8 Perfusion: Heart Failure and Anti-Heart Failure medication: Diuretics, Angina and Organic Nitrates
Heart failure is a condition in which the heart can’t pump enough blood to meet the body’s needs. Right-side heart failure occurs if the heart can’t pump enough blood to the lungs to pick up oxygen, whereas left-side heart failure occurs if the heart can’t pump enough oxygen-rich blood to the rest of the body. Heart failure is a very common condition, with over 5.7 million people in the United States having this chronic condition. There is no cure, but the symptoms can be managed for several years with lifestyle modifications and several different types of medications. Causes of heart failure include hypertension, myocardial infarction, and other cardiac and respiratory diseases. Common symptoms of heart failure include peripheral edema and shortness of breath that occur as a result of fluid overload. Many patients are treated with diuretics to manage fluid overload symptoms and antihypertensives to manage blood pressure. Other medications, such as digoxin and dobutamine, may also be used to increase the contractility of the heart.
Learning Objectives
- Understand the etiology, pathophysiology, and clinical manifestations of heart failure and the major differences with left and right-sided heart failure.
- Discuss the non-pharmacological treatments for a client with fluid volume excess.
- Explain the mechanism of action, indications for use, adverse effects, and nursing process implications for cardiac glycosides, phosphodiesterase inhibitors, human B-type natriuretic peptides, and organic nitrates.
- Understand the etiology, pathophysiology, and clinical manifestations of angina.
- Describe non-pharmacological measures to control angina, interventions to increase therapeutic effects, and concerns about these conditions in special populations.
Glossary
Ascites: An accumulation of serous fluid in the peritoneal cavity
Avitaminosis: Disease (such as pellagra) resulting from a deficiency of one or more vitamins
Etiopathogenesis: The cause and development of a disease or abnormal condition
Heart failure: A condition in which the heart can’t pump enough blood to meet the body’s needs. A clinical syndrome caused by structural or functional cardiac disorders that impair a ventricle’s ability to fill with or eject blood.
left-sided heart failure: inability of the left ventricle to fill or eject sufficient blood into the systemic circulation (synonym: left ventricular failure)
Nocturia: The need for patients to get up at night regularly to urinate
Orthopnea: shortness of breath when lying flat.
Right-sided heart failure: inability of the right ventricle to fill or eject sufficient blood into the pulmonary circulation (synonym: right ventricular failure)
I. Etiology, pathophysiology, and Clinical Manifestations of Heart Failure
Heart failure (HF) is when the heart cannot pump enough blood to meet the body’s needs, disrupting homeostasis. This occurs due to circulatory system disorders, leading to decreased cardiac output relative to the body’s metabolic demand.
Heart failure manifests in various forms:
- Chronic Heart Failure (CHF): Diagnosed previously or develops gradually.
- Acute Heart Failure (AHF)
- Decompensated Heart Failure: A worsening of CHF, either suddenly or slowly.
Heart failure’s etiopathogenesis involves cardiovascular diseases affecting blood filling or ejection from the heart, genetic factors, and non-circulatory factors such as:
- Hyperthyroidism
- Kidney diseases
- Obesity
- Diabetes
- Anemia
- Avitaminosis
Myocardial damage can result from lifestyle choices or substance abuse (alcohol, drugs) and varies with geographic region, economic development, sex, and race.
Symptoms develop gradually and vary based on the type of heart failure and individual predispositions.
Clinical Manifestation:
Subjective: Fatigue, cachexia, weight loss
Objective: Cyanosis, jaundice, lower limb edema, shortness of breath, pleural fluid, nocturia, oliguria, abdominal pain, constipation, ascites, diarrhea, anxiety, fear, depressive symptoms, chest pain, palpitations, and low blood pressure.
As heart failure progresses, reduced output from the left ventricle can lead to additional symptoms. Reduced gastrointestinal perfusion results in altered digestion, while decreased brain perfusion can cause dizziness, lightheadedness, confusion, restlessness, and anxiety due to reduced oxygenation and blood flow. Increased stress can exacerbate dyspnea, creating a vicious cycle. Sympathetic nervous system stimulation causes peripheral blood vessels to constrict, making the skin appear pale or ashen and feel cool and clammy.
Triggers for heart failure progression include discontinuation of medication, frequent therapy changes, infections, arrhythmias, and hypertension.
