Drugs Afecting the

Cardiovascular and Renal Systems

RNSG 1301 Fall 2013 Wilhelmina Rich MSN, RN
Brief physiologic review
Circulatory System
Parasympathic vagus nerve
Sympathetic actions
Regulation of arterial pressure
AP = PR x CO
ANS
renin-angiotensin-alosterone
!ineys
Natriuretic pepties
Brief physiologic review
"ran#-Starling mechanism
Cariac output = stro#e volume x $R
%yocarial contractility
Cariac preloa
Cariac afterloa
Antilipemic agents
Treat conditions associated with excess cholesterol in the blood stream
&he goo' (a an ugly lipis
Chylomicrons
)ery low ensity lipoproteins *)+,+-
+ow ensity lipoprotein *+,+-
$igh ensity lipoprotein *$,+-
Antilipemic Agents, Chapter 32
&riglyceries . cholesterol are the two primary forms of lipis in the (loo
&riglyceries are an energy source' . are store in aipose tissue
Cholesterol is primarily use to ma#e steroi hormones' cell mem(ranes' . (ile aci
&he liver is the ma/or organ where lipi meta(olism occurs
Antilipemic rugs are use to lower high levels of lipis within (loo
&reatment0
,rugs
+ifestyle changes
%a/or classes of rugs0
$%1-CoA reuctase inhi(itors
Bile aci se2uestrants
Niacin
"i(ric aci erivatives
Cholesterol a(sorption inhi(itor 34etia5
HMG-CoA Reductase nhibitors
6statins7
8nhi(it $%1-CoA en9yme to ecrease cholesterol concentration in the (loo stream
3cholesterol production5
Common %eication0 Ator!astatin 3+ipitor5
Sie :ffects0 18 istur(ance' liver en9yme levels
"ile Acid #e$uestrants
Bile acis release in intestine liver releases cholesterol to (in to (ile acis
increase (ining leas to ecrease a(sorption in intestine 3cholesterol absorption5
Common %eication0 Cholest%ramine 3;uestran5
Sie :ffects0 18 istur(ance' liver en9yme levels
"i(ric Aci ,erivatives
- 1emfi(ro9il . clofi(rate synthesis of )+,+
- 1enerally well tolerate
- 18 complaints most common s<e
Nicotinic aci =niacin=vitamin B>
- :ffective in treating most hyperlipiemias
- )arious effects at ifferent oses
- "ew patients can tolerate continue use0 flushing' itching' peptic ulcer' ia(etic
intolerance
General &atient 'ducation &oints (or Antilipemia
Sie :ffects
%uscle pain' other unexplaine pain
18 upset' constipation
?ellow iscoloration of s#in
,ecrease sex rive
Nursing Consierations
%onitor liver an renal function stuies
%onitor cholesterol level
1ive meication with evening meal
,O NO& CR@S$ &AB+:&S
Aminister with ABC to ADC ml of water
:at raw vegeta(les' fruit . (ran' low fat iet
%oerate exercise
,rin# at least BCCC ml water each ay
Cariac Physiology . Pathophysiology
Bloo circulation to $eart
Atherosclerosis
Angina pectoris
,rugs that $R' (looflow or cause flui retention may precipitate anginal episoes
Antiangina Agents, Chapter 3)
Treat Angina &ectoris
Angina pectoris is the name given to a feeling of chest iscomfort arising from the heart
(ecause of lac# of oxygen to heart cells<
8t is also #nown as ischemic heart isease
Primary cause0 atherosclerosis E fatty eposits in the arterial walls<
)essels (ecome narrow E coronary artery isease
Complete (loc# of (loo through coronary arteries0 myocarial infarction
%ost commonly occurs with the elerly
&hree types of angina pectoris0
Chronic sta(le angina
@nsta(le angina
)asospastic angina
%ain classes of rugs to treat angina0
Nitrates . nitrites
Beta (loc#ers
Calcium channel (loc#ers
Overall goal0
8ncrease (loo flow to ischemic myocarium' ecrease myocarial oxygen
eman' or (oth
1oal is relief of pain
*itrogl%cerin
Nitrates
Relaxation an ilation of constricte coronary arteries
