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Nursing Pharm - Cardiovascular

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olanjones's version from 2016-07-11 15:17

Hypertension

Question Answer
The Joint National Committee's 7th report (JNC-7) is the standard for BP treatment, at what point is treatment generally startedWhen a personal has Stage I HTN: 140/90 (Norm <119/79, PreHTN 120/80, Stage II: 160/100)
How does HTN affect the heart?increased workload leads to heart failure, damages blood vessels
How does HTN affect the brain?decreased O2 leads to TIAs, CVAs
How does HTN affect the kidneys?progressive loss of function can result in kidney failure
How does HTN affect the eyes?damages the retina causing visual impairment or blindness
What therapeutic lifestyle change can have the greatest effect on HTN?cessation of smoking / tobacco use
Aside from smoking cessation, what other therapeutic lifestyle changes can help treat HTN?limit ETOH, restrict sodium, decrease saturated fats, increase fruits & veggies, increase aerobic exercise
For initial treatment of HTN, what is JNC-7 drug of choice?Thiazide & thiazide-like diuretics
What factors indicate a second antihypertensive drug should be used?Risk status & hx of CAD or other co-morbidities such as DM (JNC-7 recommends aggressive eval & adjustment of dosage for optimum BP control)
Synergistic effect occurs with using agents from different categories, how does this affect prescribing?it allows decreased doses of each medication to be prescribed which decreases complications & SE
Which HTN drugs are associated with hypokalemia? Thiazide & thiazide-like diuretics, Loop (high-ceiling) diuretics, Calcium Channel blockers (not as common)
Which HTN drugs are associated with hyperkalemia? Potassium sparing diuretics, ACE inhibitors, ARBs
Which HTN/CV drugs are associated with hypoglycemia in DM?Adrenergic antagonists, Fibric acid agents
Which HTN drugs are associated with hyperglycemia in DM?Diuretics
Which HTN drugs have 'first-dose phenomenon'?ACE inhibitors, ARBs, Adrenergic antagonists, Direct vasodilators
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Diuretics

Question Answer
What are the indications of treatment with drugs like HCTZ / Microzide (prototype - thiazide & thiazide-like)?mild to moderate HTN (produces 10-20 mmHg decrease in BP), also indicated for mild to moderate heart, liver, & renal failure (not for severe impairment)
The primary adverse effect of HCTZ is potassium loss, what other conditions should the nurse monitor for?hypotension, electrolyte imbalance, I&O for fluid loss, hyperglycemia in DM; continued HTN may indicate insufficient treatment
The primary advantage of using spironolactone / Aldactone (prototype - potassium sparing) is that is does not deplete K levels, what are the drawbacks?provides only modest diuresis; alters the effectiveness of digoxin; can cause hyperkalemia, esp in pts on ACE inhibitor or ARB
Spironolactone is often used in pts at risk for hypokalemia or who are using thiazide or loop diuretics, what are other indications for this med?used to reduce edema r/t HF, nephrotic syndrome, or liver disease
The most effective diuretics are loop (high-ceiling) such as furosemide / Lasix (prototype), why are they not ideal as maintenance meds?block Na & Cl reabsorption in the loop of Henle & increase K excretion, cause kidney to excrete large amounts of fluid in a short period of time, risk of dehydration
The primary indications for furosemide are edema (r/t HF, cirrhosis, CRF) & acute pulmonary edema, what differs in dosing when used for HTN?twice daily dosing is required due to short half-life
Why should a patient report hearing changes immediately when using furosemide?It can be ototoxic
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Anti-hypertensives

