Lesson 4.

CARDIAC LABORATORY STUDIES

NCM 103A

COMPLETE BLOOD COUNT Fibrin degradation products (fdp)

 Indicates the type and number of formed elements in the blood  N = <5 g/mL (Brunner TB)
Males 4.2-5.4 million/mm3  N = <10 mcg/mL (Brunner Lab)
Females 4.6-6.2 million/mm3  After a fibrin clot forms in response to vascular injury, the clot is
RETICULOCYTE COUNT 0.5%–1.5% of red cells eventually degraded by plasmin, a fibrin-dissolving enzyme.
Hemoglobin  The resulting fragments are known as FSP.
 Measures the haemoglobin available in circulation, which is the gas-  This test detects FSP in the diluted serum that’s left in a blood sample
carrying capacity of RBCP after clotting and is a reflection of clotting activity and breakdown.
Males 13–18 gm/dL  also called fibrin degradation products (FDPs) or fibrin breakdown products.
Fibrin d-dimer
Females 12–16 gm/dL  N range = 0-0.5 mcg/mL
Hematocrit
 The most sensitive indicator to differentiate DIC from primary fibrinolysis
 The ratio of the RBC volume to the volume of whole blood
 Elevated in DIC
Males 42%–52%
Females 35%–47%
Rbc indexes SERUM LIPID PROFILE
 MCV – estimates the size of RBC  A measurement used to determine the risk for developing atherosclerosis
 MCH – measures the content of Hgb in RBC’s from a single cell Total serum lipids
 MCHC – a more accurate measurement of the Hgb content of RBC as it  400–800 mg/dL
measures the entire volume of RBCs Triglycerides
Mean corpuscular volume (MCV) 84–96 Fl/cell  N range = 100–200 mg/dL
Mean corpuscular hemoglobin (MCH) 28–33 pg/cell  Lipids stored in fat tissue, readily available for energy production
Mean corpuscular haemoglobin concentration (MCHC) 33%–35%  Without elevated cholesterol, up to 250 mg/dL may be accepted
platelet cholesterol
 one of the most important screening tests of platelet function.  The main lipid associated with atherosclerotic disease
PLATELET 150,000–450,000/cu mm  N serum value = 150–200 mg/dL in adults
Lipoproteins
SERUM FERRITIN, TRANSFERRIN & TOTAL IRON-BINDING  Proteins in the blood to transport cholesterol, triglycerides and other fats
CAPACITY (TIBC) High-density lipoproteins (hdl)
 Used to evaluate iron levels  transport cholesterol to the liver for excretion
 Ferritin measures iron in plasms, a direct reflection of total iron stores  HDL/Total cholesterol ratio should be at least 1:5
 Transferrin in the major iron-transport protein  1:3 is more ideal
 TIBC measures the amount of iron that would appear in plasma if all the Low-density lipoproteins (ldl)
transferrin were saturated with iron  Transport cholesterol to peripheral tissues
 High values are associated with increased risk of coronary artery disease
Pre-procedure nursing care
 NPO 12-14 hours before testing to ensure accurate results
FERRITIN
Males 20–250 ng/mL
Females12–250 ng/mL
TRANSFERRIN 200–380 mg/dL SERUM ENZYME
TIBC 250–475 g/dL
 Increased in blood of a person with heart damage
WHITE BLOOD CELL COUNT  Measurements of serum enzyme levels evaluates myocardial tissuse
 Leukocytosis – an abnormal elevation of WBC count infarction (injury to myocardium from decreased oxygenation)
 Leukopenia – decrease in the number of WBC  Serial testing over time detects trend and determines peak time and
 Differential count refers to the breakdown of the different types of cells extent of injury
Creatine kinase (ck)
 Formerly known as creatine phosphokinase (CPK)
WBC COUNT 4,500–11,000/cu mm (4.5–11 x109/L)  If elevated, indicates muscle injury
DIFFERENTIAL  CK-MB is specific to myocardial muscle
Neutrophils 45%–73% (0.45–0.73 x109/L)  Its level rises within 6 hours of injury
Eosinophils 0%–4% (0.00–0.04 x109/L)  Peaks at 18 hours post-injury
Basophils 0%–1% (0.00–0.01x109/L)  Returns to normal in 2-3 days
Lymphocytes 20%–40% (0.2–0.4 x109/L)  Useful for early diagnosis of MI
Monocytes 2%–8% (0.02–0.08 x109/L) Lactase dehydrogenase (ldh)
 Found in many body tissues
COAGULATION STUDIES  A cardiac origin is confirmed with the analysis of isoenzymes (L1 is greater
Bleeding time than L2; “flipped” from normal levels)
 N range = 1.5–9.5 min  Elevation is detected within 24 hours to 72 hours after MI
 Used in the evaluation of platelet function  Peaks in 3-4 days
 Extended bleeding times are seen in thrombocytopenia and in aspirin  Returns to normal in 2 weeks
therapy  Useful in delayed diagnosis of MI
Prothrombin time (pt) troponin
 The rapidity of blood clotting  Has an onset before CK-MB in MI
 N range = 9.5–12 sec  Peaks at 24 hours
