Transcript Cardiovascular Pharmacology

Cardiovascular
Pharmacology
A Good Resource:
http://www.cvpharmacology.com/index.html
Concept Map: Selected Topics in Cardiovascular Nursing
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
Cardiac Monitoring
Lab Monitoring
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…
PATHOPHYSIOLOGY
Myocardial Infarction
Acute Coronary Syndrome
Valvular Heart Disease
Pacemakers
CABG
Abdominal Aortic Aneurysm
Pericarditis
Peripheral Vasc Disease (PVD)
Fem-Pop Bypass Graft
Shock / Fluid Deficit
Raynaud’s Phenomenon
Arrhythmias / Dysrhythmias
PHARMACOLOGY
Cardiac Glycosides
ACE Inhibitors
Beta Blockers
Antiarrhythmics
Catecholamines
Anticoagulants
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary
Cardiovascular Pharmacology
ACE
Inhibitors
Calcium
Channel
Blockers
Loop Diuretics
Alpha
Blockers
Beta Blockers
AntiArrhythmics
AntiHypertensives
Anti-Anginals
Anti-Lipemics
Potassium –
Sparing /
Combination
Diuretics
Thiazide /
Related
Diuretics
Digitalis
Glycosides
Platelet
Aggregation
Inhibitors
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-pril------------------------------- ACE Inhibitor
-lol or –olol ------------------Beta Blocker
-pine --------------------- Ca Channel Blocker
-statin --------------- anti-lipemic
-nitr ------------- nitrates
-zosin --------------- alpha blockers
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Alpha Blockers
Beta Blockers
Ca Channel Blockers
ACE Inhibitors
Anti-Lipemic
Nitrates
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atenolol (Tenormin ®)
carvedilol (Coreg ®)
metoprolol (Toprol XL ®, LoPressor ®)
propranolol HCl (Inderal ®)
-olol
-pril
-pine
-statin
-nitr-zosin
-lol
benazepril HCl (Lotensin ®)
captopril
(Capoten®)
enalapril maleate (Vasotec®)
lisinopril
(Prinivil ®, Zestril®)
amlodipine besylate (Norvasc ®)
diltiazem HCl (Cardizem ®, Dilacor ®)
nifedipine (Adalat ®, Procardia XL ®)
Verapamil HCl (Calan ®, Isoptim ®, Covera ®)
•atorvastatin calcium (Lipitor ®)
•lovastatin ( Mevacor ®)
•pravastatin (Pravachol ®)
•rosuvastatin calcium (Crestor ®)
•simvastatin (Zocor ®)
•isosorbide dinitrate
(Isordil ®)
•isosorbide mononitrate (Ismo®)
•Nitroglycerin
doxazosin mesylate (Cardura®)
prazosin HCl
(Minipress®)
ACE Inhibitors
hypertension
CHF
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benazepril HCl (Lotensin ®)
captopril (Capoten®)
enalapril maleate (Vasotec®)
lisinopril
(Prinivil ®, Zestril®)
Diabetic
Neuropathy
Left
Ventricular
Dysfunction
After
MI
ACUTE M.I.
“The Multi-Purpose Group !”
Prototype: captopril
• ACE Inhibitors produce desired effect by
blocking production of angiotensin II, resulting
in arteriolar vasodilation, excretion of sodium
and retention of potassium
• Indications: Heart failure, HTN, MI (reduce
mortality, reduce heart failure), diabetic &
non-diabetic nephropathy.
• Nursing Implications: orthostatic hypotension,
cough, potential hyperkalemia
The –pril’s: ACE Inhibitors
• Treatment of Hypertension
• captopril, enalapril, lisinopril—tx of HTN, CHF,
decreased L ventricular function after MI
• Always check BP before administering—hold
PRN (parameters)
• Teach patient to change positions slowly to
avoid postural hypotension
C.O. = HR x SV
• “cough”
BP = C.O. x PVR
Alpha Blockers
• doxazosin mesylate
• prazosin HCl
(Cardura®)
(Minipress®)
Prototype: prazosin
• Alpha blockers cause venous and arterial
dilation, smooth muscle relaxation of prostate
• Indications: HTN
• Nursing Implications: monitor BP closely after
initial dose; orthostatic hypotension
The –zosin’s: Alpha Blockers
sympatholytic
Uses:
• Treatment of HTN
• BPH (doxazosin (Cardura®)
Nursing Implications
• Teach patient to avoid
changing positions rapidly
(postural hypotension)
• Check blood pressure prior
to administration; hold med
PRN (Parameters)
C.O. = HR x
BP = C.O.
