Questions for Unit Test

1. List the indication and nursing consideration for salbutamol. (4)

2. Write short note (4 x 2= 8)

a) Expectorant

b) Aminophylline

3. What is H2 receptor antagonist? Write nursing implication for

pantoprazole. (2+6 = 10)
 Unit 4
Drugs Used in Cardio-Vascular
System
 Classification of anti-hypertensive drug
• ACE inhibitors (Angiotensin converting enzymes)
• Angiotensin receptor blocker (ARB)
• Central sympatholytic
• Alpha - adrenergic blocker
• Vasodilators
• B-blocker
• Calcium channel blocker
• Diuretics
What is hypertension?
 ACE inhibitors : (Angiotensin reconverting enzymes)

• The liver creates and releases a protein called angiotensinogen. This

is then broken up by renin, an enzyme produced in the kidney, to
form angiotensin I.

• Angiotensin is a hormone that helps regulate your blood pressure by

constricting (narrowing) blood vessels and triggering water and salt
(sodium) intake
 ACE inhibitors : (Angiotensin converting enzymes)

 Enalapril

 Captopril

 Lisinopril
Mechanism of Action

Angiotensin converting enzyme is inhibited and prevent the

conversion of angiotensin I to angiotensin II as a result no
vasoconstriction and decrease in sodium and water retention occurs
which leads to decrease in BP.
Indication

 Hypertension

 Myocardial infraction (Heart attack)

 Congestive heart failure

 Diabetic nephropathy (Kidney)

Dose

• Enalapril : 2.5 to 20mg OD or BD

• Captopril :- 2.5 to 50mg TDS

Adverse effect (Pneumonic-CAPTOPRIL)

 Cough (Dry) (C).  Proteinuria (P) (seen protein in

 Angioedema (A) (allergic urine)

reaction)  Rashes (R)

 Proteinuria (P)  Itching (I)

 Taste alteration (T)  Loss of appetite (L)

 Hypotension (0)
Contraindication
 Hypersensitivity

 Pregnancy

 Hypotension
 Nursing Management

• BP should be monitored regularly.

• Counsel patient that they may experience hypotensive effect during

adjustment dose.

• Instruct patient not to discontinue medication abruptly without

monitoring.

• Advice patient to rise slowly in-order to avoid postural hypotension

 Cont’d…

• Advice patient to avoid driving and other works until they are confident that
they have no dizziness.

• Report physician about excessive dehydration, vomiting diarrhea as it may

lead to fall in BP.

• Avoid the use of OTC product (Cough and cold) unless directed by prescriber.
 Angiotensin Receptor Blocker

 Losartan

 Telmisartan
Mechanism of Action

Angiotensin receptor blocker blocks the binding of angiotensin II to the

AT1 receptors found in tissues which ultimately leads to vasodilation
and sodium and water retention. As a result blood vessel decreases.
Indication

 Hypertension Stroke

 Myocardial infraction

 Congestive heart failure

Dose

 Losartan: 25 to 100mg OD/BD.

 Telmisartan 10 to 80mg OD
Adverse effect

 Dizziness  Fatigue

 Insomnia  Indigestion

 Nausea/vomiting  Upper respiratory tract

infection.
 Hyperkalemia
Contraindication
 Hypersensitivity

 Pregnancy
 Nursing Management

 BP should be monitored regularly

 Counsel patient that he/she may experience hypotensive effect during

adjustment of dose.

 Instruct patient not to discontinue medication abruptly without

monitoring.
 Cont’d…

 Raise patient slowly to avoid postural hypotension

 Suggest for salt restriction and avoidance of alcohol

 Suggest not to operate machinery equipment and driving.

 Central Sympatholytic / Central Acting

 Clonidine

 Methyldopa
Mechanism of Action

It inhibits sympathetic center in CNS which reduces cardiac output,

pulse rate and blood pressure.
Indication

 Hypertension

 Hyper activity disorder

 Hypertensive crisis
Dose

 Clonidine – 0.1 to 0.2 mg per day

 Methyldopa 200 250 to 500mg BD/ TDS

Adverse effect

 Drowsiness  Rashes

 Sedation  Dry mouth

 Hypotension  Constipation

 Nausea/ Vomiting
Contraindication
 Hypersensitivity

 Bleeding disorder
 Nursing Management

• BP should be monitored regularly.