 Evaluates the extrinsic coagulation pathway which include factors I, II, V,  Returns to normal around 2 weeks
VII, X  Provides early sensitivity, extended blood levels, and is more specific to
 INR (International Normalized Ratio) often used instead of PT because it cardiac injury for diagnosis of MI with an uncertain timeframe
is a standardized value
 Therapeutic range = 2-3 seconds (depending on the condition)
Partial thromboplastin time (ptt) SERUM ELECTROLYTE LEVELS
 N= 21 to 35 seconds Serum potassium
 Evaluates the intrinsic coagulation pathway or fibrin clot formation  Is affected by renal function and may be decreased by diuretic agents that
Activated partial thromboplastin time (aptt) are used to treat heart failure
 Lower limit of normal: 20–25 sec  Decreased in potassium causes cardiac irritability and predisposes the
 Upper limit of normal: 32–39 sec client receiving digitalis toxicity and dysrhythmia
 Modified PTT, preferred because it is quicker to perform  Increased potassium is manifested by myocardial depression and
 APTT is used in heparin therapy and in the evaluation of hemophilia ventricular irritability
 APTT is increased in anticoagulation therapy, liver disease, vit K  Both hypokalemia & hyperkalemia can lead to the ventricular fibrillation or
deficiency, and DIC cardiac standstill
fibrinogen Potassium 3.5–5 mEq/L
 N range = 200–400 mg/dL (2–4 g/dL)
 A soluble plasma protein that is decreased in DIC and fibrinogen disorders calcium
and increased in acute infections, hepatitis, and oral contraceptive use  Necessary for blood coagulability and neuromuscular activity
 an important coagulation protein, originates in the liver and is converted  Hypocalcemia and hypercalcemia can cause dysrhythmia
to fibrin by thrombin during clotting. Calcium 8.6–10.2 mg/dL
 Because fibrin is necessary for clot formation, fibrinogen deficiency can
produce mild to severe bleeding disorders. sodium
 Fibrinogen is increased in diseases of tissue damage and inflammation.  Reflect relative fluid balance

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 Hyponatremia indicates fluid excess
 Hypernatremia indicates fluid deficit
Sodium 135–145 mEq/L
SERUM GLUCOSE LEVEL
 Many patients with cardiac disease also have diabetes mellitus (DM)
Fasting blood sugar
 Fasting: 60–110 mg/dL
 fasting plasma glucose (or fasting blood sugar) test is used to measure
plasma glucose levels after a fast of at least 8 hours.
 This test is commonly used to screen for diabetes mellitus and
prediabetes, in which absence or deficiency of insulin allows persistently
high glucose levels.
Post prandial blood sugar level
 Postprandial (2 h): 65–140 mg/dL
 Blood sugar level taken 2 hours after a meal
Random/casual plasma glucose
 defined as any time of day without regard to time since the last meal
Glycosylated hemoglobin
 Glycohemoglobin is blood glucose bound to hemoglobin.
 In the presence of hyperglycemia, an increase in glycohemoglobin causes
an increase in HbA1c.
 If the glucose concentration increases because of insulin deficiency, then
glycosylation is irreversible.
 Glycosylated hemoglobin values reflect average blood sugar levels for the
2- to 3-month period before the test.
 N = 4% to 6%
HEMODYNAMICS MONITORING
Central venous pressure (cvp)
 Reflects the pressure of the blood in the R atrium
 Engorgement is estimates by how far the venous column can be observed
as it rises from an imagined angle at the point of manubrium (angle of
Louis)
 With N physiologic condition, the jugular venous column rises no higher
than 2-3 cm above the clavicle with the client in sitting position at a 45
angle
CVP is a measurement of:
 Cardiac efficiency
 Blood volume
 Peripheral resistance
procedure
 A cardiac catheter is passed from a cutdown in the antecubital, subclavian
jugular, or basilic vein to the R atrium and attached to a precalibrated
manometer or transducer
 N CVP = 2-8 cm H20 or 2-6 mmHg
 Decrease indicates circulating volume
 Increase indicates increase blood volume or R heart failure
To measure:
 Pt should be flat with the zero point of manometer at the same level as
the R atrium, which corresponds to the mid-axillary line of the patient line
of the pt or approximately 5 cm below the sternum
 Fluctuations follow the pt’s respiratory function
 will fall on inspiration and rise on expiration due to the changes in
intrapulmonic pressure
Lesson 5. MEDICATIONS THAT AFFECT THE CARDIOVASCULAR SYSTEM
 Some cardiovascular medications are used for their effects on the
heart’s action.
