using nursing process for patients receiving anti-anginal medication therapy. 1

Drugs to Treat Heart Failure  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for patients receiving heart failure medications: o ACE/ARB o beta blockers o cardiac glycosides  digoxin  Develop a nursing plan of care using nursing process for patients receiving medication therapy for heart failure. Drugs that Affect Coagulation  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for patients receiving anticoagulant medications: o anticoagulants  heparin  warfarin o thrombolytics  alteplase o antifibrinolytic  aminocaproic acid  Develop a nursing plan of care using nursing process for patients receiving anticoagulant medication therapy. Antilipemic Drugs  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for patients receiving antilipemic medications: o statins o fibric acid derivative  gemfibrozil  Develop a nursing plan of care using nursing process for patients receiving medication therapy for elevated cholesterol. Antidysrhythmic medications  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for patients receiving antidysrhythmic medications: o Class III: potassium channel blocker 2

 amiodarone o adenosine  Develop a nursing plan of care using nursing process for patients receiving medication therapy for cardiac dysrhythmias. DO YOU KNOW THIS?  What is the difference between a cardio selective and a nonselective beta blocker? What happens when a beta 1 receptor is blocked? What happens when a beta 2 receptor is blocked? Cardio selective Beta 1 blockers block beta 1 receptors in the heart (ex. atenolol (Tenormin)) •  Slows automaticity of the SA node resulting in a slower heart rate (a negative • chronotropic effect) • Decreased heart rate prolongs diastole allowing more coronary artery • perfusion, reducing ischemia •  Decreases contractility and oxygen demand (a negative inotropic effect) •  slower signal conduction through the AV node (a negative dromotropic effect) •  inhibit release of renin-angiotensin-aldosterone (decrease preload and • afterload) •  some beta-blockers have vasodilatory effects Nonselective: beta 1/beta 2 blocker (ex. propranolol (Inderal))   Beta 1 blocker effects   Block beta 2 receptors located in smooth muscles of the bronchioles and  blood vessels  Causes bronchoconstriction of the airways  Block glycogenolysis leading to hypoglycemia  Blunt symptoms of hypoglycemia: tachycardia, tremor, nervousness  EXCEPT sweating  Block secretion of insulin leading to hyperglycemia  Release of free fatty acids elevating triglyceride levels and decreasing HDL (good cholesterol)  What are the therapeutic uses for beta blockers? What box warning has been issued for beta blockers? What significant adverse effects may occur? What assessments must be made prior to administration? What patient education must be completed? Therapeutic Purpose/Indications   Management of hypertension   Treatment of angina   Cardioprotective blockade of norepinephrine and epinephrine  post myocardial infarction   Acute treatment of supraventricular tachycardia   Treatment of heart failure   prevention of migraine headaches and some essential tremors 3

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  open-angle glaucoma  FDA: BOX WARNING: do NOT abruptly stop, taper off over a period of 1-2 weeks Adverse effects   Bradycardia, Depression, Impotence, Nausea, vomiting, Constipation, Fatigue, Delay recovery from hypoglycemia (type 1 diabetic), Heart failure, Dizziness, Low WBCs and platelets, Hyperlipidemia, Alopecia, Wheezing, Dry mouth Administration/Teaching  Assess blood pressure and heart rate prior to administration (Count apical heart rate for one full minute)  Assess weight, intake and output, breath sounds, and blood glucose levels  Assess for sexual dysfunction issues  Assess adherence to therapy  Teach not to abruptly stop, drug MUST be weaned  Take exactly as directed, do not skip doses, do not double doses   May be taken with or without food  No caffeine/alcohol  Increase fiber in diet, and increase fluids  What are the therapeutic purposes of calcium channel blockers? What adverse effects can occur? What assessments must be made prior to administration? What patient education must be completed? Therapeutic purpose/Indications  Treatment of angina, hypertension, atrial fibrillation/flutter with controlled ventricular response, paroxysmal supraventricular tachycardia (PSVT)  Treatment of coronary artery spasm and Raynaud’s disease INTERACTION: grapefruit juice: increased effect; decreased heart rate with beta blockers, amiodarone; toxicity with statins, antifungals, antivirals, and erythromycin Adverse effects  Potent effect, Hypotension  Palpitations, variable heart rate  Constipation/nausea  Dyspnea, edema, rash Administration/teaching   Do not crush, puncture, or open sustained-release tablets or capsules   Teach to avoid grapefruit   Do not abruptly stop, withdraw slowly 4

