CARDIOVASCULAR SYSTME MEDICATIONS

INTRODUCTION
- The carsoivascular system is responsible for delivering oxygen and nutrients
to all of the cells in the body and for removing waste products for excretion
- It consistes of the a pump, the heart and a series of interconnected tubes that
consinually move the blood throughout the body

I. ANTIHYPERTENSIVE AGENTS

BLOOD PRESSURE CONTROL

- Blood flows from areas with higher pressure to areas with lower
pressure
- The area of highest pressure in the system is always the left ventricle
during the systole. The pressure from this area propels the blood out of
the heart to the aorta and into the systmeic circulation
- The lowest pressure is in the right atrium, which collects deoxygenated
blood rfom the body
- If the pressure bocomes too high, the perosn is said to become
hypertensive
- If the pressure cannot be delivered effectively, the person is said to be
hypotensive
- The pressure in the cardiovascular system is determined by 3 elements:
• Heart rate
• Stroke volume: amount of blood that is pump out of the ventricle
with each heartbeat
• Total peripheral resistance: the resistance of the muscular
arteries to the blood being pumped through
- Arterioles determine peripheral resistance ; they are very
responsive to stimulation of the SNS and constrict when
stimulated increasing total prepheral resistance and blood
pressure
- Baroreceptors:
• As the blood leaves the ventricle through the aorta, it
influences speciallized cells in the aorta called baroreceptors
• Similar cells are located in the carotid arteries, which
deliver blood to the brain
• If there is sufficient pressure in these vessles, the
baroreceptors are stimulated, sendnig information to the
brain
• If the pressure falls, the stimulation if the baroreceptors
fall of and that information is sent to the brain
• The sensory input from the baroreceptors is received in
the medulla, in th earea called the cardiovascular center or
vasomotor center
• If the pressure is too high, the medulla stimulates
vasodilation and decrease cardiac rate and output, causing
blood pressure systme to drop
• If the pressure is low, the medulla directly stimulates an
increase in cardiac rate and output and vasoconstriction; this
increases peripheral resistance and raises the blood pressure
- Renin Angiotensin System:
• Compensatory mechanism which is activated when the blood
pressure in the kidney falls = the system is called renin-
angiotensin-aldosterone system
• Release of renin is stimulated by:
______________________________________________________________
______________________________________________________________
____________

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 • Renin is released into the blood stream and arrives in the liver
to convert angiotensinogen to angiotensin I. Angiotensin I
travels the bloodstream and arrives in the lungs and it will be
converted Angiotensin II by Angiotensin Converting Enzyme
(ACE). Angiotensin II reacts with angiotensin II receptor sites
in the blood vessels and causes vasoconstriction. This will
raise total preipheral resistance leading to an increase in
blood pressure. Angiotensin II also stimulates the adrenal
cortex to release aldosterone. Aldosterone acts on the
nephrons to cause sodium and water retention. This effect will
increase the blood volume, increasing the cardiac output and
then lead to an increase in blood pressure. The sodium rich
blood also stimulates the osmotic receptors in the
hypothalamus to cuase the release of ADH which in turn
causes water retnetion contributing to the further rise blood
volume.
- Hypertension:
• Is also known as high blood pressure
• It is defined as persistent systolic pressure of >/= 140
mmHg, diastolic pressure of >/= 90 mmHg or current use
of antihypertensive medication
• Epidemic rate world wide is upto 1 billion people
• Causes: idiopathic (type 1), increased SNS activity,
overproduction of sodium retaining hormones, increased
sodium intake, greater than ideal body weight, diabetes
mellitus, excessive alcohol consumption, renal disorders,
liver disorder, endocrine disorders, brain tumors,
medications and cardiac disorders
- Hypotension:
• Is low blood pressure
• It can progress to shock
• Can occur in the following situations:
a. ________________________________________________________
b. ________________________________________________________
c. When there is extreme stress and the body’s
borepinephrine is depleted leaving the body unabale to
respond to stimuli to raise the blood pressure
- The Seventh Joint National Committee on Prevention,
Detection, Evaluation and Treatment of Hypertension, from the
National Institute os Health has established a stepped care
approach to treating hypertension:
a. Step 1: Lifestyle Modifications
Weight reduction, reduction of sodium intake,
moderation of alcohol intake, smoking
ceassation, increase physical activity
b. Step 2: Inadequate Response
Continue lifestyle modifications
Initial drug selection:
1. Diuretic or beta blocker
2. ACE inhibitor, calcium channel
blocker, alpha blocker, alpha and beta
adrenergic blocker
c. Step 3: Inadequate Response
Increase the dose or
Subtitute another drug or
Add another drug from another classification
d. Step 4: Inadequate Response
Add a second or third agent or diuretic if not
already prescribed

