Antineoplastics
Alkylating Agents (Chemotherapy)
Cyclophosphamide (Cytoxan)
Use: Breast cancer, Leukemia, Lymphoma, Hodgkin’s Disease, Multiple myeloma
Contraindications: hypersensitivity, myelosuppression, pregnancy, hodgkin's disease, multiple myeloma
Route: PO, IV
Onset of Action: PO: 7 days
Interactions: Garlic and ginko increase antiplatelet effect. Echinacea decreases effects of immunosuppressive drugs. Ginseng and kava kava alters bleeding times.
MOA: Directly damages DNA (the genetic material in each cell) to keep the cell from reproducing. These drugs work in all phases of the cell cycle.
Advantages: Especially useful for Hodgkins’s disease if resistant to other drug combinations.
Disadvantages: Severe vesicant that can cause tissue necrosis if it infiltrates into the tissues. Can cause long term damage to the bone marrow
SE: Nausea, Vomiting, Diarrhea, Weight loss, Hematuria, Alopecia, Impotence, Sterility, Ovarian fibrosis, Headache, Dizziness
AE: Leukemia, Vesicant: Tissue necrosis, Hemorrhagic cystitis, Cardiotoxicity, Hepatotoxicity
NI: Monitor IV site for extravasation: Cold compresses. Assess need for IV hydration. The client should be well hydrated (2L/day) to prevent hemorrhagic cystitis. Observe for s/s of hematuria. Monitor BUN and creatinine. Avoid direct skin, eye, and mucus membrane contact with drug.
CE: Take medication early in the day to prevent accumulation of drug in the bladder. Report signs of infection. Do not visit anyone who has a respiratory infection Emphasize protective precautions. Rationale for chemotherapy. Teach importance of birth control while receiving therapy.
Plant Alkaloids - Mitotic Inhibitors (Chemotherapy)
Paclitaxel (Taxol)
Use: Breast cancer, Lung cancer, Myelomas, Lymphomas, Leukemias
Contraindications: pregnancy, hypersensitivity
Route: IV
Interactions: Increased bleeding risk with NSAIDS, anticoagulants
MOA: Mitotic inhibitors are often plant alkaloids and other compounds derived from natural products. They work by stopping mitosis in the M phase of the cell cycle but can damage cells in all phases by keeping enzymes from making proteins needed for cell reproduction.
Disadvantages: These medications can cause nerve damage.
SE: Peripheral neuropathy, Bradycardia, Hypotension, Nausea/Vomiting, Diarrhea, Mucositis/stomatitis, Alopecia, Arthralgia
AE: SVT, Neutropenia, Leukopenia, Thrombocytopenia, Anemia, Tissue necrosis, Pulmonary edema
NI: ECG monitoring. Monitor for hypotension. Assess for paresthesias. Premedicate with antiemetics. VS during first. Monitor IV site for extravasation: Apply ice pack.
CE: Report signs of infection: fever, sore throat, flulike symptoms. Report signs of anemia: fatigue, headache, faintness, SOB, irritability. Report bleeding. Bleeding precautions. Avoid vaccinations.
Alpha2-Adrenergic Agonists
Clonidine (Catapres), Methyldopa (Aldomet)
Use: Hypertension, Management of opioid withdrawal
Contraindications: Narrow-angle Glaucoma, Cardiogenic Shock, Dysrhythmias
Route: PO, Transdermal patch (Clonidine)
Onset of Action: Po: 30 mins- 2 hrs
Interactions: Do not give with Beta Blockers – accentuates bradycardia and rebound hypertension of therapy discontinuation.
MOA: Decreases the release of norepinephrine from sympathetic nerves and decreases peripheral adrenergic receptor activation. Produce vasodilation which decreases blood pressure.
Advantages: Methyldopa can be used in PIH
Disadvantages: Can cause sodium and water retention. Often given with diuretics for this reason.
SE: Sedation Dizziness, Headache, Nausea/Vomiting, Urinary retention, Dry mouth
AE: Orthostatic hypotension, Pulmonary edema, Dyspnea
NI: Monitor vital signs, Monitor liver enzymes, I&O, Daily weight
CE: Do not stop abruptly: rebound hypertension can occur. Instruct on how to take BP.