 Others are used for their effects on blood vessels.
 Medications that stimulate or strengthen the heart’s pumping action are
called cardiotonics.
 Medications that regulate heart rhythm are called antiarrhythmics.
 Medications that primarily act on the blood vessels are called
vasoconstrictors (constrict or narrow the blood vessels) and vasodilators
(dilate or widen blood vessels).
 Often, vasodilators are used to lower and control blood pressure.
 In addition, a number of other medications are used to control blood
pressure.
Cardiotonics
 Cardiotonics are heart stimulants.
 Commonly used cardiotonics include digoxin (Lanoxin, Novo-Digoxin
[Can], Digitek), a derivative of the digitalis leaf.
 main action - to strengthen the force of ventricular contractions and, in
doing so, increase cardiac output.
 In turn, increased cardiac output results in a slower heart rate and less
heart workload.
 Digoxin is available in oral and parenteral forms.
Dosages
 vary according to individual needs.
 The initial dose, called the digitalizing dose, is prescribed to reduce the
heart rate to the desired rate of 60 to 80 beats/minute.
 When a stabilizing dose maintains desired heart rate, the client is placed
on a maintenance dose, administered daily.
 Most clients taking digoxin continue the medication for life.
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 Reading should be obtained at the highest point of fluctuation
 If the pt is on ventilator, its use should be discontinued during the reading
of CVP
 Increase indicates fluid overload or congestive heart failue
 Decrease indicate low blood volume and more parenteral infusions are
needed
Pulmonary artery pressure (pap) monitoring
 Appropriate for critically ill patietns requiring more accurate assessments
of the L heart pressures
 Includes pt undergoing open heart surgery, pts in shock or with serious
MIs
 Pulmonary artery catheter (Swan-Ganz) has the tip in the pulmonary
artery
 Pressure measurement fromt his catheter is obtained after the tip is
wedged in a pulmonary capillary, and is called pulmonary capillary wedge
pressure (PCWP)
 A good indicator of L ventricular end diastolic pressure (LVEDP)
 Allows calculation of actual cardiac output and other hemodynamic
parameter at frequent intervals in critically ill patients
Client preparation
 Obtain consent according to policy
 Insertion is done using strict sterile technique, usually at the bedside
 Explain to the pt that sterile drapes may cover the face (with an internal
jugular or subclavian insertion site)
 Assist to position the client flat or in slight Trendelenburg, as tolerated
 Instruct the client to remain still during the procedure
Nursing care during insertion
 Assist the physician in mainitaining sterile field
 Administer medications ordered
 Monitor and document HR, BP and ECG during the procedure
 Reassure the client throughout the procedure
Post-procedure nursing care
 Monitor VS, ECG at frequtn intervals post-insertion
 Maintain the client in bedrest and instruct him/her to avoid unnecessary
movements
 Follow the policy to maintain patency and sterility of the catheter
Nursing responsibilities in hemodynamic monitoring
 Position the transducer at the level of the R atrium (L midaxillary line, 4 th
ICS – phlebostatic axis)
 Level the CVP or pulmonary artery catheter (Swan-Ganz) transducer to
this point at regular intervals according to policy (usually each shift) and
before each measurement
 Maintain patency of catheter with a constant small amount of fluid
delivered under pressure
Intra-arterial blood pressure monitoring
 Measurement of systolic, diastolic and mean BP by using an intra-arterial
catheter flushed with heparinized saline inserted usually in the radial artery
 If the radial artery is used, it is necessary to verify the presence of ulnar
artery flow by an Allen Test
 Performed by occluding the ulnar and radial arteries with the
examiner’s fingers
 The client’s hand should be elevated in this position for 5 mins
 When the ulnar artery is released, the blood flow should return to
the hand, indicating adequate blood circulation in the ulnar artery
 Because heart rate slows in response to digoxin, the apical pulse rate is
counted for 1 full minute before administration.
 If the client’s heart rate is below 60 beats/minute or if irregularities in
heart rhythm are present, withhold the medication and report the
information. Rationale: The primary healthcare provider may wish to
change or omit the dose for that day.