  Monitor breath sounds, assess for dyspnea, edema   Change positions slowly to prevent falls, implement safety plan for  inpatient care   Assess bowel habits, last BM, increase fiber (and fluids as allowed),  monitor for constipation   Monitor for manifestations of heart failure   Take BP and heart rate prior to administration  How is an ACE inhibitor different than an angiotensin receptor blocker (ARB)?  ACE inhibitor: what the therapeutic purposes? What box warning has been issued? Who would not benefit from an ACE inhibitor? What adverse effects may occur? What lab work should be monitored? What teaching should be completed? Ex. of ACE inhibitor: captopril (All ACE inhibitors end in “pril”) Therapeutic Purpose/Indications  Management of hypertension  Management of heart failure  Prevention of left ventricular hypertrophy following MI  Renal protective: reduced glomerular filtration pressure  Prevent proteinuria and progression of diabetic  Nephropathy  FDA: BOX WARNING: fetal toxicity  Persons of Black race do NOT respond to ACE inhibitors for BP management  INTERACTIONS: NSAIDS: decrease BP effect, risk of renal failure; risk of lithium toxicity; risk of hyperkalemia with potassium supplements  Assess/teach manifestations of hyperkalemia  Monitor electrolytes, especially potassium  Avoid potassium supplements and salt substitutes made from potassium  chloride Adverse Effect  Fatigue  Dizziness, mood changes, headaches  Dry nonproductive cough (reversible with discontinuation  of therapy)  Hyperkalemia  Angioedema  May cause acute renal failure in patients with severe  heart failure  ARBs: what the therapeutic purposes? What box warning has been issued? What adverse effects may occur? What lab work should be monitored? What teaching should be completed? Example of ARB: losartan (Cozaar) - All ARBs end in “sartan” 5

Therapeutic Purpose/Indications  Treatment of hypertension  Associated with a lower mortality after MI compared to ACE inhibitors  as effective in treating heart failure compared to ACE inhibitors  as renal protective in diabetics as ACE inhibitors  FDA: BOX WARNING: fetal toxicity  Caution: older adults  Caution: renal impairment  INTERACTIONS: NSAIDs and rifampi Adverse Effect  Chest pain, Fatigue, Weakness, Hypoglycemia, Diarrhea, Urinary tract infection, Cough (less likely than ACE inhibitors), and Hyperkalemia (less likely than ACE inhibitors) Teaching/Administration  Take with meals  Report dizziness, dyspnea, or excessive fatigue to HCP  Take BP and apical heart rate prior to administering  Monitor potassium levels, monitor for manifestations of hyperkalemia  What lifestyle changes should be made to reduce high blood pressure?  Smoking cessation  Reduce alcohol intake  Dietary changes o Reduce salt intake o Reduce cholesterol and fat intake o Increase intake of vegetables, fruits nuts, legumes, fish, and whole grains  Physical activity o 150 minutes/week of moderate exercise  Stress management  What general teaching should be done for any patient receiving antihypertensives?   Teach patient about hypertension and potential chronic complications   Treatment for primary hypertension is lifelong   Teach about prescribed medication   Teach to not skip doses, do not double doses and to take exactly as directed   Lack of adherence to therapy causes REBOUND HYPERTENSION and is the primary cause of malignant hypertension and end target organ damage   Teach patient to monitor BP at home   Teach lifestyle measures to reduce hypertension 6