SV
x
PVR
Anti-Anginals
• isosorbide dinitrate
(Isordil ®)
• isosorbide mononitrate (Ismo®)
• Nitroglycerin
•
Nitro-dur®,
•
Transderm Nitro ®
•
Nitrol ®
•
Nitrostat ®
•
Nitrotab ®
Prototype: nitroglycerin
• Vasodilation of coronary artries increases
myocardial oxygen supply; decreases
myocardial oxygen demand via vasodilation
and reduction of preload
• Indications: angina treatment and/or
prophylaxis;
• Nursing Implications: hypotension, orthostatic
hypotension, cough, potential hyperkalemia
The –”NITR’s” Anti-Anginals
(effect: vasodilation)
• nitroglycerin sl, nitropaste, nitroderm
• Chest pain regimen: 1 tab NTG sl, q5 min X 3
• Isosorbide dinatrate (Isordil®)
• Treatment / Prophylaxis of angina, CHF
C.O. =
HR x
BP =
C.O.
SV
x
PVR
Anti-Arrhythmics
( Anti-Dysrhythmics )
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amiodarone HCl (Cordarone ®, Pacerone® )
lidocaine HCl
(Xylocaine ®)
procainamide (Procanbid ®, Pronestyl ®)
quinidine (Quinaglute ®)
Prototype: lidocaine
• Class Ib antiarrhythmic; decreases electrical
conduction, decreases automaticity, increases
rate of repolarization
• Indications: short-term use for ventricular
dysrhythmias; monitor respirations—respiratory
arrest. Cardiac monitor—vital signs
• Nursing Implications: CNS effects—drowsiness,
altered mental status, paresthesias, seizures
A “Slight” Side-Effect
of IV Amiodarone !
• Lidocaine HCl—the old reliable; used for
PVC’s, ventricular ectopy, ventricular
tachycardia
• Amiodarone –Management of life-threatening
ventricular arrhythmias unresponsive to less
toxic meds; assess for pulmonary toxicity
• Both of these: Infusion pumps, monitor v.s.
frequently, cardiac monitor
Anti-Hypertensives
• clonidine (Catapres ®, Catapres Patch ®,
Catapres TTS ®)
• hydralazine HCl (Apresoline ®)
• hydroclorothiazide / lisinopril (Prinzide ®,
Zestoretic ®)
• minoxidil (Loniten ®)
Prototype: clonidine
• Sympatholytic—decreases HR causes decrease
in C.O., peripheral vasodilation—decreases BP
• Indications: HTN, severe cancer pain
• Nursing Implications: hypotension, orthostatic
hypotension, administer twice daily in divided
dose
• Hydralazine—tx of essential hypertension
• HCTZ/Lisinopril—combination drug –essential
hypertension
• Always check BP prior to administration—hold
PRN (Parameters)
• Postural hypotension precautions
Anti-Lipemics
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atorvastatin calcium (Lipitor ®)
colestipol (Colestid ®)
gemfibrozol (Lopid ®)
lovastatin ( Mevacor ®)
Niacin ( Niacor ®, Niaspan ®)
nicotinic acid (Slo-Niacin ®, Vitamin B)
pravastatin (Pravachol ®)
rosuvastatin calcium (Crestor ®)
simvastatin (Zocor ®)
Prototype: atorvastatin
Beta Blockers
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atenolol (Tenormin ®)
carvedilol (Coreg ®)
metoprolol (Toprol XL ®, LoPressor ®)
propranolol HCl (Inderal ®)
Prototype: metoprolol
• Remember that there are cardioselective and
non-selective Beta blockers; Beta1 adrenergic
blockage to reduce heart (- chronotrope) rate,
decrease myocardial contractility (-inotrope),
decrease rate of conduction through the AV
node
• Indications: angina, HTN, dysrhythmias, MI,
Heart failure,
• Nursing Implications: Apical pulse; monitor VS;
• Contraindicated in AV Block, SB.
• Used for tx of HTN, MI, angina prophylaxis,
CHF
• Cardioselective vs nonselective B-Blockers
and Respiratory
• Nursing: Apical Pulse
C.O. =
HR
BP
C.O.