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 A. Angiotensin Converting Enzyme Inhibitor (ACEI)

Sample Medictions:
Indicated for:
a. Hypertension only
benazepril (Lotensin), moexipril (Univasc), perindopril (Aceon)
b. Hypertension and CHF
ramipril (Altace), fosinopril(Monopril), quinapril (Accupril)
c. Hypertension, CHF and Myocardial Infarction
captopril (Capoten) also used for Diabetic nephropathy,
enalapril (Vasotec), trandolapril (Mavik), lisinopril (Prinivil),
Action: ACE inhibitors prevent angiotensin-converting enzyme from converting
angiotensin I to
Angiotensin II, a powerful vasoconstrictor and stimulator of aldosterone release.
This action leads to
A decrease in blood pressure and in aldosterone secretion with a resultant slight
increase in serum
Potassium and a loss in serum sodium and fluid.
Contraindication and caution:
• Allergy
• Impaired renal function
• Pregnancy and lactation
Caution with:
• CHF because a change in hemodynamics could be detrimental in some
cases
• Salt volume depletion
Adverse effects:
Common: those associated with vasodilations and alterations in blood flow such
as reflex tachycardia, chest pain, angina, CHF, cardiac arrhythmias
GI: irritation, ulcers, constipation, liver injury, renal insufficiency, rash alopecia,
dermatitis, photosensitivity
hypotension, dizziness, lightheadedness, cough, difficulty breathing, swelling of
the feet, hands or face, palpitations
Nursing Responsibilities:
 __________________________________________________________________________
____
 _________________________________________________________________________ (
food decreases absorption of ACE inhibitors)
 Alert the surgeon and mark the patient’s chart if he is about to undergo
surgery to alert medical staff that the blockade of compensatory
angiotensin II could result in hypotension after surgery and that it could
be reversed through voume expansion
 Give parenteral forms only if an oral form is not feasible; transfer to an
oral form as soon as possible to avert increased adverse reactions
 Consult with prescriber to reduce dose if patient has renal damage, to
account for their lower than normal production of renin and angiotensin II
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions
 There is an increased risk of hypersensitivity reaction if these drugs are
taken with allopurinol.
 Monitor the blood pressure before and after giving the drug.
 Be alert for situations that might lead to a drop in blood pressure like
excessive sweating, vomiting, diarrhea and dehydration.
 Educate patients that they may experience dry cough that does not
subside until the drug therapy is discontinued.

B. _________________________________ (ARB)

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 Sample Medications and their Indications:
a. Hypertension
valsartan (Diovan) candesartan (Atacand), telmisartan (Micardis),
eprosartan (Teveten)
b. Hypertension and diabetic nephropathy
Losartan (Cozaar), irbesartan (Avapro),
Action:
________________________________________________________________________________
__
Contraindications and cautions:
• Allergy, pregnancy and lactation
• Caution: hepatic and reanl dysfunction and patients with hypovolemia
Adverse effects: headache, dizziness, syncope, and weakness which could be
associated with a drop in the blood pressure; abdominal pain, nausea, dry
mouth, tooth pain, symptoms of upper respiratory tract infection, cough, rash
dry skin alopecia and preclinical trials have been associated with cancer
development
Nursing Responsibilities:
 Encourage the patient to implement lifestyle changes including weight
loss, smoking cessation, decreased alcohol and salt in the diet
 Alert the surgeon and mark the patient’s chart if he is about to undergo
surgery to alert medical staff that the blockade of compensatory
angiotensin II could result in hypotension after surgery and that it could
be reversed through voume expansion
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions,
appropriate skin care
 Monitor the blood pressure before and after giving the drug.
 Administer without regards to meals.
 Be alert for situations that might lead to a drop in blood pressure like
excessive sweating, vomiting, diarrhea and dehydration.
 Ensure that female patient is not pregnant before beginning of therapy
and suggest use of barrire contraceptive while taking this drug
 Find alternative method of feeding the baby if nursing
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation

C. _________________________________ (CCB)

Amlodipine (Norvasc), diltiazem (Cardizem), felodipine (Plendil), nicardipine

(Cardene), nifedipine (Procadia, Calcibloc), verapamil (Isupten)
Action: Inhibit the movement of calcium ions across the membranes of
myocardial and arterial
Muscle cells, altering the action potential and blocking muscle cell contraction.
This effect will depress
Myocardial contractility, slow cardiac impulse formation and relax and dilate
arteries.
Indication:
Contraindications and caution:
Presence of allergy, heart block, sick sinus syndrome, hepatic and renal
disorders and pregnancy and lactation
Adverse effects:
Relate to their effects on cardiac output and on smoth muscle
dizziness, lightheadedness, headache and fatigue, hypotension, bradycardia,
peripheral edema, and heart block, skin flushing and rash

D. ____________________________
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 Nitroprusside (Nitropress), diazoxide (Hyperstat), , hydralazine (Apresoline),
minoxidil (Loniten),
Action: Act directly on vascular smooth muscles to cause muscle relaxation,
leading to vasodilation and a
Drop in blood pressure.
Indication: severe hypertension
Minoxidil: severe hypertension that has not responded to other
therapy
Nitroprusside (Nitropress) __________________________
Contraindications and cautions:
• Pregnancy, allergy and lactation
• Caution: peripheral vascular disease, CAD CHF, tachycardia
Adverse effects:
Changes in blood pressure: dizziness, anxiety, headache, reflex tachycardia,
abnormal hair growth with minoxidil.
GI: upset, nasusea and vomiting
Cyanide toxicity: dyspnea, headache, vomiting, dizziness, ataxia, loos of
consciousness, dilated pupils, pink color, distant heart sounds, shallow
breathing, hypothyroidism – associated with nitropusside
Nursing Responsibilities:
 Be alert for signs of cyanide toxicity with intake of nitroprusside such as
dyspnea, headache, vomiting, dizziness, dilated pupils, pink color, distant
heart sounds (metabolized to cyanide
o And also suppresses iodine uptake and can cause hypothyroidism)
 Monitor blood pressure closely during administration to evaluate for
effectiveness and to
o Ensure quick response if blood pressure falls rapidly or too low.
 Minoxidil increases the heart rate, notify the physician if the HR is 20
beats above the normal.
 Nitroprusside and diazoxide are used to treat patients a hypertensive
emergency.
 Nitroprusside infusion bottles are wrapped in aluminium foil or other
opaque material to protect the drug from light. If protected from light, it
remains stable for up to 24 hours.
 Encourage the patient to implement lifestyle changes including weight
loss, smoking cessation, decreased alcohol and salt in the diet
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions,
appropriate skin care
 Monitor the blood pressure before and after giving the drug.
 Be alert for situations that might lead to a drop in blood pressure like
excessive sweating, vomiting, diarrhea and dehydration.
 Monitor electrolyte levels
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation

E. DIURETICS
- Will be discussed in detail in drugs that affects that renal system
- Increase the excretion of sodium and water
- Often the first agents given for mild hypertension
F. BETA BLOCKERS (-olols)
- Block vasoconstriction, increases the heart rate and cardiac muscle contraction
which increases the blood flow to the kidney to decrease the release of renin.
- Atenolol, metoprolol, nadolol, propanolol
G. ALPHA ADRENERGIC BLOCKERS (-zosins)
- Decrease sympathetic tone in the vasculature and cause vasodilation leading to a

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 decrease in the blood pressure
- Prazosin, terazosin,
NURSING RESPONSIBILITIES FOR ANTIHYPERTENSIVE DRUGS:
1. Before therapy with antihypertensive drugs, obtain blood pressure and pulse rate
on both arms with the patient standing, sitting and lying.
2. The blood pressure and pulse rate must be obtained immediately before each drug
administration and compared with previous readings. If blood pressure is
significantly low from baseline values, the nurse should not give the drug but
should notify the physician.
3. Obtain daily weights because of sodium and water retention. Examine the
extremities for edema. Report a weight gain of 2 lbs or more per day.
4. If postural hypotension occurs, the nurse advises the patient to rise slowly from a
sitting or lying position.
5. Advise pt. Not to discontinue the drug. These drugs control but do not cure
hypertension. Skipping doses of the drug or discontinuation may cause severe,
rebound hypertension.
6. The nurse educates the patient about lifestyle modifications to manage
hypertension.