Diagnosis involves various tests to objectively assess the body’s condition, such as echocardiography, electrocardiography, chest X-ray, lab diagnostics, coronary angiography, heart CT scans, and endomyocardial biopsy.
Treatment focuses on reducing symptoms, preventing disease progression, reducing mortality, and improving quality of life. It includes lifestyle modification, health education, pharmacological treatment, electrotherapy, laser therapy, cell therapy, and heart transplantation.
II. Non-pharmacological treatments for a client with fluid volume excess
Excess fluid volume, fluid overload, and fluid or water retention are all phrases to describe the medical term hypervolemia. Hypervolemia is when the body has too much fluid. Fluid overload occurs when the body can’t get rid of fluid or holds onto it (retention). The most common causes of true hypervolemia include underlying disease processes such as liver cirrhosis, kidney failure, and congestive heart failure. Mild hypervolemia can occur as a part of normal hormonal fluctuations or by eating too much salt. Without underlying disease, the body’s normal compensatory mechanisms will excrete the excess fluid.
The following are the common clinical manifestations of excess fluid volume. Based on patient reports and nurse assessments, they are categorized into subjective and objective data.
Subjective (Patient reports)
- Difficulty breathing
- Anxiety
- Weight gain or swelling
Objective (Nurse assesses)
- Shortness of breath (orthopnea, dyspnea, increased respiratory rate)
- Adventitious breath sounds (rales or crackles)
- Abnormal electrolyte levels
- High Blood Pressure
- Edema
- Change in mental Status
- Restlessness
- Decrease hemoglobin or hematocrit
- Increased central venous pressure
- Jugular vein distention
- Oliguria
- Tachycardia
- Pulmonary congestion/edema
Key Takeaway
Nonpharmacological Management of a Patient with Fluid Volume Excess
Nursing Assessment
The initial and most crucial step of comprehensive nursing care is the meticulous nursing assessment, during which the nurse diligently gathers extensive physical, psychosocial, emotional, and diagnostic data. In the forthcoming section, we will cover both subjective and objective data related to excess fluid volume.
- Assess for potential causes of excess fluid volume.
- Chronic conditions such as heart failure, kidney failure, and cirrhosis can easily lead to fluid overload.
- Monitor intake and output.
- Monitoring intake (oral, IV) and comparing it to the patient’s output (if a urinary catheter is inserted) will help prevent fluid overload.
- Monitor vital signs
- Sudden changes in heart rate, increased blood pressure, and respiratory rate can indicate increased fluid volume.
- Monitor lung sounds
- Lung sounds described as “wet” or crackles can indicate increased pulmonary congestion.
- Assess for edema and weight gain.
- Pitting edema to the body, such as in the arms, hands, legs, feet, or sacrum, is a sign of fluid in the tissues. A sudden weight gain also indicates fluid retention. Patients with liver cirrhosis may develop ascites, which is an accumulation of fluid in the abdominal cavity.
- Palpate pulses
- A bounding peripheral pulse is a sign of fluid overload.
- Monitor lab values
- With excess fluid volume, electrolytes may be diluted, causing low sodium (hyponatremia). Serum osmolality will be decreased with overhydration. Hematocrit will also decrease with an excess of circulating blood volume. BUN measures kidney function and will decrease with too much fluid.
Nursing Interventions
Nursing interventions and care are essential for the patient’s recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with excess fluid volume.
- Enforce fluid restrictions and educate them on their importance.
- If a fluid restriction is ordered, the nurse should educate the patient and their family on the reason for better adherence. Fluid restrictions prevent the patient from taking in too much extra fluid.
- Record accurate intake and output.
- Along with enforcing fluid restrictions, monitoring and recording accurate I&O is vital. All intake from IV fluids, water taken with medications, and meal intake need to be documented to be compared to the patient’s urine output.
- Record daily weights
- A patient at risk for fluid overload should have their weight monitored daily. This should be done at the same time each day using the same scale or bed scale. If at home, the patient should weigh themselves at the same time (preferably in the morning before eating and dressing).
- Educate the patient and family on signs of fluid gain
- Swelling in extremities, shortness of breath, needing to sleep sitting up (orthopnea), weight gain of 2 pounds in 24 hours or 5 pounds in a week, and observed mental status changes are signs of fluid retention and overload.
