RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)
HYPERTENSION
DEFINITION
●Sustained elevation of blood pressure. BP of 140/90 mmHg or above, it can also present with H/A, fatigue, dizziness, flushing and palpitation.
●BP: Force exerted by the blood against the walls of blood vessels.
● White coat hypertension: Blood pressure is higher when it is taken in a medical setting than it is when taken at home.
RISK FACTORS
Modifiable Non-modifiable
●Stress ●Family history
●Obesity ●Age
●Diet ●Gender
●Smoking ●Race
●Sedentary lifestyle
●Excessive alcohol intake
PHARMACOLOGIC INTERVENTIONS
1. ACE INHIBITORS: Drugs: captoPRIL (Capoten), EnalaPRIL (Vasotec), ramiPRIL (Altace), lisinoPRIL (Prinivil).
S/E: “CHF” C-ough (persistent dry), H-ypotension, H/A, Hyperkalemia, F-ood has metallic or salty taste or loss of taste + dizziness.
2. BETA BLOCKERS: Drugs: 1. Cardioselective – metoproLOL (Lopressor), atenoLOL (Tenormin). 2. Non-selective – propanoLOL (Inderal), nadoLOL (Cogard). Avoid in patients with asthma and COPD.
S/E: “BLOCK”: B-roncospasm, L-ibido loss/impotence, O-rthostatic hypotension, C-ardiac dysrythmias, K-an’t sleep!
3. CALCIUM CHANNEL BLOCKERS: Drugs: Verapamil (Calan), NifediPINE (Adalat), amlodiPINE (Norvasc), Diltiazem (Cardizem)
“Very Nice Drugs” S/E: V-ery low BP (hypotension), N-o stool (constipation) D-ysfunction sexual and H/A. Avoid grapefruit.
4. ARBs (Angiotensin II Receptor Blockers): Drugs: 1. candesartan (Atacand), 2. eprosartan (Teveten), 3. irbesartan (Avapro),
4. telmisartan (Micardis), 5. valsartan (Diovan), 5. losartan (Cozaar), and
6. olmesartan (Benicar). S/E: Cough, hyperkalemia, abnormal food taste (metallic), diarrhea, hypotension, dizziness, headache.
HYPERTENSIVE CRISIS
INTERVENTIONS
1. Monitor blood pressure and pulse q 20-30 minutes during the initial administration of antihypertensive drugs, by using an automated BP monitoring machine.
2. Encourage complete bed rest.
3. Monitor urine output q 1 hour.
4. Frequent neurological and cardiac assessment.
RATIONALE
1. Initial treatment goal is to decrease mean arterial pressure 10% to 20% in the first 1 to 2 hours. Lowering the BP too fast or too far may decrease cerebral perfusion or stroke.
2. Getting up may cause severe cerebral ischemia and fainting.
3. To assess renal perfusion.
4. Help detects any changes in the patient’s condition.
NON-PHARMACOLOGIC INTERVENTIONS
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Weight reduction – exercise 3 to 4 times per week (aerobic and cardio exercise).
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Diet – Avoid excessive salt, low fat diet, eat fruits, vegetables, fish and poultry, and avoid caffeine and limit alcohol intake.
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Stress management– relaxation techniques (yoga, meditation, massage etc…).
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Smoking cessation.
DASH diet: Dietary Approaches to Stop Hypertension (diet rich in fruits, vegetables, low salt and low-fat dairy products with a reduced content of saturated and total fat.)
5. DIURETICS: Drugs: 1. Thiazides – hydrochlorothiazide/HCTZ (Diuril, Microzide) 2. Loop – furosemide (Lasix) 2. Potassium-sparring – spironolactone (Aldactone). Increase potassium in the diet but except in K sparring.
ANGINA
Main problem: Temporary myocardial ischemia - insufficient blood flow through the coronary arteries d/t obstruction by atherosclerosis (fatty plaque, thrombus), which result of inadequate oxygen supply causing intermittent chest pain.
Myocardial cell becomes ischemic – ↑production of lactic acid – pain.