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 How does the alpha 2 receptor agonist clonidine lower blood pressure? What significant adverse effects may occur? What teaching should be completed?  Alpha 2 receptor agonist stimulates central alpha 2 receptors which inhibit sympathetic outflow, norepinephrine levels and blood pressure AND  Inhibits the renin-angiotensin-aldosterone system (angiotensin is a potent vasoconstrictor) Adverse effects  Not a front-line drug due to high risk of adverse side effects including:  Orthostatic hypotension, Fatigue, Dizziness, Drowsiness, Nausea, vomiting, constipation, dry mouth. Impotence, and rash Administration/ teaching   Comes in topical and oral forms   Teach: remove old patch (applied weekly) prior to applying a new one to chest or  upper arm   Patch must be removed prior to an MRI (magnetic resonance imaging)   Must be tapered off, DO NOT ABRUPTLY STOP   Do not take any OTC medications, alcohol, or CNS depressants without consulting HCP first   Avoid excessive heat as perspiration can lead to dehydration and hypotension   Use with CAUTION in the elderly (drug is on the Beer’s List)  What teaching should be done for a patient taking the vasodilator hydralazine? Therapeutic purpose/indication  Treatment of hypertension Administration/ teaching  Complete a neurological assessment focusing on cognition and level of consciousness  Rise slowly to a standing position to decrease orthostatic hypotension, dizziness, syncopal episode  Institute safety protocols in hospital settings, and safety measures at home (remove  obstacles, install handrails)  May cause systemic lupus erythematosus: hold drug and notify HCP immediately  Photosensitivity, skin rash  CNS changes  Dropping blood counts  IV hydralazine administration requires proper ongoing monitoring and implementation  of safety measures  Take with food  What are the indications for the use of the diuretic furosemide? What cross allergy is possible? What box warning has been issued? What adverse effects can occur? What lab should be monitored? What teaching should be completed? Therapeutic purpose/indications  Useful when rapid diuresis is required  Can be used even when kidney function decreases 7

 Used to treat pulmonary edema and edema states associated  with heart failure, liver disease (ascites), renal failure  Management of hypertension, especially associated with heart  failure  Increase renal excretion of calcium in patients with  Hypercalcemia Allergy  Chemically related to sulfonamide antibiotics (A cross reaction is possible but not likely) FDA: BOX WARNING: Severe electrolyte loss Adverse effects   hypokalemia, hyperglycemia, hyperuricemia   Elevated liver enzymes (ALT, AST)   dizziness, headache, tinnitus   Ototoxicity with long term administration   Nausea, vomiting, diarrhea   Reduced WBCs, RBCs, platelets   aplastic anemia (rare)   erythema multiforme, exfoliative dermatitis   photosensitivity Administration/teaching   Give oral medications early in the morning   Monitor potassium levels, assess prior to administration   Assess/report manifestations of hypokalemia   Encourage potassium foods, sometimes potassium supplements may be  required   Pregnancy category C   Severe adverse effects are more likely to occur in the older patient   IV administration is given for acute situations, rapid diuresis will follow   Wear sunscreen and protective clothing, UVA/B eye protection   Hearing screening, monitor/report changes   Monitor for rash, teach to hold dose and contact HCP  What are the indications for use of the diuretic spironolactone? What contraindications to its use are there? What adverse effects can occur? What teaching should be done? What lab should be monitored? Therapeutic purpose/indications   Treatment of hyperaldosteronism   Management of hypertension   Reverse potassium loss caused by loop and thiazide diuretics 8

  Management of heart failure   Ascites associated with liver disease   Other uses   Swelling in the legs   Female acne   Hirsutism (face and body in women)   May help with female pattern hair loss Contraindications  Allergy  Hyperkalemia  Severe renal failure or anuria Adverse effects  Dizziness, headache, Cramps, nausea, vomiting, diarrhea, Urinary frequency, weakness, Hyperkalemia, Hyperchloremia, Gynecomastia, Amenorrhea, Irregular menses, Post-menopausal bleeding Administration/teaching  Relatively weak compared to loop and thiazide diuretics, may be used in combination with a thiazide  Avoid salt substitutes made of potassium chloride and high potassium foods  May be prescribed for children with heart failure (has a protective effect on left ventricular function)  Pregnancy category D  What are the indications for the use of the diuretic hydrochlorothiazide? What are contraindications to its use? What adverse effects can occur? What labs should be monitored? What teaching is required? Therapeutic purpose/indications  Treatment of heart failure  Treatment of hypertension  Treatment of edema  Treatment of idiopathic hypercalciuria (excess loss of calcium in urine) Contraindication  Allergy  Chemically related to sulfonamide antibiotics  A cross reaction is possible but not likely  Do not use if creatinine clearance (a measure of kidney function) is less than 30 – 50 mL/min (normal: 125 mL/min) Adverse effects 9