Digitalis toxicity
 When a client is receiving digoxin, observe closely for toxicity.
 Overdose of digoxin can dangerously lower heart rate or cause cardiac
arrest.
Signs and symptoms of toxicity or overdose include
 nausea, vomiting,
 headache,
 premature ventricular contractions,
 diarrhea,
 confusion, drowsiness, blurred vision, or visual disturbances in which
lights appear much brighter than they really are or appear to have halos
around them.
NURSING ALERT
 Digoxin doses are very small (approximately 0.125 to 0.425 mg/day).
 Because these doses are so small, they are usually ordered as
micrograms (mcg).
 Thus, the doses noted would be ordered as 125 to 425 mcg/day.
 Because these dosages are so minute, even a small overdose could be
fatal.
 Physicians routinely check the client’s blood level of the digoxin to
ensure that the correct dose is being prescribed.
 The nurse must be aware that digoxin toxicity occurs very quickly if the
client’s potassium (K+) level is low.
 Many clients with cardiovascular disorders are on potassium-wasting Propranolol hydrochloride (Inderal)
diuretics, and low potassium levels are common.  is a beta blocker; it reduces the irritability of the myocardium, thus
 Potassium is necessary for proper functioning of muscles, including the decreasing heart rate and the force of ventricular contraction.
cardiac muscles.  It results in increased cardiac output and lowered blood pressure.
 Increased cardiac output improves coronary circulation, which is
effective in decreasing vasoconstriction, spasm, and pain associated with
Antiarrhythmics angina pectoris.
 act on the heart’s electrical conduction system to regulate and slow  By decreasing the irritability of the myocardium, propranolol is also
heart rate. effective in treating and preventing atrial arrhythmias, such as atrial
Quinidine sulfate (Quinidine) flutter and atrial fibrillation.
 is an antiarrhythmic used to treat atrial arrhythmias. Propranolol hydrochloride (Inderal)
 action - regulates the number of times the atria contract in a given  Route - oral or IV
period.  Side effects - dizziness, fainting, drowsiness, insomnia, weakness,
 It may be administered orally or IM. confusion, mental depression, vivid dreams, and loss of libido.
 Side effects - dizziness, headache, ventricular tachycardia, angina,  Propranolol is also used to prevent migraine headaches, treat essential
bradycardia, and nausea. tremor, and help prevent subsequent MIs.
Procainamide hydrochloride (Pronestyl) Lidocaine hydrochloride (Xylocaine)
 is used to treat atrial fibrillation;  is used to treat lifethreatening ventricular arrhythmias following MI.
 it is more commonly used for ventricular arrhythmias, such as  Route - IV or IM forms
ventricular tachycardia or premature ventricular contractions.  should be used only in intensive care settings
 Route - oral, IM, or IV Other antiarrhythmics include
 Side effects - anorexia, nausea, vomiting, skin rash, urticaria (hives), and  acebutolol HCl (Sectral),
arthralgia (joint pain).  adenosine (Adenocard),
Verapamil hydrochloride  amiodarone (Cordarone),
 a calcium channel blocker approved to treat cardiac arrhythmias.  Carvedilol (Coreg),
 It also has antianginal and antihypertensive effects.  flecainide acetate (Tambocor),
 Verapamil slows the electrical conduction rate of the atrioventricular  ibutilide fumarate (Corvert), and
(AV) node, resulting in a slower heart rate and decreased cardiac  tocainide HCl (Tonocard)
workload.  The antiarrhythmics are generally pregnancy category C agents.
 Side effects - bradycardia, heart block, and constipation.

Selected Cardiovascular System Medications

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MEDICATIONS THAT AFFECT THE BLOOD VESSELS
 Many abnormal conditions can affect the body’s arteries and veins.
 Medications that constrict blood vessels are referred to as vasoconstrictors
 those that dilate the blood vessels are called vasodilators.
Vasoconstrictors
 Vasoconstrictors (vasopressors) are used to control superficial
hemorrhage, increase the heart’s pumping action, raise blood pressure,
and relieve nasal congestion.
Norepinephrine bitartrate (Levophed, Levarterenol)
 potent medication used to raise and sustain blood pressure in acute states
of hypotension, such as those caused by haemorrhage or shock.
 also is used in cardiac arrest.
 Given IV in solution, this medication should be administered only in
intensive care units.
Metaraminol bitartrate (Aramine)
 a pregnancy category D agent,
 indirectly affects the release of norepinephrine, to raise blood pressure.
 used to prevent hypotension or to raise or maintain blood pressure in
cases of hemorrhage, hypotension related to spinal anesthesia, trauma, and
surgical complications.
