Transcript Cardiac Medications

Medications Affecting the
Adrenergic System - Propranolol
Case Study Development
• A 79 year old female patient
presented to the Emergency Room
with complaints of increasing
shortness of breath, weight gain,
decreasing LOC and irregular
heartbeat and chest pain.
Case Study Development
• During the interview process the
patient’s family remarked that they
believed that the patient had been
unable to take her medications over the
last few days, because they lacked the
money to refill the prescription.
Case Study Development
• The patient’s history included HTN,
MI, DM type II, Renal Insufficiency
and left ventricular enlargement.
The patient is transferred to the
Cardiac ICU and assigned to your
care.
Case Study Development
• After reviewing her home medications you
note the following:
• Furosemide (Lasix) 20mg PO qam
• Insulin (Humolog) SSI q ac/hs
• Potassium 10mEq Bid
• ASA 81 mg qhs
• Inderal (propranolol) 20mg Bid
Case Study Development
• On transfer to the ICU the patient’s vital signs
were as follows:
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BP 175/85
HR 122
Temp. 99.2
RR 26
Spo2 91% on 1LNC
Blood Glucose 110
Case Study Development #1
• Given that your patient has
missed an unknown amount of
their scheduled medication,
what are some of the potential
side effects/adverse reactions
associated with abrupt
withdrawl of propranolol?
Answers : Case Study
Development
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Myocardial Ischemia
Infarction
Ventricular arrhythmias
Severe hypertension
Angina
Case Study Development
• Which of your patient’s s/s
could possibly be attributed
to the lack of medication?
Why?
Case Study Development
–BP
–Irregular HR
–RR
–Chest pain
–Change in LOC
–SOB
Case Study Development #2
• According to the patients family, the
patient suffered from depression since
she was found to have Hypertension
• The Patient stated that she did not feel
that she could go on any further.
• What does the nurse understand about
this in relation to the RX.
Case Study Development #3
• Which of the following
assessment findings are most
important to notify the
physician.
Case Study Development #3
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1. Crackles and
oxygen saturation
2. New onset Atrial
fibrillation
3. Apical murmur
and pulse of 97
4. Peripheral edema
and weight gain
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Medications Affecting the
Adrenergic System
• Understanding the effects of the NonSelective Beta Blocker Propranolol on the
ANS.
Adrenergic
Beta 1 and Beta 2
Physiologic Consequences of
Beta 1 Receptor Activation
Physiologic Consequences of
Beta 2 Receptor Activation
ANS - Sympathetic nervous
system (Adrenergic)
- Drugs
that block = adrenergic
blockers, sympatholytics
* Adrenergic antagonists prevent a response = Blockers
Sympathetic Division of the
ANS
Figure 157
Beta 1 and Beta 2
How do I know??/
I only have 1 Heart
(Unless I am a Time Lord)
I have 2 Lungs
Beta Adrenergic Receptor Systems
Drug Overview
Tissue
Heart
Adipose tissue
Receptor
beta 1
beta 1
Vascular smooth muscle
Airway smooth muscle
Kidney-renin release
beta 2
beta 2
beta1
Beta-adrenergic receptors
Blockade – Clinical Manifestations
Beta 1 Effects
Beta 2 Effects
• Heart
– Decreased rate
– Decreased contraction
• Kidney
– Decreased Renin
– Decreased Angiotensin
– Decreased Blood
Pressure
• Smooth Muscle – GI tract
– Decreased tone and motility
• Lungs
– Bronchoconstriction
• Uterus
– Contraction of smooth
muscles
• Liver
– Decreased glycogenolysis
– Decreased Blood Glucose
The Adrenergic Receptors
Drug Action
Effects on Body Tissues
Drug Overview
PROPANOLOL
Adrenergic blocking agents that lyse
the effects of the sympathetic nervous
system are classified as
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1. Alpha 1
agonists
2. Beta Bundle
Blockers
3. Sympatholytics
33%
33%
33%
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1
2
3
Beta Adrenergic Blockers
Pathophysiology
• Decrease activity of the
sympathetic nervous system on
certain tissue
• Decrease the excitability of the
heart, decrease cardiac
workload, and O2 consumption,
and provide stabilization of
dysrhythmias
Adrenergic blocking agents
blood
pressure and _____ the heart rate by preventing
reaction in the sympathetic nervous system.
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1. Decrease/Increase
2. Increase/Decrease
3. Decrease/Decrease
4. Increase/Increase
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3
25%
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4
Pharmacokinetics
• Well absorbed through GI tract.
– Crosses Blood brain barrier and placenta
– Found in breast milk
– Hepatic First Pass medication
Beta-Blockers “olol”
Use
• Indications:
– Propranolol (Inderal) - PSVT,
atrial fib/flutter, ST, Angina,
HTN, Essential Tremor,
Hypertrophic sub aortic stenosis
– Adjunct therapy in
pheochromocytoma
Nonselective Beta blockers
• Nonselective have an equal
inhibitory effect on B1 & B2
receptors
• Drugs have lots of interactions
due to lots of alpha/beta receptor
sites throughout body
Special Populations
You are caring for a child who has a heart
problem. Propanolol has been ordered for this
patient. What would the dosage of the drug be
based on?
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1. Body weight and
age
2. Childs BMI
3. Age and Gender
4. Age and Height
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Case Study Development
• List Geriatric
considerations for the
administration of
Propranolol
Geriatric Considerations
• More likely to experience adverse
side effects
• May have preexisting conditions in
hepatic or renal function.
• May potentially need to be started on
lower doses than Adult population.
