Quote from Gramea
I am preparing to teach a Critical Care Course to new graduate nurses and experienced nurses changing to the critical care field. I am struggling with an interesting way to teach cardiac medications. I am looking for possible games or interactive ideas to reinforce my teaching points that keep the students interested. Thanks for your help.
A few ideas:
"MONA" greets everyone at the door.
a. Oxygen at 4 L/min
b. Aspirin 160-325 mg (crushed or chewed)--antiplatelet action
c. Nitroglycerin SL or spray--if BP > 90
d. Morphine IV (2-4mg q5 min)--if pain not relieved with NTG
Pressor: something which causes the blood pressure to go up
Alpha pressor: pressorizes the arteries
Beta pressor: heart or lungs
ONE heart: Beta1
TWO lungs: Beta2
Alpha pressors tighten up the arteries by stimulating the alpha receptors in the arteries.
Beta pressors stimulate the beta1 receptors in the heart. This increases both heart rate and inotropy (contractility), which increases cardiac output and hopefully blood pressure.
Nice up-to-date index of cardiac drugs:
Great website for creating interactive classroom strategies:
Discovery School's Puzzlemaker (great resource!!):
My personal organization of cardiac medications for my lecture:
Angiotensin-convering enzyme (ACE) inhibitors: Inhibits the angiotensin-converting enzyme that converts angiotensin I to angiotensin II; decreases afterload and blood pressure. Acts as a vasodilator.
Indications: Mild to severe hypertension; treatment of heart failure.
Given within 48 hours of an MI to prevent ventricular remodeling and the development of heart failure. Increase survival rate after an MI.
Monitor for hypotension, cough, hypokalemia; increased creatinine & BUN.
Examples: enalapril (Vasotec); lisinopril (Zestril); captropril (Capoten)
Antibiotic prophylaxis: Antibiotics taken before a surgical or dental procedure to prevent infection (especially of valves of the heart).
Antithrombotic agents¾Prevent the formation of new blood clots (thrombus) and keep existing blood clots from growing larger by decreasing the coagulability (fibrin system) of the blood. Does not dissolve existing clots. Contraindicated in persons with active bleeding.
Heparin: Inhibits thrombin and other coagulation enzymes; affects PTT value.
- Antidote the nurse should have on hand: protamine sulfate
- Oral anticoagulant started 3-5 days before I.V. infusion discontinued.
- Watch for bleeding.
Coumadin: Interferes with vitamin K-dependent coagulation factors; affects PT/ INR values.
- Action is cumulative and more prolonged than heparin
- Should be taken at the same time each day.
- Dose is adjusted to maintain a PT/ INR 2-3 X the control
- Antidote: Vitamin K
- Watch for bleeding
Antiplatelet agents/ platelet-aggregation inhibitors: Make the platelets less sticky so they won't adhere to the fibrin mesh. Contraindicated in persons with active bleeding. Does not dissolve existing clots.
Monitor for bleeding.
Examples: Aspirin; Plavix (Clopidogrel); Ticlid; ReoPro, Integrilin, Aggrastat
Thrombolytics (clot-busting drugs): Degrade fibrin threads already present in the formed blood clot by activating plasminogen to plasmin. Used to dissolve thrombi in the coronary arteries and restore myocardial blood flow during the first 6 hours of an MI ("Time = muscle").
Contraindications: active internal bleeding; recent stroke, surgery, or trauma; severe hypertension; pregnancy
Examples: Retavase, TNKase (tenecteplase), t-PA (tissue plasminogen activator), streptokinase
Antidysrhythmics: Treatment for abnormal electrical activity of the heart (atrial and ventricular dysrhythmias). Divided into several different classes.
Monitor: heart rate and rhythm; hypotension.
Examples: Amiodarone; lidocaine; quinidine; procainamide
Antilipid medications: Help to lower circulating lipid and LDL cholesterol levels. Initiate only after diet and other non-pharmacologic therapies have proven ineffective.
Monitor for muscle weakness (statins); GI disturbances.
Examples: Lovastatin (Mevachor), simvastatin (Zocor), atorvastatin (Lipitor); Niacin; Questran; gemfibrozil (Lopid).
Statins: lower cholesterol by blocking enzymes that are essential to the production of cholesterol in the body.
Rare side effect: rhabdomyolysis (upper arm and muscle weakness)
Beta blockers: Block the beta1 adrenergic receptors in the heart. Block catecholamine-induced increases in heart rate, blood pressure, and force of contraction. (Prolonged exposure to catecholamines stresses the heart and worsens cardiac function.) Beta blockers slow the heart rate and decrease blood pressure; prolong diastole and increase myocardial perfusion while reducing the force of myocardial contraction (decrease myocardial O2 demand).
Indications: Mild to moderate hypertension; moderate to severe angina; post-myocardial infarction (Beta-blockers decrease the size of the infarct, ventricular dysrhythmias, and mortality rates in clients with MI.)