oxygen an nutrient supply to the heart muscle
8%%:,8A&: R:+8:" of angina chest pain
S+' PO' ointment' patches' translingual spray' an 8)
Common %eication0 Nitroglycerin 3Nitrostat5F Nitro-(i'isosor(ie initrate
Sie :ffects0 $eaache an $ypotension
Sie effects=A,R . contrainications
A< "lushing' heaache' i99iness
B< $ea trauma' hypotension' %8
&oxicity0 severe hypotension usu< transitory
Beta-Bloc#ers
$R an force of myocarial contraction
Reuces myocarial oxygen eman' reuces heart wor#loa
+ong-term prevention of angina chest pain
Common %eications0 %etoprolol 3+opressor5
@ses0 prophylactic therapyF antihypertensive agentF prevent suen eath
A,R . contrainications0 most common s<e< are fatigue . mental lassitue'
(ronchospasmsG (loo glucose control
Atenolol' la(etalol' metoprolol
Calcium Channel Bloc#ers
Prevent influx of calcium ions into vascular smooth muscle an myocarial cells
+ong-term prevention of angina chest pain
Common %eications0 Nifeipine 3Procaria5
Nursing Consierations an &eaching Points
Nitroglycerin S+ 3most common aministration of nitroglycerin50
,ose may (e repeate every H minutes for AH minutes 3> oses5
8" NO R:+8:" A"&:R three 3>5 ,OS:S 8N AH %8N@&:S CA++ IAA
Store meication in am(er (ottle an #eep away from light
S+ ta(lets shoul sting or (urn when place uner the tongue
&a(lets are only goo for > to J months
8) infusion re2uires special tu(ing
Place patch on clean' ry' non-irritate s#in an wash hans thoroughly
$ave the client sit up for a few minutes (efore staning<
Hypotension is a common adverse SE.
Headache is common SE
%onitor for BP' $R' an irregular rhythm
:tiology of $eart failure
&ositi!e notropic Agents, Ch 3+
Treat Congesti!e Heart ,ailure
$eart failure is a cluster of signs . symptoms that occur when the +' R' or (oth ventricles
lose the a(ility to pump enough (loo to meet the (oyGs circulatory nees<
Heart failure is treated with a combination of vasodilator, inotropic, and diuretic
therapy
Terms
)asoilators reuce preloa so that the high volume of (loo returning to the heart is
ecrease< &his ecreases pulmonary congestion . allows the patient to (reathe<
Positive 8notropic agents stimulate the heart to increase the force of contractions, thus
boosting cardiac output< &hey also help reuce pulmonary congestion . improve tissue
perfusion<
Negative inotropic agents ecrease the force of contraction 3(eta (loc#ers' calcium
channel (loc#ers5<
,iuretics help ecrease (loo volume . water retentionF they reuce the preloa an
central venous pressures' which are the filling pressures of the ventricles<
8notropic rugs influence the force of muscular contractions
Chronotropic rugs influence the rate of the heart(eat
,romotropic rugs influence the conuction of electrical impulses
:/ection "raction reflects heart contractility
Positive inotropic rug classes0
Cardiac glycosides
Phosphoiesterase inhi(itors
Cariac 1lycosies
Lanoxin (digoxin)
ncreases force of contraction (pos. inotropy)
Slows the $R 3neg< chronotropy5
Reuces electrical conuction in heart 3neg< romotropy5
Sie :ffects0
N=)' Restlessness=8rrita(ility' Confusion' ,isorientation' Blurre vision' $alos aroun
o(/ects' ,ysrhythmias 3toxicity5
&herapeutic rug level of ,igoxin = C<H E B<C ng=m+
S!S "igoxin toxicity# inuce arrhythmias' hyper#alemia 3level KH m:2=+5'
ventricular tachycaria or fi(rillation
Hypo#alemia occurs when patient has anorexia' nausea' vomiting' iarrhea or heavy
iuresisF predisposes pt. to digitalis toxicity.