II. ANTIHYPOTENSIVE AGENTS

- See entry on sympathomimetic (dobutamine, dopamine,
ephedrine, epinephrine, isoproterenol, midodrine)

III. CARDIOTONIC AGENTS

- Affect the intracellular calcium levels in the heart muscles
leading to increased contractility
- Increase in contraction leads to incareased cardiac output which
causes increased renal blood flowand increased urine production
- Increased renal blood flow also decreases renin release leading
to decreased blood volume
- This is generally indicated to patients with CHF, a disorder which
the heart fails to pump blood around the body effectively

A. _____________________________

• Originally derived from the digitalis plant

• Digoxin (Lanoxin), digitoxin (Crystodigin)
Action: increase intracellular calcium and allow more calcium to enter
myocardial cells during depolarization, causing the following effects:
1. Increased force of myocardial contraction (a positive inotrope effect)
2. Increased cardiac output and renal perfusion (which has a diuretic effect,
increasing urine output and decreasing blood volume while decreasing
the activation of the RAA mechanism)
3. Slowed heart rate by slowing the rate of cellular repolarization (a
negative chronotropic effect)
4. Decreased conduction velocity through the AV node
The over-all effect is a decrease in myocardial workload and relief of CHF.
Indications: treatment of CHF, atrial flutter, atrial fibrillation and paroxysmal
atrial tachycardia
Adverse effects: headache, weakness, drowsiness and vision changes (a yellow
halo around objects is often reported with digoxin toxicity), bradycardia,
anorexia. GI upset and anorexia also commonly occur.
Contraindications and caution:
• Allergy, ventricular tachycardia, fibrillation, idiopathic hypertrophic
subaortic stenosis, electrolyte abnormalities
• Caution in pregnancy and lactation

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 Nursing Responsibilities:
 Consult with the prescriber about the need for a loading dose when
beginning therapy.
 Check the dosage and preparation carefully because it has a small
margin of safety
 Check pediatric dosage with extreme care
 Follow dilution instructions carefully for intravenous route
 Monitor apical pulse for 1 full minute before administering the drug. Hold
the dose if pulse is less than 60 in adults or less than 90 in infants; retake
pulse in 1 hour.
 Administer IV doses very slowly over at least 5 minutes. Avoid IM
because it could be quite painful
 Avoid administering the oral drug with food or antacids to avoid delays in
absorption.
 Monitor the patient for therapeutic digoxin level 0.5-2 ng/ml.
 Severe toxicity with digoxin is treated with digoxin immune fab
(Digibind).
 Avoid hypokalemia. Hypokalemia makes the heart muscle more sensitive
to digitalis, increasing the possibility of developing digitalis toxicity.
 Arrange to weigh ddaily at the same time each day wearing the same
clothes
 Maintain emergency equipment on standby: potassium salts, lidocaine,
phenytoin, atropine and cardiac monitor
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation
 Offer support and encouragement

B. Phosphodiesterase Inhibitors

• Sample Medications:
Action: block the enzyme phosphodiesterase; this blocking effect lead to an
increase in myocardial cell cAMP, which increases calcium levels in the cell.
Increased cellular calcium causes a stronger contraction and prolongs the
effects of sympathetic stimulation which leads to vasodilation, increased
oxygen consumption and arrhythmias
Indications: short-term treatment of CHFnot responsive to digoxin, diuretics, or
vasodilators
Contraindications and cautions:
• Allergy to bisulfites
• Aortic or pulmonic valvular disease, acute MI, fluid volume deficit,
ventricular arrhthmias
• Caution in elderly, pregnant and lactating women
Adverse effects:
Ventricular arrhythmias (which can progress to fatal ventricular
fibrillation)hypotension and chest pain, nausea, , vomiting, anorexia and
abdominal pain, thrombocytopenia, hypersensitivity reactoins including
vasculitis, pericarditis, pleuritis, and ascitis
Nursing Responsibilities:
 Protect the drug from light to prevent drug degradation.
 Monitor pulse and blood pressure periodically during administration.
 Monitor input and output and record daily weights to evaluate resolution
of CHF.
 Monitor platelet counts prior to and regularly during therapy.
 Monitor injection sites and provide comfort measures. Infusions are

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 painful
 Provide life support equipment on standyb in case of severe reaction
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation
 Offer support and encouragement