Antidysrhythmic Class Ib
Lidocaine (Xylocaine)
Use: Frequent PVCs; Ventricular tachycardia; Alternative antiarrhythmic agent to amiodarone in the treatment of cardiac arrest secondary to VF or pulseless VT resistant to CPR, cardioversion (after 2 to 3 shocks) and a vasopressor (epinephrine).
Contraindications: Adams-Stokes syndrome, Heart block
Route: IV
Onset of Action: 45-90 seconds
Interactions: Lidocaine toxicity – cimetidine, beta blockers. Increase lidocaine effects – barbiturates, ciprofloxacin.
MOA: Decreases irritability of the heart muscle. Increases electrical stimulation threshold of ventricles, which stabilizes cardiac membrane and decreases automaticity.
Disadvantage: Severe adverse effects from lidocaine toxicity
SE: Headache, Dizziness, Drowsiness, Blurred vision, Phlebitis
AE: Heart block, Seizures, CNS depression, Respiratory depression, Malignant hyperthermia, Lidocaine toxicity
NI: Administer IVP at a rate of 25-50 mg/minute. Monitor lidocaine blood levels. Continuous ECG monitoring. Observe for prolonged PR interval and QRS complex. Have resuscitative equipment readily available. Watch for malignant hyperthermia: tachypnea, tachycardia, changes in BP, increased temperature. Monitor for signs of toxicity (hearing impairment, muscle twitching, confusion, seizures).
CE: About the use of lidocaine. Report signs of toxicity (hearing impairment, muscle twitching, confusion).
Direct Acting Vasodilators
Hydralazine (Apresoline), Nitroprusside (Nipride)
Use: Hypertension, Hypertensive crisis, Severe heart failure, Acute MI with hypertension and persistent chest pain and /or left ventricular failure
Contraindications: Systemic Lupus, Severe tachycardia with heart failure
Route: PO, IV
Onset of Action: PO: 20-30 min, IV: rapid
Interactions: Increase antihypertensive effects: ACE inhibitors, vasodilators, diuretics, alcohol, MAOIs, tricyclic antidepressants, hawthorn.
MOA: Relaxes smooth muscles of the blood vessels, mainly arteries, causing vasodilation. Promotes an increase in blood flow to the brain and kidneys.
Advantages: Nitroprusside is a potent vasodilator that rapidly decreases BP in hypertensive crisis.
Disadvantages: Adverse effects eliminate use of these drugs as drug of choice.
SE: Headache, Dizziness, Hyperglycemia, Sodium and water retention, Peripheral edema
AE: Reflex tachycardia, Hypotension, Rebound hypertension
NI: Monitor vital signs, I&O, glucose. Daily weight. Nitroprusside: Monitor BP frequently with continuous cardiac monitoring.
CE: Purpose of medication. Safety precautions. Move slowly from lying or sitting to standing position.
Anthracyclines (Chemotherapy)
Doxorubicin (Adriamycin)
Use: Breast cancer, Ovarian cancer, Lung cancer, Bladder cancer, Leukemia
Contraindications: pregnancy, severe cardiac disease
Route: IV
Onset of Action: IV: 7-10
Interactions: Calcium channel blockers increase risk of cardiotoxicity. Green tea may enhance effects. Garlic, St John’s wart may decrease effects of chemo.
MOA: These drugs are not like the antibiotics used to treat infections. They work by altering the DNA inside cancer cells to keep them from growing and multiplying. anti-tumor antibiotics that interfere with enzymes involved in DNA replication. These drugs work in all phases of the cell cycle. They are widely used for a variety of cancers.
Disadvantages: Severe cardiotoxic side effects can occur. Potent vesicant. Cannot exceed lifetime dose of 550mg/m2.
SE: stomatitis, anorexia, N/V, diarrhea, rash, alopecia
AE: Vesicant, Esophagitis, Thrombocytopenia, Anemia, Cardiotoxicity, CHF, Anaphylaxis
NI: Give through large bore IV needle. Monitor IV site for extravasation: Apply ice pack. Notify MD.; Dexrazoxan IV. Assess cardiac status.
CE: Signs/symptoms of cardiac dysfunction. Drug causes urine to turn pink or red. Report signs of infection or bleeding. Protective precautions. Do not visit anyone with a respiratory infection.