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 Hypokalemia, Hypomagnesemia, Hypochloremic alkalosis, Hypercalcemia, Hyperlipidemia, Hyperglycemia, Hyperuricemia, Dizziness, Anorexia, nausea, vomiting, diarrhea, Impotence, and photosensitivity Administration/teaching  Produces sodium rich urine, not a large watery urine output like furosemide  Women are more likely to experience hyponatremia  Monitor potassium levels, assess prior to administration  Assess/report manifestations of hypokalemia  Encourage potassium foods, sometimes potassium supplements may be required  What lifestyle interventions should be implemented in a patient with atherosclerosis and angina? You should modify the following:  Smoking  Elevated blood pressure  Glucose intolerance  Elevated cholesterol  Decreased activity  Obesity  Stress  Toxins/viruses, immune reactions  How does nitroglycerin work to reduce chest pain? What drug class cannot be taken with NTG? What are common adverse effects of NTG? How should a patient be instructed to take sublingual NTG? What precautions should be taken with topical NTG? When should NTG be held? What teaching should be done? Mechanism of action  nitrate class  venous dilator: reduces preload which reduces contractility and oxygen demand  vasodilation of arteries, especially the coronary arteries which increases oxygen supply  CONTRAINDICATION/INTERACTION: erectile dysfunction drugs cause severe drop in pressure, possibly fatal  INTERACTION: added hypotension with alcohol, beta blockers, calcium channel blockers,phenothiazines  NOTE: oral nitroglycerin has a large first pass effect Adverse effects  most adverse effects are transient  severe headache (acetaminophen may be given)  tachycardia  postural hypotension  tolerance, especially with long-acting forms or getting dose around the clock 10

Administration/teaching  assess breath sounds, heart sounds, rate, and rhythm  complete assessment of chest pain, report to HCP: ECG and other diagnostics may be ordered  administered while resting in bed or sitting in a chair to avoid injury from hypotension  Sublingual tablets (or spray): treatment or prevention of ACUTE chest pain  Store in original container tightly capped: avoid exposure to light, plastic, cotton filler, air, heat, moisture deactivate NTG  NTG has a limited effectiveness period, check expiration dates and replace  Take at the first sign of chest pain. Sit down and administer dose. IF PAIN is NOT relieved in one dose (5 minutes), ACTIVATE 911. May take up to 3 total tablets all spaced 5 minutes apart  Place under tongue and do not swallow until completely dissolved o Tablet should burn or fizz while dissolving. If it does not, the medication has lost its potency  Onset of action 2-3 minutes with a duration of 30-60 minutes  Teach to take prior to activities that provoke anginal attacks  IV forms are given for BP control, treatment of ischemic pain, heart failure, and pulmonary edema associated with MI (HIGH ALERT: dosing errors have occurred)  Must have proper VS monitoring, NTG must be run through a pump.  Use specific non-polyvinyl-chloride intravenous bags and tubing  Hold med if systolic BP is less than 90 mmHg, contact HCP prior to administering dose  Hold med if apical heart rate is less than 60 beats/minute or greater than 100  beats/minute and contact HCP  Teach: change position carefully; implement home safety measures. Safety plan implementation if inpatient  Avoid alcohol, hot temperatures, saunas, hot tubs and excessive exertion as these may drop blood pressure too low  Oral and topical doses are for long-term prevention of chest pain o Topical forms allow for slow continuous delivery   Do NOT touch NTG with ungloved fingers  Apply ointments and patches to clean, dry, hairless skin on the chest or body above the elbows  → Rotate sites  → Remove old patch and clean off any remaining ointment before applying new  ointment patch  → Cover with dressing such as saran wrap and tape with an occlusive seal o transdermal patches should be removed at night for 8 hours to prevent tolerance  → remove old patch and clean site prior to applying new  → apply at the same time every day  oral forms should be taken before meals with 6 oz of water  What are the normal values for a lipid panel? What primary prevention measures should be implemented in addition to drug therapy? 11

