Chapter 35 PHARM

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Frank Phillips College *

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1236

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Medicine

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Apr 3, 2024

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Chapter 35 Antianginal and Vasodilating Drugs Atherosclerosis: disease characterized by deposits of fatty plaques on the inner walls of arteries Angina: acute pain in the chest resulting from decreased blood supply to the heart muscle Pulmonary arterial hypertension (PAH): high blood pressure in the pulmonary artery (heart to lungs), which can also cause chest pain and results in heart failure if not treated Antianginal Drugs — Actions Beta (β)-blockers: reduce heart rate and contractility which reduces the amount of oxygen needed by the heart muscle Calcium channel blockers: act by inhibiting the movement of calcium ions across cell membranes of cardiac muscle cells; effects on the heart: blood vessels relax, increase the supply of oxygen to the heart, reduced cardiac workload Nitrates: relax smooth muscle layer of blood vessels, increasing the lumen of the artery or arteriole, increases the amount of blood flowing through the vessels Antianginal Drugs — Uses -Relieve cardiac pain and acute anginal attacks -Prevent angina -Treat chronic stable angina pectoris Antianginal Drugs — Adverse Reactions Central Nervous System Reactions: -Headache (severe and persistent) Dizziness -weakness, restlessness Other Reactions: -Hypotension -Flushing -Rash -Reactions associated with the route of administration Antianginal Drugs — Precautions Nitrates are used cautiously in clients with: -Severe hepatic or renal disease -Severe head trauma -Hypothyroidism -Lactation and pregnancy (pregnancy category C) Nitrates — Interactions

Calcium Channel Blockers — Interactions Drugs Used to Treat Pulmonary Artery Hypertension Action :

-Orphan drugs: depends on route of administration but most PAH drugs work by blocking receptors in pulmonary smooth muscles allowing vasodilation and better oxygenation -Phosphodiesterase type 5 inhibitors: cause relaxation in the smooth muscles of the pulmonary tissue and vasodilation of pulmonary capillaries Adverse reactions : -headache, flushing, and nausea; oral drugs can cause fetal defects and hepatotoxicity Contraindicated in pregnancy Nursing Process —Client Receiving an Antianginal Drug #1 Preadministration Assessment Objective Data -Vital signs -Inspect physical appearance, noting skin color and lesions -Auscultate the lungs for adventitious sounds -Weight -Laboratory tests: ECG, stress test, chest x-ray, laboratory panels, and possible pregnancy testing Preadministration Assessment (continued) Subjective Data -Pain assessment -Client’s ideas regarding the cause of pain and remedies used -Medical/family history of hypertension and modifiable factors -Current list of all drugs and supplements Ongoing Assessment -Monitor frequency and severity of any episodes of anginal pain -Ongoing assessment is usually conducted on an outpatient basis -Teach the client or family to monitor vital signs frequently during administration -If client’s heart rate falls below 50 bpm or if the systolic BP is below 90 mm Hg, hold the drug and notify the provider Ongoing Assessment (continued) Clients taking beta- or calcium channel blockers should be assessed for signs of heart failure -Dyspnea -Weight gain -Peripheral edema -Abnormal lung sounds -Jugular vein distention -Assess client’s cardiac status via telemetry when drug is being titrated to a therapeutic dose Nursing Diagnosis -Injury Risk related to hypotension, dizziness, or lightheadedness -Pain related to narrowing of peripheral arteries, decreased blood supply to the extremities