Plant Alkaloids - Topoisomerase Inhibitor (Chemotherapy)
Topotecan (Hycamtin), Irinotecan (Camptosar, CPT-11)
Use: Leukemia, Lung cancer, Ovarian cancer, GI cancer
Contraindications: Pregnancy, Breastfeeding, Bone marrow depression
Route: PO, IV
Interactions: Increased bleeding risk with NSAIDS, anticoagulants, platelet inhibitors.
MOA: These drugs interfere with enzymes called topoisomerases, which help separate the strands of DNA so they can be copied during the S phase. (Enzymes are proteins that cause chemical reactions in living cells.)
SE: Alopecia, Constipation, Diarrhea, Nausea, Vomiting, Damage peripheral nerve fibers, Motor instability
AE: Leukopenia, Hypersensitivity, Neurotoxicity, Loss of DTRs, Bone marrow suppression
NI: Monitor IV site for extravasation: Apply ice pack. Notify MD.; Assess liver and renal function studies.; Increase fluid intake to 2-3 L/day unless contraindicated.
CE: Rinse mouth 3-4 times/day with water; Brush teeth with soft toothbrush for stomatitis. Teach that total alopecia may occur. Hair grows back but is different in color and texture. Avoid foods with citric acid or hot and rough texture if stomatitis is present. Avoid vaccines, toxoids. Report signs of anemia: fatigue, headache, faintness, SOB, irritability.
Angiotensin-converting Enzyme (ACE) Inhibitors
Captopril (Capoten), Enalapril (Vasotec), Lisinopril (Zestril, Prinivil), Moexipril (Univasc), Ramipril (Altace)
Use: DOC for Heart failure, Hypertension, MI
Contraindications: Do not give during pregnancy
Route: PO, IV
Onset of Action: PO: 1-2 hrs, IV: 15-30 mins
Interactions: Hyperkalemia can result if taken in combination with potassium-sparing diuretics or eating salt substitutes.
MOA: Suppress the Renin Angiotensin System (RAS). Prevents the conversion of Angiotensin I to Angiotensin II. This results in arterial dilation and increased stroke volume. ACE inhibitors block aldosterone so the client loses sodium and water and retains potassium.
Advantages: Effective in treating heart failure.
Disadvantages: African Americans and older adults do not respond to ACE inhibitors with the desired reduction in blood pressure without the addition of a diuretic.
SE: Dizziness; Hyperkalemia; Hypermagnesemia; Fatigue; Headache; Dry, nonproductive cough
AE: Angioedema, Orthostatic hypotension
NI: Monitor BP and HR. Monitor potassium and magnesium levels. Initiate safety precautions.
CE: Rise slowly from lying or sitting to standing position. Safety precautions. Can be administered with food (EXCEPT: Moexipril) Do not use salt substitutes with potassium.
Anti-hypertensive / Beta-Adrenergic Blockers (Beta Blockers
Atenolol (Tenormin) Metoprolol (Lopressor) Propranolol (Inderal) Carvedilol (Coreg)
Use: Hypertension, Angina, Dysrhythmias, MI; Unlabeled Use: Migraines; Tachycardia due to stage fright
Contraindications: 2nd & 3rd degree - Heart block, Cardiogenic shock, Hypotension, Acute Heart Failure, Sinus Bradycardia
Route: PO, IV
Onset of Action: PO - 15 minutes, IV - Immediate
Interactions: Digitalis worsens bradycardia. Other antihypertensives and alcohol worsen htn. NSAIDS, Licorice, ma-haung, ephedra decrease effect of beta blockers causing hypertension. Black cohosh, Hawthorn, Parsley, Goldenseal increase hypotensive effect.
MOA: Blocks beta receptor cells (catecholamines) to decrease vascular resistance, decrease BP, decrease HR, decrease myocardial contractility, decrease workload of the heart, decrease cardiac output, decrease renin release.
Advantages: Well tolerated in low doses.
Disadvantages: African Americans do not respond well to Beta Blockers alone for control of HTN. Use in conjunction with diuretics
SE: Blurred vision, Mental changes, Nasal stuffiness, Photosensitivity, Sexual dysfunction, Fatigue, Weakness, Dizziness, Lethargy, Nausea/ Vomiting, Diarrhea, Headache, Depression, Insomnia
AE: Bradycardia, Hypotension, 2nd & 3rd degree Heart block, Thrombocytopenia, Bronchospasm, Wheezing
NI: Monitor for increased BUN, Creatinine, AST, LDH, Glucose. Do not discontinue abruptly: Rebound HTN, angina, dysrhythmias, MI can result. Monitor BP & pulse. Hold for HR < 60 / min.