=
x
x
SV
PVR
Calcium Channel Blockers
• amlodipine besylate (Norvasc ®)
• diltiazem HCl (Cardizem ®, Dilacor ®,
Tiamate ®, Cardizem SR ®, Cardizem CD ® )
• nifedipine (Adalat ®, Procardia XL ®)
• Verapamil HCl (Calan ®, Isoptim ®, Covera ®)
Prototype: nifedipine
• Vasodilation of peripheral arterioles; clocking
of CA+ channels in heart causes decreased
force of contraction, decreased heart rate,
decreased pulse. (-inotrope, -chronotrope)
• Indications: HTN, angina, selected
dysrhythmias
• Nursing Implications: hypotension, orthostatic
hypotension, cardiac monitor, monitor pulse
rate
• Contraindications: AV blocks, hypotension,
bradycardia, aortic stenosis, severe heart failure
• Treatment of HTN, vasospastic angina, angina
prophylaxis, Atrial Fibrillation (sometimes) ,
rapid atrial dysrhythmias
• Nursing: Check BP, hold PRN (Parameters)
• Postural Hypotension
Precautions
C.O. = HR
x
SV
BP
=
C.O.
x
PVR
Digitalis Glycosides
• digoxin (Lanoxin ®)
• (+) Inotrope, (-) Chronotrope
• CHF, Atrial Tachy-arrhythmias (A-Fib, AFlutter), Cardiogenic Shock
• Assess Apical Pulse
•
Dig Toxicity—anorexia, fatigue, weakness, yellow-green halo’s
around lights
• Role of K+ ! (Can be Dig Toxic with therapeutic Dig levels if K+
is low!) Therapeutic Level = 0.5-2.0 ng/ml
• Low K+: Possible U Waves on EKG
Prototype: digoxin
• (+) inotropic effect; (-) chronotropic effect;
improves stroke volume and C.O.
• Indications: treatment of heart failure;
treatment of atrial fibrillation
• Nursing Implications: AP, monitor dig levels,
monitor K+
• Contraindicated: Ventricular rhythm
disturbances: VF, VT, 2nd -3rd degree AV block
Loop Diuretics
• bumetanide (Bumex ®)
• furosemide (Lasix ®)
• Monitor serum K+ 3.5 – 5.0 mEq/L
• Potassium rich foods
Prototype: furosemide
• Block reabsorption of NA and Cl, prevent
reabsorption of H2O, causing extensive
diuresis;
• Indications: Pulmonary edema d/t Heart
failure
• Nursing Implications: I&O, daily weights,
hypotension, diuresis (foley?), orthostatic
hypotension, monitor K+, RELATE THIS MED IN
RELATION TO OTHER MEDS. Dietary
counseling.
Platelet Aggregation Inhibitors
• clopidogrel bisulfate (Plavix ®)
• dipyridamole (Persantine ®)
• ticlopidine HCl (Ticlid ®)
• Prevention of TIA’s, CVA; combined with
warfarin or ASA for heart valves, MI, bypass
grafts, stents.
Prototype: aspirin
• Prevent platelets from clumping or
aggregating;
• Indications: Primary prevention of MI;
prevention of CVA (stroke);
• Nursing Implications: bleeding , GI Upset ; use
cautiously in those with anticoagulants and
NSAID’s (potentiates).
Potassium Sparing / Combination
Diuretics
• hydrochlorothizide / triamterene
•
(Dyazide ®, Maxzide ®)
• spironolactone (Aldactone ®)
• Treatment of edema and hypertension
• Avoid high K= foods (oranges, bananas, salt
substitute, dried apricots, dates,
• Weigh Daily
Prototype: spironolactone
• Spironolactone is classified as a potassiumsparing diuretic.
• Indications:congestive heart failure, cirrhosis
of the liver, and kidney disease. It can also be
used in combination with other drugs to treat
elevated blood pressure.
• Nursing Implications: Used with other
diuretics; Give with meals; Avoid salt
substitutes containing potassium;
• Monitor I and O
Thiazides / Related Diuretics
• chlorthalidone
•
(Hygroton ®, Hylidone ®, Thalitone ®
• hydrochlorothiazide [hctz] (Hydrodiuril ®)
• indapamide (Lozol ®)
• metolazone (Zaroxylyn ®)
• NOTE THAT MORE THAN ONE HYPERTENSIVE –
SOMETIMES SEVERAL--MAY BE NEEDED TO
CONTROL HTN; USED IN COMBINATION WITH
DIURETICS; Tx edema, HTN
• Monitor for hypokalemia
Anti-Coagulants
• Heparin
• Enoxaparin
• Warfarin
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Antidotes:
Heparin = protamine sulfate
Coumadin = vitamin K
Digoxin = Digibind, Digifab,
Prototype: heparin
• Inactivation of thrombin formation vis
inhibition of fibrin formation,
• Indications: DIC, stroke, prophylaxis agains
post-op DVT,
• Nursing Implications: bleeding (remember:
internal & external bleeding) Heparin Induced
Throbocytopenia (HIT)—stop if platelets
<100,000; monitor aPTT (< 2 x baseline)
• Antidote: Protamine sulfate
Thrombolytic Medications
Prototype: streptokinase
• Act by dissolving clots.