• Instruct patient not to discontinue medication abruptly and without

monitoring

• Counsel patient that they may experience hypotensive effect during

adjustment of dose.
 Cont’d…

• Raise patient slowly to avoid orthostatic hypotension

• Suggest not to use OTC medication, alcohol or CNS depressants drugs or

unless directed by prescriber.
 B-Blocker

 Metoprolol

 Atenolol

 Propanolol
Mechanism of Action

•ß-blockers are response drugs that inhibits sympathetic mediated

through ß-receptor. ß-blockers binds to ß-receptors and blocks all the
action. As a result, decreases cardiac contractility and heart rate which
leads to decrease in BP.
Indication

• Myocardial infraction (M)

• Angina pectoris (A)

• Hypertension (H)

• Arrhythmia (A)

• Migraine (Propanolol) (excessive headache)

Dose

 Atenolol:-25 to 100mg OD

 Metoprolol: 150 to 300mg 12.5mg to 100mg OD/BD

 Propanolol:- 10 to 40mg OD/BID

Adverse effect

 Hypotension  Fatigue

 Bradycardia  Insomnia

 Dyspneic  Broncho constriction

 Nausea/Vomiting  Disturbances in lipid metabolism

Contraindication
 Bradycardia

 Hypersensitivity

 Pulmonary edema
 Nursing Management
 BP should be monitored regularly.

 Counsel patient that he/she may experience hypotensive effect during

adjustment of dose.

 Instruct patient not to discontinue medication abruptly without

monitoring.

 Patient with respiratory disease should be monitor closely for respiratory

issues such as wheeze and difficulty in breathing.
 Cont’d…
 Raise patient slowly to avoid postural hypotension

 Suggest not to breast feed while taking this drug

 Report the physician promptly about difficulty breathing, cough and

swelling of extremities.
 Vasodilators

 ACE inhibitors

 ARBs

 Calcium Channel blockers

 Hydralazine
Mechanism of Action

•A vasodilator is a drug that causes vasodilation, a widening

(opening) of blood vessels that results from relaxation of the smooth
muscle of the vessels. What widens in vasodilation actually is the
diameter of the interior (lumen) of the vessel. The opposite of
vasodilation is vasoconstriction.
Indication

• Cardiac Failure

• Hypertension (H)
Dose

 Hydralazine tablet: 25 mg TID / BID increasing to a maximum dose

as 50 mg BD
Adverse effect

• Headache • Palpitations

• Fatigue • Dizziness

• Edema (fluid retention) • Nausea

• Pulmonary edema • Flushing

• Low blood glucose

Contraindication
 Hypersensitivity

 Pregnancy

 Hypotension
 Nursing Management
 BP should be monitored regularly.

 Advice to change position slowly for prevention of orthostatic

hypotension

 Instruct patient to inform if she suspects for pregnancy

 Injection should be given slowly

 Alpha Blockers

 Prazosin

 Terazosin
Mechanism of Action

It stimulates the alpha receptors which results to decreased sympathetic

outflow resulting to decrease of blood pressure.

Indication

• Moderate to severe hypertension

• Congestive heart failure

Dose

 Prazosin: 0.5 mg to 1 mg TID or QID

(Maximum dose upto 20 mg/ day in divided doses)

Adverse effect

• Headache • Impotence

• Fatigue • Nasal Stiffness

• Orthostatic hypotension

• Bradycardia

• sedation
Contraindication
 Hypersensitivity

 Hepatic diseases
 Nursing Management
 Monitor vital signs regularly

 Precautions to be taken for patient with hepatitis

 Injection should be given slowly 0.2 mg over 1 minute

Calcium Channel Blocker [Calcium for Cardiac Muscle]

 In the cells of the cardiac muscle, calcium ions play a crucial role in

coupling excitation and contraction.

