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Ppt chapter 31
1.
Chapter 31 Drugs
Affecting Cardiac Rhythm Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
2.
Physiology • Contractions
of the heart are dependent on the unique electrical conduction system of the cardiac muscle. • The conduction system connects to highly specialized cardiac cells that allow the heart to beat predictably and rhythmically. • The system is composed of the sinoatrial (SA) node, the atrioventricular (AV) node, the bundle of His, the bundle branches, and the Purkinje fibers. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
3.
Physiology (cont.) •
The SA node, influenced by both the sympathetic and the parasympathetic nervous systems, is known as the pacemaker of the heart. • It is important to understand how potassium, sodium, and calcium ions bring about electrical changes in the cardiac cells that stimulate contraction of the cardiac cells. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
4.
Travel of Electrical
Current Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
5.
Electrocardiogram Copyright ©
2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
6.
Movement of Electrolytes
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
7.
Pathophysiology • Arrhythmias,
also called dysrhythmias, are a disturbance in the electrical activity of the heart. • Some arrhythmias are insignificant and do not create any problems for the patient. • Others disrupt the function of the heart, increase the oxygen demand of the heart, and interfere with cardiac output. • Changes in the ionic currents through ion channels of the myocardial cell membrane are the main cause of cardiac arrhythmia. • Ionic changes allow arrhythmias to develop in one of the three ways: through a disorder with impulse formation, through a disorder of the impulse conduction system, or through a combination of both. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
8.
Drugs and Other
Therapies to Treat Arrhythmias • Drug therapy previously was the mainstay for treating arrhythmias; now ICDs are added to that treatment. • ICDs have an established and definitive role in preventing sudden cardiac death. • Arrhythmias can be treated by catheter ablation. • Antiarrhythmics are agents used to prevent, suppress, or treat a disturbance in cardiac rhythm. • The primary outcomes are to decrease automaticity, decrease speed of conduction, and decrease reentry. • When antiarrhythmic drugs were developed, a system of classification was sought in an attempt to organize the complex information into a conceptually meaningful fashion. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
9.
Class I Antiarrhythmic
Drugs • Class I antiarrhythmics are local anesthetics or membrane-stabilizing agents that depress phase 0 in depolarization. • The drugs in subgroups of A, B, and C are not interchangeable because they have different pharmacotherapeutics. • Class IB antiarrhythmics prototype drug: lidocaine (Xylocaine) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
10.
Lidocaine: Core Drug
Knowledge • Pharmacotherapeutics – Treat all acute ventricular arrhythmias. • Pharmacokinetics – Administered: IV. Metabolism: liver. Excreted: kidneys. T1/2: 1.5 to 2 hours • Pharmacodynamics – Decreases automaticity, excitability and membrane responsiveness. Decreases action potential duration and effective refractory period of Purkinje fibers and ventricular muscle Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
11.
Lidocaine: Core Drug
Knowledge (cont.) • Contraindications and precautions – Hypersensitivity, several cardiac conditions, digitalis toxicity, hypovolemia, shock • Adverse effects – Cardiac arrhythmias, hypotension, dizziness, lightheadedness, fatigue, drowsiness • Drug interactions – Many classes of drugs Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
12.
Lidocaine: Core Patient
Variables • Health status – Determine whether the patient has a type of ventricular arrhythmia that is an indication for therapy. • Life span and gender – Pregnancy category B • Environment – Should be given in hospital or emergency setting with continuous ECG monitoring Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
13.
Lidocaine: Nursing Diagnoses
and Outcomes • Decreased Cardiac Output related to cardiac changes secondary to adverse effects of drug therapy – Desired outcome: The patient will not develop deleterious cardiac changes that alter cardiac output. • Risk for Injury, such as hepatic toxicity, related to adverse effects of drug therapy – Desired outcome: The patient will not incur hepatic toxicity while on drug therapy. • Change in level of consciousness related to CNS changes secondary to adverse effects of drug therapy – Desired outcome: The patient will not experience dangerous CNS changes while on therapy. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
14.
Lidocaine: Planning and
Interventions • Maximizing therapeutic effects – After initial (or several) IV push dose of 50 to 100 mg, continuous drip of 1 to 4 mg/minute may be started. • Minimizing adverse effects – Monitor rhythm continuously with ECG. – Notify prescriber immediately of arrhythmias, CNS depression or irritability. – Monitor liver and kidney function tests. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
15.
Lidocaine: Teaching, Assessment,
and Evaluations • Patient and family education – Explain the purpose of the drug and the potential adverse effects. – Explain the rationale for ECG monitoring and frequent blood testing. • Ongoing assessment and evaluation – Monitor the patient’s ECG and pulse throughout Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins therapy. – Check lidocaine blood levels, liver enzymes, renal function, and complete blood counts.
16.
Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Serum levels of lidocaine above ______ are considered toxic. – A. 2 mcg/mL – B. 4 mcg/mL – C. 6 mcg/mL – D. 8 mcg/mL
17.
Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • C. 6 mcg/mL • Rationale: When serum levels of lidocaine are greater than 6 mcg/mL, toxicity is present and the patient is at risk for developing seizures and loss of consciousness.
18.
Class IA Antiarrhythmics
• The class IA drugs are similar to lidocaine (class IB) and class IC drugs because they depress phase 0 (although not as much). • These drugs also may cause arrhythmias in addition to treating them. • Unlike lidocaine, their use in treating life-threatening ventricular arrhythmias has not been shown to improve survival. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
19.
Class IC Antiarrhythmics
• Class IC drugs are flecainide (Tambocor), propafenone (Rythmol), and moricizine. • These drugs depress phase 0 considerably. • They have a slight effect on repolarization and decrease conduction substantially. • Flecainide and propafenone have proarrhythmic effects. • Both of these class IC drugs can be given orally. • Their use has been limited to patients with life-threatening arrhythmias. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
20.
Class II Antiarrhythmic
Drugs • Antiarrhythmic class II drugs (beta blockers) depress phase 4 depolarization. Beta blockers slow heart rate by suppressing the SA node, slow the speed of conduction through the AV node, and decrease the force of contraction. • They effectively reduce mortality in patients who have had a recent MI, those with symptomatic heart failure, and those with congenital long QT syndrome. • Researchers have found that beta blockers are the most effective drugs for controlling the ventricular rate in AFib. • It is important to keep in mind that only some of the beta blockers are approved for use as antiarrhythmics. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
21.
Class III Antiarrhythmic
Drugs • Class III antiarrhythmics produce a prolongation of phase 3 (repolarization). • Action potential duration and refractory periods are prolonged, leading to reduction in membrane excitability of all myocardial tissue. • Prototype drug: amiodarone (Cordarone, Pacerone) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
22.
Amiodarone: Core Drug
Knowledge • Pharmacotherapeutics – Approved for use only in life-threatening arrhythmias • Pharmacokinetics – Absorbed slowly; bioavailability of a single dose of the drug is about 50%. Highly lipid soluble. • Pharmacodynamics – Prolongation of the refractory period, and noncompetitive alpha- and beta-adrenergic inhibition Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
23.
Amiodarone: Core Drug
Knowledge (cont.) • Contraindications and precautions – Severe sinus-node dysfunction, 2nd and 3rd degree Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins AV block • Adverse effects – Pulmonary toxicity, exacerbation of the arrhythmia, and liver disease • Drug interactions – Digoxin, flecainide, and warfarin
24.
Amiodarone: Core Patient
Variables • Health status – Determine cardiac status. • Life span and gender – Safety has not been established in children. • Environment – Assess environment where drug will be given. • Culture and inherited traits – May be genetically related, however, little is known yet about this variation Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
25.
Amiodarone: Nursing Diagnoses
and Outcomes • Decreased Cardiac Output related to cardiac arrhythmia. – Desired outcome: cardiac rhythm will return to normal, allowing for normal cardiac output. • Risk for Injury related to adverse effects of drug therapy – Desired outcome: The patient will not suffer permanent injury or death as a result of drug therapy. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
26.
Amiodarone: Planning and
Interventions • Maximizing therapeutic effects – Administer the prescribed loading doses. – Mix the drug in glass bottles or polyolefin bags. – Use a volumetric infusion pump to prevent underdosage. • Minimizing adverse effects – It is important to correct electrolyte disturbances before beginning therapy. – Use pulse oximetry or arterial blood gases to assess for changes in respiratory function. – Assess for symptoms of visual impairment. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
27.
Amiodarone: Teaching, Assessment,
and Evaluations • Patient and family education – Explain the purpose of the drug and possible adverse effects of the drug. – Emphasize the importance of returning for follow-up blood work and ECGs. – Teach patients to use appropriate protection when out in the sun and to limit sun exposure. • Ongoing assessment and evaluation – The patient’s ECG should be monitored intermittently throughout therapy. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
28.
Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Question • The most serious side effect of amiodarone is – A. Pulmonary toxicity – B. Other arrhythmias – C. Liver disease – D. Seizures
29.
Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • A. Pulmonary toxicity • Rationale: Amiodarone can cause pulmonary toxicity. It is important to monitor lung function during therapy.
30.
Class IV Antiarrhythmic
Drugs • Class IV antiarrhythmics depress phase 4 depolarization and lengthen phases 1 and 2 of repolarization. • Prototype drug: verapamil (Calan) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
31.
Verapamil: Core Drug
Knowledge • Pharmacotherapeutics – Antiarrhythmic for chronic atrial flutter or fibrillation • Pharmacokinetics – Well absorbed after oral administration. Metabolized: liver. Excreted: kidneys • Pharmacodynamics – Inhibits the movement of calcium ions across the cardiac and arterial muscle cell membrane Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
32.