CE: Teach how to take radial pulse and BP. Rise slowly to prevent postural hypotension. May cause sexual dysfunction. Report constipation: Eat foods high in fiber.
Direct Vasodilators
Nesiritide (Natrecor)
Use: Acute treatment of heart failure in clients with dyspnea at rest and/or minimal activity.
Contraindications: Valvular stenosis, Cardiomyopathy, Pericardial tamponade
Route: IV
Onset of Action: IV: 15 mins
MOA: A B-type natriuretic peptide, which is normally produced by the ventricular myocardium. It relaxes and dilates blood vessels, lowering blood pressure.
Advantages: Useful for clients decompensating from acute heart failure.
Disadvantages: For short term IV use only: up to 48 hrs. Nephrotoxic.
SE: Headache, Dizziness, Nausea/Vomiting
AE: Hypotension, Irregular HR, Chest pain, Fever, Unusual weakness
NI: Monitor creatinine level. Monitor vital signs, hourly urine output. ECG monitoring. Daily weight. Monitor for allergic reaction (rash, pruritus, laryngeal edema, wheezing).
CE: Purpose of medication. Report s/s of allergic reaction.
Anti-Estrogens (Hormone Therapy)
Tamoxifen (Nolvadex)
Use: Palliative treatment of advanced breast cancer; positive lymph nodes in postmenopausal women
Contraindications: pregnancy, breastfeeding, hypersensitivity
Route: PO
Interactions: Increased risk of bleeding with anticoagulants.
MOA: This male hormone (androgen) promotes regression of tumors by competing with estradiol at estrogen receptor sites. Decreases DNA synthesis. Reduces risk of breast cancer in postmenopausal women.
Advantages: Prevents tumor recurrence in both pre-menopausal and postmenopausal women.
SE: Masculine secondary sexual characteristics, Hot flashes, Irregular menses, Fatigue, Headaches, Impotence, Decreased interest in sexual activity.
AE: Increases risk of developing uterine cancer, Stroke, Pulmonary embolism, Thrombocytopenia
NI: Monitor CBC, platelet count weekly. Monitor for allergic reactions.
CE: Avoid use of St. John’s wart, dong qui, black cohosh. Use nonhormonal contraception during and for 2 months after discontinuing treatment. Notify prescriber of signs of stroke. Increase fluids to 2 liters/day unless contraindicated. Protect from sun.
Platinum Drugs (Chemotherapy)
Cisplatin
Use: Advanced bladder cancer, Metastatic testicular cancer, Metastatic ovarian cancer
Contraindications: Pregnancy, Breastfeeding, Preexisting hearing impairment, Bone marrow suppression
Route: IV
Interactions: ASA, NSAIDS, Alcohol increase bleeding risk. Bumetanide, furosemide increase ototoxicity risk. Loop diuretics increase nephrotoxicity risk.
MOA: Alkylates DNA, RNA; Inhibits enzymes that allow for the synthesis of amino acids in proteins; activity not cell-cycle-phase specific.
Advantages: Less likely to cause leukemia later than alkylating agents.
Disadvantages: Extravasation can occur damaging tissue.
SE: Tinnitus, Blurred vision, Altered color perception, N/V, Diarrhea, Weight loss, Impotence, Amenorrhea, Alopecia
AE: Extravasation, Bone marrow depression, Renal toxicity, Bleeding, Ototoxicity, Seizures
NI: Monitor IV site for extravasation: Sodium Thiosulfate. Cold compresses. Monitor CBC, platelet count weekly. Hold drug for WBC < 4000 or platelet <100,000. Monitor BUN, creatinine. Monitor for signs of anaphylaxis. Monitor temperature q4h Monitor for bleeding. Increase fluid intake to 2-3 L/d to prevent calculi and promote elimination of medication.
CE: Report s/s of infection. Report s/s of anemia. Report bleeding, bruising, petechiae Bleeding precautions. Report decreased urine output/flank pain. Do not receive vaccinations during treatment.