 Amlodipine (Important)

 Nifedipine

 Verapamil

 Diltiazem
 Mechanism of Action

• Calcium channel blocker blocks

calcium channel in heart and
smooth muscles which blocks
entry of calcium. As a result,
contraction force is decreased
and causes vasodilation which
lowers blood pressure.
Indication

• Myocardial infraction (M)

• Angina pectoris (A) [excessive chest pain awe to oxygen]

• Hypertension (H)

• Arrhythmia (A) (abnormal rhythmic)

Dose

• Amlodipine : -2.5 to 10mg OD

• Nifedipine : 5 to 20mg

• Diltiazem 30 to 60mg TDS

Adverse effect (Mnemonic- ADVERSE)

• Ankle edema (A) • Rashes (R)

• Dizziness (D) • Flushing (S)

• Vomiting/Nausea (V) • Edema (Peripheral) (E)

• Edema (E) • Edema (Pulmonary) (E) ·

Contraindication

• Bradycardia

• Hypotension

• Hypersensitivity

• Congestive Heart failure.

 Nursing Management

 Blood pressure should be monitored regularly.

 Counsel patient that he/she may experience hypotensive effect during

adjustment dose.

 Assess the patient for peripheral edema and report to physician.

 Instruct patient not to discontinue medication abruptly without

monitoring.
 Cont’d…

 Tell patient to swallow whole drug without breaking and crushing.

 Avoid concomitant ingestion of grape fruit juice

 Suggest to take product as prescribed, not to double or skip dose

 Suggest to maintain diet and stress reduction along with regular exercise and
smoking cessation.
 Diuretics

Diuretics are drug which are used to increase the flow of urine. The main
objective is to excrete water and electrolytes which is accumulated in the form
of edema.
 Potassium sparing diuretics – Spironolactone

 Loop diuretics - Frusemide (Lasix)

 Osmatic diuretics – Mannitol

 Thiazide diuretics – Hydrochlorothiazide

 Carbonic Anydrase Inhhibitor

Mechanism of Action

• Diuretics inhibits the Na+ /K+ /Cl- co-transport system which leads to
inhibition of reabsorption of Na+, k+ & Cl- in ascending loop of Henle.
As a result water is excreted in the form of urine.
Indication

 Hypertension

 Hyperkalemia

 Pulmonary edema

 Increased intracranial pressure.

 Poisoning elimination

 Cerebral edema
Dose

• Lasix : 20 to 80 mg 0D/BD (7am & 3pm)

• Spironolactone: 25-100 mg daily in divided doses

Adverse effect

 Hypotension  Headache

 Hypokalemia  GI disturbances.

 Dehydration  Hyponatremia

 Dizziness
Contraindication
• Pregnancy Lactation

• Hypersensitivity

• Anuria (not able to produce urine by kidney)

 Nursing Management

 Monitor the level of sodium and potassium

 Maintain the input and output chart of the patient

 Although Frusemide rarely leads to hypokalemia potassium rich

diet is always advisable.

 Raise patient slowly may occurs hypotension and dizziness

 Cont’d…
 Administer drug in the morning and early afternoon to avoid nocturia and
interruption of sleep.

 Note GI irritation and administer drug with food if needed.

 Suggest to contact physician if rashes, cramps, nausea dizziness,

weakness occur.

 Suggest to take/use sunscreen cream or wear protective clothes to prevent

photosensitivity.
Thank You !!!
 Anti-arrhythmic drugs

• Arrhythmia is the disturbance in cardiac

rhythm. An arrhythmia describes irregular
heartbeat. The beat too fast, too slowly, too
early or irregularly. Arrhythmia occurs
when the electrical signals to the heart that
coordinates heartbeat are not working
properly.
 Anti-arrhythmic drugs

• Anti-arrhythmic drugs are the agents which are used to restore the normal
rhythm.

