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Terms in this set (29)

-First line agents to relieve angina
-Routes include oral, which is swallowing a tablet; sublingual, which can be a spray or a tablet; intravenous, which can only be administered in ICU or emergency department only; ointment; and transdermal patch.
-IV is used for myocardial infarction, heart failure, and hypertensive crisis.
-Nitro-glycerine is not taken by mouth, where the tablet is swallowed, for acute myocardial infarctions because it has a large hepatic-first pass effect and is almost completely inactivated by the liver.
-Look at the dose of nitro-glycerine: SL dose is 0.4 mg/tablet.
-Oral forms of dinitrate and mononitrate are dosed at 10-40 mg or 5-20 mg, respectively.
-The reason for the big change in dosage is hepatic first pass of the oral forms.
-Isosorbide dinitrate and mononitrate can be taken orally for sustained release action, these are used to prevent angina for clients with chronic or stable angina and are not used for unstable angina and MI's

-MOA: increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions, produces vasodilation (venous greater than arterial), decreases preload, reduces myocardial oxygen consumption

-Contraindications: allergy, severe anemia, hypotension, closed-angle glaucoma

-Side effects: headache, hypotension, dizziness, weakness, and faintness
-What drug do you think would be helpful in controlling this elevated heart rate? Beta-blockers

-Drug interactions: erectile dysfuntion drugs (sildenafil, vardenafil, avanafil, tadalafil)
Assessments should include:
-Baseline vital signs: Systolic blood pressure below 90 mm Hg is a reason to withhold Nitroglycerin.
-Drug history and health history (especially look for erectile dysfunction medications, those drugs that end in "afil". )
-Pain-level, quality, precipitating factors

Diagnoses could include:
-Decreased cardiac tissue perfusion related to blood clot in coronary artery causing decreased blood flow.
-Acute pain

Planning:
-Patient will be free from chest pain after administration of nitroglycerin.

Implementation:
-Nitroglycerin SL can be administered for 3 doses, 5 minutes apart. You would give the first dose, if pain does not COMPLETELY go away, you would administer a second dose after 5 minutes, then a 3rd dose after 5 minutes if pain still unrelieved.
-Monitor vital signs because hypotension is common with nitrates: Systolic blood pressure below 90 mm Hg is a reason to withhold subsequent doses of nitroglycerin
-Position patients sitting or lying when taking nitroglycerin for angina. It helps reduce the workload of the heart and it helps prevent orthostatic hypotension. The patient should remain seated or lying for a minimum of 30 minutes after last dose taken.
-Monitor response to nitro throughout the treatment (After each dose).
-Offer a sip of water before giving SL nitro. Dry mouth can decrease absorption. Place the tablet under the tongue and let it dissolve. Tingling sensation normally occurs and shows the medication is effective.
-Wear gloves when applying transdermal nitroglycerin (ointment or TD patch) or your might have orthostatic hypotension because you were exposed to NTG.

Patient teaching:
-Teach patient to take SL nitro if chest pain occurs. Wait for 5 minutes after 1st dose and call 9-1-1 if the pain is not relieved after the 1st dose. Do not drive to the hospital, call 911. The patient can take up to 3 doses in 15 minutes (each 5 minutes apart)
-Teach patient to lie down with phone when taking a dose of nitro; this will help prevent fainting)
-Teach patient about storage of NTG-original dark container, room temperature, away from light and keep dry. Once bottle is opened, the pills last only about 3-6 months before they expire.
-Teach patient that if they do not feel the "tingling sensation under their tongue, it could mean the medication is no longer effective.
-Teach to apply transdermal patches to any hairless site (avoid distal extremities or areas with cuts or calluses). Apply firm pressure over patch to ensure contact with skin, especially around edges. Apply a new dose unit if the first one becomes loose or falls off. Units are waterproof and not affected by showering or bathing. Do not cut or trim system to adjust dosage. Patch may be worn for 12-14 hour and removed for 10-12 hour at night to prevent development of tolerance.
-Avoid hot tubs and saunas while wearing TD patches, may cause too much vasodilation

