Transcript Chapter 25

Pharmacology for Nurses
A Pathophysiologic Approach
Third Edition
CHAPTER
25
Drugs for Angina
Pectoris and
Myocardial Infarction
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Coronary Artery Disease
• One of the leading causes of death in
United States
• Narrowing or occlusion of a coronary
artery
• Narrowing causes myocardial ischemia
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Atherosclerosis
• Most common etiology of CAD
• Caused by presence of plaque
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Figure 25.1 Atherosclerosis in the coronary arteries Source: Mulvihill et al., Human Diseases: A Systematic Approach,
6th ed., © 2006, p. 115. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.
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Blood Flow to Heart
• Myocardium receives blood via coronary
arteries
• Diverge into smaller branches around
heart
• Provide continuous supply of oxygen and
nutrients
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Angina Pectoris
• Acute chest pain due to insufficient O2 to
myocardium
• Accompanies physical exertion or
emotional excitement
• Causes increased myocardial oxygen
demand
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Signs and Symptoms
• Steady, intense pain in anterior chest
• Pain radiating to left shoulder, left arm,
spine, jaw
• Fear of impending death
• Pallor, dyspnea, diaphoresis
• Tachycardia, elevated blood pressure
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Duration Usually Short
• Pain diminishes with physical rest and/or
stress reduction
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Classification
• Stable angina is fairly predictable as to
frequency, intensity, duration
– Usually relieved by rest
• Vasospastic angina caused by spasms of
coronary arteries
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Classification (continued)
• Silent angina occurs in absence of angina
pain
• Unstable angina when episodes occur
more frequently, more intense, during
periods of rest
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Angina vs. Myocardial Infarction
• Identify and differentiate the two conditions
• Pharmacological treatment differs
considerably between conditions
• Myocardial infarction carries a high
mortality rate
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Pharmacologic Management of
Angina
• Therapeutic outcomes
– Reduce intensity and frequency of episodes
– Improve exercise tolerance
• Two categories of drugs
– Those that terminate acute angina episode
– Those that decrease frequency of episodes
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
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Reduce Myocardial Demand
for O2 by:
•
•
•
•
Slowing heart rate
Reducing preload
Reducing contractility
Lowering blood pressure (reduced
afterload)
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Role of Nurse
• Monitor client’s condition
• Provide education on prescribed drug
treatment
• Obtain vital signs and medical and drug
history
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Role of Nurse (continued)
• Obtain information on lifestyle and dietary
habits
• Obtain description of symptoms and
pharmacological treatment initiated by
client
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Nitrates
• Obtain blood pressure and monitor
• IV nitrates have greatest risk for severe
hypotension
• Educate client that alcohol is
contraindicated with nitrates
• If hypotension occurs, withhold nitrates
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Nitrates
• Prototype drug: nitroglycerin (Nitrostat)
• Mechanism of action: relax both arterial and
venous smooth muscle; dilate coronary arteries
– Short acting-terminate acute angina episode
– Long-acting-decrease severity and frequency
of episodes
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Nitrates (continued)
• Primary use: for lowering myocardial oxygen
demand
• Adverse effects: hypotension, dizziness,
headache, flushing of face, rash
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Beta-Adrenergic Blockers
• Assess apical heart rate
• Obtain blood pressure and continue to
monitor
• Monitor respiratory status
• Monitor serum-glucose levels
• Educate client not to stop medications
abruptly
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Beta-Adrenergic Blockers
• Prototype drug: atenolol (Tenormin)
• Mechanism of action: to reduce the cardiac
workload by slowing heart rate and reducing
contractility
• Primary use: for prophylaxis of stable angina
• Adverse effects: fatigue, insomnia,
drowsiness, impotence, bradycardia, confusion
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Calcium Channel Blockers (CCB)
• Assess vital signs
• Hold medication if client hypotensive
(heart rate of 60 or below)
• Obtain blood pressure in lying, sitting, and
standing positions
• Assess for signs of heart failure
• Obtain daily weights
• Assess bowel functions
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Calcium Channel Blockers
• Prototype drug: diltiazem (Cardizem)
• Mechanism of action: to reduce cardiac
workload by relaxing arteriolar smooth muscle;
dilate coronary arteries
• Primary use: for lowering blood pressure;
bring more oxygen into myocardium
• Adverse effects: hypotension, bradycardia,
heart failure, constipation, headaches, dizziness,
edema
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Figure 25.2 Blockage and reperfusion following myocardial infarction: (Source: Figures (a) and (c): Mulvihill et al.,
Human Diseases: A Systematic Approach, 6th ed., © 2006, p. 105. Reprinted by permission of Pearson Education,
Inc., Upper Saddle River, NJ.