$ntidote# ,igoxin 8mmune "AB 3,igi(in5
,rug 8nteractions0 Potassium sparing iuretics . Beta-Arenergic Bloc#ers
Nursing Consierations
Chec# $R
JC (pm - ABC (pm
+ess than JC or greater than ABC' "% &%' ()E %:,8CA&8ON
&a#e apical pulse for one full minute when igoxin is aministere 3patients are
instructe how to ta#e raial pulse when at home5
%onitor ,igoxin level . %onitor serum potassium level
Bran in large amounts may ecrease a(sorption of oral igitalis rugs 3o not ta#e oral
igoxin at same time as eating (ran fi(er5
Phosphoiesterase 8nhi(itors
8ncrease the force . velocity of myocarial contractions
Relax vascular smooth muscle to cause vasoilation' reucing preloa . afterloa
@se for short-term management of systolic ysfunction heart failure in patients
who have not respone to igitalis' iuretics' or vasoilator therapy
:xamples0
8nocor 3inamrinone5
&rimacor -milrinone5
Averse effects
&hrom(ocytopenia 3inamrinone5
,ysrhythmias 3milrinone5
$ypotension seconary to vasoilation 3(oth5
Cariac properties
Conuctivity' Automaticity' 8rrita(lity' Contractility' :xcita(ility
Antid%srh%thmic Agents, Chapter ./
Treat a !ariet% o( d%s(unction heart rh%thms
Normal pathway of electrical conuction through the heart0
,ysrhythmia L
occurs when there is a istur(ance of the normal electrical conuction system of the
heart' resulting in an a(normal heart muscle contraction or heart rate
must (e ientifie with the ai of an :C1 3tracing of the electrical activity of the heart5
Cause (y the firing of a(normal pacema#er cells' or the (loc#age of normal electrical
pathways' or a com(ination of (oth
Antiysrhythmic rugs classifie accoring to where . how they affect cariac cells .
accoring to their mechanisms of action
Class 8' 8a' 8(' 8c' 88' 888' an 8)
Action an @se
Primary purpose0 treat a(normal electrophysiologic function
Antiysrhythmic agents
Lidocaine' Phenytoin
%orici9ine
;uiniine
"lecainie
Beta arenergic (loc#ing agents
Sotalol
Amiodarone
Bretylium tosylate
)erapamil' iltia9em
Aenosine
Sie :ffects0 $eaache' ,i99iness' Nausea' Blurre )ision
Mith amioarone' photosensitivity' . (lue-gray s#in iscoloration
Nursing Consierations
$ave emergency e2uipment reaily availa(le
%onitor :C1 for changes
%onitor $R' BP' general well-(eing' s#in color' (reath souns
%onitor serum electrolyte levels
Caution patients that suen withrawal of meication may (e life threatening
Bloo Pressure
Antih%pertensi!e Agents
Treat H%pertension
$ypertension 3efinition5
All antihypertensives in some way affect cariac output 3C<O<5 an=or systemic vascular
resistance 3S)R5
%a/or groups of antihypertensives0
,iuretics
Arenergic ,rugs
Central acting
Peripheral acting
AC: 8nhi(itors
)asoilators
Calcium Channel Bloc#ers 3CCB5
Angiotensin 88 Receptor Bloc#ers 3ARB5
Diuretic Agents, Chapter 35
Treat Edema, Congestive Heart ailure, and Hypertension
,unctions o( Renal #%stem
"ormation an :xcretion of @rine
Regulates flui an electrolyte (alance
Regulates (loo pressure 3renin en9yme5
Stimulates prouction of RBCs in (one marrow 3erythropoietin hormone5
0iuretics
8nhi(it Na rea(sorption
Cause volume epletion
)asoilation of peripheral arterioles
Prescri(e in com(ination therapy
Potentiate the hypotensive activity of the noniuretic antihypertensive agents
+ow incience of averse effects
Common %eications0 "urosemie 3+asix5
$yrochlorothia9ie 3$yro,8@R8+5
0iuretic Agents
Mechanisms o( action 1 t%pes o( diuretics depend on anatomical site2
3oop 0iuretic
8nhi(its Na rea(sorption 3in tissue5 (y irect action on ascening +oop of $enle
Common %eication0 ,urosemide 3+asix5
Onset of action of >C-NH minutes
Side Effects# hyponatremia, hypo*alemia
&otassium Sparing 0iuretic
8nhi(its Na rea(sorption in the collecting ucts an istal convolute tu(ules
Common %eications0 #pironolactone 3Alactone5
Sie :ffects0 hyponatremia' hyper#alemia
4smotic 0iuretic
Causes a shift in flui to move into the renal tu(ules from the surrouning tissue
Common %eications0 Mannitol 3Osmitrol5
Prouces greatest amount of urine output
Sie :ffects0 Circulatory overloa
Thia5ide 0iuretic
8nhi(its Na' ! . Cl resorption in the istal convolute tu(ule
Common %eication0 h%drochlorothia5ide 3$yro,8@R8+5
Commonly useF least expensive
Sie :ffects0 hypo#alemia' hypercalcemia' hyperlipiemia' hyperglycemia .