• Those drugs directly act on the cardiac cells by inhibiting the function of specific
ion channels or by altering the automatic input into the heart.
 Classification of Anti-arrhythmic drugs

• Class I- (Na + channel blockers)

• Class II- ( Beta adreno-receptor blockers)

• Class III

• Class IV (Ca+ channel blockers)

• Others
 Lidocaine

Mechanism of Action

• It decrease the depolarization,

automatically and excitability in the
ventricle during diastolic phase
Indication

• Ventricular arrhythmia
Dose

 50 - 100 mg IV bolus under ECG monitoring at the rate of 25 – 50

mg/min

 A second dose after 5 min

 Max. dose 300mg in 1 hr

 This is followed by infusion: 1-4 mg/min. Rate is closely monitored

 IM: 200 – 300 mcg in deltoid muscle

Adverse effect

 Hypotension

 Blurred vision

 Drowsiness

 Dizziness

 GI disturbances
Contraindication
 Hypersensitivity

 A. V block

 Severe heart break

 Special Precaution in CCF

 Hepatic and rental impairments

 Nursing Management

 Regular monitoring of blood pressure and heart rate.

 ECG should be done.

 Before giving the drugs label should be studied properly because of

availability of drug in different doses.

 Do not administer lignocaine along with adrenaline (can prolong the

duration of sedation and numbness of operating site)
 Procainamide

Mechanism of Action

• It blocks the sodium channels and ultimately increases duration of

action potential. This results to slow conduction and ultimately, the
decreased rate of action potential.

Indication

 Ventricular arrhythmia
Dose

 200 to 300mg TDS.

Adverse effect

 Hypotension

 GI disturbances

 Rashes

 Fever

 Tinnitus

 Cardiac failure
Contraindication
 Hypotension

 Heart failure

 Pregnancy

 Kidney and liver diseases

 Decrease platelets
 Nursing Management

 Monitor signs of serious reaction after first dose. If there is unusual

sign, inform the doctor.

 Explain about diarrhea as side effects. It may occur after a few days

 Monitor ECG and blood pressure regularly.

 Instruct patient to report immediately if any side effect occurs.

 Cont’d…

 Do not chew or crush tablets

 Check the pulse before administration of drug especially during

drug adjustment

 Assess CNS symptoms for confusions, psychosis, numbness. If

present, medicine should be discontinued.
 Antianginal Drugs

• Angina is characterized episodes of

chest pain due to imbalance between
oxygen supply and oxygen demand
of myocardial

• Angina pain occurs when coronary

blood flow is insufficient to meet
metabolic requirement of heart
muscles.
 Antianginal Drugs

• Drugs that & terminates or prevents attacks of

angina pectoris is called anti-anginal drugs.

• Acts by increasing myocardial oxygen supply or

by decreasing myocardial oxygen demand or
both.
 Stable angina
 Unstable angina
 Variant angina
Drug Name

 GTN (Glyceryl trinitrate)/ (Nitroglycerine)

 Isosorbid mononitrate

 Isosorbid dinitrate
 Nitroglycerine

• Lipid soluble substance rapidly absorbed across the sublingual and buccal
mucosa. Its onset of action occurs within 2 to 5 minutes, with maximal effect
observed at 3 to 10 minutes
Mechanism of Action

 It relaxes the smooth muscle especially in the blood vessels. It also

reduces venous return
Indication

 Angina pectoris

 Myocardial infraction

 Hypertension

 Congestive heart failure

Dose

 0.5mg every 3 minutes until pain subsites

 2.5 to 5 mg orally BD or TDS in sustained release

tablet/ operations
Adverse effect

 Headache

 Flushing

 Dizziness

 Tachycardia

 Hypotension
Contraindication
 Glaucoma

 Severe anemia

 Hypotension

 Pregnancy
 Nursing Management

 Drugs should be stored tightly in glass container as the drugs can

evaporated away.

 Sublingual doses is administered when required or at bed time if

angina is nocturnal.

 Drug dose is reduced gradually to prevent withdrawn symptoms.

 Cont’d…
 Advice patient to avoid alcohol as can cause hypertension

 Instruct patients to take drug in empty stomach

 Take sublingual tablets while sitting to avoid postural hypotension

 Localized burning sensation may occur in sublingual

administration. So explain it to patient

 Sublingual dose should be administered prior to stress (if

anticipated) and before bed if angina is nocturnal.
 Cardiac Glycosides

• Drugs used for treatment of heart failure and certain irregular heart beats.