Adverse Effects
• Caution
– Bronchospasm, Diabetes,
hepatic dysfunction
• Contraindications
– Allergy
– Bradycardia, heart block,
shock, or CHF
– COPD, Bronchial Asthma
Adverse Effects
• Adverse Reactions
–Dizziness, insomnia,
fatigue, nausea,
vomiting, arrhythmias,
hypotension, CHF,
pulmonary edema,
bronchospasm
Adrenergic blocking agents are to be used
with caution in what population of patients?
1.
2.
3.
4.
5.
6.
Hypotension
Heart Block
COPD
Hepatic Disease
Liver Disease
All the Above
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17%
2
17%
17%
3
4
17%
5
17%
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Contraindications
Beta 1
• Monitor for existing
conditions or diseases
– Existing Bradycardia
– Decreased cardiac
contractility
– Decreased conduction
Beta 2
• Monitor for existing
conditions or diseases
– Increased airway resistance
Adverse Reactions / Nursing Implications
Beta 1 -adrenergic blocking agents
• Bradycardia • Monitor Heart rate, notify MD
if symptomatic. Prepare to
administer ATROPINE.
• Use Cautiously in clients with
Diabetes:
– Medication can mask
Tachycardia, an early sign of
hypoglycemia.
Adverse Reactions / Nursing Implications
Beta 1 -adrenergic blocking agents
• Decreased
Cardiac
Output
• Use cautiously in clients with
Heart Failure
• There may be a delayed
response of 1-3 months
• Monitor for s/s of worsening
condition
Adverse Reactions / Nursing Implications
Beta 1-adrenergic blocking agents
• AV Block
• Beta 1 effects are
contraindicated in patients
with heart block
• Obtain Baseline EKG
Adverse Reactions / Nursing Implications
Beta 1 -adrenergic blocking agents
• Orthostatic • Advise client to sit or lay down
hypotension
if dizzy
• Change positions slowly
• Rebound
• Myocardium becomes
myocardial
sensitized to catecholamine's
excitation
with long term use of
BBlockers
• Do not discontinue medication
abruptly
Adverse Reactions / Nursing Implications
Beta 2 -adrenergic blocking agents
• Bronchoconstriction
• Avoid in clients with Asthma
• Glycogenolysis • DM rely on breakdown of
is inhibited
glycogen into glucose to
manage low blood glucose
• Decreased HR effects Mask
Low blood glucose
Adverse Reactions
Beta-adrenergic blocking agents
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Fatigue
H/A
Drowsiness
N/V
Dyspnea
Dizziness
Bronchospasm
Postural
hypotension
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Bradycardia, Hypotension
CHF
Dizziness,
Rash
Hypoglycemia
Sexual dysfunction
Eye irritation
Joint pain
!!Black Box Warning!!
• Abrupt withdrawl of drug may cause
exacerbation of angina or MI. Discontinue
gradually, reducing dosage over a few
weeks. Even if taking for reasons other
than Myocardial diseases.
Nursing Interventions
• Vitals
• Monitor weight
• Teach patient to get up slowly and
avoid hot showers, not to d/c drug
without doctors orders
• Inderal can cause bronchial
constriction
Nursing Process
• Assessment
–Past Medical HX
–Allergies
–Medications
• RX and Herbal
Patients taking both diabetic drugs
and adrenergic blocking agents are at
an increased risk for
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1. Hyperglycemia
2. Hypoglycemia
3. Elevated Blood
Pressure
4. Elevated Heart
Rate
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2
3
4
Nursing Process
• Diagnosis
–Deficient Knowledge
–Risk for Injury r/t side
effects
–Imbalanced Nutrition
–Ineffective Tissue
Perfusion
Nursing Process
• Planning
– Patient Education
– Take Medication as prescribed
– Pt. experiences relief from disease
– Compliant
– Demonstrate knowledge of
specifics of medication
– Free of injury
Nursing Process
• Implementation
– Take Medication as prescribed
• Outcome - Many drugs affect non-selective
beta blocker
– Pt. experiences relief from disease
• Outcome - Free of s/s of chief complaint
– Compliant
• Outcome – do not discontinue abruptly
Nursing Process
• Implementation
– Demonstrate knowledge of
specifics of medication
• Outcome – monitor pulse and BP, ocntact
physician if HR < 50
• S/S of adverse effects of medicaiton
– Free of injury
• Medical alert bracelet
• Provides relief does not cure
• Change positions slowly
Nursing Process
• Evaluation
– Monitor BP’s and for possible side
effects
– Pt. free from syncope and injury
related to medication
– Pt. compliant with regime
Patient Teaching
• Take medication as prescribed
• Keep medications out of reach of
children
• Notify physician for s/s of NV and
palpitations or if diagnosed for other
medical conditions or starting new
medications
• Take Medication with Meals, in
prescribed doses.
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Upon discharge which information
if stated by the client would
require futher education?
1. She will weigh herself
1st thing in am
2. Call MD if SOB or tires
easily
3. Drink at least 2500mL
of fluid daily
4. Move slowly when
cahnging positions
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25%
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25%
25%
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3
25%
4
Patient Teaching
• Report weight gains greater than
2LBs in a 24 hour period.
• Medication may be given in addition
to Diuretic in certain populations.
Case Study Development #
• What are the key teaching
points for the patient to
understand upon
discharge?
Answers : Case Study
Development #
• Medication should not be stopped
abruptly
• Teach lifestyle changes to including
diet, exercise and other risk factors
• Report any adverse effects to the
MD including Trouble breathing
Beta-adrenergic Blocking Agents
• Inhibits beta1 and beta2
sympathetic receptors
• Reduce heart rate
• Reduce contractility
• Decrease supraventricular and
ventricular rhythms
• Decrease blood pressure
What's
all this mean for our BP?
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