Cardiac glycosides inhibit the sodium-potassium pump, thus increasing intracellular calcium, which causes the heart muscle fibers to contract more efficiently.
Cardiac glycosides are used for heart failure and cardiogenic shock, atrial tachycardia, atrial fibrillation, and atrial flutter. (PR ↓)
These medications are contraindicated in those with ventricular dysrhythmias and second or third-degree heart block and should be used with caution in clients with renal disease, hypothyroidism, and hypokalemia.
side/adverse effect: GI trouble (A/N/V/D), abdominal pain), neurological sign (headache, drowsiness), visual disturbances (diplopia, blurred vision, photophobia), K ↓, bradycardia (If the apical pulse rate is lower than 60 beats/minute, the medication should be withheld and the HCP notified.)
An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, or hypothyroidism.
The therapeutic digoxin range is 0.5 to 2 ng/ml. The levels above 2 ng/mL are toxic.
Home care instructions: Commonly 2 times/day. Administer 1 hour before or 2 hours after feedings. Do not mix the medication with foods or fluid. If a dose is missed and more than 4 hours have elapsed, withhold the dose and give the next dose at the scheduled time. If the child vomits, do not administer a second dose. Do not increase or double the dose.
Check the lipid profile every 4 to 6 weeks. Monitor serum liver enzyme levels. Instruct the client who is taking an antilipemic medication to report any unexplained muscular pain to the HCP immediately. Instruct the client to receive an annual eye examination because the medications can cause cataract formation. If lovastatin is not effective in lowering the lipid level after 3 months, it should be discontinued. Avoid grapefruit because it increases toxicity. Take low fat and high fiber diet. Lovastatin (Mevacor), with food. Rosuvastatin (Crestor), regardless of time, evening.
A patient should be advised to take aspirin on an empty stomach, with a full glass of water.
A patient should be advised to avoid acidic food such as coffee, citrus fruits, and cola.
The normal activated partial thromboplastin time (aPTT) is 20 to 36 seconds in most laboratories but may be as high as 40 seconds. To maintain a therapeutic level of anticoagulation when the client is receiving a continuous infusion of heparin, the aPTT should be 1.5 to 2.5 times the normal value (60 to 80 seconds). aPTT therapy should be measured every 4 to 6 hours during initial continuous infusion therapy and then daily.
3-3. ★ warfarin sodium (Coumadin) ↔ vitamin K (phytonadione)
The normal PT is 9.6 to 11.8 seconds. Warfarin sodium prolongs the PT. The therapeutic range is 1.5 to 2 times the control value. (target PT 15 to 24 sec)
The normal INR is from 1.3 to 2.0. An INR of 2 to 3 is appropriate for most clients, although for some clients the target INR is 3 to 4.5.
warfarin 복용 환자가 주의해야 하는 음식: vitamin K 가 많은 음식 ex) broccoli, cauliflower, spinach, kale, cabbage, brussels sprout
contraindications: active internal bleeding, history of hemorrhagic brain attack, intracranial problems (including trauma), intracranial or intraspinal surgery within the previous 2 months, history of thoracic or pelvic or abdominal surgery in the previous 10 days, history of hepatic or renal disease, uncontrolled hypertension, recently required CPR, known allergy to the specific product or any of its preservatives
4. ★ furosemide (Lasix)
Loop diuretics: Loop diuretics inhibit sodium and chloride reabsorption from the loop of Henle and the distal tubule.
Used for hypertension, pulmonary edema, edema associated with heart failure, hypercalcemia, and renal disease.
Use loop diuretics with caution in the client taking digoxin or lithium and, in the client, taking aminoglycosides, anticoagulants, corticosteroids, or amphotericin B.
side/adverse effect: hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, thrombocytopenia, hyperuricemia, GI upset, orthostatic hypotension, dehydration, ototoxicity, and deafness, thiamine deficiency
Instructions: Instruct the client to take the medication in the morning to avoid nocturia and sleep interruption. Instruct the client to take the medication with food to avoid gastrointestinal upset. Instruct the client to eat foods high in potassium. Instruct the client to change position slowly to prevent orthostatic hypotension.
Furosemide (Lasix) is an appropriate drug for the nurse to administer to decreased left ventricular preload in a client in cardiogenic shock with a PAWP of 24 mmHg. (PAWP normal range : 6 ∼ 12 mmHg)
① Dobutamine (Toburex): Dobutamine increases myocardial force and cardiac output through the stimulation of β-receptors.
② Dopamine (Dopramine): Dopamine increases BP and cardiac output through positive inotropic action and increases renal blood flow through its action on α and β receptors.
③ epinephrine: Used for cardiac stimulation in cardiac arrest. Used for bronchodilation in asthma or allergic reactions.
Calcium channel blockers decrease cardiac contractility (negative inotropic effect by relaxing smooth muscle) and the workload of the heart, thus decreasing the need for oxygen. Calcium channel blockers promote vasodilation of the coronary and peripheral vessels.
ex) amlodipine (Norvasc), nifedipine (Adalat)
side/adverse effect: bradycardia, hypotension, reflex tachycardia as a result of hypotension, headache, dizziness, lightheadedness, fatigue, flushing of the skin, peripheral edema, gingival hyperplasia, constipation, changes in liver and kidney function
digoxin과 β-blocker와 병용 시 서맥 주의. NTG와 자몽주스 및 술과 병용 시 저혈압 주의. Instruct the client not to crush or chew sustained-release tablets. Instruct the client not to discontinue the medication.
7. ★ β-blocker
β-blockers decrease the workload of the heart and decrease oxygen demands. ex) propranolol (Inderal), atenolol (Tenormin)
Contraindicated in the client with asthma, bradycardia, heart failure, severe renal disease, severe hepatic disease, hyperthyroidism, or brain attack.
Monitor V/S. Assess for respiratory distress and for signs of wheezing and dyspnea. Withhold the medication if the pulse or BP is not within the prescribed parameters. (Hold if the pulse is below 50 times/minute.) β-blocker should be used with caution in the client with DM because the medication may mask symptoms of hypoglycemia. Instruct the client to take insulin to monitor the blood glucose level. Instruct the client not to stop the medication because rebound hypertension, rebound tachycardia, or an anginal attack can occur. Instruct the client to avoid OTC medications. Administer with a meal or after a meal. Atenolol, bid.
8. ★ ACE inhibitors
ACE inhibitors prevent peripheral vasoconstriction by blocking the conversion of angiotensin1 to angiotensin2. (Angiotensin Converting Enzyme inhibitor
ex) benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec)
A persistent dry cough is a common complaint about those taking ACE inhibitors. Instruct the client to contact the HCP if this side effect occurs and persists. Then replace ACE inhibitors with ARBs. Avoid use with potassium supplements. Captopril (Capoten) on an empty stomach, at the regular time.
9. ★ ARBs
ARBs prevent peripheral vasoconstriction and secretion of aldosterone and block the binding of angiotensin2 to type1 angiotensin2 receptors. (Angiotensin2 Receptor Blocker
ex) losartan (Cozaar), valsartan (Diovan)