Question

List the nursing implications and education needs for each of the following categories of medication related to heart failure: o Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) o Beta-adrenergic receptor blockers o Diuretics o Positive inotrope agents o Sympathomimetic agents o Phosphodiesterase inhibitors

Answer 1

Nursing implications and education

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB)

Angiotensin-converting enzyme(ACE) inhibitors help to lower the blood pressure by inhibiting the enzyme which forms angiotensin II, this angiotensin II narrows the blood vessels. Whereas the angiotensin receptor blockers (ARB) blocks the action of angiotensin II by preventing the angiotensin II from binding to its receptor.

Nursing Implications

• Monitor the BP and pulse regularly, as the patient may have hypotension.
• Check the weight of the patient daily
• Maintain a strict intake and urine output chart.
• Check the patient for the sign and symptoms of edema
• Monitor kidney function.
• If the patient is also on any diuretics, then a close observation is required
• Administration of ACE inhibitors can make the patients hypotensive, therefore they should be advised to lie down for 2-4 hours after medication.

Patient Education

• Explain the drug, dose, and timing to the patient
• Advise the patient to avoid drinking and to keep track of the intake of fluids.
• Instruct not to stop the medicine without the physicians' order.
• Patients using ACE inhibitors may have a cough, therefore educate the patient that it is a side effect of the drug.
• Instruct the patient to avoid excessive potassium intake. Example: banana, spinach

Examples of Angiotensin-converting enzyme(ACE) inhibitors:

• Captopril
• Ramipril
• Benazepril
• Fosinopril

Examples of angiotensin receptor blockers (ARB)

• Telmisartan
• Losartan ‘
• Olmesartan
• Valsartan

Beta-adrenergic receptor blockers

Beta-adrenergic blockers lower the blood pressure and heart rate by blocking the neurotransmitters norepinephrine and epinephrine from binding to its receptors.

Nursing implications

• Take a complete and thorough patients history for allergies, respiratory problems, diabetes, etc
• Monitor the heart rate and blood pressure regularly
• Weigh the patient daily
• Maintain an intake and output chart
• Check the laboratory values for BUN, electrolytes, creatinine.

Patient education

• Counsel the patient regarding the drug, dose, and timings
• If the patient is taking metoprolol, instruct the patient to take the drug along with meals.
• Educate the patient regarding the possible side effects
• Instruct the patient to seek medical help if he develops shortness of breath, chest pain, etc.

Examples:

• Propranolol
• Metoprolol

Diuretics

Diuretics lower the blood pressure by increasing the absorption of sodium and water from the renal tubules.

Nursing implications

• Take a complete and thorough patient history.
• Monitor the blood pressure of the patient before and after drug administration.
• Monitor the patient for edema, skin turgor, lung sounds
• Assess the patient for muscle weakness, tingling, numbness, confusion. It can be because of electrolyte imbalance.
• Weigh the patient daily
• Maintain an intake and output chart
• Check the laboratory values for BUN, electrolytes, creatinine.
• Monitor the patients' vision and hearing ( as loop diuretics may be ototoxic and thiazide diuretics along with digoxin can cause visual changes)

Patient education

• Counsel the patient regarding the drug, dose, and timings
• If the patient is taking metoprolol, instruct the patient to take the drug along with meals.
• Educate the patient regarding the possible side effects
• Instruct the patient to consult the physician for the potassium dietary guidelines.
• Counsel the client to use sunscreens to prevent the photosensitive reactions.
• Instruct be patient to seek immediate medical help if a patient has severe muscle cramping, weakness, tingling, dizziness, etc

Examples:

• Furosemide ( loop diuretic)
• Choloropthiszide ( Thiazide diuretic)

Positive inotrope agents

Positive Ionotropes increase the force of muscular contractions of heart by increasing the intracellular calcium and by increasing the receptor protein sensitivity to calcium.

Nursing Implications:

• Assess the patient for contraindications ( hypersensitivity, renal insufficiency, MI)
• Check the patients' weight before starting the medicine. Also, have a thorough physical examination.
• Monitor the patients' vitals regularly.
• Withhold the drug if the heart rate is below 60 bpm, notify the physician
• Auscultate the heart sounds for abnormal rhythm or pattern
• Have a baseline ECG
• Weigh the patient daily
• Maintain an intake and output chart
• Check the laboratory values for BUN, electrolytes, creatinine.
• Monitor the patient serum drug levels( serum digoxin level) and check whether they are within the therapeutic levels

Patient education

• Counsel the patient regarding the drug, dose, and timing
• Do not skip the dose of medicine
• Take the medicine at the same time daily
• Do not take over the counter drugs without the physicians' order
• Report for sudden weight gain( more than 1kg/day)
• Report to the nurse or physician if heart rate comes below 60bpm or above 110 bpm
• To notify if a patient develops anorexia, diarrhea, vomiting, and visual disturbances as it may be a sign of toxicity.

Examples

• Digoxin
• Milirone

Sympathomimetic agents

Sympathomimetic agents are stimulant compounds that mimic the effects of the sympathetic nervous system.

Nursing Implications:

• Assess the patient for contraindications (allergies, pheochromocytoma, fatal arrhythmias)
• Conduct the patients thorough physical examination
• Monitor the patients’ vitals regularly.
• Auscultate the lung for adventitious sounds to know the effect of drugs on bronchi
• Monitor the breathing pattern of the patient
• Have a baseline ECG
• Weigh the patient daily
• Maintain an intake and output chart
• Check the laboratory values for BUN, electrolytes, creatinine.

Patient education

• Counsel the patient regarding the drug, dose, and timing
• Do not skip the dose of medicine
• Do not take over the counter drugs without the physicians' order
• Instruct the client to report if he develops bleeding through the nasal cavity
• To seek immediate medical attention if the patient develops shortness of breath, dizziness, palpitation, etc

Examples

• Amphetamines
• Ephedrines

Phosphodiesterase inhibitors

These drugs inhibit the Phosphodiesterase enzyme. These drugs cause pulmonary vasodilation and also penile smooth muscle relaxation.

Nursing Implications

• Assess the patients cardiovascular status
• Monitor heart rate and blood pressure regularly.
• Monitor for sign and symptoms of angina
• Conduct baseline laboratory check-up
• Monitor LFT periodically

Patient education

• Counsel the patient regarding the drug, dose, and timing
• Avoid the excessive use of alcohol
• Do not take more than one tablet a day
• To notify the physician if the patient develops chest pain, shortness of breath, dizziness, etc

Example

• Revatio
• Adcirca