Question Answer
With all anti-hypertensives the nurse/pt must monitor BP and pulse, what values require a hold of medication?BP of <90/60 (adrenergic antagonists , CCB, ACE inhibitors/ARBs, nitrates), P >100 (nitrates, adrenergic antagonists) , AP <60 (beta-blockers)
Why must CCB, adrenergic antagonists, and direct vasodilators be discontinued gradually?to prevent rebound HTN, tachycardia (chest pain, palpitations, or MI possible) - abrupt d/c of direct vasodilators may cause SEVERE rebound HTN
How do calcium channel blockers work to treat HTN?Block calcium ion channels in cardiac & arteriole smooth muscle which limits degree of muscular contraction thereby decreasing peripheral resistance which decreases BP
How do selective CCB such as nifedipine / Procardia (prototype) differ from non-selective such as verapamil / Calan), diltiazem / Cardizem (prototypes)?nifedipine affects arterioles only, verapamil & diltaizem affect arterioles and heart
Because of the mechanism of action what are most CCB SE associated with?vasodilation: hypotension, dizziness, & HA (pt's should also report chest pain, dyspnea, wt gain, swelling, hives)
CCB are associated with herbal interactions (nifedipine & melatonin, verapamil & hawthorne), what food interaction should pts be educated on?Grapefruit / grapefruit juice may enhance absorption
Why are drugs such as enalapril / Vasotec & lisinopril / Prinivil (prototype - ACE inhibitor) first line agents for HTN & HF?They block the final step of RAAS which is a primary mechanism for maintaining BP & fluid balance (decrease peripheral resistance & blood volume)
Due to 'first-dose phenomenon' orthostatic hypotension is the most common SE associated with drugs like enalapril, what other serious (rare) SE can occur ?angioedema (swelling of throat & tongue)
What annoying SE may cause patients to stop using drugs such as enalapril?dry, hacking cough
What drug interactions should be considered with the use of drugs such as enalapril?NSAIDs can decrease action of ACE inhibitors; ACE inhibitors can increase lithium levels (danger of toxicity)
Angiotensin II receptor blockers (ARBs) also work on the RAAS, how do they differ from ACE inhibitors?They have fewer SE associated with them (No ACE cough); ACE inhibitors are associated with a reduction in mortality from HTN, ARBs are not
Adrenergic Antagonists (alpha & beta-blockers) act by antagonizing the normal ANS fight or flight responses, what are indications for use?HTN, angina, dysrhythmias, MI prophylaxis, can be selective or nonselective
'First-dose phenomenon' associated with doxazosin / Cardura (prototype - alpha-blocker) and atenolol / Tenormin (prototype - beta-blocker) can cause what?orthostatic hypotension (take at bedtime to reduce problems), reflex tachycardia from rapid drop in BP
Direct vasodilators are typically reserved for HTN emergencies (nitroprusside often used) and HTN unresponsive to other agents, how do they work?act directly on BV causing vasodilation & decreasing BP; may also be used to treat HF, angina, & MI
What SE are associated with drugs like hydralazine / Apresoline (prototype - direct vasodilator)?HA, tachycardia, palpitations, flushing, nausea, & diarrhea are common but should resolve, watch for peripheral edema
Why is important to monitor BP and HR closely during a hypertensive crisis?too rapid of a decrease could affect O2 to brain, IV infusions of drugs like hydralazine may need titration until effective (start low and go slow)
In what conditions are drugs like hydralazine contraindicated?lupus, CV disease, rheumatic heart disease
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Lipid Disorders

Question Answer
Why are serum lipid profiles used to used the treatment of dyslipidemia?because lipid levels contribute to plaque formation they can predict risk of CAD (NCEP guidelines: Total <200, LDL <100, HDL >60, Tri <150)
What therapeutic lifestyle changes can improve dyslipidemia?regular serum lipid level checks (know where you're at), wt control, exercise, decrease dietary fats, increase dietary fiber, STOP SMOKING
Why is compliance often an issue for hyperlipidemia treatment?pts do not “feel sick”, TLC changes are difficult, unpleasant SE of treatment
HMG-CoA Reductase Inhibitors “Statins” (prototype - atorvastatin / Lipitor) are the most effective drugs to treat hyperlipidemia, how do they work?by inhibiting the primary regulatory enzyme in cholesterol biosynthesis
Drugs like atorvastatin are pregnancy category X, what education point should the nurse teach the patient about?statins have the potential to interact with other drugs (Birth Control Pills, antimicrobials), grapefruit juice inhibits the metabolism of statins
The most common SE of drugs like atorvastatin are gas, constipation, stomach pain, heartburn; what AE are associated with these drugs?Rhabdomyolysis (rare - check CK levels) & hepatic impairment (check LFTs)
How do drugs like cholestyramine / Questran (prototype - bile acid sequestrant) work?bind bile acids (preventing re-absorption of cholesterol from small intestine) increasing the excretion of cholesterol in the stool
Why should drugs like cholestyramine be used cautiously in patients with GI conditions?SE are limited to GI system (abd pain, bloating, diarrhea, steatorrhea, constipation)
Fibric Acid Agents such as gemfibrozil / Lopid (prototype) work by what action?Inhibit peripheral lipolysis, decrease triglyceride production, increase HDLs (use is contraindicated in gallbladder & liver disease)
What drug interactions are of particular concern when using gemfibrozil?gemfibrozil enhances the hypoglycemic effect of antidiabetic agents & displaces warfarin from protein binding sites (increases bleeding)
What is an important education point associated with Niacin (nicotinic acid)?Because it is available OTC pts may self-medicate. SE include headache, dizziness, flushing, pruritis, nausea
The only drug in the Cholesterol Absorbtion Inhibitor class is ezetimibe / Zetia, how does it work?blocks the absorption of cholesterol from the small intestine by up to 50% but has no effect on synthesis (often used with a statin)
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Angina Pectoris & MI