Angiotensin II Receptor Blockers (ARBS)
Losartan (Cozaar), Olmesartan (Benicar), Valsartan (Diovan)
Use: Hypertension, Heart Failure
Contraindications: Pregnancy
Route: PO
Onset of Action: 2 hrs
Interactions: MAOIs, alcohol, diuretics may increase hypotensive effects. ACE inhibitors and ASA may increase hyperkalemia and renal dysfunction.
MOA: Prevent the release of aldosterone. They act on the renin-angiotensin system (RAS). ARBS block angiotensin II from the angiotensin I receptors found in tissue. Potent vasodilator. Decreases peripheral resistance. Decrease the workload of the heart by decreasing afterload. This will increase cardiac output and keep blood moving forward out of the heart.
Advantages: Do not cause the constant, irritating dry cough that ACE inhibitors do.
Disadvantages: Less effective for treating hypertension in African-American clients.
SE: Headache, Dizziness, Drowsiness, GI complaints, Fatigue
AE: Orthostatic hypotension, Hypoglycemia, Hyperkalemia, Renal dysfunction, Angioedema
NI: Monitor BP and HR. Monitor AST, ALT, BUN, Creatinine.
CE: Rise slowly from lying and sitting position to standing position. Safety precautions. Can be taken on empty or full stomach. Do not use salt substitutes.
Calcium Antagonists / Calcium Channel Blockers
Amlodipine (Norvasc), Diltiazem (Cardizem), Ranolazine (Ranexa)
Use: Angina, Hypertension, Dysrhythmias, Migraines, Raynaud’s Disease
Contraindications: Heart Block, Hypotension, Severe heart failure
Route: PO, IV
Onset of Action: PO: 10-30 mins; IV: 3 mins
Interactions: Increased levels of digitalis, theophylline. Decreased effects of lithium. Increased hypotensive effects with grapefruit juice.
MOA: Blocks the calcium channel in the vascular smooth muscle cells. This causes vasodilation of the arterial system to decrease arterial resistance and decrease blood pressure. This decreases afterload, which decreases the workload of the heart. These medications dilate the coronary arteries so more oxygen reaches the heart muscle.
Advantages: Decreases afterload and increases oxygen to the heart muscle. Decreases BP better in African Americans than drugs in other categories.
Disadvantages: Need to reduce dose with known liver disease.
SE: GI upset, Ankle edema, Dermatitis, Flushing, Headache, Dizziness
AE: Bradycardia, Reflex Tachycardia, Heart Block, Hypotension, Dyspnea, Wheezing
NI: Taper dose: Do not discontinue abruptly. Monitor BP, HR – Notify PHCP for HR < 50 or Systolic BP < 90. Monitor for increased AST, ALT, Alk phosphatase, BUN, Creatinine, and cholesterol.
CE: Do not stop taking abruptly. Rise slowly. Increase fluids and fiber to counteract constipation. Teach how to take pulse and BP. Avoid hazardous activities until dizziness is no longer a problem. Avoid grapefruit products. Report chest pain, palpitations, irregular heart rate, swelling of extremities, tremor
Oxygen
Oxygen
Use: Hypoxemia, Severe anemia, Carbon monoxide poisoning, Shock, Heart failure
Contraindications: Use cautiously in clients who have lost hypoxic respiratory drive. However, never deny oxygen to someone who needs it.
Route: NC, Face mask, Non-rebreather face mask, ET, CPAP/BiPAP
MOA: Inadequate oxygenation produces hypoxemia and significant physiologic changes to all body systems, therefor oxygen is a first-line drug for all emergency situations. Oxygen also acts as a potent pulmonary vasodilator and is beneficial for clients in heart failure.
Disadvantages: An FiO2 above 50% for a prolonged period can lead to oxygen toxicity and detrimental effects to the pulmonary system.
SE: Dry or bloody nose, Skin irritation, Morning headaches, Fatigue; ET: mucus plugs, tracheal injury, infection, ET misplacement
AE: Oxygen Toxicity
NI: Make sure that the client’s airway and breathing are adequate to promote optimal oxygenation and ventilation. Monitor pulse oximetry. Optimal oxygen saturation is at or above 94%. Notify primary healthcare provider for oxygen saturation less than 90%.
CE: Purpose of oxygen therapy. Fire risk: Do not smoke or have open flame around oxygen source.