- Review dietary restrictions
- Patients may be on a low or restricted sodium diet. Monitor for appropriate meals, provide salt substitutes, and educate on diet changes such as reading food labels, restricting fast or frozen foods, and eliminating table salt.
- Consult with a dietician.
- Patients who cannot maintain proper diets or restrictions may require further education and intervention from a registered dietician.
- Provide mouth care
- Fluid restrictions can be uncomfortable, resulting in dry mouth and poor oral hygiene. To reduce discomfort, the patient should be offered mouth swabs and frequent oral care.
- Reposition and provide skincare
- Place patients in Semi-Fowlers or High-Fowler positions as tolerated to assist with breathing. Reposition every 2 hours and elevate extremities to promote circulation. Patients with edema are at a high risk of skin breakdown.
Key Takeaways
Fluid volume excess, also known as hypervolemia or fluid overload, occurs when the body retains too much fluid. It is often caused by underlying conditions like liver cirrhosis, kidney failure, and congestive heart failure. In milder cases, it can result from hormonal fluctuations or excessive salt intake. The body can usually excrete excess fluid unless a disease is present.
Clinical Manifestations:
– Difficulty breathing, anxiety, weight gain, or swelling, shortness of breath, abnormal breath sounds (crackles), high blood pressure, edema, electrolyte imbalances, jugular vein distention, pulmonary congestion, decreased hemoglobin, and increased central venous pressure.
Treatment and Care:
Management focuses on reducing fluid overload through diuretics, managing underlying conditions, and close monitoring of fluid and electrolyte levels. Nursing care includes regular assessment of vital signs, monitoring for signs of respiratory distress, and ensuring proper fluid balance.
Key Takeaways
Nursing interventions are crucial in managing fluid volume excess and supporting patient recovery.
Key interventions include:
- Enforce fluid restrictions and educate the patient and family on their importance.
- Monitor intake and output (I&O) accurately, including IV fluids and meals, compared to urine output.
- Record daily weights at the same time each day to track fluid retention.
- Educate the patient and family on signs of fluid gain like swelling, shortness of breath, and rapid weight gain.
- Administer diuretics to reduce excess sodium and water, alleviating edema and shortness of breath.
- Review dietary restrictions, especially low-sodium diets, and provide guidance on healthier food choices.
- Provide mouth care to relieve discomfort from fluid restrictions.
- Assist with procedures such as paracentesis for liver failure or dialysis for kidney failure to remove excess fluid.
- Reposition and provide skincare regularly, using Semi- or High-Fowler positions to aid breathing and prevent skin breakdown.
Phosphodiesterase Inhibitors
Phosphodiesterase inhibitors (PDE inhibitors) are a class of medications that block the action of phosphodiesterase (PDE) enzymes, which are responsible for breaking down cyclic nucleotides (such as cyclic AMP and cyclic GMP) in cells. By inhibiting these enzymes, PDE inhibitors increase the levels of these cyclic nucleotides, which have various physiological effects depending on the specific PDE enzyme being targeted and the tissue in which it is active.
Common Conditions Treated with PDE Inhibitors:
– Heart failure
– Chronic obstructive pulmonary disease (COPD)
– Pulmonary arterial hypertension (PAH)
Side Effects and Nursing Considerations:
-Hypotension: which PDE causes vasodilation.
– Headaches, flushing, and dizziness: Often seen with PDE inhibitors due to their effects on blood vessels.
– Nausea and gastrointestinal issues: Common with PDE inhibitors.
– Arrhythmias: PDE inhibitors, while used to support heart function, can sometimes cause dangerous irregular heart rhythms.
Nursing Implications:
When administering phosphodiesterase (PDE) inhibitors, nurses play a crucial role in ensuring patient safety, optimizing therapeutic outcomes, and managing potential side effects. Below are key nursing interventions based on the type of PDE inhibitor used and the condition being treated:
- Monitor Vital Signs:
– Blood Pressure: PDE inhibitors can cause significant hypotension. Regularly monitor blood pressure before and after administration.
– Heart Rate: (e.g., Milrinone) used in heart failure can affect heart rate and rhythm, so continuous cardiac monitoring is essential to detect tachycardia or arrhythmias.
– Respiratory Rate: detect early signs of respiratory distress.