Question Answer
Angina is a symptom of progressive blockage (CAD) and is predictive of MI & CVA risk, what are common nonpharm interventions for this?percutaneous transluminal coronary angioplasty (PCTA) & coronary artery bypass grafting (CABG)
In order to manage angina a reduction in O2 demand of the heart is needed, how can this be accomplished?by slowing HR, dilating veins so heart gets less blood (reduced preload), cause heart to contract with less force (reduced contractility), lower BP (reduce afterload)
What is the goal in treating an MI?immediate reperfusion – “time is muscle” Meds are used to meet need for reperfusion, maintain heart function, control pain (MONA - morphine, O2, Nitro, ASA)
What are the functions of antiplatelet & anticoagulants in MI treatment?they are used as adjuncts to relieve s/s, reduce complications and mortality
How are nitrates (prototype - nitroglycerin) used in MI treatment?to assist with dx of MI; dilate veins, decreasing amount of blood returning to heart (preload), reducing cardiac output & workload which decreases O2 demand of heart. Also treats vasospastic type
What is the role of beta-blockers (prototype - atenolol / Ternormon) in MI treatment?decrease myocardial O2 demand by slowing HR, & reducing contractility (not effective for vasospastic but helps with exercise tolerance)
Why are ACE inhibitors used in MI treatment?EBP indicates that admission within 24 hrs onset following MI increases survival rates
What is the purpose of pain management in MI treatment?patient comfort as well as to reduce stress & relieve anxiety (typically opioids are used)
What med is used in MI treatment when beta-blockers (atenolol) are not tolerated?CCB (prototype - diltiazem / Cardizem), work by reducing afterload & dilating coronary arteries to increase O2 to myocardium (esp good for vasospastic – drug of choice for this)
What concerns are associated with use of drugs like atenolol?can worsen depression, cause severe hypotension, med interactions (digoxin, insulin, CCBs), can cause hypoglycemia in DM, sudden withdrawal can cause angina, MI, thyroid storm
Nitroglycerin is available in short acting (used to terminate acute attack) & long-acting, what should the nurse pay special attention to?ordered route & appropriate administration, specific route considerations (SR not appropriate with glaucoma)
Long acting nitroglycerin treats frequency or severity of angina episodes (also s/s of heart failure), what may develop if used regularly?Tolerance, can be potentially serious (usually develops/reverts quickly)
Why should nitroglycerin not be used with sildenafil / Viagra?can cause life-threatening hypotension and CV collapse
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Coagulation Disorders

Question Answer
What are the 4 mechanisms by which drugs modify coagulation?Prevention of clot formation: inhibit specific clotting cascade factors (heparin), Prevention of clot formation: inhibit platelet clotting action (ASA), Removal of existing clot (alteplase), Promotion of clot formation (aminocaproic acid).
What are important PE points for anticoagulant use?Have labs checked regularly, Report s/s pf bleeding, Wear medic alert bracelet, Inform dentist / other providers of med, Avoid activities with potential injury, warfarin is pregnancy category X
Thrombolytics such as reteplase / Retavase & alteplase / Activase, t-PA are known as "clot busters", why?They are non-specific: dissolve ALL clots
Why do reteplase & alteplase require strict, continuous monitoring during administration?There is NO antidote – may need to transfuse with blood, blood products, or hemostatics (pt should remain quiet in bed during treatment)
Reteplase is often used during MIs when clots obstruct coronary arteries (restores circulation to myocardium), what is associated NC?It is most effective if admin within 12 hours of onset, ineffective after 24 hours; Very narrow therapeutic window
What NC concern is associated post-administration of alteplase?patient is at risk for post-thrombolytic bleeding for 2-4 days
Parenteral anticoagulants such as heparin (prototype) are drug of choice for acute thromboembolic disorders, what should be on-hand when using?Antidote - protamine sulfate
What is a serious complication associated with the used of heparin?Heparin-induced thrombocytopenia (affects 30% of pts)
Pts are often on heparin 1st for thromboembolism and transition to oral anticoagulants (prototype - warfarin / Coumadin) for long-term prophylaxis, how?both drugs must be given concurrently for 2-3 days to transition (labs for heparin - PT/aPTT; labs for warfarin - PT/INR)
What is the antidote for warfarin OD?Vitamin K (if given IV can reverse effects within 6 hours)
Why are hemostatics (prototype - aminocaproic acid / Amicar) often used to control post-op bleeding?they promote formation of clots (opposite action of anticoagulants); also called antifibrinolytics because they keep fibrin from dissolving
What should a nurse monitor for when aminocaproic acid is being used?hypotension and bradycardia (should be used cautiously in pts with a hx of thromboembolic disease)
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