MYOCARDIAL INFARCTION
Main problem: Also known as heart attack, complete or nearly complete occlusion of the coronary artery (d/t atherosclerotic plaque, thrombus) causing profound imbalance between O2 supply and demand (ischemia) leading to infarction (cell death).
Most common site: Anterior wall of the left ventricle.
CLINICAL MANIFESTATIONS
P- Exertion/physical activity, exposure to cold/windy weather, heavy meals, emotional stress, excitement and stressful situation.
-Relieved by rest or sublingual nitroglycerin.
P- anytime, sudden onset, even at rest.
Q- Constricting, pressing, squeezing, tight, like a band across the chest (retrosternal).
R- To the lower jaw, epigastrium, shoulders, back and left arm.
S- Mild to moderate rarely described as severe.
T- Lasts < 15 minutes.
R- Often radiates widely.
S- More severe.
T- Lasts > 15 minutes.
PQRST ASSESSMENT
Associated symptoms: Dyspnea, nausea and vomiting, diaphoresis, cool and clammy skin, weakness, shortness of breath, anxiety and a feeling of impending doom.
COMPARISON OF TYPES OF ANGINA
TYPES: STABLE ANGINA
ETIOLOGY: Myocardial ischemia, usually secondary to CAD.
CHARACTERISTICS: ●Episodic pain lasting 5-15 min.
●Provoked by exertion.
●Relieved by rest or nitroglycerin.
UNSTABLE ANGINA
Rupture of thickened plaque, exposing thrombogenic surface.
●New-onset angina.
●Increase frequency, duration, or severity.
●Occurs at rest with minimal exertion.
●Pain refractory to nitroglycerin.
PRINZMETAL’S ANGINA
Coronary vasospasm.
●Occurs primarily at rest.
●Triggered by smoking.
●May occur in presence or absence of CAD.
●May occur from exposure to cold.
Patient/family education:
●Smoking cessation. ●Maintain ideal body weight.
●Stress management. ●Avoid caffeine.
●Eat a diet low in cholesterol and fat.
●Avoid strenuous exercise and exposure to extreme temp.
●Avoid excitement and eating a large meal.
●Take medication as prescribed.
Sex tips:
●Must be able to climb at least 2 flights of stairs before resuming sexual activity.
●Less fatiguing position: Side-lying, or bottom.
●Best in morning – after taking medication.
●CAUTION not to take sildenafil (Viagra) while on nitroglycerine.
INTERVENTIONS
ANGINA
1. Position patient in high fowlers.
2. Administer oxygen 2L by nasal cannula.
3. Assess vital signs and pain (PQRST-U).
4. Obtain a 12 lead ECG.
5. Administer pain medication as ordered (nitroglycerine).
●Assess V/S especially BP before administering the medication.
●Caution: Contraindicated on sildenafil (Viagra), tadalafil (Cialis),
or vardenafil (Levitra).
6. Notify doctor if pain persists after 3 doses of nitroglycerin in 15 mins.
7. Reassure and advise patient to stay on bed rest.
8. Explain to patient the importance of notifying nurse immediately if any pain.
9. Continue to monitor patient’s vital signs, heart and lungs sounds q 1 hour or as needed.
10. Monitor intake and output.
11. Encourage patient to continue on bed rest and explain the importance of limiting activity.
12. Explain to the patient not to rise quickly after the administration of nitroglycerine.
13. Encourage lifestyle change. (see patient/family education p. 2)
MYOCARDIAL INFARCTION
1. Position patient in high fowlers.
2. Administer oxygen 2L by nasal cannula.
3. Assess vital signs and pain (PQRST-U).
4. Obtain a 12 lead ECG.
5. Notify the doctor.
6. Administer pain medication as ordered (morphine, Demerol,).
7. Reassure and advise patient to stay on bed rest.
8. Secure a venous access as ordered.
9. Obtain a baseline blood works (cardiac markers).
10. Explain to the patient the importance of notifying nurse immediately if any pain.
11. Monitor intake and output.
12. Encourage patient to continue on bed rest and explain the importance of limiting activity.
13. Explain to the patient not to rise quickly after the administration of nitroglycerine and lifestyle changes.
ECG changes:
-ST segment elevation/depression, peaked or inversion of T-wave and abnormal Q-wave.
