Cardiovascular medications

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Types of cardiovascular drugs

  • Positive inotropic drugs: increase the force of myocardial contraction
  • Negative inotropic drugs: decrease the force of myocardial contraction
  • Positive chronotropic drugs: increase heart rate by altering the rate of impulse formation at the SA node
  • Negative chronotropic drugs: decrease heart rate by altering the rate of impulse formation at the SA node
  • Positive dromotropic drugs: increase the conduction of electrical impulses
  • Negative dromotropic drugs: decrease the conduction of electrical impulses

Epinepherine (Adrenalin)

Class

  • Sympathomimetic
  • Epinephrine stimulates alpha-, beta1-, and beta2-adrenergic receptors in dose-related fashion. It is the initial drug of choice for treating bronchoconstriction and hypotension resulting from anaphylaxis as well as all forms of cardiac arrest. It is useful in managing reactive airway disease, but beta-adrenergic agents are often used initially because of their convenience and oral inhalation route. Rapid injection produces a rapid increase in systolic pressure, ventricular contractility, and heart rate. In addition, epinephrine causes vasoconstriction in the arterioles of the skin, mucosa, and splanchnic areas and antagonizes the effects of histamine.

Onset & Duration

Onset:

(SQ) 5-10 min (IV) 1-2 min

Duration:

5-10 min

Indications

– Bronchial asthma
– Acute allergic reaction
– Cardiac arrest
– Asystole
– Electromechanical dissociation
– Ventricular fibrillation unresponsive to initial defibrillatory attempts

Contraindications

•Hypersensitivity
Hypovolemic shock
Coronary insufficiency
Hypertension

 

Nursing Implication and intervention:

1. Monitor BP, pulse, respirations, and urinary output and observe patient closely following IV administration. Epinephrine may widen pulse pressure. If disturbances in cardiac rhythm occur, withhold epinephrine and notify physician immediately.

2. keep physician informed of any changes in intake-output ratio.

3. Use cardiac monitor with patients receiving epinephrine IV. Have full crash cart immediately available.

4. Check BP repeatedly when epinephrine is administered IV during first 5 min, then q3–5min until stabilized.

5. Advise patient to report to physician if symptoms are not relieved in 20 min or if they become worse following inhalation.

6. Advise patient to report bronchial irritation, nervousness, or sleeplessness. Dosage should be reduced.

7. Monitor blood glucose & HbA1c for loss of glycemic control if diabetic

 

Atropine

Generic name: atropine.

Trade name: Sal-tropine.

Class: anticholinergic or parasympatholytic agents

 

Mechanism:

blocks the bradycardia associated with some drugs used in anesthesia such as halothane.

 

Indication:

To restore cardiac rate and arterial pressure during anesthesia, when vagal stimulation produced by intra-abdominal surgical traction causes a sudden decrease in pulse rate and cardiac action.

 

Contraindication:

Atropine is contraindicated in patients with narrow-angle glaucoma, hypersensitivity to anticholinergic drugs, cardiac insufficiency, myocardial ischemia, unstable cardiac status during acute hemorrhage, GI obstructive disease.

 

Side effect

Dryness of the mouth, blurred vision, photophobia and tachycardia commonly occur with chronic administration of therapeutic doses.

 

Nursing Implication and intervention:

1. Assess for allergies, presence of BPH, glaucoma, tachycardia, MI, CHF, hiatal hernia,and GI or GU obstruction.

2. Perform baseline assessment of VS and systems overview .

3. Medications should be taken exactly as prescribed to have the maximum therapeutic effect.

4. Overdosing can cause life-threatening problems.

5. Check with physician before taking any other medication, including OTC medications.

6. Patients should report the following to their physician: urinary hesitancy and/or retention, constipation, palpitations, confusion, excessive dry mouth or fever.