Antimetabolites (Chemotherapy)
5-Fluorouracil (5-FU) (Adrucil), Methotrexate (Rheumatrex)
Use: Leukemias, Breast cancer, Ovarian cancer, Intestinal tract cancer
Contraindications: pregnancy, severe infection
Route: IV, IM
Onset of Action: IV: 1-9 days
Interactions: Cimetidine increases effect of F-FU. Methotrexate: ASA, phenytoin increase toxicity of the drug.
MOA: Interfere with DNA and RNA growth by substituting for the normal building blocks of RNA and DNA. These agents damage cells during the S phase, when the cell’s chromosomes are being copied. Methotrexate acts as a substitute for folic acid, which is needed for the synthesis of proteins and DNA.
Disadvantages: Clients receiving methotrexate must receive leucovorin calcium to “rescue” normal cells from the adverse effects of the drug.
SE: Bone marrow suppression, Stomatitis, Nausea/Vomiting, Anorexia, Alopecia, Rash, Photosensitivity, Erythema, Hematic and renal dysfunction
AE: Bone marrow suppression, Thrombocytopenia, Hemorrhage, Renal failure, Extravasation
NI: Monitor IV site for extravasation: Apply ice pack. Notify MD. Avoid direct skin contact with medication. Administer antiemetic 30-60 minutes before therapy. I&O. Monitor blood counts. Encourage mouth rinses every 2 hours with normal saline.
CE: Report signs of infection. Examine mouth daily/ report signs of stomatitis. Do not visit anyone with a respiratory infection. Use sunscreen when outdoors. Maintain protective precautions. Good oral care with soft toothbrush. Encourage small, frequent meals. Encourage cool, bland foods.
Progestins
Medroxyprogesterone acetate (Depo-Provera), Megestrol acetate (Megace)
Use: Breast cancer, Endometrial carcinoma, Renal cancer, Stimulate appetite
Contraindications: pregnancy, hypersensitivity
Route: PO
MOA: Act by shrinking the cancer tissues. Thought to bring about cell death.
Advantages: Megace stimulates appetite by unknown action.
SE: Mood swings, Insomnia, Depression, Indigestion, Diarrhea, Weight gain, Flatus, Nausea/vomiting
AE: Fluid retention, Thrombotic disorders
NI: Assess PSA levels in men with prostate cancer. Monitor for thrombophlebitis.
CE: Report vaginal bleeding Teach signs of fluid retention. Monitor glucose if diabetic.
Antianginal / Nitrates
Nitroglycerin (Nitrostat, Nitro-Bid) Isosorbide (Isordil)
Use: Angina, MI, Pulmonary edema
Contraindications: Pre-existing Hypertension, Head trauma, Increased ICP, Pericardial tamponade
Route: SL – 1 tab every 5 min. up to 3 doses., Tablet, Spray
Onset of Action: SL /IV – 1-3 min, PO – 20-30 min, Ointment – 20-60 min, Transdermal – 30-60 min
Interactions: Enhance hypotensive effects: Beta blockers, Calcium channel blockers, Vasodilators, Alcohol, Erectile dysfunction meds. May antagonize effects of Heparin: IV nitroglycerin.
MOA: Acts directly on the smooth muscle of venous and arterial blood vessels, causing relaxation and dilation. Dilates coronary arteries. Sublingual administration rapidly absorbs into the internal jugular vein and right atrium. IV nitroglycerin vasodilates the client to decrease afterload which increases cardiac output, so that more blood can be pumped forward.
Advantages: Decreases preload, afterload, and workload of the heart Increases blood flow to heart muscle Reduces myocardial oxygen demand.
SE: Headache, Faintness/Syncope, Nausea/vomiting, Dizziness, Flushing, Palpitations, Diaphoresis, Tolerance, Contact dermatitis with topical
AE: Hypotension Reflex, Tachycardia, Paradoxical Bradycardia, Circulatory Collapse
NI: Monitor Blood pressure. Do not leave client until BP stabilizes. Assess cardiac output. Evaluate pain relief. Safety precautions. Maintain adequate hydration. IV: Use a pump; hold for systolic BP < 100.
