Drug TherapyDrug Therapy Heart Failure Heart Failure
by Pat Woodbery, MSN, ARNPby Pat Woodbery, MSN, ARNP
Heart FailureHeart Failure
Congestive Heart Failure (CHF)Congestive Heart Failure (CHF)– Heart cannot pump enough blood.Heart cannot pump enough blood.
Impaired myocardial contractionImpaired myocardial contraction Impaired filling of ventriclesImpaired filling of ventricles
When CHF occurs When CHF occurs Compensatory MechanismsCompensatory Mechanisms
Increased catacolaminesIncreased catacolamines Increased force of contractionIncreased force of contraction Increase HRIncrease HR Increase vasoconstrictionIncrease vasoconstriction
Heart FunctionHeart Function
AFTERLOAD: Force against AFTERLOAD: Force against which the ventricles eject which the ventricles eject bloodblood
PRELOAD: Blood return to PRELOAD: Blood return to the heart (Diastolic filling the heart (Diastolic filling pressure)pressure)
WORKLOAD: Actual ejection WORKLOAD: Actual ejection
Digoxin (Lanoxin)Digoxin (Lanoxin)
Cardiotonic Effect Cardiotonic Effect – Improvement of cardiac pumpingImprovement of cardiac pumping– Increased emptying of ventriclesIncreased emptying of ventricles– = Increased CARDIAC OUTPUT== Increased CARDIAC OUTPUT=
How Does Digoxin Work?How Does Digoxin Work?
Inhibits cardiac muscle enzymeInhibits cardiac muscle enzyme Na,K-adenosine triphosphataseNa,K-adenosine triphosphatase– Decreased movement of Na out of the myocardial Decreased movement of Na out of the myocardial
cells after contractioncells after contraction– Calcium enters the cell in exchange for sodiumCalcium enters the cell in exchange for sodium– This stimulates more Calcium = activated This stimulates more Calcium = activated
contractile proteinscontractile proteins– Increased myocardial contractilityIncreased myocardial contractility
How Does Digoxin Work?How Does Digoxin Work?
Slows the rate of ventricular Slows the rate of ventricular contractionscontractions– Depresses cardiac conduction Depresses cardiac conduction
tissuestissues– Depresses AV nodeDepresses AV node– Stimulates Vagus NerveStimulates Vagus Nerve
Indications for Use of Indications for Use of DIGOXINDIGOXIN
Heart FailureHeart Failure
Atrial FibrillationAtrial Fibrillation
Atrial FlutterAtrial Flutter
Administration of DigoxinAdministration of Digoxin
ORALORAL Onset 30 minutes to 2 hoursOnset 30 minutes to 2 hours Peak 6 hoursPeak 6 hours
Intravenous (IV)Intravenous (IV) Onset 10-30 minutesOnset 10-30 minutes Peak 1-5 hoursPeak 1-5 hours
DigitalizationDigitalization
Administration of an amount of Digoxin sufficient to Administration of an amount of Digoxin sufficient to produce therapeutic effectsproduce therapeutic effects
Digoxin ToxicityDigoxin Toxicity
Nonspecific Early SymptomsNonspecific Early Symptoms– Anorexia, nausea, confusionAnorexia, nausea, confusion
Signs and Symptoms of Heart DiseaseSigns and Symptoms of Heart Disease– Atrial FibrillationAtrial Fibrillation– Rapid Ventricular RateRapid Ventricular Rate
Rapid Ventricular ResponseRapid Ventricular Response
Diagnosis of Diagnosis of Digoxin ToxicityDigoxin Toxicity
Serum Drug LevelsSerum Drug Levels EKGEKG
Treatment of Treatment of DIGOXIN TOXICITYDIGOXIN TOXICITY
Discontinue DrugDiscontinue Drug
Treat Cardiac ArrhythmiasTreat Cardiac Arrhythmias
Digoxin immune fab (Digibind)Digoxin immune fab (Digibind)
Nursing ActionsNursing Actions
Check Dosing CAREFULLYCheck Dosing CAREFULLY Check Apical PulseCheck Apical Pulse Give with food or after mealsGive with food or after meals Inject slowly (over 5 minutes)Inject slowly (over 5 minutes)
Observe forObserve for Therapeutic Effects Therapeutic EffectsDecreasedDecreased IncreasedIncreased
DyspneaDyspnea Activity ToleranceActivity Tolerance
Heart RateHeart Rate Well BeingWell Being
CyanosisCyanosis
CoughCough
AnxietyAnxiety
EdemaEdema
Antianginal DrugsAntianginal Drugs
Angina PectorisAngina Pectoris
Clinical SyndromeClinical Syndrome
Episodes of Chest PainEpisodes of Chest Pain
Deficit in Myocardial OxygenDeficit in Myocardial Oxygen
Most often caused by Most often caused by atherosclerotic plaquesatherosclerotic plaques
Antianginal DrugsAntianginal Drugs
Decrease Myocardial Decrease Myocardial Demand for OxygenDemand for Oxygen
Increase Blood Supply Increase Blood Supply to Myocardiumto Myocardium
Organic NitratesOrganic NitratesNitroglycerine (Nitrostat SL)Nitroglycerine (Nitrostat SL)
1. Relax Smooth Muscle
2. Produce Vasodilation
3. Decrease Preload
4. Decrease Workload
5. Decrease Afterload
SublingualSublingual– Action 1-3 minutesAction 1-3 minutes– Duration 30-60 minutesDuration 30-60 minutes
Nitroglycerine Nitroglycerine
Client TeachingClient Teaching
Original ContainerOriginal Container Replace every 6 Replace every 6
monthsmonths Headache and Headache and
DizzinessDizziness Avoid OTCAvoid OTC Avoid AlcoholAvoid Alcohol
How to Administer Nitroglycerine?How to Administer Nitroglycerine?
Under tongueUnder tongue Take at first sign of an attackTake at first sign of an attack If no relief in 5 minutes take a If no relief in 5 minutes take a
second SL tabletsecond SL tablet If no relief in 5 minutes take a If no relief in 5 minutes take a
third SL tabletthird SL tablet
Nursing ActionsNursing Actions
Check Blood Pressure and Check Blood Pressure and Heart Rate BEFORE each Heart Rate BEFORE each dosedose
Observe for relief of chest Observe for relief of chest painpain
Observe for hypotension, Observe for hypotension, dizziness, tachycardia, dizziness, tachycardia, headacheheadache
Test QuestionsTest Questions