- Assess for Side Effects:
– Headache, Dizziness, or Flushing: Common with PDE inhibitors due to vasodilation effects. Educate the patient to report these symptoms, and monitor their severity.
– Gastrointestinal Issues: PDE inhibitors can cause nausea, diarrhea, or weight loss. Monitor bowel patterns and nutrition status.
– Injection Site Reactions: For intravenous PDE inhibitors, assess for pain, swelling, or signs of infection at the injection site.
- Monitor Cardiac Function:
– Electrocardiogram (ECG): Continuous ECG monitoring is critical when administering PDE inhibitors like Milrinone, as they can cause arrhythmias. Look for changes in the patient’s heart rhythm and take appropriate action if irregularities occur.
– Monitor for Heart Failure Symptoms: In patients receiving PDE inhibitors for acute heart failure, monitor for signs of improvement (e.g., reduced shortness of breath, less edema) and for worsening symptoms (e.g., increased fatigue, chest pain).
- Monitor Fluid and Electrolyte Balance:
– PDE inhibitors can promote diuresis (increased urine output), so monitor fluid intake/output and electrolytes, especially potassium and magnesium levels. Imbalances can lead to arrhythmias and other complications.
- Patient Education:
– Lifestyle Modifications: Educate patients on managing risk factors such as smoking, diet, and physical activity, especially in conditions like PAH or heart failure, to improve overall treatment outcomes.
– Symptoms to Report: Encourage patients to immediately report symptoms such as chest pain, severe dizziness, fainting, visual disturbances, or worsening heart failure symptoms (e.g., increased shortness of breath, swelling).
- Monitor Renal Function:
– Some PDE inhibitors, like milrinone, are excreted by the kidneys, so it’s important to monitor renal function (e.g., serum creatinine levels) and adjust doses as needed in patients with renal impairment.
- Monitor Respiratory Status:
– In patients with pulmonary arterial hypertension closely monitor respiratory function, oxygen saturation, and any signs of worsening dyspnea or fatigue.
- Follow Protocol for IV Administration:
– When administering intravenous PDE inhibitors, ensure proper infusion rates and monitor for signs of extravasation. Adjust doses based on the patient’s hemodynamic response and renal function.
In summary, the safe and effective use of PDE inhibitors in nursing practice requires vigilant monitoring of vital signs, cardiac and renal function, patient education, and timely intervention for potential side effects.
Examples
Type your examples here.
- First
- Second
Cardiac Glycoside
Cardiac glycosides enhance the strength of heart muscle contractions. (Inotropic refers to anything that affects the force of myocardial contractility.)
Digoxin
Digoxin is a cardiac glycoside medication used for centuries to treat heart failure. It has three effects on heart muscle: positive inotropic action (increases contractility, stroke volume, and, thus, cardiac output), negative chronotropic action (decreases heart rate), and negative dromotropic action (decreases the conduction of cardiac cells).
Mechanism of Action: Digoxin works by inhibiting the sodium and potassium pump, which results in an increase in intracellular sodium and an influx of calcium into cardiac cells. This causes the cardiac muscle fibers to contract more efficiently and increases cardiac output.
Indications for Use: This medication is used as second-line treatment for patients who have heart failure or atrial fibrillation. Due to the risk for digoxin toxicity, the clinical use of digoxin has decreased, and alternative, safer medications are being used.
Nursing Considerations Across the Lifespan: The apical pulse should be taken for a full minute before administering this medication. If it is less than 60, the dose should be withheld, and the prescribing provider should be notified.
Serum digoxin levels should be monitored, with a normal therapeutic range from 0.8 to 2 ng/mL.
Serum potassium levels should also be closely monitored for digoxin patients because hypokalemia increases the drug’s effect and can result in digoxin toxicity. The normal potassium level is 3.5 to 5.5 mEq/L, and a result less than 3.5 should be immediately reported to the provider.
Nurses should closely monitor signs of digoxin toxicity. Geriatric patients are at an increased risk for developing digoxin toxicity, which is treated with Digibind.
