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Admitting Diagnosis: Acute Coronary Syndrome

Acute Coronary Syndrome(ACS) is a syndrome due to decreased blood flow in the coronary arteries
such that part of the heart muscle is unable to function properly or dies.

Cause/Etiology: Acute coronary syndrome is typically caused by coronary artery disease. Coronary
artery disease, also called heart disease, is caused by atherosclerosis, or hardening of the arteries.

Atherosclerosis causes a substance called plaque to build up in the coronary arteries. Plaque causes
angina by narrowing the arteries. The narrowing limits blood flow to the heart muscle. A heart attack
happens when blood flow is completely blocked.

Signs and Symptoms: The cardinal symptom of decreased blood flow to the heart is chest pain,
experienced as tightness around the chest and radiating to the left arm and the left angle of the jaw.
This may be associated with diaphoresis (sweating), nausea and vomiting, as well as shortness of breath.
In many cases, the sensation is "atypical", with pain experienced in different ways or even being
completely absent (which is more likely in female patients and those with diabetes). Some may report
palpitations, anxiety or a sense of impending doom (angor animi) and a feeling of being acutely ill.

Prevention: Acute coronary syndrome often reflects a degree of damage to the coronaries by
atherosclerosis. Primary prevention of atherosclerosis is controlling the risk factors: healthy eating,
exercise, treatment for hypertension and diabetes, avoiding smoking and controlling cholesterol levels;
in patients with significant risk factors, aspirin has been shown to reduce the risk of cardiovascular
events.

Medications:

Generic Name: Captopril


Brand Names: Capoten, Acepril, Ace-Bloc, Bloc-Med, Capomed, Capotec, Captogen, Captor, Captril, Cardiovaz
Classification: ACE Inhibitor
Pregnancy Category: D

Route: Oral
Preparations: 12.5, 25, 50, 100 mg

Indication: Captopril is used alone or in combination of other drugs for the management of hypertension. It is
also used in combination with other drugs in the treatment of heart failure after a heart attack. Also used to treat
kidney problems caused by diabetic nephropathy.

Contraindications: Allergy to other ACE inhibitors. Aortic stenosis, outflow obstruction, renovascular disease.
Pregnancy and Lactation. Caution in cases where patients also have Leukemia, COPD, renal or thyroid disease.

Action: Used to block the action of angiotensin converting enzyme (ACE) which is naturally produced in the body.
ACE produces angiotensin II which causes constriction and narrowing of the blood vessels thereby increasing blood
pressure. By blocking ACE, production of angiotensin II decreases allowing the blood vessels to relax and widen
resulting in decrease blood pressure.
Therapeutic Effect: Lowers blood pressure and increases blood and oxygen supply to the heart in patients with
hypertension. Decreases preload and afterload for patients with heart failure. Slows down or reduces progression of
blood vessels disease within the kidney caused by high blood pressure in patients with diabetic nephropathy.

Dosage: Hypertension: Initial dose of 12.5 mg twice a day, increase gradually at 2-4wk interval. Maintenance
dose of 25-50 mg twice a day, maximum of 50 mg thrice a day. Heart Failure: Initial dose of 6.25mg-12.5mg.
Maintenance dose of 25 or 50 mg bid, maximum dose of 50 mg tid.

Diabetic Nephropathy: 75-100mg daily in divided doses.

Pharmacokinetics:

Absorption: Rapidly absorbed (75%) from the GI tract. Food decreases absorption.
Distribution: Widely distributed but does not cross the blood brain barrier. Crosses the placenta, small amounts
enter breast milk.
Metabolism and Excretion: 50% metabolized by the liver. 50% excreted unchanged by the kidneys.

Pharmacodynamics:

Onset: 15- 60 min


Peak: 60-90 min
Duration: 6-12 hr
Side Effects: hypotension, dizziness, dry mouth, itching, sleep problems, rashes, diarrhea, constipation, hair loss,
dry irritating cough, changes in the way things taste, upset stomach, abdominal pain, shortness of breath,
agranulocytosis, neutropenia

Interactions: Additive hypotension with other antihypertensive, phenothiazines, acute ingestion of alcohol and
vasodilators. Hyperkalemia may result from concurrent use of potassium supplements or potassium-sparing
diuretics, Antihypertensive response may be blunted by non-steroidal anti-inflammatory agents. Absorption may be
decreased by antacids. Increases levels and may increase risk of digoxin or lithium toxicity. Probenecid decreases
elimination and increases levels of captopril. Risk of hypersensitivity reactions increased by concurrent use of
allopurinol.