Serum enzymes: 1. Troponin – most sensitive; increase levels in 3-6h, can stay elevated 7-14 days. “Gold standard test”. 2. CK-MB – peaks 18-21 hours. 3. LDH – peaks 48-72 hours.
PHARMACOLOGIC INTERVENTIONS FOR MYOCARDIAL INFARCTION
Morphine SONATA: (Morphine, Stool softener, Oxygen, Nitroglycerine, Anticoagulant, Thrombolytic, Aspirin).
1. Narcotics (Morphine/Demerol).
2. Thrombolytics: t-PA, streptokinASE (Streptase), alteplASE (Activase). – Converting plasminogen to plasmin that destroys the fibrin in the blood clot. – It should be administer within 4-6 hours after acute MI.
3. Anticoagulants: Heparin – started before termination of thrombolytics – monitor aPTT/PT. - warfarin (Coumadin) – given while patient is on heparin d/t desired therapeutic effect takes 3-5 days – monitor INR.
4. Antiarrythmics – Lidocaine (Xylocaine 1%) - ↓ cardiac excitability & delay cardiac conduction in the atrium and ventricles.
5. ASA (Aspirin), clopidogrel (Plavix) – platelet aggregation (anti-platelet).
6. Lactulose (Cephulac) - Stool softener, prevents straining.
HEART FAILURE
Also known as “pump failure”, occurs when the heart is not able to pump enough blood to the needs of the rest of the body d/t weakening of the heart muscle caused by a heart attack, hypertension, cardiomegaly, cadiomyopathy, and heart valve disease.
Left-sided Heart Failure
Most common form, result from LV dysfunction, which cause blood to back up through the left atrium and into the pulmonary veins.
SIGNS AND SYMPTOMS
CHOP
C-ough
H-emoptysis
O-rthopnea
P-ulmonary crackles
P-aroxysmal nocturnal dyspnea
Right-sided Heart Failure
Causes backward flow to the right atrium and venous circulation.
PHARMACOLOGIC INTERVENTIONS
1. Diuretics.
2. Digitalis.
3. Vasodilators.
4. ACE inhibitors.
5. Lipid-lowering agents.
SIGNS AND SYMPTOMS
HEAD
H-epatomegaly
E-dema (pitting)
A-scites
D-istended jugular vein
INTERVENTIONS (CHF exacerbation)
1. Position patient in high-fowlers (keep the leg straight) and put patient’s arm on a pillow. 2. Administer oxygen by nasal cannula or mask.
3. Monitor vital signs (BP, pulse, O2 saturation), evaluate respiration (rate and rhythm), and assess pulmonary and cardiovascular system.
4. Administer medication as ordered. 5. Assess abdomen and I&O daily. 6. Weight patient daily (same time of the day). 7. Assess for signs and symptoms of hypokalemia. 8. Evaluate presence of dyspnea during activity. 9. Offer small frequent meals. 10. Limit fluid intake as per doctor’s order. 10. Evaluate degree of edema if present. 11. Encourage patient to do leg exercises. 12. Encourage moderate exercises as tolerated and restrict sodium intake.
MANAGEMENT: CONGESTIVE HEART FAILURE
Patient/Family education: M-edication, A-ctivity, W-eight, D-iet, S-ign and symptoms
Medications:
●Take as medication as ordered. ●Do not take over-the-counter medications without MD’s advice. ●Notify MD for any side effects.
Activities:
● Stay active as tolerated. ●Do activities with rest periods. ●Do more activities when medication starts to work or when feeling better.
●Smoking cessation: if unable, introduce to support group, involve family member, ask health care provider.
Weight:
●Teach patient to weigh on the same scale every morning before eating and after urinating (wearing light clothes).●Scale should be on a hard surface-not on a rug. ●Write weight on a chart/daily weight diary, then bring it when patient visit his/her doctor. ●Note: If patient gain weight 2-3lbs or 1kg in a day, call MD immediately.