CE: Activate EMS if pain unrelieved after taking 1 tab SL or spray. Do not swallow SL nitro. Keep in dark, glass bottle. Do not mix medications in bottle with nitroglycerin. Do not open bottle frequently. Keep dry and cool. May or may not burn or fizz in mouth. Renew every 3-5 months; 2 years of spray.
Cardiac Glycosides
Digoxin (Lanoxin, Digitek)
Use: Heart failure, Atrial fibrillation
Contraindications: Ventricular dysrhythmias, Heart blocks
Route: PO, IV
Onset of Action: PO: 30 min- 2 hrs; IV: 5-30 mins
Interactions: Loop diuretics can cause hypokalemia and dig toxicity. Ginseng may elevate digoxin levels St John’s wort decreases absorption of digoxin. Decrease dig absorption with antacids.
MOA: Promotes increased force of cardiac contraction, cardiac output, and tissue perfusion. Decreases ventricular rate. So heart contraction is stronger, heart rate slows down. This allows more blood to be ejected out of the ventricles in a forward direction.
Disadvantages: Can cause digoxin toxicity. Elderly are more prone to dig toxicity.
SE: headache, dizziness
AE: Dig toxicity: anorexia, n/v, weird arrhythmias, vision changes.; Heart block
NI: Monitor Digoxin level (Normal 0.5-2 ng/mL) Monitor potassium (Low K+ can increase risk for dig toxicity) Monitor apical pulse. Hold dig for HR < 60 bpm in adults. Administer IV dose slowly over 5 minutes. Monitor for signs of dig toxicity: anorexia, nausea/vomiting, weird arrhythmias, vision changes. Antidote: Digoxin immune Fab (Digibind).
CE: Teach client how to take pulse. Teach the signs of dig toxicity.
Phosphodiesterase Inhibitors
Milrinone (Primacor), Inamrinone (Inocor)
Use: Short term management of heart failure
Contraindications: Acute MI, Severe pulmonic valvular disease
Route: IV (no longer than 48-72 hours)
Onset of Action: IV: 2-5 mins
Interactions: Increased effect with other antihypertensives and diuretics.
MOA: Inhibits the enzyme phosphodiesterase, promoting a positive inotropic response and vasodilation. Stroke volume and cardiac output are increased.
Disadvantages: Do to risk of toxicity these medications are generally reserved for clients who do not respond to cardiac glycosides or ACE inhibitors.
SE: Headache, Nausea, Vomiting, Anorexia
AE: Ventricular arrhythmias, Hypotension, Chest pain, Thrombocytopenia
NI: Continuous cardiac monitoring; BP & pulse every 5 minutes; I&O; Daily weight; Monitor electrolytes, liver function
CE: Purpose of medication. Report angina immediately.
Gonadotropin-Releasing Hormone
Leuprolide (Lupron), Goserelin (Zoladex)
Use: Advanced Breast cancer, Prostate cancer
Contraindications: pregnancy, breastfeeding
Route: IM, Sub Q
Onset of Action: IM: 1-2 wks
Interactions: Increased antineoplastic action with megestrol. Black cohosh may interfere with treatment.
MOA: Suppress the secretion of follicle-stimulating hormone and luteinizing hormone from the pituitary gland. Initially an increase in testosterone levels is seen. However, with continued use the pituitary gland becomes insensitive to this stimulation, leading to a reduction in the production of androgens and estrogens.
SE: Memory impairment, Depression, Peripheral edema, Alopecia, Anorexia, Diarrhea, Hot flashes, Impotence, Nausea/vomiting
AE: Seizures, MI, PE, Dysrhythmias, GI bleeding
NI: Assess for increased bone pain. Monitor for allergic reaction.
CE: Notify prescriber if menstruation continues – menstruation should stop. Bone pain should disappear after 1 week. Monitor weight. Report weight gain of > 2 lbs (0.9 kg)/day. How to administer SubQ/IM medication.
Selective Estrogen Receptor Modulators (SERMS)
Raloxifen (Evista), Toremifene (Fareston)
Use: Breast cancer, prophylaxis in postmenopausal women
Contraindications: pregnancy, breastfeeding, hypersensitivity
Route: PO
Interactions: Decrease action of anticoagulants.
MOA: Act like antiestrogens to slow tumor growth, but have fewer side effects than tamoxifen.