Nursing Considerations

Monitor blood pressure and pulse frequently.


Monitor weight and assesses patient frequently for signs of fluid overload if with concurrent diuretic
therapy.
assessments of urine protein may be ordered. Proteinuria and nephrotic syndrome may occur with
therapy.
Monitor BUN, Crea and electrolyte levels periodically.
WBC should be monitored prior to therapy and periodically thereafter.
May cause false positive result for urine acetone
Patient/Family Health Teachings

Instruct patient to take captopril exactly as directed. Missed dose should be taken as soon as remembered
but not if almost time for next dose.
Do not double doses.
Instruct patient not to discontinue captopril therapy unless directed by health care provider.
Encourage patient to comply with additional interventions for hypertension.
Instruct patient and family on proper technique of blood pressure monitoring. Advice them to check blood
pressure at least weekly and to report any significant changes.
Caution patient to avoid foods containing high levels of sodium or potassium.
Advice patient that any changes in taste sensation will reverse itself within 8-12 weeks.
Instruct patient to change position slowly to minimize occurrence of orthostatic hypotension.
Advice patient that exercising in hot weather may increase hypotensive effect.
Instruct patient to consult with a health care provider before taking any over the counter medications or
cold remedies.
Advice patient of ingesting excessive amount of tea, coffee or cola.
Advice patient to avoid driving or other activities that require alertness until response to therapy is known.
Instruct patient to notify health care provider if rash, sore throat, fever, irregular heart beat, chest pain,
swelling of face, eyes, lips or tongue and difficulty of breathing occurs.
Emphasize importance of follow up examinations for monitoring purposes.

Generic Name:Omeprazole
Brand Name:Losec,Prilosec
Classifications:gastrointestinal agent; proton pump inhibitor
Pregnancy Category:C
Availability: 10 mg, 20 mg, 40 mg capsules

Actions
An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the
H+, K+-ATPase enzyme system [the acid (proton H+) pump] in the parietal cells.

Therapeutic effects
Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing.

Uses
Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis (4 to 8 wk
treatment). Long-term treatment of pathologic hypersecretory conditions such as Zollinger-Ellison syndrome,
multiple endocrine adenomas, and systemic mastocytosis. In combination with clarithromycin to treat duodenal
ulcers associated with Helicobacter pylori.

Contraindications
Long-term use for gastroesophageal reflux disease, duodenal ulcers; lactation.

Route & dosage

Gastroesophageal Reflux, Erosive Esophagitis, Duodenal Ulcer


adult: PO 20 mg once/d for 48 wk

Gastric Ulcer
adult: PO 20 mg b.i.d. for 48 wk
Hypersecretory Disease
adult:PO 60 mg once/d up to 120 mg t.i.d.

Duodenal Ulcer Associated with H. pylori


adult:PO 40 mg once/d for 14 d, then 20 mg/d for 14 d, in combination with clarithromycin 500 mg t.i.d. for 14 d

Administration

Oral
Give before food, preferably breakfast; capsules must be swallowed whole (do not open, chew, or crush).
Note: Antacids may be administered with omeprazole.

Adverse effects
CNS:Headache, dizziness, fatigue.
GI:Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests.
Urogenital:Hematuria, proteinuria.
Skin:Rash.

Nursing implications

Assessment & Drug Effects

Lab tests: Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged
use.
Patient & Family Education

Report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in
urine.
Report severe diarrhea; drug may need to be discontinued.
Do not breast feed while taking this drug.

Generic name: Aspirin


Brand name: Aspergum, Bayer, Easprin, Ecotrin, Empirin, Genprin, Halfprin, Norwich
Pregnancy Category: D
Drug Classes: Analgesic, Anti-inflammatory, Antiplatelet, Antipyretic, Antirheumatic, NSAID, Salicylate

Therapeutic actions:

1. Analgesic and antirheumatic- inhibits prostaglandin (an inflammatory mediator) synthesis


2. Antipyretic effect this action is not fully understood but drug study of aspirin is correlated with the
ability of the drug to act in the thermoregulatory center of the hypothalamus by blocking the
endogenous pyrogen through inhibiting synthesis of prostaglandin intermediary.
3. Antiplatelet aspirin drug study reveals the ability of the drug to inhibit thromboxame A2 (a potent
vasoconstrictor and inducer of platelet aggregation) synthesis
Indications:

1. Mild to moderate pain


2. Fever
3. Inflammatory conditions such as rheumatic fever, arthritis, and spondyloarthropaties
4. Reduction of risk of recurrent transient ischemic attack (precursor to stroke) or cardiovascular accident
(stroke) in patients with history of TIA due to fibrin platelet emboli or ischemic stroke
5. Unlabeled use: prophylaxis against cataract formation with long-term use
Contraindications and cautions:

1. People with allergy to salicylates or NSAIDs. This is more common to people with nasal polyps, asthma,
and chronic urticaria.
2. People with haemophilia, allergy to tartrazine (cross-sensitivity is common), bleeding ulcers, blood
coagulation defects, and with Vitamin K deficiency (increased risk of bleeding)
3. Caution with people who have impaired renal function, children and teenagers (risk for developing
Reyes Syndrom), patients who will have surgery within 1 week, and pregnant women (it readily
crosses placenta and is a possible teratogen) as well as lactating mothers.
Available forms:

1. tablets 81, 165, 325, 500, 650, 975 mg


2. Sustained release tablets 650, 800 mg
3. Gum tablets 227.5 mg
4. Suppositories 120, 200, 300, 600 mg
Dosages:
(Adults)

1. Ischemic stroke and TIA: 51-325 mg/day


2. Angina or recurrent myocardial infarction (MI): 75-325 mg/day
3. Suspected MI: 160-325 g as soon as possible; continue for 30 days
4. All forms of arthritis: 3g/ day in divided doses
5. Acute rheumatic fever: 5-8g/day
(Pediatric patients)

1. Analgesic and antipyretic: 10-15 mg/kg/dose every 4 hours, up to 60-80 mg/kg/day


Note: Do not give to patients with chickenpox and influenza symptoms as well as febrile children with signs and
symptoms of dehydration (e.g. increased thirst, irritability, dry skin and mucous membranes, etc).

Pharmacokinetics:

1. Oral route: onset 5-30 minutes; peak 15-120 minutes; duration 3-6 hours
2. Rectal route: onset 1-2 hrs; peak 4-5 hrs; duration 6-8 hours
Metabolism: Hepatic
Half-life: 15 minutes-12 hours
Distribution: Crosses placenta, enters breastmilk
Excretion: Urine

Side Effects and Adverse Reactions:

1. Acute aspirin toxicity respiratory alkalosis, hemorrhage, tachypnea, confusion, asterixis, pulmonary
edema, seizures, tetany, metabolic acidosis, renal and respiratory failure
2. Aspirin intolerance exacerbation of bronchospasm, rhinitis
3. Gastrointestinal: nausea, dyspepsia, heartburn, epigastric discomfort, anorexia, hepatotoxicity
4. Hematologic: occult blood loss, hemostatic defects
5. Hypersensitivity: anaphylactoid reactions to anaphylactic shock
6. Salicylism: dizziness, tinnitus, difficulty hearing, nausea, vomiting, diarrhea, mental confusion
Nursing Responsibilities:

Check and verify with doctors order and Kardex.


Observe rights in medication administration such as giving the right drug to the right patient using the
right route and at the right time.
Assess skin color and presence of lesions as this may indicate hepatotoxicity, allergy, bleeding, and other
complications.
Assess patients orientation to time and place as the drug may cause dizziness and confusion.
Give drug with food or after meal if GI upset occurs.
To reduce the risk of the tablet lodging in the esophagus, give drug with full glass of water.
Ensure that patient does not crush and chew tablets as well as sustained release preparations to prevent
losing drugs effectivity.
If aspirin has vinegar-like odor, do not use and dispose.
In case of overdose, institute emergency procedures and prepare equipments for gastric lavage, induction
of emesis, and activated charcoal.
Continue monitoring clotting factors, bleeding time, liver and renal function tests for long-term drug
therapy.
Observe patient for signs and symptoms of bleeding such as easy bruising, bleeding in the gums, and
nosebleeds.
Monitor vital signs.
Raise side rails up to ensure patients safety.
Monitor for signs and symptoms of drug allergy such as difficulty of breathing, pruritus, and rashes.
Provide a room environment conducive for resting.
Client and Family Teaching:

Instruct to keep drugs from children.


