Case study: ACE Inhibitors T.L.

is admitted to the medical unit with complaints of a 10-pound weight gain over the past week, swollen ankles, and increasing shortness of breath. Although Lasix was partially effective, the MD chooses to add an ACE inhibitor. T.L. is started on captopril 12.5 mg PO t.i.d. His blood pressure is currently 140/74. Significant history includes an anterior myocardial infarction 12 months ago; he has been told that he has renal artery stenosis involving the right kidney.

1. Based on the absorption of captopril, what guidelines would you give T.L. regarding taking his medication?

2. T. L. wants to know what his doctor meant when he said the medication would help with the reninangiotensin system. You want to review your thoughts on this before you develop an explanation in lay terms for him. To better understand the mechanism of the renin-angiotensin system, you must know how this system responds. Explain the trigger mechanisms for the renin-angiotensin system.

3. You explain to T. L. what is meant by the renin-angiotensin system. Now he wants to know how the Captopril works. Again, you have to review your thoughts before you translate this to lay terms. What are your thoughts?

3. T.L. wants to know what significant adverse effects can be expected with ACE inhibitors such as captopril?

4. You are administering the first dose of captopril. What must you be concerned about?

Case Study: Coronary artery disease- Calcium Channel Blockers Mrs. C.D. is a 67-year-old female patient admitted to the hospital with chest pain unrelieved with sublingual nitroglycerine. Her past medical history includes long-standing coronary artery disease with angioplasty and coronary artery bypass graft two years ago, peripheral vascular disease in right leg; she also smokes 12 packs of cigarettes per day. In the ER she was started on heparin and nitroglycerine drips. She arrived in the CCU pain free. Her medications at home include enteric coated ASA daily, Lanoxin 0.25 mg daily, and Lopressor 25 mg twice a day. Her heart catherization showed her grafts were open but she had narrowing of distal left anterior descending artery. The cardiologist then discontinued the heparin and NTG drip and started nifedipine (Procardia XL) and strongly recommended she stop smoking. 1. Briefly describe the classification and action of nifedipine.

3. What instructions would you give Mrs. C.D. specific to taking sustained-release Procardia?

4. Why is it a good idea that she is already on a beta blocker (Lopressor)?

5. What are some adverse effects of nifedipine that Mrs. C.D. needs to know?

Case Study: Hypertensive crisis- Vasodilators Mr. George Allen is a 55-year-old patient who has just been admitted for a hypertensive crisis. His blood pressure is 240/160. The health care providers are concerned that he may have a massive cerebral vascular accident (stroke or CVA) if his blood pressure is not brought down now. The physician orders an intravenous infusion of nitroprusside sodium mixed as 50 mg in 500 ml of D5W. This is to be started in a large vein and to be safely administered on a controller pump. Mr. Allen weighs 85 kg. 1. Knowing that nitroprusside sodium (Nipride) creates a rapid response (within 12 minutes), what should the nurse assessand how oftenin order to follow the results of the drugs and the patients response?

2. What would you do if Mr. Allens blood pressure dropped 30 mm Hg in 2 minutes after starting the drip and another 30 mm Hg in the next 2 minutes. What should you do?

3. Mr. Allen has remained on the nitroprusside for 3 days now. You have concerns about several adverse effects. You know that giving more than 10 mcg/kg/min would create a significant adverse effect. For this patient, how much would this toxic dose be? (Calculate the amount of medication, and then calculate how many ml per minute that would be.)

4. Mr. Allen has improved significantly. The physician has decided to prescribe hydralazine for him on a long-term basis to control his blood pressure. Several disadvantages to using hydralazine are what?

5. Mr. Allen wants to know how the hydralazine can make a difference in his blood pressure. Before you discuss this with him you review in your mind how selectivity of vasodilator determines hemodynamic effects. What are the effects?