7. Teach patients to limit physical exertion, and avoid high temperatures and strenuous exercise.

8. Monitor for therapeutic effects.

 

Dopamine (Inatropin)

Class

• Sympathomimetic

• Dopamine is chemically related to epinephrine and norepinephrine. It acts primarily on alph1- and beta1- adrenergic receptors, increasing systemic vascular resistance and exerting a positive inotropic effect on the heart. In addition, the actions of this drug on dopaminergic receptors dilate renal and splanchnic vasculature, maintaining blood flow. Dopamine is commonly used to treat hypotension associated with cardiogenic shock.

Onset & Duration

Onset:

2-4 min

Duration:

10-15 min

Indications

– Hypotension
– Low cardiac output states

 

Contraindications

– Tachydysrhythmias
– Ventricular fibrillation
– Patients with pheochromocytoma

 

Side effect

Nausea, vomiting, headache, chest pain; dizziness; irregular heartbeat; pain, redness, or swelling at the injection site.

 

Assessment & Drug Effects

  • Monitor blood pressure, pulse, peripheral pulses, and urinary output at intervals prescribed by physician. Precise measurements are essential for accurate titration of dosage.
  • Report the following indicators promptly to physician for use in decreasing or temporarily suspending dose: Reduced urine flow rate in absence of hypotension; ascending tachycardia; dysrhythmias; disproportionate rise in diastolic pressure (marked decrease in pulse pressure); signs of peripheral ischemia (pallor, cyanosis, mottling, coldness, complaints of tenderness, pain, numbness, or burning sensation).
  • Monitor therapeutic effectiveness. In addition to improvement in vital signs and urine flow, other indices of adequate dosage and perfusion of vital organs include loss of pallor, increase in toe temperature, adequacy of nail bed capillary filling, and reversal of confusion or comatose state.

 

Digoxin

  • Pharmacologic class: Cardiac glycoside
  • Therapeutic class: Inotropic, antiarrhythmic
  • action: acts by inhibiting the sodium-potassium ATPase, which makes more calcium available for contractile proteins;
    uses: CHF, atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia.
  • Inhibits sodium potassium ATPase (Sodium potassium exchange pump)
  • Results in increased quantity of Ca in sarcoplasmic reticulum
  • Increased Ca will result in greater contractile strength
  • Increased contractile strength results in increased glomerular pressure (Mild diuretic)

 

Contraindications

Ventricular fibrillation; ventricular tachycardia except in certain cases; digitalis toxicity; beriberi heart disease; hypersensitivity to digoxin; some cases of hypersensitive carotid sinus syndrome.

 

SIDE EFFECTS:

The most common side effects are related to digoxin toxicity and heart rhythm disturbances. Other side effects include abdominal pain, nausea, vomiting, loss of appetite, breast enlargement, skin rash, blurred vision, and mental changes.

 

Assessment & Drug Effects

Be familiar with patient’s baseline data (e.g., quality of peripheral pulses, blood pressure, clinical symptoms, serum electrolytes creatinine clearance) as a foundation for making assessments

 

Lab tests:

– Baseline and periodic serum digoxin, potassium, magnesium, and calcium. Notify physician of abnormal values. Draw blood samples for determining plasma digoxin levels at least 6 h after daily dose and preferably just before next scheduled daily dose. Therapeutic range of serum digoxin is 0.8–2 ng/ml; toxic levels are >2 ng/mL.

– Take apical pulse for 1 full min noting rate, rhythm, and quality before administering. If changes are noted, withhold digoxin, take rhythm strip if patient is on ECG monitor, notify physician promptly.

– Withhold medication and notify physician if apical pulse falls below ordered parameters (e.g., >50 or 60/min in adults and >60 or 70/min in children).