Instruct to avoid OTC drugs as many of those contain aspirin so serious overdose can occur.
Encourage client to ask for assistance when performing activities of daily living such as bathing because
this drug can cause dizziness and confusion.
In case of nausea and vomiting, instruct client to eat crackers and have carbonated drink before rising in
the morning.
Emphasize with the client to avoid or limit intake of highly-seasoned and oily food such as bacon and
canned goods as these can increase the risk of developing heartburn and nauseous feeling.
Instruct client to use soft-bristled toothbrush and electric razor to prevent bleeding.
Inform client that he or she will experience these common side effects: epigastric discomfort, nausea,
difficulty hearing, tinnitus or ringing in the ears, vomiting, and dizziness.
Instruct client to report bloody stools, rapid or difficult breathing, and confusion.
Encourage client to increase oral fluid intake to facilitate excretion of drug.
Instruct client to swallow drug whole and to take it with food to prevent GI upset and promote drug
effectivity.

Generic Name:Lactulose(laktyoo-lose)
Brand Name:Cephulac, Chronulac ,Movelax,Lilac
Classifications:gastrointestinal agent; hyperosmotic laxative
Pregnancy Category:C

Availability
10 g/15 mL solution, syrup

Actions
Reduces blood ammonia; appears to involve metabolism of lactose to organic acids by resident intestinal bacteria.

Therapeutic effects
Acidifies colon contents, which retards diffusion of nonionic ammonia (NH3) from colon to blood while promoting its
migration from blood to colon. In the acidic colon, NH3 is converted to nonabsorbable ammonium ions (NH4) and is
then expelled in feces by laxative action. Decreased blood ammonia in a patient with hepatic encephalopathy is
marked by improved EEG patterns and mental state (clearing of confusion, apathy, and irritation). Osmotic
effect of organic acids causes laxative action, which moves water from plasma to intestines, softens stools, and
stimulates peristalsis by pressure from water content of stool.

Uses
Prevention and treatment of portal-systemic encephalopathy (PSE), including stages of hepatic precoma and coma,
and by prescription for relief of chronic constipation.

Cautious use
Diabetes mellitus; concomitant use with electrocautery procedures (proctoscopy, colonoscopy); older adult and
debilitated patients; pediatric use.

Route & dosage

Prevention and Treatment of Portal-Systemic Encephalopathy


adult:PO 3045 mL t.i.d. or q.i.d. adjusted to produce 23 soft stools/d
child/adolescent: PO 4090 mL/d in divided doses adjusted to produce 23 soft stools/d
infant: PO 2.510 mL/d in 34 divided doses adjusted to produce 23 soft stools/d

Management of Acute Portal-Systemic Encephalopathy


adult: PO 3045 mL q12 h until laxation is achieved, then adjusted to produce 23 soft stools/d.
Rectal 300 mL diluted with 700 mL water given via rectal balloon catheter, and retained for 3060 min, may
repeat in 46 h if necessary or until patient can take PO

Chronic Constipation
adult:PO 3060 mL/d prn
child:PO 7.5 mL/d after breakfast

Administration

Oral

Give with fruit juice, water, or milk (if not contraindicated) to increase palatability. Laxative effect is
enhanced by taking with ample liquids. Avoid meal times.
Rectal

Administer as a retention enema via a rectal balloon catheter. If solution is evacuated too soon, instillation
may be promptly repeated.
Do not freeze. Avoid prolonged exposure to temperatures above 30C (86F) or to direct light. Normal
darkening does not affect action, but discard solution that is very dark or cloudy.
Adverse effects
GI:Flatulence,borborygmi,belching,abdominal cramps,pain,and distention (initial dose);diarrhea (excessive dose);
nausea, vomiting, colon accumulation of hydrogen gas; hypernatremia.

Nursing implications

Assessment & Drug Effects

In children if the initial dose causes diarrhea, dosage is reduced immediately. Discontinue if diarrhea
persists.
Promote fluid intake (>=15002000 mL/d) during drug therapy for constipation; older adults often self-
limit liquids. Lactulose-induced osmotic changes in the bowel support intestinal water loss and potential
hypernatremia. Discuss strategy with physician.
Patient & Family Education

Laxative action is not instituted until drug reaches the colon; therefore, about 2448 h is needed.
Do not self-medicate with another laxative due to slow onset of drug action.
Notify physician if diarrhea (i.e., more than 2 or 3 soft stools/d) persists more than 2448 h. Diarrhea is a
sign of overdosage. Dose adjustment may be indicated.
Do not breast feed while taking this drug without consulting physician.