• Indications: Acute MI; DVT; Pulmonary emboli,
ischemic stroke (alteplase)
• Nursing Implications: MONITOR FOR BLEEDING;
monitor VS; (see p. 310, ATI Pharm)
• Contraindications: prior intracranial
hemorrhage, active internal bleeding, significant
trauma within 3 months, acute pericarditis, brain
tumors.
EMERGENCY
CARDIAC
PHARMACOLOGY
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Oxygen
Epinephrine
Atropine
Adenosine
Lidocaine (or amiodarone)
Oxygen
• 100 % ! (during resuscitation, for all clients,
including those with chronic respiratory
conditions, e.g., COPD)
Epinephrine
(Adrenaline)
catecholamine
• Pharmacologic action: vasoconstriction;
increased heart rate (+ chronotrope);
increased rate of conduction; increased BP;
increased myocardial contractility.
• Indication: Cardiac arrest; ventricular
fibrillation
• Administration: IV, IV push
• Dose: 1 mg IV push q3-5min
• Nursing Implications: Monitor blood pressure,
peripheral pulses, urinary output
Use infusion pump
Atropine
sympathomimetics
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•
Pharmacologic Action:
Indication: SYMPTOMATIC BRADYCARDIA
Administration: IV
Nursing Considerations: weigh the risks to
increased myocardial oxygen demand in CV
patient
• 1 mg rapid IV. Repeat q3-5 minutes up to
maximum total dose of 0.04 mg/kg.
Adenosine
class V antiarrhythmic
• Pharmacologic Action: Class V antiarrhythmic; causes transient heart block in
the AV node
• Indication: SVT & WPW
• Administration: IV Bolus
• Nursing Considerations: after IV bolus, causes
a transient asystole
•
6 mg rapid IV, followed by saline flush. If no response in 1-2 minutes give 12 mg
rapid IV. May repeat in 1-2 minutes if needed.
Lidocaine
anti-arrhythmic
• Indications: ventricular fibrillation, ventricular
tachycardia
• Pharmacologic Actions: anti-arrhythmic
• Administration: IV
• Nursing Considerations: monitor the patient!
If received bolus, needs to receive a
continuous infusion afterwards; CNS effects—
drowsiness, altered mental status, seizures
• 1 to 1.5 mg/kg q3-5min. Maximum total: 3 mg/kg.
Amiodarone
anti-arrhythmic
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Indications:
Pharmacologic Actions:
Administration:
Nursing Considerations:
Matching
Column A
•
Column B
Alpha Blocker
C J
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Beta Blocker
S V
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Calcium Channel Blocker
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Anti-Anginal
A
•
G
Anti-Arrhythmic
DH K Y
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Anti-Hypertensive
E L
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Anti-Lipemic
I M N O U
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Digitalis Glycosides
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A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
X.
Y.
Z.
•
ACE Inhibitors
isosorbide dinitrate (Isordil ®)
digoxin (Lanoxin ® )
prazosin HCl (Minipres ®)
amiodarone HCl (Cordarone®, Pacerone ® )
hydralazine HCl (Apresoline ®)
dipyridamole (Persantine ®)
nitroglycerin (Nitrostat ®)
lidocaine HCl (Xylocaine ®)
simvastatin (Zocor ®)
doxazosin mesylate (Cardura®)
quinidine (Quinaglute ®)
clonidine (Catapres ®)
atorvastatin calcium (Lipitor ®)
gemfibrozol (Lopid ®)
lovastatin ( Mevacor ®)
spironolactone (Aldactone ®)
hydrochlorothiazide [hctz] (Hydrodiuril ®)
clopidogrel bisulfate (Plavix ®)
carvedilol (Coreg ®)
furosemide (Lasix ®)
colestipol (Colestid ®)
propranolol HCl (Inderal ®)
nifedipine (Adalat ®, Procardia XL ®)
ticlopidine HCl (Ticlid®)
verapamil HCl (Calan ®)
bumetanide (Bumex ®)
B
•
Loop Diuretics
T
•
Platelet Aggregation Inhibitors
F R X
•
Potassium Sparing / Combination Diuretics
P Z
•
Thiazide Diuretics
Q
W
Appendix:
Electrolytes & Imbalances
related to: Cardiac Effects
Sodium (Na+)
• Normal level =
• 135 to 145 mEq/L (adult)
• Required in acid-base and
osmotic pressure balance,
nerve function and water
equilibrium.