Monitor: heart rate and rhythm; blood pressure
Examples: Metoprolol (Lopressor); atenolol (Tenormin); carvedilol (Coreg)
Adverse effects: Fatigue, lethargy; impotence; wheezing, dyspnea, heart failure; contraindicated in bronchial asthma
Calcium Channel Blockers: Inhibit the influx of calcium through the cardiac and vascular smooth muscle cells, causing dilatation of peripheral and coronary arteries. Enhance vasodilation and myocardial perfusion; decrease afterload.
Indications: Angina; mild to moderate hypertension; dysrhythmias. Not indicated after an MI.
Monitor: heart rate and rhythm; blood pressure
Examples: Diltiazem (Cardizem), verapamil (Calan)
Diuretics: Promote excretion of water.
Used to reduce preload.
Examples: Lasix, Demadex, Edecrin, and Hydrocholorothiazide.
Administer Lasix IVP: 10 mg/ minute
Adverse effects: K+, Mg++ depletion and dehydration.
Monitor: I & O, electrolytes (especially K+), BUN/creatinine levels.
Low K+ level will potentiate the action of Digoxin and place the patient at risk for Digoxin toxicity.
Potassium Sparing Diuretics - Inhibit aldosterone, cause Na+ to be excreted in exchange for K+. Spironolactone (Aldactone).
(Positive) inotropic agents: Increase force of myocardial contraction.
Digoxin (cardiac glycosides): Makes the heart beat slower, more regular and more powerful, which allows time for the ventricles to relax for better filling (increased diastolic filling).
Result: increased cardiac output and increased blood flow to the kidneys.
Adverse effects (digitalis toxicity): anorexia, N & V, visual disturbances, lethargy, bradycardia, heart block, tachydysrhythmias.
Take apical heart rate for one full minute before administering, noting rate and rhythm.
Monitor digoxin levels for toxicity: Dig has a narrow therapeutic window: 0.8-2.0 ng/ml.
Monitor potassium levels: Persons with hypokalemia are more likely to become dig-toxic so patient needs to eat foods high in potassium; Patients on Lasix and Dig - watch for toxicity.
Digoxin Immune Fab (Digibind) is antidote for Digitalis toxicity.
Sympathomimetic drugs: Stimulates beta1 receptors in the heart. Direct-acting cardiac stimulant.
Dobutamine: Stimulates beta1 receptors, increasing cardiac contractility, CO, and SV, with minor effects on HR.
Dopamine: Immediate precursor of epinephrine in the body. Produces direct stimulation of beta1 receptors and variable (dose-dependent) stimulation of alpha receptors (peripheral vasoconstriction). At low doses, increases blood flow to the kidneys.
Epinephrine: Causes marked stimulation of alpha, beta1, and beta2 receptors, causing cardiac stimulation, bronchodilation, and decongestion.
Digoxin Fab (Digibind)
Use: life-threatening digoxin toxicity
Mechanism: antibody complex formation to digoxin
Adverse events: Exacerbation of heart failure or a-fib due to withdrawal of digoxin; potential for complex dissociation with repeat toxicity in end-stage renal disease, hypersensitivity; digoxin levels meaningless for 7 days post Digibind use.
Morphine: For relief of chest discomfort unresponsive to nitroglycerin.
Relieves MI pain, decreases myocardial oxygen demand, reduces circulating catecholamines, reduces preload.
Adverse reactions: respiratory depression, hypotension, vomiting.
Potassium supplements: Maintains acid-base balance and electrophysiologic characteristics of the cell. Contraction of cardiac, skeletal, and smooth muscle.
Indications: Treatment of potassium depletion which may be caused by other medications or medical conditions.
Adverse reactions: Nausea, vomiting, stomach cramps (can be reduced by giving with food); tingling of hands, feet; confusion; unusual tiredness or weakness; heaviness or weakness of legs (contact doctor).
Nitrates (Vasodilators): Increases coronary blood flow by dilating coronary arteries and improving blood flow to ischemic regions of the heart. Also decreases preload by dilating peripheral veins.
Variety of routes: SL, IV, PO, TD
Used for angina, hypertension, MI, CHF.
Short-acting nitrates: Nitroglycerin: For acute anginal attacks. SL dosage (0.4mg):
- Instruct patient to lie down
- Repeat at 5 minute intervals; if pain not relieved, up to 3 tablets
- If anginal pain persists after 3 doses, call doctor or go to nearest ER
- Stay with patient and monitor VS (especially BP)
- Headache and hypotension are major side effects
Long-acting nitrates: Isordil, nitroglycerin ointment, nitroglycerin transdermal patch
- Non-hairy surface for patch
- Ointment: use appropriate application paper; don't "rub in"
- Rotate sites (remove old patch, ointments)
- Avoid contact to your skin
- Nitrate-free periods (6 - 10 hrs/ 24 hr period) to prevent tolerance
- Remove patch before defibrillating as patch may explode