Advantages: Fewer side effects than tamoxifen
SE: Insomnia, Depression, Hot flashes, Peripheral edema, N/V, Diarrhea, Dyspepsia, Vaginitis, Weight gain
AE: Stroke, Thromboembolism, Pulmonary embolism
NI: Bone density test at baseline and throughout treatment.
CE: Take calcium supplements, Vitamin D if intake is inadequate. Increase exercise with weights. Report fever, acute migraine, emotional distress.
Antidysrhythmic Class III
Amiodarone (Cordarone)
Use: Used when V-fib and pulseless V-tach are resistant to a vasopressor and defibrillation. Fast arrhythmias.
Contraindications: Cardiogenic shock, 2nd degree heart block, 3rd degree heart block, Iodine allergy
Route: IV, PO
Onset of Action: IV: rapid
Interactions: MAOIs-hyperpyretic crisis, seizures.
MOA: Prolongs duration of action potential and refractory period to decrease heart rate. Decreases peripheral vascular resistance and increases PR and QT intervals. First antiarrhythmic of choice.
Advantages: Very little negative inotropic activity making it advantageous for use in clients with heart failure.
Disadvantages: Potentially serious side effects requiring careful monitoring.
SE: Photophobia, Weakness, Skin discoloration, Tremors, Impaired thinking/reactions
AE: Hypotension, Bradycardia, Difficulty breathing, Wheezing, Chest pain, Light-headed, Vision loss, Jaundice
NI: IV: Continuous ECG monitoring and BP monitoring. PO: Assess BP lying, standing. If systolic BP drops 20 mmHg, hold. Monitor Hepatic studies: AST, ALT, bilirubin.
CE: Do not skip a dose or discontinue abruptly. Do not take with grapefruit juice. Use sunscreen or stay out of sun to prevent burns. Dark glasses may be needed for photophobia.
Catecholamine
Norepinephrine (Levophed)
Use: shock, acute hypotension
Contraindications: Hypersensitivity, Tachy dysrhythmias, Pheochromocytoma, Hypovolemia
Route: IV
Onset of Action: IV: 1-2 mins
Interactions: Increase pressor effect with tricyclics, MAOIs. Decreased norepinephrine action with alpha blockers.
MOA: Potent vasoconstrictor action (alpha-adrenergic effect). It is used in shock states, often when drugs such as dopamine and dobutamine have failed to produce adequate blood pressure. Causes increased contractility and heart rate by acting on beta receptors of the heart.
Disadvantages: Has potential to impair cardiac performance and decrease organ and tissue perfusion.
SE: Headache, Anxiety, Dizziness, Insomnia, Tremor, Palpitations, Nausea/vomiting
AE: Myocardial ischemia/Dysrhythmias, Impaired organ perfusion, Tissue necrosis with extravasation, Cerebral hemorrhage, Anaphylaxis
NI: Correct hypovolemia prior to use. Continuous cardiac monitoring. Precise blood pressure monitoring and HR every 2-3 min. Taper drug slowly as abrupt discontinuation can result in severe hypotension. Monitor IV site for extravasation frequently. If extravasation occurs, inject with phentolamine. I&O.
CE: Reason for drug administration.
Sympathomimetic with Beta Adrenergic activities
Dobutamine (Dobutrex)
Use: shock
Contraindications: Hypersensitivity, Aortic stenosis
Route: IV
Onset of Action: IV: 1-2 mins
Interactions: Increased pressor effect and dysrhythmias with tricyclics, MAOIs.
MOA: The beta1 effects enhance the force of myocardial contraction (positive inotropic effect) and increasing heart rate (positive chronotropic effect). The beta 2 effects produce mild vasodilation.
Advantages: Blood pressure is elevated only through the increase in cardiac output.
SE: Headache, Nausea, Tremors, Anxiety, Dizziness, Fatigue, Palpitations
AE: Dose related: Myocardial ischemia, Tachycardia, Dysrhythmias, Hypotension, Hypertension, Hypokalemia
NI: Correct hypovolemia prior to use. Usual IV dose is 2-20 mcg/kg/min. Administer via electronic infusion pump for precision. Taper gradually to avoid clinical deterioration. Continuous cardiac and blood pressure monitoring. I&O. Monitor vital signs. Assess for signs of myocardial ischemia. Continuous ECG monitoring.
CE: Reason for drug administration