 Route - IV in a solution of normal saline or it may be given SQ or IM.
Phenylephrine hydrochloride (Neo-Synephrine)
 a pregnancy category C agent
 relieves congestion in mucous membranes
 It is also used to treat some types of shock and to raise and stabilize blood
pressure.
 Forms - ophthalmic solution, as chewable tablets, as a decongestant nasal
spray, and for injection.
Vasodilators
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 Medications that dilate blood vessels are used to treat peripheral blood
vessel disease, coronary artery disease, and hypertension (HTN).
 Vasodilators increase the lumen size of blood vessels and thereby increase
blood flow.
Nitrates
 have been used for many years to treat and prevent acute episodes of
angina pectoris (heart pain).
 dilate blood vessels, particularly in the coronary arteries, by inducing
relaxation of peripheral vascular smooth muscle fibers located in the walls
of blood vessels.
 increased blood flow to myocardial tissue decreases the constriction and
spasm of coronary blood vessels, increases blood flow to affected tissue,
and reduces or relieves the pain associated with angina.
Nitroglycerin (NTG)
 a pregnancy category C agent,
 A potent vasodilator that has long been the treatment of choice for acute
angina pectoris.
 forms- including tablets for sublingual (under the tongue) administration
(Nitrostat, Nitroquick) and a spray for translingual (sprayed onto the
tongue) administration (Nitrolingual)
 The tablet form can also be placed in the buccal pouch (cheek) or
between the lip and gum above the incisors.
 These methods provide immediate symptom relief.
 Mucous membranes quickly absorb nitroglycerin.
 Symptom relief usually occurs within 1 to 2 minutes.
 The duration of action is approximately 30 minutes.
 The expiration date should be noted after opening the bottle, because the
shelf life of sublingual nitroglycerin tablets is approximately 6 months after
the initial opening of the bottle.
Nitroglycerin
 is also available in long-acting capsules (Nitro-Time), as an ointment for
topical administration (Nitro-Bid), as transdermal patches (Nitro-Dur), or
in IV solution.
 Nitroglycerin should be protected from exposure to light; it is provided in
brown bottles and should be kept in a dark, dry place.
Nursing Alert
 Nitroglycerin tablets should not be crushed, chewed, or swallowed.
 Translingual spray should not be inhaled or swallowed.
 Sustained-release forms should be given with water.
 Clients who have recently had an MI or who have severe asthma, angle-
closure glaucoma, severe anemia, increased intracranial pressure, or
hypotension should not use nitroglycerin
Amyl nitrate
 a pregnancy category C agent
 is an antianginal drug used most frequently to treat acute angina
 relaxes the smooth muscles of blood vessel walls, causing vasodilation and
increased blood supply to affected myocardial tissue.
 Route – inhalation
 It is supplied in liquid form contained in a hard capsule and wrapped in a
protective cloth covering.
 When administering amyl nitrate, crush the capsule between the thumb
and finger and pass the substance back and forth under the client’s nose.
 Amyl nitrate has a very strong, disagreeable odor. Its vasodilating effect is
immediate and lasts approximately 3 to 5 minutes.
 Side effects include nausea, vomiting, headache, dizziness, and flushing.
 The drug should be protected from light and kept in a cool place.
 The client should be advised not to drink alcohol after amyl nitrate is
used.
Other Vasodilators
Hydralazine (Apresoline)
 a pregnancy category C agent,
 relaxes arterial smooth muscle, causing vasodilation.
 As a result, blood pressure is lowered.
 Route - oral or parenteral administration.
 Side effects - headache, palpitation, fluid retention, nausea, and vomiting.
Prazosin HCl
 acts by reducing peripheral vascular resistance, allowing arteries and veins
to dilate, thus lowering blood pressure.
 It is used to treat chronic hypertension.
 Unlike other agents, such as phentolamine, prazosin does not cause reflex
tachycardia.
 form - oral capsules.
Prazosin HCl
 Side effects - shortness of breath, orthostatic hypotension (sudden drop in
blood pressure on standing), pounding heartbeat, fluid retention, dizziness,
headache, and drowsiness.
 Because prazosin tends to cause fluid retention, it is often prescribed with
a diuretic.
ANTIHYPERTENSIVES
 Medications specifically used to reduce blood pressure on an ongoing basis
are called antihypertensives.
 Some antihypertensive agents have been discussed previously.
 Other medications used to treat chronic hypertension, or in conjunction
with other antihypertensives, include diuretics, beta blockers, calcium
channel blockers, and angiotensin converting enzyme inhibitors (ACE
inhibitors).