Verapamil: Core Drug
Knowledge (cont.) • Contraindications and precautions – Sick sinus syndrome, 2nd or 3rd degree heart block, and hypotension • Adverse effects – Constipation, dizziness, headache, nausea, hypotension, and peripheral edema • Drug interactions – Several drugs interact with verapamil Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
33.
Verapamil: Core Patient
Variables • Health status – Determine type of arrhythmia the patient has. • Life span and gender – Pregnancy category C • Lifestyle, diet, and habits – Assess alcohol use. • Environment – Assess environment where drug will be given. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
34.
Verapamil: Nursing Diagnoses
and Outcomes • Risk for Constipation related to adverse effects of the drug – Desired outcome: The patient will prevent or minimize constipation by increasing fluid intake and adding fruit and fiber to the diet. • Decreased Cardiac Output related to decreased rate and force of contraction and return to normal rhythm related to therapeutic effects of drug – Desired outcome: The patient’s decreased cardiac output will reduce symptoms of cardiac alterations without developing adverse cardiac effects from drug therapy. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
35.
Verapamil: Planning and
Interventions • Maximizing therapeutic effects – Verify that the IV line is patent before IV administration. – Digoxin may be given with verapamil to achieve the additive effect of slowing at the AV node. • Minimizing adverse effects – IV route; do not dilute it with a sodium lactate. – Do not administer IV verapamil simultaneously with (or within a few hours of) IV beta blockers. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
36.
Verapamil: Teaching, Assessment,
and Evaluations • Patient and family education – Explain the purpose of the drug and its adverse Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins effects. – Stress the importance of adequate fluid intake and dietary fruit and fiber to help prevent constipation. • Ongoing assessment and evaluation – Monitor the patient’s ECG and blood pressure throughout therapy with verapamil. – It is important to monitor liver function periodically to detect elevated serum drug levels.
37.
Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Verapamil is a pregnancy category ____ drug. – A. A – B. B – C. C – D. D – E. X
38.
Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • C. C • Rationale: Verapamil is a pregnancy category C.
39.
Potassium-Removing Resins •
Because hyperkalemia may lead to cardiac arrhythmias, potassium-removing resins are drugs used to prevent arrhythmias from occurring. • These resins bind with potassium and allow it to be excreted. • Prototype drug: sodium polystyrene sulfonate (Kayexalate) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
40.
Sodium Polystyrene Sulfonate:
Core Drug Knowledge • Pharmacotherapeutics – Potassium-removing resin used in treating hyperkalemia. • Pharmacokinetics – The drug is not absorbed systemically and is excreted through the GI tract. • Pharmacodynamics – Releases sodium ions that are replaced with potassium ions. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
41.
Sodium Polystyrene Sulfonate:
Core Drug Knowledge (cont.) • Contraindications and precautions – Use caution when giving this drug to anyone who cannot tolerate a small increase in sodium intake. • Adverse effects – Hypokalemia, other electrolyte imbalances, gastric irritation, anorexia, nausea, vomiting, and constipation • Drug interactions – When administered with nonabsorbable cation-donating antacids and laxatives, such as magnesium hydroxide and aluminum carbonate, systemic alkalosis can occur. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
42.
Sodium Polystyrene Sulfonate:
Core Patient Variables • Health status – Monitor the patient’s serum potassium level. • Life span and gender – Note the patient’s age. • Lifestyle, diet, and habits – Assess dietary history. • Environment – Be aware that sodium polystyrene sulfonate is administered in the hospital. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
43.
Sodium Polystyrene Sulfonate:
Nursing Diagnoses and Outcomes • Risk for Constipation related to adverse effects of drug therapy – Desired outcome: constipation will be prevented by administering sorbitol, orally or rectally, if warranted. • Potential complication: hypokalemia. – Desired outcome: The patient’s potassium level will be lowered only to the normal range. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
44.
Sodium Polystyrene Sulfonate:
Planning and Interventions • Maximizing therapeutic effects – Clear the GI tract with a cleansing enema before administering the drug by enema. – When the drug is administered orally, create a suspension of the powdered formula with water or syrup for greater palatability. • Minimizing adverse effects – If the potassium serum level is severely elevated, use other methods to reduce potassium. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Sodium Polystyrene Sulfonate:
Teaching, Assessment, and Evaluations • Patient and family education – Explain the therapeutic and possible adverse effects of the drug. – Emphasize the importance of repeated blood work to monitor blood electrolyte concentrations. • Ongoing assessment and evaluation – Monitor serum electrolytes throughout therapy. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Sodium polystyrene sulfonate may be administered – A. Enema – B. PO – C. SC – D. IV – E. Both A and B – F. All of the above
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Copyright © 2012
Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • E. Both A and B • Rationale: Sodium polystyrene sulfonate may be given either orally or as an enema.
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