Diet: Low salt, limit fluid, low fat
●Low salt diet-as per MD order-usually allows 2000mg but varies depending on patient’s condition. So recommend patient to ask MD about his/her daily sodium intake. ●Read the label on packages and canned foods for information on sodium (salt) content. ●Eat nutritious foods: fresh fruits and vegetables. ●Limit fluid intake-no more than 6 glasses a day or as per MD order.
Sign and symptoms:
Advise patient to call his/her doctor if…
● His/her ankles and legs become more swollen. ●Shoes or socks get tight suddenly.● Has shortness of breath that does not go away with rest.
●Gain two or three pounds in one day. ●Do not have the energy for his/her normal activities. ●Feel dizzy or weak. ●Have yellowish or blue-green vision.● Heartbeat changes (feels like a butterfly in your chest). ●Have chest pain. ●Have blurred vision or passing out. ●Have a cough that does not go away.
LDL (Low Density Lipoprotein)
●Considered as bad cholesterol
●Transport the cholesterol from the liver towards the cells and sticks to the wall of the arteries, ending up clogging the arteries.
●High level of LDL is associated with clogging of the arteries.
●Has more cholesterol and triglycerides than protein.
●The buildup of cholesterol in the form of atherosclerotic plaques leads to the narrowing of cardiac arteries, reducing blood flow to heart tissue distal to the plaque.
HDL (High Density Lipoprotein)
●Considered as good cholesterol
●Transports the cholesterol from the cells to the liver to be synthesized.
●High level HDL appears to lower the risk of heart disease.
●Contains 50% protein with cholesterol and triglycerides.
Cholesterol levels/Lipid panel: HDL, LDL, Total cholesterol and Triglycerides. Note: For accurate reading, patient must not eat or drink anything (other than H2O) for 9-12 hours before blood sample is taken.
DEEP VEIN THROMBOSIS
Formation of blood clot (thrombus) in a deep vein, predominantly in the legs.
RISK FACTORS: "VIRCHOW's TRIAD"
HYPERCOAGULABLE STATE
●Pregnancy and peri-partum period.
●Estrogen therapy
●Trauma or surgery of lower extremity, hip, abdomen or pelvis.
●Inflammatory bowel disease
●Nephrotic syndrome
●Sepsis
●Thrombophilia
VASCULAR WALL INJURY
●Trauma or surgery
●Venipuncture
●Chemical irritation
●Heart valve disease or replacement
●Atherosclerosis
●Indwelling catheters
CIRCULATORY STASIS
●Atrial fibrillation
●Left ventricular dysfunction
●Immobility or paralysis
●Venous insufficiency or varicose veins
●Venous obstruction from tumor, obesity, or pregnancy.
Doppler ultrasound:
-This test uses ultrasound to examine the blood flow in the major arteries and veins in the arms and legs.
-Non-invasive, little or no discomfort at all, no risk associated on the procedure.
-Help diagnose blood clots (DVT), venous insufficiency, arteriosclerosis of the arms and legs.
-A water-soluble gel is placed on a handheld device called a transducer which directs the high frequency sound waves to the artery or veins being tested.
Assessments:
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Calf or groin tenderness or pain with or without swelling.
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Positive Homan’s sign may be noted.
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Warm skin.
INTERVENTIONS
1. Bed rest. 2. Elevate extremity above the level of the heart. 3. Advise patient not massage the extremity. 4. Administer intermittent or continuous warm moist compress. 5. Avoid putting pillows under the knee.6. Anti-embolic stockings as prescribed.
Monitoring: 7. Palpate site gently; for warmth and edema. 8. Measure and record the circumference of the thighs and calves. 9. Monitor for SOB and chest pain for possible pulmonary embolism. Medications as prescribed: 10. Thrombolytic therapy (t-PA) – must be initiated within 5 days after the onset of symptoms. 11. Heparin therapy – prevent enlargement of the existing clot and formation of new clot. -Monitor aPTT. 12. Warfarin therapy – prescribed following heparin therapy when symptoms of DVT have resolved. Monitor PT and INR. Note: Monitor for the hazards and S/E associated with anticoagulant therapy! 13. Analgesics for pain. 14. Diuretics for edema.
PATIENT TEACHING
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Instruct the patient concerning hazards of anticoagulation therapy.
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Recognize the sign and symptoms of bleeding.