Diuretics
 medications that increase the amount of urine excreted by the kidneys.
 Thus, they decrease the body’s circulating fluid volume, thereby lowering
blood pressure.
 Indications for use of diuretics include edema, hypertension, heart failure,
and pregnancy-induced hypertension.
potassium-wasting diuretics
 One side effect of some diuretics is excessive excretion of potassium
(K+).
 These diuretics are termed potassium-wasting diuretics.
 Examples: Hydrochlorothiazide (HCTZ) and furosemide (Lasix)
 The client taking these medications will often require supplemental
potassium furnished in several oral forms.
 Thus, the potassium levels of clients taking diuretics are closely
monitored.
 Diuretics also increase sodium excretion, thereby reducing edema.
 Most diuretics are pregnancy category C agents
potassium-sparing diuretics
 HCl (Midamor), spironolactone (Aldactone), and triamterene (Dyrenium),
and the combination triamterene/hydrochlorothiazide (Dyazide)
 action on kidney tubules promotes potassium reabsorption.
 Potassium levels are still monitored
Beta ( ) Blockers
 Blood vessels contain adrenergic-blocking receptors, called alpha () and
beta () receptors.
 Stimulation of alpha receptors causes vasoconstriction and rising blood
pressure.
two types of beta receptors
 beta1 receptors - primarily located in the myocardium of the heart.
 The beta2 receptors - located in the bronchial tree and in the smooth
muscles of blood vessels.
 Stimulation of beta receptors causes vasodilation of arterioles supplying
these muscles.
specific 1-adrenergic blockers
 Because the heart has mainly beta1 receptors,
 pregnancy category C agents,
 are commonly used as first-line therapy for hypertension.
 They act directly to decrease heart rate by depressing atrioventricular
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node conduction and decreasing the strength of myocardial contraction.
 Thus, they decrease blood pressure.
Other beta blockers are type 2 blockers
 act primarily on the bronchial tree to relieve asthma and conditions such
as COPD (chronic obstructive pulmonary disease)
 Because nonspecific beta blockers can cause bronchospasm, clients with
asthma are given a cardioselective beta blocker, which acts only upon the
heart.
Examples of nonselective beta blockers
 Propranolol (Inderal) used to treat angina, HTN, arrhythmias, and migraine
 nadolol (Corgard) used to treat angina and arrhythmias; and
 timolol ophthalmic drops (Timoptic) used to treat glaucoma.
Cardioselective beta blockers include
 atenolol (Tenormin) and
 metoprolol (Lopressor).
Nursing Alert
 It is important to remember that most cardiac medications, particularly
the beta blockers, cannot be discontinued abruptly.
 This creates a high risk of rebound angina.
Calcium Channel Blockers
 pregnancy category C agents,
 inhibit or block movement of calcium ions across cell membranes,
reducing peripheral vascular resistance and resulting in lowered blood
pressure.
Diltiazem (Cardizem, Cardizem CD, Apo-Diltiaz [Can], Dilacor XR)
 is used to treat chronic hypertension.
 Route - oral and IV administration.
 Side effects - headache, fatigue, bradycardia, dizziness, and weakness.
Nifedipine (Procardia) and verapamil (Calan)
 are used to treat hypertension and angina.
 Verapamil is also used to treat arrhythmias.
Other calcium channel blockers include
 amlodipine (Norvasc),
 felodipine (Plendil), and
 nisoldipine (Sular).
Angiotensin-Converting Enzyme (ACE) Inhibitors
 reduce peripheral vascular resistance in the hypertensive client by blocking
the activation of angiotensin, a powerful vasoconstrictor.
 often used alone or in combination with thiazide diuretics.
 most widely prescribed antihypertensive agents.
Examples include
 captopril,
 enalapril, and
 Lisinopril (Prinivil, Zestril).
 ACE inhibitors are typically pregnancy category C or category D agents.
Nursing Alert
 An unrelenting cough is an undesirable side effect of the ACE inhibitors
and may require discontinuation of the medication
Angiotensin II Receptor Blockers (ARBs)
 selectively block the binding of angiotensin II to specific receptors in the
smooth muscle of the blood vessels and in the adrenal gland.
 This action blocks the vasoconstriction effect of the renin-angiotensin
system.
 are used in the treatment of HTN, alone or in combination with other
drugs.
 also used to treat heart failure and help reduce the risk of stroke.
examples
 candesartan cilexetil (Atacand),
 Eprosartan mesylate (Teveten),
 irbesartan (Avapro),
 losartan potassium (Cozaar), and
 valsartan (Diovan).
