NURS 133 Clopidogrel and Captorpril

jasmine's version from 2016-06-03 01:53

Section 1

Question Answer
Clopidogrel Reduction of atherosclerotic events (MI, stroke, vascular death) in patients at risk for such events including recent MI, acute coronary syndrome (unstable angina/non-Q wave MI), stroke, or peripheral vascular disease
Clopidogrel actions Inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to platelet receptors
Clopidogrel therapeutic uses Decreased occurrence of atherosclerotic events in patients at risk
Elimination/Excretion of Clopidogrel Rapidly and extensively converted by the liver (CYP2C19) to its active metabolite, which is then eliminated 50 percent in urine and 45 percent in feces; 2 percent of Whites, 4 percent of Blacks, and 14 percent of Asians have CYP2C19 genotype, which results in reduced metabolism of clopidogrel (poor metabolizers) into its active metabolite (may result in decrease anti-platelet effects)
Adverse/Side Effects of Clopidogrel Incidence of adverse reactions similar to that of aspirin; GI bleeding; Drug rash with eosinophilia and systemic symptoms; Bleeding, neutropenia, thrombotic thrombocytopenic purpura
Contraindications of Clopidogrel Hypersensitivity; Pathologic bleeding (peptic ulcer, intracranial hemorrhage); Concurrent use of omeprazole or esomeprazole; Impaired CYP2C19 function due to genetic variation; Lactation: Lactation
Use Clopidogrel cautiously in Patients at risk for bleeding (trauma, surgery, or other pathologic conditions); History of GI bleeding/ulcer disease; Severe hepatic impairment; Hypersensitivity to another thienopyridine (ticlopidine, prasugrel); OB: Use only if clearly indicated; Pedi: Safety and effectiveness not established
Drug/Food interactions of Clopidogrel Concurrent abciximab, eptifibatide, tirofiban, aspirin, NSAIDs, heparin, LMWHs, thrombolytic agents, ticlopidine, or warfarin may increase risk of bleeding; May decrease metabolism and increase effects of phenytoin, tolbutamide, tamoxifen, torsemide, fluvastatin, and many NSAIDs; Concurrent use with the CYP2C19 inhibitors, omeprazole, or esomeprazole may decrease anti-platelet effects-avoid concurrent use-may consider using H2 antagonist or another proton pump inhibitor (e.g., dexlansoprazole, lansoprazole, or pantoprazole) Increase bleeding risk with anise, arnica, chamomile, clove, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, and others
Medication administration of Clopidogrel PO
Nursing interventions of Clopidogrel Assess patient for symptoms of stroke, peripheral vascular disease, or MI periodically during therapy; Monitor patient for signs of thrombotic thrombocytic purpura (thrombocytopenia, micro-angiopathic hemolytic anemia, neurologic findings, renal dysfunction, fever). May rarely occur, even after short exposure (less than 2 weeks). Requires prompt treatment; Lab test considerations: Monitor bleeding time during therapy. Prolonged bleeding time, which is time- and dose-dependent, is expected. Monitor CBC with differential and platelet count periodically during therapy. Neutropenia and thrombocytopenia may rarely occur; (May cause increase serum bilirubin, hepatic enzymes, total cholesterol, non-protein nitrogen (NPN), and uric acid concentrations
Implementation of Clopidogrel Discontinue Clopidogrel 5-7 days before planned surgical procedures; If Clopidogrel must be temporarily discontinued, restart as soon as possible; Pre-mature discontinuation of therapy may increase risk of cardiovascular event; PO: Administer once daily without regard to food
Client education of Clopidogrel Instruct patient to take medication exactly as directed; Take missed doses as soon as possible unless almost time for next dose-do not double dose; Do not discontinue Clopidogrel without consulting health care professional-may increase risk of cardiovascular events; Advise patient to read the medication guide before starting Clopidogrel and with each Rx refill in case of changes; Advise patient to notify health care professional promptly if fever, chills, sore throat, rash, or unusual bleeding or bruising occurs; Instruct patient to notify health care professional before taking any other Rx, OTC, or herbal products, especially those containing aspirin or NSAIDs or proton pump inhibitors; Advise female patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding
Evaluation/Desired outcomes of Clopidogrel Prevention of stroke, MI, and vascular death in patients at risk
Potential nursing diagnoses of Clopidogrel Risk for injury (indications, side effects)