IV. ANTIARRHYTHMIC AGENTS / Antiarrhythmics

Automaticity of the Heart

- All cardiac cells poses some sort of automaticity
- These cels undergo spontaneous depolarization during diastole or rest
because they decrease the flow of potassium ions out of the cells and
probable leak of sodium into the cell causing action potential
- 5 phases of action potential:
1. Phase 0: occurs whne the cell reaches a point of stimulation.
The sodium gates open and sodium rushes into the cell. This positive
flow of electrons into the cells results in an electrical potential. This
is called depolarization
2. Phase 1: is a very short period where in the sodium ions equalizes in
and ouside of the cell
3. Phase 2: or plateau stage, occurs as the cell membranes become
less permeable to sodium and calcium slowly enters and potassium
begins to leave the cell.
4. Phase 3: is a time of rapid repolarization as sodium gates are closed
and potassium leaves the cell
5. Phase 4: occursr when the cell comes to rest, the sodium potassium
pump returns the membrane into its resting membrane potential
and spontaneous depolarization begins
- Arrhythmias or dyrrhthmias are alterations in the cardiac rhythm
possibly due to electrolyte imbalances, decrease oxygen delivery to
cells, structural damage, acidosis
A. Class I Antiarrhythmics

Class Ia drugs:
- ____________, _______________, disopyramide, moricizine
Class Ib drugs:
- lidocaine (Xylocaine), mexilitine
Class Ic drugs
- flecainide (Tambocor), propafenone (Rythmol)
Action: Stabilize the cell membrane of cardiac muscles by binding to sodium
channels, depressing phase 0 of the action potential. They have a local
anesthetic effect.
Indications: ventricular arrhythmias
Contraindications and cautions:
Allergy, bradycardia, heartblock, CHF, hypotension, shock, electrolyte
imbalances
Caution: renal and hepatic dysfunction
Adverse effects: dizziness, drowsiness, twitching, mouth numbness, slurred
speech and tremors leading to seizures, Change in taste, hypotension and
vasodilation, respiratory arrest
Nursing Responsibilities:
 Continually monitor cardiac rhythm when initiating or changing dose.
 Maintain life support on standby.give parenteral forms only if oral
administration is not possible
 Titrate the dose to the smallest amount needed to achieve control of the
arrhythmia.
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  Consult the prescriber to reduce the dosage in patients with renal or
hepatic dysfunction
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation
 Arrange periodic monitoring of cardiac rhythm when patient is receiving
long term therapy

B. Class II Antiarrhythmics

• Acetabutolol (Sectral) also used as antihypertensive,

• esmolol (Breviloc) used short term for SVT and ventricular
tachycardia adn tachycardia when unresponsive for other methods,
• propanolol (Inderal)use as antihypertensive, anti migraine
Action: Block beta receptor sites in the heart and kidneys, thereby decreasing
heart rate, cardiac excitability, and cardiac output and slowing conduction
through the AV node and decreasing the release of rennin. These effects
stabilize excitable cardiac tissue and decrease blood pressure.
Indications:
Contraindications:
Sinus bradycardia, AV block, cardiogenic shick, CHF, asthma, respiratory
depression, pregnancy and lactation
Caution:
Diabetes and thyroid dysfunction, renal and hepatic disorders
Adverse effects: dizziness, insomnia, hypotension, BRADYCARDIA,
bronchospasm and dyspnea, alterations in blood glucose level, AV block,
arrhythmias, nausea, vomiting, anorexia, diarrhea, constipation, decreaed
libido, decreased exercise tolerance

C. Class III Antiarrythmics

• Amiodarone (Cordarone), bretylium, dofetilide, ibutilide

Action: Block potassium channels and slow the outward movement of
potassium during phase 3 of the action potential
Indication: life threatening ventricular arrhythmias; atrial fibrillation and atrial
flutter (dofetilide)
Contraindications:
When used in life threatennig situations, there are no contraindications; but –
tilides should not be used with AV block if used as part of regular treatment
regimen
Caution:
Shock, hypotension, respiratory depression, prolonged QT interval, renal and
hepatic disease
Adverse effects: nausea, vomiting, GI distress, weakness and dizziness,
hypotension, CHF arryhtmias are common
Amiodarone: _____________________________________________

D. Class IV Antiarrythmics

• Sample Medcations:
Action: Block the movement of calcium ions across the cell membrane,
depressing depolarization and prolonging repolarization, which slows
automaticity and conduction
Indications: hypertension, angina, supraventricular tachycardia
Contraindications:
Allergy, sick sinus syndrome, heart block, pregnancy, lactation, CHF,