hyperuricemia
&hia9ie iuretics are consiere to (e 6potassium-wasting7
Hypo*alemia is the electrolyte imbalance most often seen
1eneral sie effects
Common sie effects of iuretic rug therapy0
Orthostatic hypotension
Hypo*alemia 3exception0 !O sparing iuretics such as spironolactone5
Hyponatremia
Nursing Consierations
%onitor renal function an urine output
,aily weight
Postural (loo pressure chec#s
Client nees to change positions slowly . rise slowly after sitting or lying
%onitor heart rate . rhythm
Assess s#in . mucous mem(ranes
%onitor serum Na an !O levels
8ncrease excretion of all meications
Aminister in the morning or early afternoon
Adrenergic 0rugs
:xert their action at ifferent sites
Central action 3in the (rain5
Cloniine' guanfacine' meth%ldopa stimulate a-B arenergic receptors in the
(rain
Peripheral action 3at the heart . (loo vessels5
,oxa9osin' pra9osin' tera9osin bloc* a-A arenergic receptors' ilating arteries .
veins to reuce P)R . thus reuce BP
Propranolol . atenolol bloc* (-A receptors . reuce renin secretion
"ual action aA . ( receptor (loc#ers 3la(etalol' carveilol 3Coreg55 reuce $R an
ilate vessels
AC: 8nhi(itors chapter >N
&age 636
Angiotensin Con!erting 'n5%me -AC'7 nhibitors
8nhi(it conversion of angiotensin 8 to angiotensin 88 3reuces peripheral arterial
resistance5
Prevent soium . water resorption (y inhi(iting alosterone secretion 3causes iuresis
. ecreases (loo volume . return to the heart5
"rug of choice for hypertensive patients with heart failure
Common %eication0 Capoten 3captopril5
Sie :ffects0 ,i99iness' chronic, dry, nonproductive Cough' Salty or %etallic &aste'
angioeema 3laryngeal swelling5
Serum levels of igoxin may increase
%ay cause increase levels of potassium
+ithium toxicity may (e inuce
:xamples0
Capoten captopril
)asotec enalapril
Accupril 2uinapril
Altace ramipril
Prinivil' 4estril lisinopril
4ther antih%pertensi!e agents
0irect 8asodilators
Cause irect arteriolar smooth muscle relaxation' resulting in reuce peripheral
vascular resistance . a ecrease in (loo pressure
Some are particularly useful in the management of hypertensive emergencies
:xamples
Nitropress' Niprie =nitroprussie soium
Apresoline hyrala9ine hcl
+oniten minioxiil
$yperstat ia9oxie
Sie :ffects
Orthostatic 3postural5 hypotension
Other sie effects specific to the meication aministere
Calcium Channel "loc9ers -CC"s7
8nhi(it the movement of calcium ions across a cell mem(rane
Cause smooth muscle relaxation . ilation of (loo vessels 3may cause constipation5
:ffective in African-Americans . the elerly
Serum igoxin levels may increase
:xamples
Norvasc amioipine
Cari9em iltia9em
Plenil feloipine
Procaria nifeipine
Calan verapamil
Angiotensin Receptor "loc9ers -AR"s7 &age 63:-6.;
Bin angiotensin at the receptors
,o not cause ry cough
Begin wor#ing within a wee#' (ut may ta#e > to J wee#s for full therapeutic effect
:xamples
Atacan canesartan
Co9aar losartan
Avapro ir(esartan
General Teaching Considerations
Nursing Consierations
%onitor BP an $R' . recor
&a#e orthostatic BP reaings 3lying' sitting . staning5
Meigh aily' . recor
Change positions slowly 3to prevent orthostatic hypotension5
&each client a(out proper iet' weight loss' an exercise
Avoi smo#ing . excessive alcohol
Avoi hot environments
Reuce stress as much as possi(le
Never stop ta#ing meication without consult
Antihypertensives may lea to epression
+ifelong therapy is usually re2uire