Section 2

Question Answer
Captorpril ACE inhibitor; Pregnancy Category D; Alone or with other agents in the management of hypertension; Management of HF; Reduction of risk of death or development of HG following MI; Decrease progression of diabetic nephropathy
Captorpril actions ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II; ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins; ACE inhibitors also increase plasma renin levels and decrease aldosterone levels; Net result is systemic vasodilation
Captorpril therapeutic uses Lowering of BP in hypertensive patients; Improved symptoms in patients with HF (selected agents only); Improved survival and decrease development of overt HF after MI (selected agents only); Decreased progression of diabetic nephropathy
Elimination/Excretion of Captorpril 50 percent metabolized by the liver to inactive compounds; 50 percent excreted unchanged by the kidneys
Adverse/Side Effects of Captorpril Cough; Hypotension; Taste disturbances; Agranulocytosis; Angioedema
Contraindications of Captorpril Hypersensitivity; History of angioedema with previous use of ACE inhibitors (also in absence of previous use of ACE inhibitors for benazepril); Concurrent use with aliskiren in patients with diabetes or moderate to severe renal impairment (CCr less than 60 mL/min); OB: Can cause injury or death of fetus if pregnancy occurs-discontinue immediately; Lactation: Certain ACE inhibitors appear in breast milk-discontinue drug or use formula
Use Captorpril cautiously in Renal impairment, hepatic impairment, hypovolemia, hyponatremia, concurrent diuretic therapy; Black patients with hypertension (monotherapy less effective-may require additional therapy-increase risk of angioedema); Surgery/anesthesia (hypotension may be exaggerated); Pedi: May be used in children of all ages; Geri: Initial dose decrease recommended for most agents due to age related decrease in renal function; Exercise extreme caution in family with history of angioedema
Drug/Food interactions of Captorpril Excessive hypotension may occur with concurrent use of diuretics and other anti-hypertensives; Increase risk of hyperkalemia with current use of potassium supplements, potassium diuretics, or potassium-containing salt substitutes; Increase risk of hyperkalemia, renal dysfunction, hypotension, and syncope with concurrent use of angiotensin II receptor antagonists or aliskiren-avoid concurrent use with aliskiren in patients with diabetes or CCr less than 60 mL/min; NSAIDs and selective COX-2 inhibitors may blunt the anti-hypertensive effect and increase the risk of renal dysfunction; Increase risk of angioedema with temsirolimus or everolimus; Food significantly decrease absorption of Captopril-administer drugs 1 hours before meals
Medication administration of Captorpril PO
Nursing interventions of Captorpril Hypertension: monitor BP and pulse frequently during initial dose adjustment and periodically during therapy; Monitor frequency of prescription refills to determine adherence; Assess patient for signs of angioedema (dyspnea, facial swelling); HF: monitor weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention); Lab test considerations: Monitor BUN, creatinine, and electrolyte levels periodically; Serum potassium, BUN and creatinine may be increased, whereas may be decreased; If increase BUN or serum creatinine concentrations occur, dose reduction or withdrawal may be required; Monitor CBC periodically during therapy; Assess urine protein prior to and periodically during therapy for up to 1 year in patients with renal impairment or those receiving greater than 150 mg/day of Captopril; If excessive or increase proteinuria occurs, re-evaluate ACE inhibitor therapy; Captopril: May cause positive ANA titer, and may cause false-positive test results for urine acetone; Monitor CBC with differential prior to initiation of therapy every 2 weeks for the first 3 months, and periodically for up to 1 year in patients at risk for neutropenia (patients with renal impairment or collagen-vascular disease) or at first sign of infection-Discontinue therapy if neutrophil count is less than 1000/mm^3
Implementation of Captorpril Correct volume deletion, if possible, before initiation of therapy; PO: Precipitous drop in BP during first 1-3 hour after first dose may require volume expansion with normal saline, yet is not normally considered an indication for stopping therapy; Discontinuing diuretic therapy or cautiously increasing salt intake 2-3 before initiation may decrease risk of hypotension; Monitor closely for at least 1 hour after BP has stabilized; Resume diuretics if BP is not controlled; Administer 1 hour before or 2 hours after meals; May be crushed if patient has difficulty swallowing; Tablets may have a sulfurous odor; An oral solution may be prepared by crushing a 25 mg tablet and dissolving it in 25-100 mL of water-shake for at least 5 minutes and administer within 30 minutes
Client education of Captorpril Instruct patient to take medication as directed at the same time each day, even if feeling well; Caution patient to avoid salt substitutes or foods containing high levels of potassium or sodium unless directed by health care professional; Caution patient to change positions slowly to minimize hypotension; Use of alcohol, standing for long periods, exercising, and hot weather may increase orthostatic hypotension; Instruct patient to notify health care professional of any new medications, especially cough, cold, or allergy remedies; Caution patient to avoid driving and other activities requiring alertness until response to medication is known; Advise patient that medication may cause impairment of taste that generally resolves within 8-12 weeks, even with continued therapy; Instruct patient to notify health care professional if rash; mouth sores; sore throat; fever; swelling of hands or feet; irregular heart beat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips, or tongue; difficulty swallowing or breathing occur; or if taste impairment or skin rash persists; Also, notify health care professional if nausea, vomiting, or diarrhea occurs and continues; Advise women of childbearing age to use contraception and notify health care professional if pregnancy is planned or suspected; If pregnancy is detected, discontinue medication as soon as possible; Emphasize the importance of follow up examinations to monitor progress; Hypertension: Encourage patient to comply with additional interventions for hypertension (weight reduction, low sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, and stress management); *Medication controls yet does not cure hypertension; Instruct patient and family on correct technique for monitoring BP; Advise to check BP at least weekly and to report significant changes to health care professional
Evaluation/Desired outcomes of Captorpril Decrease in BP without appearance of excessive side effects; Decrease in signs and symptoms of HF (some drugs may also improve survival); Reduction of risk of death or development of HF following MI; Decrease in progression of diabetic nephropathy
Potential nursing diagnoses of Captorpril Decreased cardiac output (indications, side effects); Noncompliance (patient/family teaching)