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 hypotension,
Caution: idiopathic hypertrophic subaortic stenosis, renal and liver dysfunction
Adverse effects: vasodilation, dizziness, weakness, fatigue, headache,
hypotension, edema, GI upset, nausea and vomiting

Note: adenosine and digoxin can also manage arrythmias

Nursing Responsibilties (ANTIARRHYTHMICS):

 Take and record the BP, apical and radial pulses and respiratory rate
before giving the drug.
 Notify physician if the pulse rate is above 120 bpm or below 60 bpm.
 Continual cardiac monitoring assists the nurse in assessing the patient
for adverse drug reactions.
 Lidocaine is an emergency drug for ventricular arrhythmias. Constant
cardiac monitoring is needed. Observe closely for signs of respiratory
depression, bradycardia, change in mental status, and hypotension.
Airway and suction equipment are kept at bedside. Atropine is given IV
for pronounced bradycardia.
*other nursing considerations for class II, II and IV are the same with class I

V. ANTIANGINAL MEDICATIONS
- In early cases of angina, avoidance of exertion or stressful
situations maybe sufficient
- The drugs are used to help restore the supply demand ration in
oxygen delivery of the myocardium if rest and oxygen is not
enough
- The drugs work to improve blood delivery by one or two ways:
a. Dilating the blood vessels
b. Decreasing work of the heart
A. Beta Blockers
B. Calcium Channel Blockers
C. Nitrates

• Nitroglycerin (Nitrobid, Nitrostat), isosorbide dinitrate (Isordil)

• Sublingual, transmucosal, translingual, inhalation)
Action: Act directly on smooth muscles of the heart to cause relaxation and to
depress muscle tone. Relax and dilate veins, arteries, and capillaries, allowing
increased blood flow through these vessels and lowering systemic blood
pressure because of a drop in resistance. Increases blood flow in coronary
arteries.
Indications: prevention and treatment of angina pectoris
Adverse effects: headache, dizziness and weakness; nausea, vomiting and
incontinence; hypotension; flushing, pallor, sweating, reflex tachy cardia,
syncope, fluching, pallor, diaphoresis
Contraindication: allergy, anemia, head trauma, cerebral hemorrhage,
pregnancy and lactation
Caution: hypotension, hypovolemia

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 Nursing Responsibilities:
 Give SL preparations under the tongue or in the buccal puch.
 Protect the medication from heat and light.
 Rotate the sites of topical forms and monitor for skin breakdown.
 The dose of sublingual nitroglycerin may be repeated every 5 minutes until
pain is relieved after three doses in a 15 minute period.
 The dose of topical nitroglycerin is measured in inches, 1 inch of ointment
equals 15 mg of nitroglycerin. Before the durg is applied, BP needs to be
checked. Areas that may be used for application include the chest,
abdomen, upper arms and legs.
 The nurse must not rub the nitroglycerin ointment into the patient’s skin
because this will immediately deliver a large amount of the drug through the
skin.
 The nurse should wear disposable gloves (drug may be absorbed by the
nurse)
 Transdermal nitroglycerin is applied to the skin once a day for 10 to 12
hours.
 When applying the transdermal patch, the nurse inspects the skin to be sure
it is dry, free of hair and not subject to excessive rubbing or movement.

VI. LIPID LOWERING AGENTS

- Cholesterol
- Is the base unit for formation of steroid hormones and the basic
unit for maintenance of cell membranes
- Provided through diet and fat metabolism
- The enzyme hydroxymethylglutaryl-coenzyme A recuctase
regulates early, rate limiting step in the synthesis of cholesterol
- Hyperlipidemias:
- Increase in lipid level in the blood
- Increases the person to develop CAD
- Can result from excessive intake of cholesterol, genetic
alterations in fat metabolism
- Diet is often successful in its therapy.