Coagulation Modi(%ing Agents, Chapter .;
Treat disorders o( the blood clotting s%stem
&hrom(us
:m(olus
"i(rin
Coagulation %oifying ,rugs
Anticoagulants< &arenteral
nhibit clot formation
Bins to anti-throm(in 888 to turn off activating factors which ma#e a clot
8nteractions0 Other Anticoagulants
Common %eication0 $eparin' enoxaparin 3+ovenox5
Antiote0 Protamine Sulfate
Sie :ffects0 Bleeing
Anticoagulants< 4ral
nhibit clot formation
8nhi(it )itamin ! clotting factors 388' )88' 8P' P5
8nteractions0 Other Anticoagulants
Common %eication0 warfarin 3Coumain5
Antiote0 )itamin !
Sie :ffects0 Bleeing
Antiplatelets
Mor# to prevent the platelet adhesion to site of B) in/ury
3#eep platelets from clumping together5
%echanism of action0 many affect the cyclooxygenase pathway
Common %eications0 aspirin . clopiogrel 3Plavix5
Sie :ffects0 Bleeing
Thrombol%tics
Convert plasminogen to plasmin' which (rea#own' or lyse' clots to restore (loo
supply to amage myocarium
Common %eications0 strepto#inase 3S!5' Streptase
Sie :ffects0 Bleeing
$emostatic Agents
Anti(ibrinol%tics
Promote clot formation (y inhi(iting the lysis 3(rea#own5 of fi(rin
Common %eications0 Aminocaproic Aci 3Amicar5
Sie :ffects0 Bloo Clot 3throm(us5
Replacement therap% (or hemophilia
,eficiency of factor )888' 8P or P8
,esmopressin=,,A)P
Nursing implications
1eneral Nursing Consierations
Nursing Consierations
%onitor la( tests0 eg<' $g(' $C&' P&' aP&&' 8NR 3p N>B5
Assess A++ OR8"8C:S for (leeingF report a(normal (leeing
Assess for easy (ruising
@se soft (ristle tooth(rush
Notify %, if client evelops neurological ysfunction
,o not eat foos high in vitamin !
&each patient safety while ta#ing meication at home
&a#e oral anticoagulants at the same time every ay to maintain steay (loo levels
,o not ou(le misse oses
$ematopoietic ,rugs' Chapter NB
Nutritional eficiencies0 8ron eficiency anemia
,ietary iron (ro#en own (y gastric /uices (efore (eing a(sor(e<
Oral iron preparations availa(le as ferrous salts< Shoul never (e exchange for one
another<
Parenteral preparations0 iron extran' iron sucrose' ferric gluconate
A,R0 nausea' vomiting' iarrhea'constipation' stomach cramps=pain< :xcess inta#e
leas to iron toxicity
Nutritional eficiencies0 "olic Aci eficiency anemia
8ngestion re2uire for prouction of ,NA . RNAF essential for normal erythropoiesis
Shoul not (e use until unerlying cause . type of anemia is etermine<
OBC pills'corticosterois' sulfonamies all cause signs of folic aci eficiency<
"olic aci can lower phenytoin serum levels
Nutritional eficiencies0 Cyanoco(alamin eficiency anemia
@se to treat pernicious anemia an meglo(lastic anemias<
1iven PO or intranasally' 8%
:rythropoietic ,rugs
:poetin alfa3:pogen'Procrit5 an ar(epoetin3Aranesp50 stimulates (one marrow
prouction of RBCs
@se to prevent or treat anemia associate with chronic renal failure an
myelosuppression chemotherapy<
Associate with increase cariovascular complications an tumor progression if use to
achieve normal hemoglo(in levels
Colony Stimulating "actors
"ilgrastim3Neupogen5
@se to stimulate (loo cell prouction (y (one marrow following (one marrow
transplant or chemotherapy inuce neutropenia
Platelet :nhancer
Oprelve#in3Neumega50 (oth hematopoietic rug . interleu#in
8nicate for prevention of chemotherapy-inuce severe throm(ocytopenia an
avoiance of nee for platelet transfusion in aults<
luid and Electrolytes, Chapter 3!