Evaluation:
-Relief of anginal pain. Any chest pain after receiving nitroglycerin is a red flag, even if it has decreased.
-MOA: binds antithrombin III, which turns off 3 main activating factors: activated factor II(also known as thrombin), activated factor X, and activated factor IX. Thrombin is the most sensitive to heparin.
-Heparin is normally a large molecule derived from an animal source such as pigs and cows.
-The overall action is that it turns off the clotting cascade but remember that it cannot lyse (break down) a clot

-Indications: used in situations where there is a high likelihood of clot formation: MI, unstable angina, DVT, PE prophylaxis, immobility, treatment of small clots, prevents central line clots

-Contraindications: allergy, acute bleeding process, chronic bleeding disorders

-Side effects: bleeding, Heparin-Induced Thrombocytopenia (HIT) (reduction in platelet count), anemia

-Toxicity and management of overdose: if mild withholding heparin can fix overdose, if severe may need antidote, prevent injury in client during this time
-Antidote: protamine sulfate

-Interactions: aspirin or other NSAIDs (increase the chance of uncontrolled bleeding), antiplatelet drugs, thrombolytics, other anticoagulants, herbal products

-Dosage: subcutaneous (prevent blood clots from forming, the dose is normally 5,000 units ever 8-12 hours), intravenous (eceive a dose based on their weight)

-Labs to monitor: activated Partial Thromboplastin (aPTT) (normal is 35-40 seconds for someone not on heparin, for someone on heparin want 45-112.5 seconds), platelet count (want it to be greater than 100,000), hemoglobin and hematocrit (12-16 g/dL for women, 14-18 g/dL for men hemoglobin) (34-44% for women and 38-50% for men hematocrit)
Assessment should include:
-Assess past medical history for contraindications: {chronic bleeding disorders such as hemophilia, renal disease, peptic ulcers)
-Assess current medical issues (acute bleeding processes, hemorrhagic stroke, epidural catheter LMWH)
-Assess current medications (look for drug interactions, aspirin, NSAIDS, other anticoagulants, antiplatelets, thrombolytics the 4 G herbal products)
-Assess baseline labs- make sure you know which labs should be monitored with heparin and LMWH

Diagnosis:
-Risk for injury related to decreased coagulation.
-Knowledge deficit

Implementation:
-Monitor aPTT every 2-3 days for subcutaneous heparin, every 4-6 hours for intravenous heparin
-Monitor platelet count every 2-3 days in acute care environments (Heparin and enoxaparin), look for 50% decrease in platelet count, or for platelet count to fall below 100,000. Hold dose of heparin or enoxaparin if platelets drop and notify health care provider.
-Monitor for signs of bleeding-decrease blood pressure, increased heart rate, easy bruising, excessive bruising, bleeding around IV catheter, bleeding from nares (epistaxis), blood in stool, blood in urine, etc.)
-Monitor for signs of coagulation- assess the calf area for heat, redness, pain and swelling because these are signs of a deep vein thrombosis.
-Avoid invasive procedures if overdose of heparin or enoxaparin occurs. Administer antidote as prescribed (protamine sulfate)
-Administer heparin subcutaneous in abdomen area, avoid scars, bruises, incisions and belly button. Rotate sites. Do not massage injection site as this can increase bleeding and hematoma formation. Gently palpate previous injection sites to see if hematomas have formed.
-Administer enoxaparin in love-handles area-anterolateral abdomen. Prefilled syringes come with an air bubble in them and this should not be dispelled prior to injection. This is considered an "air lock" which helps keep the medication in the subcutaneous tissue. Rotate sites, do not massage injection site as this can increase bleeding and hematoma formation. Gently palpate previous injection sites to see if hematomas have formed.
-Do not administer heparin or enoxaparin IM as this can cause large hematomas (muscle is more vascular that adipose tissue)

Patient Teaching:
-Use soft bristle toothbrush to help prevent bleeding gums. Use electric razor when shaving.
-Do not massage injection sites because this increase chance of bleeding and hematoma formation.
-Teach patient how to self-inject enoxaparin if being discharged home on therapy.
-Teach patient to report unusual bleeding and bruising.