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Avoid prolonged sitting and standing, constrictive clothing, or crossing legs when seated.
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Elevate the legs for 10-20 minutes every few hours each day.
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Plan a progressive walking program or leg exercise while sitting.
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Wear antiembolism stockings as prescribed.
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Avoid any medications unless prescribed by the MD.
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Instruct the patient concerning F/U and laboratory studies.
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Obtain and wear a Medical-Alert- bracelet.
Assessment criteria
Presenting history, physical and social factors
Position of ulceration
Pain
Ulcer characteristics
Condition of lower leg
Venous insufficiency
●Previous history of DVT.
●Pregnancy.
●Varicose veins.
●Obesity.
●Reduced mobility.
●Gaiter area, medial aspect.
●Throbbing, aching, heavy feeling.
●Improve with elevation and rest.
●Shallow with slough at the granulation tissue with flat margins.
●Moderate to heavy exudates.
●Normal capillary refill.
●Pedal pulse present.
●Crusty and dry skin.
●Haemosiderin staining.
●Eczematous itchy skin, dilated veins and limb edema.
Arterial insufficiency
●Previous history of vascular disease.
●Diabetes Mellitus.
●Hypertension.
●Obesity.
●Smoking.
●Dorsal or plantar aspect of the foot (Lateral malleolus and tibial area).
●Over pressure points.
●Intermittent claudication.
●Worse at night and at rest.
●Improves with dependency.
●Punched out, occasionally deep.
●Irregular shape, unhealthy appearance of wound bed. Presence of necrotic tissue.
●Delayed capillary refill.
●Absent or weak pedal pulse.
●Thin, shiny, dry and cold skin.
●Reduced or no hair on lower leg.
●Pallor and Gangrene development.
SHOCK
A syndrome characterized by decreased tissue perfusion and impaired cellular metabolism resulting in an imbalance between the supply of and the demand for oxygen and nutrients.
CLASSIFICATION AND PRECIPITATING FACTORS
LOW BLOOD FLOW
Cardiogenic Shock:
1. Systolic dysfunction: Inability of the heart to pump blood forward. (e.g., Myocardial infarction, cadiomyopathy).
2. Diastolic dysfunction: Inability of the heart to fill during diastole.
(e.g., Pericardial tamponade).
3. Dysrythmias.
4. Structural factors: valvular abnormalities, VSD, tension pneumothorax.
Hypovolemic Shock:
1. Absolute hypovolemia.
●External loss of whole blood (e.g., hemorrhage from trauma, surgery, GI bleeding).
●Loss of other body fluids (e.g., vomiting, diarrhea, excessive diuresis, diabetes insipidus, diabetes mellitus).
2. Relative hypovolemia.
●Pooling of blood or fluids (e.g., bowel obstruction).
●Fluid shifts (e.g., burn injuries, ascites).
●Internal bleeding (e.g., fracture of long bones, ruptured spleen, hemothorax, severe pancreatitis).
●Massive vasodilation (e.g., sepsis).
MALDISTRIBUTION OF BLOOD FLOW
Septic Shock:
1. Infection (e.g., Urinary tract, respiratory, invasive procedure, indwelling lines and catheter).
2. At risk clients: older adults, clients with chronic diseases (e.g., CKD, heart failure, diabetes mellitus), clients who is receiving immunosuppressive therapy or who are malnourished or debilitated.
3. Gram-negative bacteria most common; also gram-positive bacteria, viruses, fungi, and parasites.
Neurogenic Shock:
1. Hemodynamic consequence of injury and/or disease to the spinal cord at or above T5.
2. Spinal anesthesia.
3. Vasomotor center depression (e.g., severe pain, drugs, hypoglycemia, injury).
Anaphylactic:
1. Contrast media. 6. Vaccines.
2. Blood or blood products. 7. Drugs.
3. Environmental agents. 8. Latex.
4. Insect bites.
5. Food and food additives
ETIOLOGY
SURGICAL
●Post-operative bleeding
●Ruptured organ or vessel
●Gastrointestinal bleeding
●Vaginal bleeding
●Ruptured ectopic pregnancy
MEDICAL
●Myocardial infarction
●Dehydration
●Sepsis
●Diabetes insipidus
●Addisonian crisis
TRAUMA
●Ruptured or lacerated vessel or organ (e.g. spleen)
●Fractures, spinal injury
●Multisystem or multiorgan injury
ASSESSMENTS FINDINGS:
●Restlessness ●Confusion ●Hypotension ●Tachycardia ●Tachypnea ●Anxiety ●Decreased LOC ●Weakness Rapid, weak, thready pulse ●Cool, clammy skin (warm skin in early onset o septic and Neurogenic shock) ●Decrease O2 saturation ●Extreme thirst ●N/V ●Chills ●Cyanosis
SHOCK MANAGEMENT
NURSING INTERVENTIONS:
●Establish and maintain patent airway.
●Administer oxygen.
●Control any external bleeding with direct pressure or pressure dressing.
●Stabilize cervical spine as appropriate (if SCI).
●Notify the doctor.
●Establish IV access with two large-bore catheters (14-to 16 gauge) and fluid replacement with crystalloids as order (e.g. normal saline solution).
●Antibiotic therapy (if sepsis).
●Draw blood for laboratory studies.
●Epinephrine (if anaphylactic).
ONGOING MONITORING:
●Level of consciousness.
●Vital signs, including pulse oximetry, peripheral pulses and capillary refill.
●Respiratory status.
●Cardiac rhythm
●Urine output
CARDIOVASCULAR MEDICATIONS: CHECK
NITROGLYCERIN (NitroBid or NitroStat)
C-Coronary vasodilator, anti-angina, nitrate.
H-PRN chest pain q5min max 3tab, prophylactically 5-10 mins before activity.
E-Chest pain relief, prevention of angina attack.
C-Storing nitroglycerine pills: Keep tablets in the original package and keep it properly sealed. Replace unused tablets every 6 months. Keep the tablets in a cool, dry, and away from light place. Ask the pharmacist for a small bottle of 25 tablets to always carry in your bag/purse.
●Always sit down before using may cause short-term weakness or lightheadedness.
●SL-dissolve tab under the tongue (do not take anything p.o, do not swallow, crush or break).
●Transdermal-apply a pad daily to a site free from hair, remove patch at bedtime to provide 10-12 hr nitrate-free interval to avoid tolerance.
●Advice patient that it may cause H/A (acetaminophen [Tylenol] 650mg can be taken for H/A), flushing, dizziness and orthostatic hypotension.
●Teach patient that it can be taken before stressful activity, exercise or sexual activity.
●Advice to make position changes slowly.
●Notify MD if: Swelling in the mouth or throat, severe headache or dizziness, cold sweats, SOB, blurred vision.
●Warnings: Do not take alcohol (cause hypotension leading to cardiovascular collapse). Avoid using erectile dysfunction drugs, such as sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra). – May lead to fatal hypotension – contact MD if you have chest pain and you have used this medication.
K-Have the patient on bed rest when taking the medication. Monitor orthostatic BP, pulse. ●Assess pain PQRST, check for tolerance if taken for a long period ●Monitor for H/A, light headedness, decreased BP, may indicate a need for decrease dosage.
HEPARIN
C- Anti-coagulant.
H- No specific time, (post-MI, DVT prevention and PE).
E- Prevention of thrombi or blood clot.
C- Report any S/S of bleeding (bleeding gums, nosebleed, dark red or brown urine, dark colored stool, unusual bruising, vomiting blood (coffee ground), and excessive menstrual bleeding).
●Avoid OTC drugs (especially NSAIDS and ASA)
●Use soft-bristle toothbrush, avoid contact sports, use electric razor, and avoid IM injections.
●Wear an Emergency ID band.
●Avoid saw palmetto, ginkgo, ginseng, and basil etc… increase risk of bleeding.
K- Assess blood studies (Hgb. and Hct, occult blood in the stools) q3months if patient is in long term. Monitor aPTT and platelet count.
●Assess for bleeding gums, petechiae, ecchymosis, black tarry stools, Epistaxis, decrease in Hct, and V/S – notify MD ASAP
●Monitor for hypersensitivity: fever, skin rash, and urticaria.