 Must fast for 9 – 12 hours for accurate results  Normal Values: o cholesterol: less than 200 mg/dL o triglycerides: less than 150 mg/dL o LDL: less than 100 mg/dL o HDL: 60 mg/dL or higher Primary prevention methods  low fat, high fiber/vegetables/fruits, and decreased animal protein  omega-3 fatty acids (supplement or fish source)  weight loss  aerobic exercise  reduction of nicotine and alcohol  supplementation of fat soluble vitamins A, D, E, and K  How do HMG-COA reductase inhibitors (Statins) reduce cholesterol levels? Who should be administered a statin? What are contraindications to the use of statins? What are adverse effects of statins? Define rhabdomyolysis. What teaching is required? Ex. atorvastatin Mechanism of Action  Inhibit the HMG-COA Reductase enzyme necessary for LDL cholesterol production  Decreased liver cholesterol production, the liver increases the number of LDL receptors which moves cholesterol from the blood to the liver where it is used for steroid hormones, cell membranes, and bile Patients to be treated with statins  Atherosclerotic heart disease  LDL levels of 190 mg/dL  Diabetics who are 40 – 75 years with LDL levels 70 – 189 mg/dL and no evidence of cardiovascular disease  No evidence of cardiovascular disease or diabetes but with LDL levels between 70 – 189 mg/dL Contraindications  Allergy, Pregnancy (category X), Liver disease, and elevated enzymes Adverse effects  Headache, dizziness, fatigue, difficulty sleeping  Constipation, diarrhea, nausea  Myalgia  Muscle pain without cause may progress to rhabdomyolysis (the breakdown of muscle protein which leads to myoglobinuria (reddish-brown urine))  Myoglobin clogs the glomerulus and leads to acute renal failure 12

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 Generally reversible with cessation of drug therapy  More common in the elderly, hypothyroidism, and pre-existing renal insufficiency  Teach to report muscle pain without cause or discoloration of urine to HCP  Rash  Elevated liver enzymes Administration/teaching  May take up to 6 – 8 weeks to start reducing cholesterol levels  Take with evening meal or at bedtime  Periodic lab testing to check lipid panel and liver enzymes is required  Liver enzymes that may indicate liver damage if elevated  Aminotransferase (AST)  Alanine aminotransferase (ALT)  Elevated creatine phosphokinase (CPK)  May indicate skeletal muscle damage  Assess/teach to report nausea, vomiting, diarrhea, right upper quadrant abdominal pain, and jaundice to HCP immediately  What is the therapeutic purpose for gemfibrozil? What contraindications should be noted? What adverse effects can occur? Therapeutic purpose/indications  Decrease triglyceride levels  Increase HDL Contraindications/interactions  Allergy, Preexisting gall bladder disease, Hepatic dysfunction, Biliary cirrhosis, and Renal impairment Adverse effects  Nausea, vomiting diarrhea  Gallstones  Prolonged prothrombin time  Impotence  Decreased urine output  Drowsiness, dizziness  Pruritus, rash  What risk factors are associated with clot development? What are normal values for the coagulation labs? What bleeding precautions should be implemented for a patient on anticoagulants? What clot prevention measures should be taught to patients? Risks of Clot Development  Immobility, prolonged bedrest  Dehydration, Smoking, Obesity  CHF, CAD, PAD 13