A. ____________________________

• Cholestyramine (Questran) also used in patients with pruritus

associated with partial biliary obstruction
• colestipol (Colestid)
• colesevelam: can be used in combination with HMG COA RI and
adjunct to diet and exercise to patients with hereditary
hypercholesterolemia
Action: Bile acid sequestrants bind with bile acids in the intestine to form a
complex that is excreted in the feces. As a result, the liver must use cholesterol
to make more bile acids, so the serum levels of cholesterol and LDL decrease to
provide the cholesterol for the liver.
Indications: _____________________________
Contraindications and caution:
Allergy, complete biliary obstruction, abnormal intestinal function, pregnancy
and lactation
Adverse effects: headache, anxiety, fatigue, nausea, constipation and fecal
impaction, decreased absorption of vitamin K, vitamin A and D deficiencies,
muscle aches and pains
Nursing Responsbilities:
 Do not administer powder in dry form; the drug must be mixed in fluids
to be effective. Stir and swallow all of the dose. They maybe mixed with
fruit juices, soups, liquids and cereals or pulpy friuts. Colestipol maybe
mixed with carbonated beverages.
 If taking tablets, make sure that tablets are not cut, crushed or chewed.

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 They should be swallowed whole with plenty of fluid
 Give the drug before meals to ensure that the drug is in the GI tract with
food.
 Arrange bowel program as appropriate to effectively deal with
constipation
 Administer OTHER oral medications 1 hour before or 4 to 6 hours after
the bile sequestrant.
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation

B. Hydroxymethylglutaryl Coenzyme A Reductase Inhibitor (HMG CoA

RI)

• Atorvastatin (Lipitor), simvastatin (Zocor), lovastatin (Mevacor)

Action: Block the formation of cellular cholesterol, leading to a decrease in
serum cholesterol and a decrease in serum LDLs, with a slight increase or no
change in the levels of HDLs.
Indications:
1. adjunct with diet and exercise for the treatment of elevated cholesterol
and LDL levels in patients unresponsive to dietary restrictions alone
2. slow the progression of CAD
3. prevent first MI in patients who are at risk for MI development
Contraindications and cautions:
Allergy, liver disease, history of alcoholic or liver disease, pregnancy and
lactation
Caution: impaired endocrine function
Adverse effects: flatulence, abdominal pain, cramps, nausea and vomiting;
headache, dizziness, blurred vision, cataract development, elevated liver
enzymes
Nursing Responsibilities:
 Administer the drug at BEDTIME because the highest rates of
cholesterol synthesis occur between midnight and 5am.
 Monitor serum cholesterol and LDL levels prior to and periodically
during therapy.
 Arrange for periodic OPHTHALMIC examinations to monitor for cataract
development.
 Monitor liver function tests prior to and periodically during therapy to
monitor for liver damage.
 Ensure that the patient has attempted a cholesterol-lowering diet and
exercise program for at least 3 to 6 months before beginning therapy.
 Encourage patient to make lifestyle changes.
 Withhold lovastatatin, atorvastatin, or fluvastatin in any acute or
serious conditoins
 Suggest barrier contraceptive for women
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation

C. Cholesterol Absorption Inhibitors

• Ezetimibe (Zetia): adjunct to diet and exercise to reduce

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 cholesterol as monotherapy or combined with statins; adjunct to
diet to reduce elevated sitosterol and campesterol levels in
homozygous sitosterolemia
Action: works in the brush border of the small intestine to decrease absorption
of dietary cholesterol leading to a drop in serum cholesterol levels
Contraindications and caution:
Allergy, liver disease, pregnancy and lactation
Adverse effects: abdominal pain and diarrhea and NOT associated with
flatulence and bloating that are associate with sequestrants and fibrates; other
effects are: dizziness, fatigue, upper respiratory tract infections
Nursing Responsbilities:
 Monitor serum cholesterol, triglyceride and LDL levels and liver function
tests periodically during the therapy
 Ensure that the patient has attempted cholesterol lowering diet and
exercise programs
 Encourage lifestyle changes
 Provide comfort measures to help patient tolerate drug effects. These
include small frequent feeding, access to bathroom facilities, bowel
program is needed, environmental controls, safety precautions
 Provide thorough patient teaching, including the name of the drug,
dosage prescribed, measures to avoid adverse reactoins, warning signs
of problems and the need for periodic monitoring and evaluation

D. Other Drugs Used to Affect Lipid Levels

1. Clofibrate (Atromid S), inhibits synthesis of LDL and cholesterol, lowers

serum lipids and has an ANTIPLATELET EFFECT.
2. Fenofibrate (Tricor), inhibits triglyceride synthesis in the liver, resulting in
reducation of LDLs; increase uric acid secretion.
3. Gemfibrozil (Lopid), inhibits peripheral breakdown of lipids, reduces
triglyceride production and LDL production, and increases HDL
concentrations.

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