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Planning -Expected client outcomes depend on the reason for administration of the drug but include -Optimal response to therapy -Management of adverse drug reactions -Confidence in an understanding of the prescribed medication regimen Implementation Promoting Optimal Response to Therapy—Beta- and Calcium Channel Blockers—Preventing an Attack -Most blockers can be taken without regard to meals, but if GI upset occurs, take with food - Verapamil should be taken with food and can be opened and sprinkled on food or mixed with fluids -Diltiazem caplets can be crushed and mixed with food or fluids Implementation Promoting Optimal Response to Therapy—Nitrates—Stopping a Pain Attack -Teach clients proper administration of nitrates that are prescribed via sublingual or buccal route -Teach clients that have a nitroglycerin spray to spray the drug onto or under the tongue; do not shake the canister or inhale the spray -Dose of sublingual nitroglycerin or spray can be repeated every 5 minutes until pain is relieved or until client has received 3 doses in a 15-minute period; contact provider if angina is not relieved Implementation Promoting Optimal Response to Therapy—Administering Oral Nitrates -Sustained release oral tablet should not be crushed or chewed Implementation Promoting Optimal Response to Therapy—Administering Nitroglycerin Ointment -Topical nitroglycerin is measured in inches or millimeters -Check vital signs frequently and contact provider if blood pressure is out of normal range -Remove old paper from previous application and cleanse area, then don gloves, measure proper dose with paper and/or applicator, and apply the ointment in a thin uniform layer over a small area of the paper; do not rub direction on skin; secure the paper with tape Implementation Promoting Optimal Response to Therapy—Administering Transdermal Nitroglycerin -Be mindful that tolerance can occur -Apply the patch in the morning and leave in place for 10 to 12 hours; remove patch and leave off for 10 to 12 hours -Best time to apply transdermal patch is after morning bath or shower or cleansing routine; thoroughly dry skin -Inspect the skin at the site of application; shave if necessary; optimal sites are chest, abdomen,

and thighs; do not apply to extremities -When removing old patch, fold the adhesive side onto itself to avoid inadvertent adhesion to another person or pet - New patch should be labeled with a fiber-tipped pen: initials, date, and time of application - When removing old patch, fold the adhesive side onto itself to avoid inadvertent adhesion to another person or pet - New patch should be labeled with a fiber-tipped pen: initials, date, and time of application -Document location of application Implementation Promoting Optimal Response to Therapy—Administering IV Nitroglycerin -Must be diluted in normal saline (NS) or 5% dextrose in water (D5W) -Deliver via infusion pump and titrate per cardiologist’s orders -Given in a glass bottle and using special infusion sets -Do not mix with other drugs or blood products Implementation Monitoring and Managing Client Needs -Injury Risk -If orthostatic hypotension occurs, teach client to rise slowly from laying to sitting to standing (1 to 2 minutes in each position) or to seek assistance getting out of a chair or bed -Client should take the medication in one position and remain in that position until symptoms disappear -Monitor blood pressure frequently -Injury Risk—Lifespan Considerations -Men: If client is taking medications for erectile dysfunction, severe hypotension can occur if client takes nitrates; assess for use of ED drugs in all male clients who have been prescribed nitrates -Adolescents and Young Adults: “Poppers” are nitrates or products that contain nitrates (e.g., air fresheners) that are huffed to enhance sexual pleasure or to experience the “high” feeling; always ask about the use of poppers when injury and low blood pressure are presenting symptoms Pain -Assess and document client’s pain (full relief/partial relief, intensity, location, duration, etc.) -Provider will make adjustments in drug therapy if needed Implementation—Educating the Client and Family

-Educate all clients that blood pressures should be checked periodically -Emphasize the importance of drug therapy and following the therapeutic drug regimen -Educate the client about the adverse reactions and to contact the primary healthcare provider if adverse reactions occur - Teach client to use blood pressure machine or community resources to measure blood pressure and to keep a blood pressure record -Avoid the use of nonprescription drugs unless the primary health care provider is consulted --- Avoid alcohol and if the drug causes drowsiness, avoid driving or performing hazardous tasks - Teach client about diet restrictions and to avoid salt substitutes unless a particular brand is approved by the primary healthcare provider -If client is at risk for orthostatic hypotension, teach client and family safety methods to prevent injury and falls at home Evaluation -Was the therapeutic effect achieved? -Were adverse reactions: identified, reported, and managed? -No injury is evident -Pain is relieved -Did client and family express confidence and demonstrate understanding of drug regimen? is this new tablet for?” How should the client be instructed to use the nitroglycerin sublingual tablets?

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Chapter 35 PHARM

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