Effects:
•
•
>Decreased
Hypotension, headache, nausea,
vomiting, abdominal cramps, muscle
tremors, twitching, fatigue,
headache, nausea, vomiting,
diarrhea, abdominal cramps, muscle
tremors, twitching, weakness,
confusion, seizures, and coma
<Increased
Lethargy, irritability, muscle
twitching, tremors, dry skin and
mucous membranes, fever,
hypotension, disorientation, delirium,
cerebral hemorrhage, coma
Potassium (K+)
• Normal level =
• 3.5 to 5 mEq/L (adult)
• Major factor in
carbohydrate metabolism,
osmotic pressure balance,
acid-base balance and
normal muscle contraction.
!
Effects:
•
> Decreased
Cardiac arrhythmia, depressed S-T
segment, flattened/inverted T wave,
U wave, confusion, lethargy, muscle
weakness, paralysis, abdominal
distention, constipation, paralytic
ileus, thirst, frequent voiding
•
< Increased
Muscle weakness, paralysis,
numbness and tingling, ventricular
fibrillation, cardiac arrest, tall tented
T waves
Effects
Calcium (Ca++)
• Normal level =
• 8.5 to 10 mg/dL
• Involved in bone and tooth
formation, blood
coagulation, nerve function,
muscle contraction.
•
>Decreased
Frequent hives, chronic fatigue, canker
and cold sores, muscle cramps (Charlie
Horses), and itchy skin dementia,
depression, psychosis, tetany (Chvostek's
and Trousseau's signs), laryngospasm, or
generalized convulsions, cardiac
arrhythmias with lengthened QT
segments
•
<Increased
Muscle weakness, bone fragility, kidney
stones, loss of appetite, thirst, frequent
urination, lethargy, fatigue, joint pains,
memory loss, depression, constipation,
anorexia, nausea and vomiting, abdominal
pain, ileus, polyuria, nocturia, and
polydipsia, emotional lability, confusion,
delirium, psychosis, stupor, coma, cardiac
arrhythmias with shortened QT segment
Magnesium (Mg2+)
• Normal level =
• 1.3 to 2.1 mEq/L
• Required for activation of
an enzyme necessary for
energy metabolism and
bone formation.
•
>Decreased
Muscle weakness, fatigue, confusion,
restlessness, hyperexcitability, vertigo,
seizures, muscle tremors, nystagmus,
tachycardia, hypotension, PAC, PVC,
Toursades de Pointes arrhythmia,
anorexia, nausea, vomiting, personality
change, tetany (eg, positive Trousseau's or
Chvostek's sign or spontaneous
carpopedal spasm), and tremor and
muscle fasciculations
•
<Increased
Muscle weakness, drowsiness, lethargy,
hypotension, paralysis, coma, cardiac
and respiratory problems
Blood Glucose
Hypoglycemia
Hyperglycemia
•
Restlessness· Irritability· Confusion·
Trembling· Slurred speech · Headache ·
Tingling lips · Paresthesia· Diaphoresis
(cool skin) · Pallor· Tachycardia· Shallow
respirations· Hypertension· Weakness ·
Hunger · Coma · Tremors
Diabetic Ketoacidosis · Fatigue ·
Flushed, dry skin· Dry mouth ·
Increased thirst · Increased urination·
Blurry vision · Headache· Nausea and
Vomiting· Dehydration· Weak, rapid
pulse· Hypotension· High blood
glucose levels (>240 mg/dL).· Ketones
in urine· Increased thirst and
urination · Nausea, vomiting, and/or
stomach pain· Changes in or difficulty
breathing (Kussmaul’s respirations)·
Acid or fruity smell on breath
(Acetone breath)· Flushing ·
Dehydration · Fatigue · Stupor and
coma
Hypokalemia: ST depression,
decreased or inverted T waves, U waves
²
Hyperkalemia: peaked T waves,
decreased P waves, short QT, widened
QRS, sine wave
²
Hypocalcemia: prolonged QT, flat or
inverted T waves
²
Hypercalcemia: short or absent ST,
decreased QTc interval
²
Hypomagnesemia: prolonged QT,
flat T waves, prolonged PR, aFib, torsade
²
Hypermagnesemia: short PR, heart
block, peaked T waves, widened QRS0
²
Digitalis toxicity: ST depression
(scoop), flat T waves
²
Quinidine: prolonged QT, widened
QRS
²
Pericarditis: diffuse ST elevation with
PR interval depression
Hypomagnesemia: prolonged QT, flat T waves,
prolonged PR, aFib, torsade
²
Hypermagnesemia: short PR, heart block,
peaked T waves, widened QRS0
²
Digitalis toxicity: ST depression (scoop), flat T
waves
Appendix:
A Med-Surg Nurses description of cardiac care—things to think
about with patient care
• Monitor your patient's
response to drug therapy by
assessing his blood
pressure, heart rate, heart
sounds, ECG results, breath
sounds, urine output, and
weight. Also, assess him for
peripheral edema.