 Pelvic, abdominal, orthopedic, vascular surgery  Heart valve replacement, incompetency  History of DVT/PE, MI, Atrial fibrillation  Oral contraceptives  Recent airline travel Lab Values   Activated partial thromboplastin time (aPTT)   With heparin therapy values should be 1.5 – 2.5 times normal (25 – 35 seconds)   Therapeutic anticoagulation is 45 – 70 seconds  With IV infusion: draw level 4 – 6 hours after initiation and after any rate change  Prophylactic subcutaneous doses do NOT require monitoring   Prothrombin time (PT)   Normal value is 11 – 13 seconds   Therapeutic anticoagulation for warfarin is 1.5 times normal or 18 seconds   “normal” values vary by lab   International normalized ratio (INR)   Therapeutic anticoagulation for warfarin is 2 – 3, higher values may be required in some patients Teaching  Teach bleeding and safety precautions o  Monitor/test urine, emesis, and stools for occult blood o  No IM injections, rectal temperatures, or suppositories o  Use stool softeners, do not strain to stool o  Hold venipuncture sites for 5 minutes o  No flossing, use a soft bristle toothbrush o  Use an electric razor o  Avoid vigorous nose blowing o  Footwear o  Avoid high risk activities such as contact sports  Teach clot prevention measures o Avoid tight fitting clothes o Minimize prolonged sitting and standing o Avoid crossing the legs at the knees o Make frequent stops and walk around on long trips o Stay hydrated  What is the difference between low molecular weight heparin (enoxaparin) and unfractionated heparin? Therapeutic purpose/indication of low molecular weight heparin (enoxaparin)   Bridge therapy for patients who must stop warfarin temporarily, such as for surgery   Prevention/treatment of thromboembolism   ischemia in unstable angina 14

  Post-operative and post -MI patients Therapeutic purpose/indication for unfractured heparin   Treatment and prevention of thromboembolism   Treatment of disseminated intravascular coagulopathy (DIC)   Clotting prevention (open heart surgery, dialysis)   Lo-dose heparin: flushing central venous access ports  What cautions should be noted with the use of enoxaparin (regarding preservatives and additives)? Therapeutic purpose/indication  Bridge therapy for patients who must stop warfarin temporarily, such as for surgery  Prevention/treatment of thromboembolism  ischemia in unstable angina  Post-operative and post -MI patients Cautions  Indwelling epidural catheter: risk of epidural hematoma : FDA: BOX WARNING  Must wait 2 hours after epidural removed to give a dose  Never give at the same time as unfractionated heparin  Contains benzyl alcohol and sulfites o Benzyl alcohol: do NOT give to infants and young children cannot metabolize this preservative. If given, it can cause “gasping syndrome” (CNS depression, metabolic acidosis, gasping breaths, and death is possible) o READ the drug label carefully o Use the preservative free form  Sulfites: use carefully in patients with respiratory disorders, especially asthma, as wheezing may occur  When is unfractionated heparin used? What is heparin induced thrombocytopenia and how would it be treated? What is the antidote for heparin toxicity? What is the protocol for verifying heparin prior to administration? What lab value must be monitored? Why can warfarin and heparin be given simultaneously? Therapeutic purpose/indication for unfractured heparin •  Treatment and prevention of thromboembolism •  Treatment of disseminated intravascular coagulopathy (DIC) •  Clotting prevention (open heart surgery, dialysis) •  Lo-dose heparin: flushing central venous access ports Adverse effects  Heparin induced thrombocytopenia (HIT) o Type I  Slow reduction in platelet count  Continue heparin and watch platelet counts carefully o Type II 15

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 Acute fall in platelet count by 50% of baseline  Stop heparin  Begin a direct thrombin inhibitor such as argatroban  Assess for manifestations of paradoxical thromboembolism development Antidote: protamine sulfate Administration/teaching  Derived from pigs: assess for allergy  Heparin is a high-alert drug. Always verify order and have another RN verify an individual dose prior to administration  Requires laboratory monitoring with the activated partial thromboplastin time (aPTT)  Warfarin should be started when heparin is started. Warfarin has a long half-life and may take a week to achieve a therapeutic INR 0f 2 -3. When the INR is therapeutic, heparin is stopped  Rotate sites  What are the therapeutic purposes of warfarin? What box warning exists? How is warfarin toxicity treated? What lab value must be monitored? How should patients be advised regarding diet? Therapeutic Purpose  Prevention and treatment of thromboembolism associated with deep vein thrombosis (DVT), pulmonary embolism (PE), atrial fibrillation, coronary artery disease *At high risk for or acute active bleeding: FDA: BOX WARNING: increase risk of bleeding/hemorrhage Toxicity/overdose  Stop drug therapy  Warfarin stops production of vitamin K dependent clotting factors. It takes up to 48 hours for enough factor production to reverse warfarin effects Teaching  Monitor prothrombin time (PT) and international normalized ratio (INR)  Teach patient to maintain their normal intake of Vitamin K foods. These foods include o  Kale, Spinach, Turnip and collard greens, Brussel sprouts, Asparagus, Sauerkraut, Soybeans, Pickles, and blueberries  What are the clinical implications for use of alteplase? What potential adverse effects can occur? What nurse administration issues should be implemented? Therapeutic Use  Rapid elimination of arterial or venous clots that obstruct blood flow and tissue  perfusion  Acute MI, Acute arterial occlusion, DVT, PE, Ischemic stoke  Occlusion of shunts and catheters 16