Miscellaneous Agents
Guanethidine monosulfate (Ismelin)
 is a potent antihypertensive used to treat chronic and renal hypertension.
 Side effects - orthostatic hypotension, dizziness, fainting, and bradycardia.
 Instruct clients to monitor their BP regularly and caution them to rise
slowly from the sitting position.
Methyldopa
 reduces blood pressure by lowering peripheral vascular resistance.
 This drug is pregnancy category B (oral) and category C (IV).
clonidine HCl (Apo- Clonidine [Can], Dixarit [Can], Catapres).
 may be used on a continuing basis or in a hypertensive emergency
 onset varies according to the route of administration
 FORMS- oral, transdermal, and epidural (applied to the dura mater of the
brain or spinal cord), with the epidural form having the fastest onset.
 has numerous off-label uses, such as smoking cessation, alcohol
withdrawal, opiate withdrawal, Tourette syndrome, migraine headaches,
attention-deficit hyperactivity disorder (ADHD), and hot flashes.
MEDICATIONS THAT AFFECT THE BLOOD
 Normally, a balanced diet provides essential iron and other nutrients
necessary for blood formation.
 Other medications and products also affect the blood, assisting in blood
clotting or preventing clots from forming and serving to replace blood
volume or components lost by events such as hemorrhage.
Epoetin alfa (erythropoietin)
 a glycoprotein that stimulates red blood cell production.
 indicated in the treatment of anemia in patients receiving chemotherapy
 and those with chronic renal failure
 ROUTES - IV and SQ
Iron Replacement Preparations
 The adult male needs only small amounts (15 mg) of daily iron intake.
 Premenopausal and pregnant women need up to four times as much iron
as men.
iron-deficiency anemia
FACTORS:
 inadequate intake of iron-rich foods
 many women need iron supplements, even with a healthy diet.
 Prolonged bleeding, such as seen with bleeding ulcers, excessive menstrual
bleeding, or injury resulting in hemorrhage, also can lead to iron-deficiency
anemia.
 pregnancy, because of increased demands by the fetus. Iron supplements
are commonly given as a routine prophylactic supplement during
pregnancy
Ferrous sulfate (Feosol)
 the most commonly used form of iron replacement therapy and is
available in tablets and liquid.
 Ferrous fumarate (Femiron, Hemocyte) also is available in chewable tablets.
 The liquid form is administered through a straw. Rationale: This helps to
prevent staining the teeth.
 Remind clients who take the nonchewable tablet form to swallow the
tablet whole to avoid the unpleasant taste and prevent tooth staining.
 Oral iron preparations can irritate gastric mucosa; they should be taken
with food.
 Some oral iron preparations are designed for slow absorption and cause
less gastric irritation.
 The addition of vitamin C aids in the absorption of iron; teach clients to
drink a glass of orange juice or take a vitamin C tablet, to increase
absorption.
Key Concept
 Iron preparations turn the stool black; alert the client to this normal side
effect.
iron dextran (DexFerrum),
 can be administered parenterally
 a pregnancy category B agent
 Because injectable iron is irritating to the tissues, it should be
administered using the Z-track method, deep into the muscle
 can also discolor the skin if administered superficially.
 administration over a prolonged period may cause appetite loss, nausea,
vomiting, headache, stomach pain, diarrhea, or constipation.
 Large doses can cause poisoning, especially in children.
 Symptoms of iron overdose include headache, fever, and urticaria (hives).
Vitamins
Folic acid (folacin, folate, Folvite)
 is indicated for clients with megaloblastic anemia, a condition
characterized by abnormal RBCs.
 stimulates production of RBCs and WBCs and is necessary for normal
maturation of RBCs.
 commonly prescribed in combination with vitamins and minerals before
conception and during early pregnancy to reduce the incidence of birth
defects in infants.
 has proved particularly effective in preventing neural tube (spinal cord)
defects.
 Routinely given to clients who abuse alcohol
Vitamin B12 (cyanocobalamin)
 necessary for the manufacture of erythrocytes and healthy nervous system
functioning
 absorbed in the small intestine
 cannot be absorbed without the presence of intrinsic factor, which the
stomach secretes
 Clients who lack intrinsic factor develop pernicious anemia.
 Injections of vitamin B12 (given deep IM) can help control pernicious
anemia.
 Vitamin B12 administration is not usually associated with undesirable side
effects.
Coagulants
Vitamin K
 a fat-soluble vitamin, is necessary for the formation of prothrombin, which
is essential for normal blood clotting.
 Vitamin K deficiency results in a tendency to hemorrhage.
 Several preparations of vitamin K are available.