Evaluation:
-No new clots, clot didn't extend. Patient doesn't experience bleeding.
Assessment should include:
-Assess past medical history for contraindications: {chronic bleeding disorders such as hemophilia, peptic ulcers (can increase chance of GI bleeding)}
-Assess current medical issues (acute bleeding processes, hemorrhagic stroke, pregnancy)
-Assess current medications (look for drug interactions, aspirin, NSAIDS, garlic, other anticoagulants, antiplatelets, thrombolytics)
-Assess dietary intake of food high in vitamin K.
-Assess baseline labs (PT, INR)

Diagnosis:
-Risk for injury related to decreased coagulation.
-Knowledge deficit

Implementation:
-Monitor PT/INR every 2-3 days during initial therapy, once patient reaches therapeutic level, monitor PT every 2-4 weeks. (PT range should be 1.25-2.5 the control value=12.5-30. Therapeutic PT. INR should be between 2-3 for VTE prophylaxis and could be up to 3.5 for mechanical heart valve patients.)
-Monitor for signs of bleeding-decrease blood pressure, increased heart rate, easy bruising, excessive bruising, bleeding around IV catheter, bleeding from nares (epistaxis), blood in stool, blood in urine, etc)
-Monitor for signs of coagulation- assess the calf area for heat, redness, pain and swelling (these are signs of a deep vein thrombosis)
-If INR becomes too high, antidote vitamin K (phytonadione.) Mildly elevated INR will result in maybe a held dose and dose readjustment by healthcare provider.
-Protect the patient from harm if INR elevated above therapeutic levels, implement fall precautions, avoid invasive procedures

Patient Teaching:
-Use soft bristle toothbrush to help prevent bleeding gums. Use electric razor when shaving.
-Teach patient to be consistent in intake of foods high in vitamin K (for example, if you want to eat salad 3 times a week, then eat salad 3 times a week every week; if you decide to stop eating salad, make sure your healthcare provider knows so that the warfarin dose can be adjusted).
-Take medication as prescribed.
-Follow up lab work every 2-4 weeks; try not to skip these appointments. ( I worked with a cardiologist who would tell the patients that warfarin was rat poison that we harnessed for medical purposes (which is true) and that if you failed to keep these appointments, you might die like a rat, by bleeding to death. He did not mess around with non-compliant patients, because he didn't want the guilt of losing patients who did not follow up with their INR blood work.)

Evaluation:
-No new clots, clot didn't extend. Patient doesn't experience bleeding
Assessment:
-Assess labs- baseline cholesterol (all); AST/ALT (especially with statins)
-Assess current medications (look for the medications that have interactions with each type of antilipemic drug)
-Assess past medical history (Liver disease, renal disease for example; look at each drug and which contraindications you should look for based on each antilipemic drug)
-Assess pregnancy if on a statin

Diagnosis:
-Decreased tissue perfusion/t atherosclerosis

Planning:
-The total cholesterol level will be less than 200, LDL less than 100 and the HDL greater than 60.

Implementation:
-Monitor cholesterol levels before and periodically in therapy.
-Statin-Monitor CK, CPK levels, an increase indicates muscle break down (Rhabdomyolysis)
-Statin-Monitor liver enzymes (an increase in AST and ALT can indicate liver damage)
-Statin-Monitor skin/sclera for jaundice. (yellow discoloration, happens first in sclera)
-Statin-Monitor urine color-dark, tea-colored urine can be sign of liver damage
-Statin- upper right quadrant pain and tenderness can indicate liver damage
-Niacin-give with food to help prevent GI upset. If flushing occurs, recommend to health care provider to prescribe aspirin 30 minutes prior to niacin dose. You can also ask for non-flushing niacin.

Patient Teaching:
-Statin-report unexplained muscle pain and tenderness, muscle weakness, profound weight loss (could be rhabdomyolysis)
-Statin-Report dark, tea-colored urine, yellow color to sclera or skin, and right upper quadrant pain (could be liver damage)
-Statin-Teach not to stop abruptly (can cause 3-fold increase in cholesterol, can be fatal)
-Cholestyramine-take other medications 1 hour before or 4-6 hours after. It is a dry powder that should be mixed in juice or water.
-Cholestyramine-since causes constipation-increase fluid, fiber and ambulation
-Keep follow-up appointments, take medication as prescribed, do not stop abruptly (all of the antilipemic drugs)

Evaluation:
-Cholesterol level is decreasing, goal being lower than 200 for total cholesterol. Look back at what optimal cholesterol levels were. This is how you would evaluate. Know those lab values.