 

Digitalis Toxicity

  • Neurological
  • Visual Disturbances
  • Flashing lights
  • Altered color vision

 

  • GI Disturbances
  • Cardiac Rhythm Disturbances
  • Hyperkalemia

 

  • K and Digoxin both bind to the same site on the sdoium/K pump

 

Isoproteronol (Isuprel)

Class

• Sympathomimetic

• Isoproterenol is a synthetic catecholamine that stimulates both beta1- and beta2-adrenergic receptors (no alpha-receptor capabilities). The drug affects the heart by increasing inotropic and chronotropic activity. In addition, isoproterenol causes arterial and bronchial dilation and is sometimes administered via aerosolization as a bronchodilator to treat bronchial asthma and bronchospasm. (Because of the undesirable beta2 cardiac effects, the use of this drug as a bronchodilator is uncommon in the pre-hospital setting.)

 

Onset & Duration

Onset:

1-5 min

Duration:

15-30 min

Indications

Hemodynamically stable bradycardias that are resistant to atropine.
Heart blocks with palpable pulse

 

Contraindications

– Ventricular tachycardia
– Ventricular fibrillation
– Hypotension
– Pulseless idioventricular rhythm
– Ischemic heart disease
– Cardiac arrest

 

Dobutamine (Dobutrex)

Class

• Sympathomimetic

• Mechanism : The effects of this drug include positive inotropic effects with minimal changes in chronotropic activities or systemic vascular resistance. For these reasons, dobutamine is useful in managing congestive heart failure when an increase in heart rate is not desired.

 

Onset:

1-2 min; peak after 10 min

Duration:

10-15 min

Indications

Inotropic support for patients with left ventricular dysfunction

Contraindications

– Tachydsrhythmias
– Severe hypotension

 

Side effect:

Headache, nausea or vomiting and restlessness, hypertension, allergic reaction, muscle cramps or weakness, chest pain, trouble breathing, dizziness.

 

Nursing implication:

1. Correct hypovolemia by administration of appropriate volume expanders prior to initiation of therapy.

2. Monitor therapeutic effectiveness. At any given dosage level, drug takes 10–20 min to produce peak effects.

3. Monitor ECG and BP continuously during administration

4. Note: Marked increases in blood pressure (systolic pressure is the most likely to be affected) and heart rate,or the appearance of arrhythmias or other adverse cardiac effects are usually reversed promptly by reduction in dosage.

5. Monitor I&O ratio and pattern. Urine output and sodium excretion generally increase because of improved cardiac output and renal perfusion.

 

NORADRENALIN

Generic name: Ephedrine sulfate.

Brand name: Levophed.

Class: ACLS ( Advanced Cardiac Life Support)

 

Mechanism:

Noradrenaline functions as a peripheral pressor and as an inotropic stimulator of the heart and dilator of coronary arteries.

 

Indication:

For blood pressure control in certain acute hypotensive states ; myocardial infarction septicemia ,blood transfusion, and drug reactions.

As in the treatment of cardiac arrest and profound hypotension.

 

Contraindication:

1. vascular thrombosis

2. hypoxia,

3. hypercapnia

4. volume depletion

5. caution if TCA use ( Tricyclic Antidepressants )

6. caution if MAO-inhibitor use (Monoamine oxidase inhibitor )

 

Side effect:

Bradycardia, rise in blood pressure, arrhythmias,Anxiety, headache, Respiratory difficulty.

 

Assessment & Drug Effects

– Monitor constantly while patient is receiving norepinephrine. Take baseline BP and pulse before start of therapy, then q2min from initiation of drug until stabilization occurs at desired level, then every 5 min during drug administration.

– Adjust flow rate to maintain BP at low normal (usually 80–100 mm Hg systolic) in normotensive patients. In previously hypertensive patients, systolic is generally maintained no higher than 40 mm Hg below preexisting systolic level.

– Observe carefully and record mental status (index of cerebral circulation), skin temperature of extremities, and color (especially of earlobes, lips, nail beds) in addition to vital signs

– Monitor I&O. Urinary retention and kidney shutdown are possibilities, especially in hypovolemic patients. Urinary output is a sensitive indicator of the degree of renal perfusion. Report decrease in urinary output or change in I&O ratio.

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