 Phytonadione (Mephyton) is an emulsion of vitamin K available in tablet
form.
 used to control active haemorrhage
 Phytonadione injection (AquaMEPHYTON) is a colloidal solution of vitamin
K that may be administered parenterally, by the SQ, IM, or IV route
 Absorbable gelatin sponge (Gelfoam) is used as a packing to stop capillary
bleeding
 It can be left in a surgical wound, where it will be completely
absorbed.
 Oxidized cellulose (Oxycel) comes in the form of a treated cotton or gauze
pack that is absorbable and can be applied to check hemorrhage.
Anticoagulants
Anticoagulants
 increase the time it takes blood to coagulate.
 They are used to treat thrombophlebitis (blood clots), to prevent thrombus
formation after surgery, and to treat blood disorders in which blood
viscosity is abnormally high.
 Observe any client receiving anticoagulant therapy for evidence of
bleeding, including bleeding gums or unexplained bruising.
 Check the stool for occult (hidden) blood.
Heparin
 prevents platelets from attaching to the walls of blood vessels, the first
step in thrombus formation.
 useful in preventing postoperative thrombosis and embolism.
 administered SQ, most often in the abdominal area, or IV.
 Apply an ice pack to the area of administration 10 to 15 minutes before
injection.
 This causes vasoconstriction and decreases the possibility of
bleeding.
 Heparin is a pregnancy category C agent
Nursing Alert
 Do not aspirate when administering heparin and do not massage the area.
 Laboratory tests, specifically prothrombin time (PT), partial
thromboplastin time (PTT), and/or international normalized ratio (INR),
are obtained before beginning therapy and then used to monitor
effectiveness of anticoagulant therapy.
 measure the length of time it takes for the blood to clot.
 specific test needed will be determined by the primary provider,
depending on the medications being prescribed.
 For the client receiving heparin or any other “blood thinner,” check for
use of alternative therapies or herbal supplements.
 A number of these substances can interfere with blood clotting or
contribute to bleeding
Contraindications for Herbal/Dietary Supplements and
Complementary Therapies
 Angelica and Chinese angelica (dong quai), cat’s claw, chamomile,
chondroitin, feverfew, garlic, ginger, ginkgo, ginseng, goldenseal, grape seed
extract, green tea leaf, horse chestnut seed, ledum tincture, turmeric
 May contribute to bleeding tendencies, particularly if combined with oral
anticoagulants
 action - to interfere with heparin, leading to over heparinization (or over
anticoagulation) and bleeding.
 This is also true if the client regularly takes aspirin and, to a lesser degree,
nonsteroidal anti-inflammatory drugs NSAIDs) (e.g., ibuprofen).
 psyllium can block the absorption of anticoagulants, such as warfarin, and
of other medications, such as digoxin and lithium.
Warfarin sodium (Coumadin, Warfilone [Can])
 Anticoagulant used to treat venous thrombosis and pulmonary embolism.
 prevents thrombophlebitis by inhibiting synthesis of all types of
prothrombin
 FORM= tablets for oral administration, parenteral form for dilution in
sterile water.
 IV administration is used only when oral administration is not possible.
 Side effects = skin rash and potential for hemorrhage.
 Client and family teaching is important because clients are often sent
home on warfarin therapy.
 PT and/or PTT values are closely monitored.
 Warfarin is a pregnancy category D agent.
Low molecular weight heparins (LMWHs)
 Pregnancy category B agents
 injectable anticoagulants.
 indicated for prevention and treatment of deep venous thrombosis (DVT)
and pulmonary embolism.
 Specifically target certain clotting mechanisms and, thus, are effective in
preventing blood clots, with a lesser risk of hemorrhage than is associated
with heparin and warfarin.
 drugs of choice for postoperative prophylaxis after knee and hip
replacement surgery until the patient is able to switch to oral warfarin
 They are administered once or twice a day by SQ injection into the
abdomen.
 Local side effects following the SQ injection include mild irritation, pain,
hematoma, and erythema.
 Clients are often discharged from the hospital on this therapy, and must
be taught at the hospital to administer the SQ injection.
 Examples of LMWHs are enoxaparin (Lovenox) and dalteparin (Fragmin).
Nursing Alert
 Clients receiving any anticoagulant therapy should have regular PT or PTT
evaluations to ensure the blood is not becoming “over anticoagulated.”
 If the blood takes too long to clot, the anticoagulant dose is decreased.
 An order for the daily anticoagulant dose is written, based on the
outcome of daily blood tests.
 This may be written as a “sliding scale” dosage by the healthcare provider
for several days or may be ordered daily.