6. Explain how dilation of arterioles or veins can produce one of the side effects, reflex tachycardia.

7. Since hydralazine frequently causes reflex tachycardia, what do most patients also have prescribed to prevent this?

Case Study: Client with Hypertension Mr. R.S. is a 48-year-old African-American male who presents to ED complaining of a frontal headache and generalized complaints of not feeling well. Upon examination his blood pressure is 210/120, pulse 98, and respirations 24 and unlabored. The nurse administers a stat dose of nifedipine 10 mg PO as ordered by the physician. Thirty minutes later, Mr. R.S.s blood pressure remains elevated at 208/128, and he continues to complain of a throbbing frontal headache. He tells the nurse that he feels short of breath while resting on the stretcher. His pulse rate is now 118 and regular. As a result of his evolving congestive heart failure secondary to his hypertension, the nurse recognizes that immediate intervention is necessary and pages the physician stat. 1. Based on your knowledge of hypertension, you know that a hypertensive emergency exists when the diastolic blood pressure exceeds how many mm Hg? What else should you evaluated in addition to the blood pressure?

2. What is the rational for not lowering the blood pressure rapidly in normal conditions (i.e., in the absence of CHF, MI, hemorrhage)?

3. The doctor is considering placing Mr. R.S. on a beta blocker such as propranolol to control his blood pressure. Based on what you know and considering this situation, is this treatment acceptable? Why or why not?

4. You are concerned that Mr. R.S. may not continue his treatment because he told you that this was just a one-time happening and that everything is okay now. He no longer has a headache, so he knows he is okay. What do you explain to the patient who is hypertensive about the consequences of not complying with treatment?

5. Mr. R.S. is overweight. You also find out in your complete assessment from him that he is a closet smoker. He never lets anyone see him smoke. He wants to get a pill to control his HTN that would not interfere with his usual life. What do you say?

Client with Angina Pectoris Mr. J.C. is a 75-year-old man admitted to the hospital with substernal chest pain which was not relieved by three sublingual nitroglycerin tablets. In the emergency room, they started Mr. J.C. on a nitroglycerin intravenous drip, which relieved his pain after he received a dosage of 33 micrograms/hour. He has been admitted to the coronary care unit. He has no changes in his ECG and is without pain. The physicians believe that he is having chronic stable angina and not a myocardial infarction (MI). The physician orders enzymes to rule out the MI. The results are negative, and there are no changes in Mr. J.C.s ECG. The physician orders that he be weaned from the nitroglycerin drip and that nitroglycerin transdermal patches 10 mg/24 hours be started. He is also started on atenolol, which he is to receive once a day. As the nurse assigned to Mr. J.C., you have to decide how to wean him from the NTG drip, start the patches, and assign the time for the atenolol to meet his needs. It is 11 AM when you receive the order for these medications. Mr. J.C. also tells you he has a severe headache. 1. Briefly describe when you would apply the NTG transdermal patch and how this schedule relates to weaning Mr. J.C. from the NTG drip knowing that he has the headache.

2. Mr. J.C. has had the NTG drip turned off, the NTG patch is on, and the atenolol has been administered. He asks the nurse what may have been the reason that his NTG sublingual tablets did not work. Based on what you know about NTG sublingual tablets, explain why the tablets may not have relieved his angina pectoris since he was not having an MI.

3. Mr. J.C. asks you about his medications. His doctor has told him that he wants him to take the NTG patch after discharge. What important aspects about this medication are essential for Mr. J.C. to know?

4. Mr. J.C. asks what else he can do to help decrease his chances of having a heart attack. You ask him about his lifestyle and learn that he smokes 1 pack of cigarettes a day, he is 20 pounds overweight, and his exercise has been playing golf once every 2 weeks.

Case Study: Heart Failure 68-year-old T.B. was being treated for congestive heart failure and had been taking digoxin (Lanoxin) 0.25 mg PO daily as prescribed by his physician. However, he quit taking the digoxin when he began to have headaches, which he attributed to the medication. It has been 10 days since T.B. last took his medication, and he is now being admitted to the coronary care unit with a medical diagnosis of congestive heart failure with acute pulmonary edema. 1. What are the major classifications of drugs used to treat heart failure?

2. Electrolytes are drawn, and the only abnormality found is a potassium level of 2.9. What is your concern with this?

3. Why might an ACE inhibitor be an excellent drug to use if T.B. had diabetes mellitus?

4. The physician has decided to start T.B. on digoxin again. The order reads digoxin 0.25 mg PO as a loading dose and then 0.125 mg every day. The pharmacy sends you 0.125 mg tablets. What should you do?

5.

T.B. has been taking the digoxin for 1 week now. The MD orders digoxin levels. Why?