Adverse/Side Effects: Overdose or accumulation of digoxin causes digoxin toxicity. Signs and symptoms of digoxin toxicity are bradycardia (heart rate less than 60), nausea, vomiting, visual changes (halos), and arrhythmias. Cardiotoxicity is a serious adverse effect of ventricular dysrhythmias. The toxicity of this medication typically occurs at greater than 2 ng/mL, but some patients may have signs and symptoms at lower levels. Pediatric patients typically present with bradycardia or arrhythmias if toxicity is occurring.
Decreased renal function, hypokalemia, hypercalcemia, and hypomagnesemia may increase the risk for digoxin toxicity.
Common side effects include GI symptoms, headache, weakness, dizziness, anxiety, depression, delirium, and hallucination.
Patient Teaching & Education: The patient should be instructed to follow the prescribed dosing regimen and take medications at the same time each day. The patient should be cautious not to double up on medication doses. Additionally, the patient should consult the healthcare provider if two or more doses of medication are missed for follow-up instruction.
Patients should receive education regarding pulse rate monitoring and report any pulse rate less than 60. If the patient experiences signs of digoxin toxicity, this should be reported to the provider immediately. The medication should be stored in its original container, and care should be taken not to mix it with other medications.
Now, let’s take a closer look at the medication grid for digoxin in Table:
Table: Digoxin Medication Grid
| Class/
Subclass |
Prototype-
generic |
Administration
Considerations |
Therapeutic Effects | Adverse/Side Effects |
|---|---|---|---|---|
| Cardiac glycosides | digoxin | Assess apical heart rate
Assess serum digoxin and potassium levels Assess for signs and symptoms of digoxin toxicity |
Increased cardiac output | Digoxin toxicity: early signs include nausea, vomiting, and diarrhea
Bradycardia and arrhythmias Headache, weakness, dizziness, and mental changes such as anxiety or hallucinations Gynecomastia (with prolonged use) |
Overview of Coronary Artery Disease (CAD)
Coronary artery disease (CAD) occurs when the intima, the inner layer of the coronary arteries, is damaged, resulting in the accumulation of lipids and fibrous material. Various irritants, such as chemicals, drugs, or viruses, can further contribute to this injury.
Angina pectoris is a clinical syndrome typically marked by episodes of pain or pressure in the front of the chest. It is caused by inadequate coronary blood flow, which reduces the oxygen supply to the heart when there is an increased demand for oxygen, such as during physical activity or emotional stress. Simply put, the heart’s oxygen needs surpass the available supply (Janice L. Hinkle, 2014).
Understand the etiology, pathophysiology, and clinical manifestations of angina
Angina is typically caused by atherosclerotic disease and is most commonly associated with a significant blockage in at least one major coronary artery. Under normal conditions, the myocardium extracts substantial oxygen from the coronary circulation to meet its constant demands. When the demand for oxygen increases, blood flow through the coronary arteries must also increase. However, if a coronary artery is blocked, this increased flow cannot occur, leading to ischemia.
Factors that can trigger an angina attack include:
- Physical exertion: This increases the heart’s oxygen demand, potentially triggering an angina attack.
- Cold exposure: Cold weather can cause vasoconstriction and elevate blood pressure, both of which increase oxygen demand.
- Heavy meals: After eating, blood flow is redirected to the digestive system, reducing the amount of blood available to the heart. In individuals with a severely compromised heart, this can be enough to provoke angina.
- Stress or emotional situations: Stress causes the release of catecholamines, which raise blood pressure, heart rate, and myocardial workload, all of which can trigger anginal pain (Janice L. Hinkle, 2014).
Non-pharmacological measures to control angina:
Non-pharmacological measures to control angina focus on lifestyle modifications and interventions aimed at reducing the frequency and severity of angina episodes. These include:
1. Dietary changes: Adopting a heart-healthy diet low in saturated fats, trans fats, cholesterol, and sodium helps control weight, reduce blood pressure, and improve cholesterol levels, lowering the risk of angina.
2. Regular exercise: Moderate physical activity, such as walking, can improve cardiovascular health and reduce angina episodes. However, exercise should be tailored to the individual’s condition and capacity.
3. Smoking cessation: Stopping smoking is one of the most critical steps in reducing the risk of angina and other cardiovascular conditions. Smoking damages blood vessels and increases the workload on the heart.
4. Weight management: Maintaining a healthy weight reduces strain on the heart and lowers the risk of angina.
5. Stress management: Techniques such as meditation, yoga, or counseling can reduce stress, which is a known trigger for angina.