Common cardiac Glycosides are

• Digoxin

• Digitoxin
 Mechanism of Action

• It inhibits Na+ , K+ exchange by Na+/K+ ATPase enzyme as a result of

which promotes the movement of calcium from the extracellular
cytoplasm to intracellular cytoplasm and strengthening the myocardial
contraction. It also acts on CNS to increase vagal tone that means it slows
the conduction through the SA and AV nodes i.e. it shows the
antiarrhythmic action

• It also acts as diuretics

 Dioxin
Mechanism of Action
Inhibits N+,K+ Atpase

Increase intracellular sodium (Na+)

Accumulation of Ca2+ through Na+ / Ca2+ exchange system

Increase cardiac contractility

Increase cardiac output

Indication
Dose

 0.25 to 1.25 mg per day depending upon the desired speed of

digitalization

 For slow digitalization, 0.25 mg/ day is given. It takes 5 to 7 days to

develop full respose
Adverse effect

 Digitalis toxicity  Headache

 Disturbances of color vision.  Confusion

 Photophobia  Hypotension

 Headache  Drowsiness
Contraindication
 Hypokalemia

 Hypersensitivity

 Ventricular tachycardia

 Myocarditis infraction

 Hypercalcemia

 Severe renal and hepatic diseases

 Nursing Management
 Suggest to take digoxin after food to prevent GI irritation.

 Note ECG and rhythm.

 Make sure that right medicine and right dose is given to right patient at
right time in right route of administration because digoxin overdose
brings serious complications

 Monitor pulse rate, rhythm and quality before each dose. If rate goes
below 60 beats/minute, stop medication and inform to physician
 Cont’d…
 Don't administered calcium rapidly by IV route to patient receiving
digoxin as it affects cardiac contractility.

 While starting and increasing dose, note adverse effect carefully and
report to doctor.

 Follow directions carefully for taking the medications. If one close of

drug is missed, don't double up in next dose.

 Maintain intake and output charting as it works as diuretics as well.

Drugs used in CV/shock
 Shock

 A serious, life-threatening condition that happens when body doesn’t get enough
blood flow because of reduced cardiac output. Lack of blood flow to organs
means they won’t get enough oxygen, which can cause them to fail. Shock may
also lead to a lack of oxygen in your body’s tissues (hypoxia) and can cause
heart to stop (cardiac arrest).

 Sudden reduction of blood volume due to bleeding

 Reducing pumping action of the heart following damage

 Septic shock usually due to gram negative bacterial infection

 Drugs used in CV/shock

 Dopamine

Mechanism of Action

• Dopamine stimulates Beta 1 receptor of heart and increases

myocardial contraction and cardiac output

• At higher dose, vasoconstriction occurs in skeletal muscles and a rise

in BP occurs.
Indication
 Congestive heart failure

 Cardiogenic shock

 Acute renal failure drug

Dose
 2 to 5 mcg (microgram)/kg per minute maximum up to 20mcg/kg
per minute.


Adverse effect

 Tachycardia  Hypotension

 Arrhythmia  Necrosis

 Palpitation  Gangrene

 Anxiety  Nausea

 Ectopic beats  Vomiting

 Nursing Management
 Explain about the side effects of the drugs

 Administer only IV infusion (IV bolus or IM can not be given)

 Drug must be diluted before use

 Report immediately if urinary flow rate is reduced.

 Monitor BP and pulse.

 Monitor urinary output

 Cont’d…

 Check IV site for extravasation

 Advice the patient to inform if he has pain, swelling or burning

sensation around the cannula site

 Advice patient to avoid calcium antagonist as it may make the cardiac

failure worst
Thank You !!!
 Anticoagulants

Anti-coagulant is class of drug that works to

prevent coagulation of blood.

Drug Name
 Heparin
 Warfarin
Mechanism of Action

• It is the antagonist of vitamin K which

interfere with the action of thrombus
formation.