●For Subq use at least 25-G-3/8 needle, do not massage area or aspirate, do not pull back plunger leave in 10 sec, and apply gentle pressure for 1 min. Give the same time of the day to maintain steady blood levels.
●Protamine sulfate as antidote 1mg/100 units of heparin.
Note: Coumadin and Lovenox is applicable for this CHECK
●Warfarin (Coumadin tab.)– INR and PT – 3-5 days to reach therapeutic concentration - antidote vit. K
●Enoxaparin (Lovenox) – LMWH – Love handles – Less bleeding risk – Less or no monitoring needed (no aPTT monitoring) – Longer half-life (not for emergency), Less shot (once a day) than heparin, Less preparation needed (prefilled) = 8L’s
●S/E apart from bleeding are: Chest pain, pain/blue/dark discoloration of arm or legs, diaphoresis, SOB, fever, rash, hives, body malaise etc…
NITROGLYCERIN PROTOCOL for patients with chest pain!
1. Stop what you are doing and sit down – sometimes rest can help relieve chest pain (angina).
2. Take one nitroglycerin sublingual tablet or spray. Wait 5 minutes.
3. If chest pain (angina) does not go away, take another nitroglycerin sublingual tablet or spray. Wait 5 minutes.
4. If you still have chest pain (angina), act quickly. Call 911 (or your local emergency number) for assistance or go to a hospital emergency department. Do not drive yourself.
5. After you call for emergency help, you can continue taking your third dose if needed. (Take exactly as recommended by your doctor.)
HEPARIN–acts on intrinsic coagulation, increase antithrombin activity and prevents the conversion of fibrinogen to fibrin.
Monitor APTT/PTT.
IWARFARIN (Coumadin) – acts on extrinsic coagulation mechanism. Antagonist of vit. K – Interferes with hepatic synthesis of vit. K clotting factors IX, X, VII and II. INR monitoring is important for dose adjustment.
“BRANDIM” anticoagulant patient teaching
B-lood test monitoring, B-leeding reporting. R-azor electric and soft-bristle toothbrush must be used. A-void ASA, NSAID, antibiotics, and other herbs.
N-o contact sports. D-entist and other health care provider (report that you are in anticoagulant), Diet – low in vit. K. I-M injections is a no no. M-edical alert bracelet must wear at all times.
DIGOXIN(Lanoxin)
C- Cardiac glycoside, inotropic antidysrhythmic (Tx for HF and certain heart rhythm disorder).
H- No specific time (But best taken same time of the day/evening-same with Coumadin).
E- Strengthen the heart, regulate HR, slow HR, and increased CO.
C- Do not take antacids and laxative at the same time (↓absorption) and other OTC medications including cough, cold, and allergy preparation.
●Advise to check pulse 1 min before taking the dose (teach how) (if <60 bpm – notify MD).
●Advise patient to maintain a sodium restricted diet as ordered; and take potassium supplement as ordered to prevent toxicity.
●Avoid prune juice, wheat cereals and food rich in fibers - ↓ absorption.
●Teach patient to notify MD for S/S of digitalis toxicity.
●Take medication at the same time of the day, take missed dose within 12 hours, do not double the dose; notify prescriber if 2 doses are missed/2 days (same teaching for Coumadin).
●Do not take med 6-12 hours before digoxin level test/as per MD instruction.
●Advise patient to always wear a medical alert bracelet. K- Assess and document apical pulse for 1 min before giving the medication, if <60 bpm take it again in 1h if no change notify MD. (Note rate, rhythm, character).
●Monitor electrolytes (especially K and Na).
●Monitor digoxin level (0.5-2 ng/Ml).
●Monitor I&O, weight, lung sounds and edema (HF).
●Assess for signs of digitalis toxicity – Digoxin immune Fab as antidote (DigiFab).
Digoxin toxicity: “BAD BAD Headache”
B-lurred vision (yellow-green vision)
A-norexia
D-rowsiness (+ fatigue and weakness)
B-radycardia (dysrhythmias)
A-bdominal pain
D-iarrhea and Disorientation
Headache + Hypokalemia and Hypomagnesemia