6. Limiting alcohol consumption: Reducing or eliminating alcohol can improve heart health and reduce the likelihood of angina episodes.
Interventions to increase therapeutic effects of these non-pharmacological measures:
1. Education: Ensuring patients understand the importance of adhering to lifestyle changes and providing tools or programs to help them stay committed.
2. Regular follow-up: Monitoring patients regularly to assess the effectiveness of lifestyle changes and provide encouragement or adjustments to their regimen.
3. Cardiac rehabilitation programs: These structured programs help patients adopt and maintain lifestyle changes, often combining exercise training, counseling, and education.
4. Collaboration with a multidisciplinary team: Working with dietitians, physical therapists, and mental health professionals can enhance the impact of non-pharmacological measures.
Concerns about angina management in special populations:
1. Elderly patients: Older adults may have comorbidities such as arthritis, which can limit their ability to exercise. They may also have difficulty adhering to strict dietary changes. Furthermore, age-related changes in metabolism and organ function may influence the effectiveness of interventions.
2. Diabetic patients: People with diabetes have a higher risk of cardiovascular disease and may experience silent ischemia (angina without pain). For these patients, managing blood sugar levels and adopting heart-healthy habits are crucial.
3. Women: Women may experience angina differently from men, with symptoms that are less typical (such as fatigue, shortness of breath, or nausea). This can lead to underdiagnoses or delayed treatment.
4. Patients with mental health issues: Conditions like anxiety and depression can worsen angina or make adherence to lifestyle modifications more difficult. Integrating mental health care is important in these cases.
5. Low socioeconomic status (SES) populations: Individuals from lower SES backgrounds may face barriers to accessing healthy foods, safe environments for exercise, and healthcare services, making it harder to adopt non-pharmacological measures.
These concerns highlight the importance of individualized care and tailoring interventions to fit the unique needs of each patient group to ensure effective angina management.
Antianginals
Antianginal medications treat angina pectoris, a type of chest pain caused by insufficient blood flow to the heart, leading to reduced oxygen supply to cardiac tissue. Angina can manifest as chronic pain due to atherosclerosis in coronary artery disease or as acute pain during a myocardial infarction. Antianginals work by either increasing blood flow to the heart or reducing the heart’s oxygen demand. Nitrates, which induce vasodilation in coronary arteries and veins, are commonly used. Beta-blockers and calcium channel blockers are also utilized to lower the heart’s workload and oxygen requirements.
Nitrates are available in various forms, including sublingual tablets, extended-release tablets, creams, transdermal patches, and intravenous preparations. The following grid emphasizes the use of sublingual tablets, which are prescribed on an as-needed basis (“PRN”) for patients with chronic, stable angina associated with coronary artery disease.
Mechanism of Action: Nitroglycerin relieves angina by relaxing vascular smooth muscle, resulting in vasodilation.
Indications for Use: Nitroglycerin relieves angina due to coronary artery disease, during an acute attack, or prophylactically.
Nursing Considerations Across the Lifespan: Patients taking sildenafil (Viagra) or similar medications for erectile dysfunction in the previous 24 hours may not take nitroglycerin as this may result in a dangerous drop in blood pressure.
Nitroglycerin should not be used in pregnant women or those who are breastfeeding.
Nitroglycerin is contraindicated in patients with severe anemia, increased intracranial pressure, hypersensitivity, or circulatory failure.
Adverse/Side Effects: Patients taking nitroglycerin may experience side effects such as low blood pressure (hypotension), palpitations, headache, weakness, sweating, flushing, nausea, vomiting, or dizziness.
Patients should allow the medication to dissolve under their tongue when using it. This method ensures rapid absorption into the bloodstream, bypassing the liver’s first-pass metabolism. To alleviate chest pain, patients can take one tablet every 5 minutes, with a maximum of three sublingual tablets within a 15-minute period. If the chest pain persists after the first dose, emergency services (911) should be contacted immediately. Nitroglycerin can also be used preventatively, 5 to 10 minutes before activities that might trigger an acute attack.
Patient Teaching & Education: Advise patients to refrain from eating or smoking during administration, as these activities can affect the medication’s absorption. Patients should sit down while taking the medication to reduce the risk of injury due to potential hypotension, dizziness, or weakness. Nitroglycerin is sensitive to heat and light, so it should be stored in its original, airtight glass container to prevent decomposition.