About 60% of adult body is fuid (TBW)
Intracellular fuid, interstitial fuid, and plasma volume
luid location terminolo!y by reference point"
#ells" I#, $#
Blood vessels" intravascular
Tissues" Interstitial
%e&ydration leads to disturbance in balance bet'een amount of fuid in
e(tracellular compartment ) intracellular compartment
Types of de&ydration
*ypertonic" fuid moves out of cells, de&ydratin! t&e cells (e!+, fever 'it&
perspiration)
*ypotonic" fuid moves into cells (loss of salt , loss of 'ater)
Isotonic" decrease in volume of $# (loss of -a ) 'ater from body, e!+,
diarr&ea ) vomitin!)
Crystalloids are fuids !iven by I+.+ in/ection t&at supply 'ater ) sodium to
maintain t&e osmotic !radient bet'een t&e e(travascular and intravascular
compartments
-ormal 0aline
1actated 2in!er3s
%4W
5lasma61yte
7ay be"
Isotonic (0+8% normal saline)
*ypotonic (0+94% -0)
*ypertonic (:0% %4W)
$lectrolytes (12, 51)
An isotonic solution is one in '&ic& normal body cells can be placed 'it&out
causin! eit&er s&rin;a!e or s'ellin! of cells
A &ypertonic solution 'ill cause cells to s&rin;
Colloids are lar!e protein particles t&at cannot lea; out of t&e blood vessels
*i!&er concentration of colloid solutes inside blood vessels t&an outside t&e
blood vessels< fuid moves to'ard t&is &ypertonic area in an attempt to ma;e it
isotonic
5roteins (albumin)
#arbo&ydrates (de(trans or starc&es)
ats (lipid emulsion)
Animal colla!en (!elatin)
Administer I+.+, slowly & cautiously to prevent fuid overload and &eart failure
Albumin is administered at room temperature
Blood products are t&e only class of fuids capable of carryin! o(y!en
Blood products are !iven =-1> 'it& -ormal 0aline 0+8%
%4W 'ill cause &emolysis of 2B#s in transfusions
Blood products are al'ays c&ec;ed by t'o nurses before administerin!
If adverse reaction"
Electrolytes
5otassium (?@)" A+4 to 4+0 m$BC1
$ssential for maintenance of acid6base balance, isotonicity, ) t&e
electrodynamic c&aracteristics of t&e cell
ood sources" ruit and /uices, Ds&, ve!etables, poultry, meats, and dairy
products
*ypo;alemia" let&ar!y, mental confusion, muscle 'ea;ness, nausea (T("
5otassium 0upplements)
*yper;alemia" red fus&ed s;in, dry mucus membranes, t&irst, decreased
urination, cardiac rhythm irregularities (T(" ?aye(alate)
-$.$2 !ive undiluted potassium c&loride E can result in ventricular
Dbrillation ) cardiac arrest
-$.$2 !ive potassium IV push or IV bolus
Fsual dose is 90 m$B ?@C:000 m1 fuid at a rate not to exceed G0 m$BC&our
0odium (-a@)" :A46:94 m$BC1
5erforms many p&ysiolo!ic roles necessary for t&e normal function of t&e
body, principally involved in control of 'ater distribution, fuid ) electrolyte
balance, ) osmotic pressure of body fuids
ood sources" 0alt, Ds&, meats, and ot&er foods favored, seasoned, or
preserved 'it& salt
*yponatremia" let&ar!y, &ypotension, stomac& cramps, vomitin!, diarr&ea
) seiHures
*ypernatremia" edema, t&irst, tac&ycardia, 'ea;ness, convulsions, coma