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Figure 25.2 (continued)
Blockage and Reperfusion Following Myocardial Infarction
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Figure 25.2 (continued) Blockage and reperfusion following myocardial infarction: Source: Figures (a) and (c):
Mulvihill et al., Human Diseases: A Systematic Approach, 6th ed., © 2006, p. 105. Reprinted by permission of Pearson
Education, Inc., Upper Saddle River, NJ.
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Copyright ©2011 by Pearson Education, Inc.
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Figure 25.2 (continued) Blockage and reperfusion following myocardial infarction
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Thrombolytics
• Assess for conditions that may place client
at increased risk for bleeding
• Start IV and arterial lines, and insert Foley
catheter
• Monitor vital signs and intake and output
• Monitor changes in laboratory values
• Assess for changes in neurological status
• Assess for dysrhythmia
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Thrombolytics
• Prototype drug: reteplase (Retavase)
• Mechanism of action: to dissolve clots
obstructing coronary arteries
• Primary use: for restoring circulation to
myocardium
• Adverse effects: excessive bleeding
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Reteplase Animation
Click here to view an animation on the topic of reteplase.
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Adjunct Drugs for Myocardial
Infarction
• Nitrates
– Diagnosis of MI; arterial and venous dilation;
relieve coronary artery vasospasm
• Beta-Adrenergic Blockers
– Reduce myocardial oxygen demand; slow
impulse conduction through the heart
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Adjunct Drugs for Myocardial
Infarction (continued)
• ACE Inhibitors
– Increased survival for those MI patients
administered captopril (Capoten) or lisinopril
(Prinivil, Zestoretic)
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Nitrates
• Potent vasodilator
• Isosorbide dinitrate (Isordil), isosorbide
mononitrate (Imudur), Nitroglycerin
(Nitrostat)
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Beta-Adrenergic Blockers
• Reduce cardiac workload
• Prophylaxis for chronic angina
• Lopressor, Toprol-XL, Inderal
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Calcium Channel Blockers
• Reduce cardiac workload and dilate
coronary arteries
• Bring more oxygen to myocardium
• Norvasc, Vascor, Cardizem
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Thrombolytics
• Dissolve clots
• Restore circulation to myocardium
• Reteplase
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Drug Therapy for Angina and
Myocardial Infarction
• Assessment
– Monitor client’s condition and provide
education
– Obtain and monitor vital signs
– Obtain history: lifestyle, current drugs, and
dietary habits
– Obtain description of the frequency and
severity of symptoms
– Ascertain any pharmacological treatment
initiated by the client
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Possible Nursing Diagnoses
• Knowledge deficit regarding condition
• Ineffective regimen management
• Risk for hypotension
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Client Goals and
Expected Outcomes
• Client’s ability to explain angina pectoris
• Client able to verbalize ability to follow
prescribed therapy
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Implementation
• Encourage compliance with medication
regimen
• Provide additional education as needed
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Evaluation
• Ideal outcome criteria
– Free of, or reduced, episodes of angina or MI
– Clients verbalize importance of taking
prescribed medications
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
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Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
Adams • Holland
Copyright ©2011 by Pearson Education, Inc.
All rights reserved.