Traditionally, patients were instructed to seek emergency help (call 911) if their chest pain persisted after taking three doses of the medication. However, according to new guidelines from the American Heart Association, patients should call 911 after the first dose if their symptoms do not improve or worsen.
Sublingual nitroglycerin should be stored in its original, air-tight glass container.
Now, let’s take a closer look at the medication grid for nitroglycerin in the table below
Table: Nitroglycerine Medication Grid
| Class/
Subclass |
Prototype-
generic |
Administration Considerations | Therapeutic Effects | Adverse/Side Effects |
| Nitrate |
Nitroglycerine |
Patients may take up to 3 sublingual tablets within 15 minutes (1 every 5 minutes) to relieve chest pain.
If symptoms do not improve after the first dose or become worse, or if the pain persists after the 3rd dose of medication, seek emergency help (call 911). Nurses should check BP after each dose No eating or smoking during the administration of SL tablet Do not chew or crush SL tablet Advise patients to sit while taking this medication |
Decrease chest pain | Hypotension and palpitations
Headache, weakness, sweating, flushing, nausea, vomiting, and dizziness |
Critical Thinking
A patient was administered the first dose of nitroglycerin at 1305 for acute angina. What should the nurse evaluate after administration?
Active Learning
- Why should a nurse assess the apical pulse for one full minute before administering digoxin?
- How does a nurse evaluate if digoxin is effective?
- Why must the nurse monitor serum potassium levels as well as digoxin levels?
- A nurse enters a patient’s room, and the patient complains, “My vision seems strange, and I feel nauseated.” What is the nurse’s next best action?
Human B-type natriuretic peptides
Human B-type natriuretic peptide (BNP) is a hormone produced primarily by the heart’s ventricles in response to increased pressure and stretching of the heart muscle, typically seen in conditions like heart failure. It plays a crucial role in regulating blood pressure, fluid balance, and overall cardiovascular health.
Mechanism of Action:
- Vasodilation: BNP causes blood vessels to widen, which helps reduce blood pressure and the workload on the heart.
- Diuresis (increased urine production): It promotes the excretion of sodium and water by the kidneys, helping to reduce blood volume and pressure.
- Inhibition of the renin-angiotensin-aldosterone system (RAAS): BNP reduces the production of hormones like renin and aldosterone, which regulate blood pressure and fluid balance. This helps decrease fluid retention and lower blood pressure.
Use:
Acute decompensated heart failure (ADHF): Nesiritide is used in hospitalized patients who have severe heart failure symptoms, such as significant fluid overload and difficulty breathing. It is usually administered through intravenous (IV) infusion for short-term relief of symptoms.
Nesiritide is particularly effective in reducing shortness of breath in patients with ADHF by improving cardiac output and decreasing pulmonary congestion.
Contraindication:
- Hypotension: One of the primary side effects of nesiritide is significant lowering of blood pressure (hypotension), which can limit its use in patients with low baseline blood pressure.
- Kidney function: There have been concerns about the potential for worsening renal (kidney) function with the use of nesiritide, although studies have provided mixed results on this issue.
- Limited long-term benefit: Nesiritide is typically used only for short-term management in acute settings, as it provides symptomatic relief but does not improve long-term survival or reduce hospital readmissions in heart failure patients.
Current Practice:
While nesiritide was once widely used, its use has declined in recent years due to concerns about its safety and efficacy compared to other available therapies. Other medications, such as diuretics, vasodilators (like nitroglycerin), and inotropic agents, are more commonly used as first-line treatments for ADHF.
Patient Teaching:
– While using this medication, regular monitoring of your blood pressure, pulse, and heart rhythm will be required.
– Since bed rest is necessary, please request assistance when you need to use the restroom.
– Notify the nurse if you experience any pain at the injection site.
– Report any shortness of breath, chest pain, numbness, or tingling immediately.
Takeaway:
In summary, nesiritide is reserved for certain cases of acute decompensated heart failure to provide rapid symptom relief, but its use is carefully monitored due to potential side effects like hypotension and concerns about kidney function.
In summary, BNP is a key player in the body’s response to cardiovascular stress, especially in heart failure, and is widely used in clinical practice for diagnosis and management.