• If the physician prescribes a
digitalis glycoside, take your
patient's apical pulse for a
full minute before
administering the drug.
Withhold the drug if his
apical pulse is less than 60
beats per minute.
• Begin digitalis glycoside
therapy by administering a
loading dose (AS ORDERED)
to achieve a therapeutic
level more quickly. Monitor
your patient's serum
digoxin level to ensure that
it remains in the
therapeutic range of 1 to 2
ng/ml. Also, assess him for
signs and symptoms of
digitalis toxicity.
• If he's also receiving a
thiazide or loop diuretic,
monitor his serum
potassium level; a low
potassium level can lead to
digitalis toxicity.
• Other drugs that increase
the risk of digitalis toxicity
include beta-blockers,
anticholinergics, quinidine,
verapamil, nifedipine,
amiodarone, and
propafenone.
• If your patient is receiving one of
these drugs during digitalis
glycoside therapy, monitor his
heart rate and rhythm and assess
for signs of digitalis toxicity, such
as gastrointestinal, neurologic, or
vision disturbances. If he shows
evidence of toxicity, HOLD THE
MEDICATION & NOTIFY THE
PYSICIAN--the digitalis glycoside
will most likely be on hold until
his level returns to the
therapeutic range.
• During therapy, reduce
your patient's cardiac
workload by restricting his
activity. Provide oxygen
through a face mask or
nasal cannula, as
prescribed, to support his
heart's oxygen demands
• After therapy, your patient may
be referred to an occupational
therapist to learn how to
conserve oxygen and energy
while performing daily activities.
The therapist also may help your
patient modify his environment
to reduce cardiac workload. For
example, the therapist may
suggest moving bedroom
furniture to the first floor and
obtaining a bedside commode.
• Teach your patient and his
family about his prescribed
drug therapy. If a digitalis
glycoside has been
prescribed, instruct him to
take his pulse before taking
the drug. Tell your patient
that he may need
potassium supplements
with diuretic and digitalis
glycoside therapy.
• Tell him to withhold the dose and
call the physician if his pulse is
lower than 60 beats per minute.
Also, teach him the signs and
symptoms of digitalis toxicity,
such as nausea, vomiting,
diarrhea, fatigue, vision changes,
and an abnormally slow pulse
rate; hypokalemia, such as
weakness, fatigue, nausea,
abdominal cramps, and diarrhea;
and hyperkalemia, such as muscle
tenderness, fatigue, and
constipation.
• Tell your patient that he
may need potassium
supplements with diuretic
and digitalis glycoside
therapy.
• If your patient is taking
more than one drug, help
him devise a dosage
schedule that
accommodates his lifestyle.
For example, advise him to
take twice-daily drugs
before breakfast and dinner
(if not contraindicated) to
avoid forgetting to take
them during a busy
workday.
• Instruct the patient to
follow a low-sodium diet. If
necessary, refer him to a
dietitian. Tell him to record
his daily weights in a log
and to report a weight gain
greater than 3 pounds over
2 days or less.
• Tell him to conserve his
energy by resting
frequently. Explain how to
obtain and use
supplemental oxygen, if
prescribed.
• Most patients with heart failure
benefit from a home care
referral. If your patient will have
a home care nurse, tell him that
the nurse will perform a
complete assessment of his
cardiac and respiratory status.
And the nurse will answer
questions about his drug
regimen and monitor his
compliance with the drug
regimen and dietary restrictions.
• The home health nurse will
also instruct him and his
family about using home
oxygen therapy, if
prescribed.