• Prevents conversion of prothrombin to

thrombin and fibrinogen to fibrin
Indication

 Used as anti-coagulant

 Venous thrombosis stroke prevention

 Myocardial infraction

 Angina

 Prophylaxis of embolism
Dose
 Treatment of thromboembolism

Adult: 5000-1000 U IV bolus followed by continuous IV

infusion 15-25 units/ kg/hr

• For prophylaxis 5000 units 12 hourly

Child: 50-100 units/ kg every 4 to 6 hour

Adverse effect

 Hemorrhage (excessive bleeding)

 Dermatitis

 Alopecia (Hair fall)

 Diarrhea

 Nausea and vomiting

 Hypotension
Contraindication

 Bleeding disorder

 History of heparin induced thrombocytopenia

 Pregnancy

 Peptic ulcer

 Surgery

 So severe hypertension.
 Nursing Management

 If over dose, vitamin K should be used as antidote.

 Patient is advised to stop smoking.

 Patient shouldn't take any drug without consultation of physician.

 Tell patient to report if any unusual bleeding occurs.

 Suggest to take drug exactly as prescribed.

 Cont’d…
 Baseline investigations should be done

 Monitor aPTT level closely (dose is managed to keep aPTT 1.5 to 2.5
times normal control level).

 Antidote: Protamine Sulfate (1% solution) should be kept on hand.

 Protect from injury and notify physician for pink, red, dark brown or
cloudy urine, red or dark brown vomitus, red or black stools, bleeding
gums or oral mucosa ecchymosis, hematoma, epitaxies, unusual increase
of menstrual blood flow
Thank You !!!
 Lipid Lowering Drug
Cholesterol and Triglycerides are fat like material present in blood. Lipid
lowering drugs are used to reduce such high levels of fat like materials.

Drug Name

 Atorvastatin  Simvastatin

 Rosuvastatin  Bezafibrate
Mechanism of Action

• This drug completely inhibits HMG COA (Three- Hydroxyl, 3methyl,

glutaryl, co-enzyme A) which inhibits the process of synthesis of
cholesterol.
Indication

 Hyper cholesterolemia

 Hyper triglyceridemic

 Stroke prophylaxis

 Myocardial infraction prophylaxis

Dose

• Atorvastatin: 5 to 40mg per day

• Rosuvastatin: 5 to 20 mg per day

Adverse effect

 Dyspepsia  Nausea, vomiting

 Flatulence  Myalgia (Muscle pain)

 Headache  Insomnia

 Arthralgia
Contraindication
 Pregnancy

 Lactation

 Liver disease

 Hypersensitivity
 Nursing Management

 Give single dose at night with or without food.

 Determine lipid level within 2 to 4 weeks then adjust dose accordingly.

 Review dietary habits, weight, exercise pattern and identify lifestyle

changes needed.

 Report immediately if any unexplained muscle pain or weakness occurs

 Suggest to avoid if the patient is pregnant

 Anti-Platelet Drugs
Anti-platelet drugs suppress platelet aggregation. These groups of drug
are used to prevent thrombosis.

Drug Name

 Aspirin

 Sulphinpyrazone
Mechanism of Action

Aspirin
• Aspirin inhibits the platelet aggregation by inhibiting synthesis of
thromboxane A2 (TXA2)
Indication

 Myocardial infraction

 Angina

 Stroke prevention
Dose

 5.50 to 300mg OD/ day

Adverse effect

 GI bleeding

 Nausea, vomiting Bronchospasm

 Stevanjohnson Syndrome

 Reyes syndrome

 Agranulocytosis

 Dyspepsia
Contraindication
 Bleeding disorder

 Hypersensitivity

 Peptic ulcer
 Nursing Management

 Advise patient to take medicine only after meal to minimize GI upset

 Assess for history of asthma and hypersensitivity

 Check for signs of FI bleeding especially gums and look for melena
(dark stool)
 Cont’d…

 Encourage intake of plenty of fluids

 Discontinue dugs if tinnitus, hearing impairment, mental confusion,

thirst and seating is complained.
Thank You !!!