Adverse effects  Intracranial and internal bleeding  Nausea, vomiting, Hypotension, and Cardiac dysrhythmias Administration/teaching  Given via IV  Has a very short half-life of about 5 minutes so heparin therapy is initiated to prevent re- occlusion  Monitor puncture sites for bleeding  DO NOT give any drugs by the IM route  Informed consent should be obtained  Continuous VS monitoring  When would aminocaproic acid be given? To prevent and treat excessive bleeding from systemic hyperfibrinolysis or bleeding during or after surgery  What are the mechanisms of action of digoxin? What are its therapeutic uses? What is a therapeutic digoxin level? What can contribute to digoxin toxicity? What are the manifestations of digoxin toxicity? What labs should be monitored? How is digoxin toxicity treated? When should digoxin be held? Mechanism of action  cardiac glycoside  positive inotropic effect to enhance myocardial contractility without greater oxygen demand  increase stroke volume  slows the heart rate to enhance diastolic filling of the coronary arteries (negative chronotropic effect)  slows the speed of conduction between the SA and AV node (negative dromotropic effect)  promotion of diuresis (decreased preload)  decrease dyspnea and improved exercise tolerance Therapeutic purpose/indications  systolic heart failure  atrial fibrillation * licorice decreases potassium levels increasing toxicity risk* Assessing for causes of digoxin toxicity  hypokalemia and hypomagnesemia leading contributors  reduction in renal function (monitor BUN, creatinine, weight, I&O, urine output color and quantity)  pacemakers (toxicity even at lower dosage levels)  hypercalcemia (bradycardia) 17

Treatment of toxicity  withhold dose  administration of antidote: digoxin immune Fab (Digifab)  if potassium levels are elevated  life threatening dysrhythmia: ventricular tachycardia or fibrillation, or sinus bradycardia or heart block unresponsive to atropine or cardiac pacing  overdose: greater than 10 mg in adults or 4 mg in children  dose is based on serum digoxin levels  after treatment, digoxin blood levels may be inaccurate so assess for other manifestations (or rather improvement of) digoxin toxicity Teaching/Administration  monitor electrolyte levels  assess/report manifestations of low potassium and low magnesium  assess apical heart rate o hold for heart rate less than 60 beats/minute and notify HCP  monitor serum digoxin level: 0.5 to2 ng/mL; higher levels required to manage atrial fibrillation  What types of dysrhythmias can be treated with amiodarone? What are contraindications to its use? What adverse effects can it cause? What box warning has been issued? What teaching should be done? Therapeutic purpose/indications  Ventricular tachycardia and fibrillation  Difficult to treat supraventricular dysrhythmias Adverse effects  Lipophilic concentration in tissues  Corneal microdeposits causing halos, dry eyes, and photophobia  Photosensitivity  Pulmonary toxicity with progressive dyspnea and cough  Proarrhythmic  constipation  FDA: BOX WARNING: hepatotoxicity, pulmonary toxicity, and proarrhythmic effects Contraindications  Allergy, Severe sinus bradycardia, and Heart block Administration/teaching  Long half-life so adverse effects take longer to wear off  Wear sunscreen and protective clothing, UVA/B eyewear  Encourage fiber and fluids (as tolerated) to prevent constipation  What is the purpose of adenosine? What is its adverse effect and how should it be administered? 18

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Therapeutic purpose/indication  Conversion of paroxysmal supraventricular tachycardia to sinus rhythm when verapamil (a calcium channel blocker) has failed Adverse effects  Causes momentary asystole Administration/teaching  Given by rapid IV push 19

NSG 251 Exam 5 Blueprint

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