KNOW YOUR MEDS

A System for Safe Medication Administration

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„ Find medication information quickly

„ Make it patient-specific
„ Know what to monitor and why!

©2006 Ed4Nurses, Inc. All rights reserved

 Know Your Meds: A System for Safe Medication Administration
(Excerpt)
© 2006 Ed4Nurses, Inc.

The ABCs (D&N too) of Cardiac Drugs

Anti-arrhythmics, beta-blockers, calcium-channel blockers, diuretics, and nitrates are the
most commonly prescribed cardiac medications. Learn simple ways to remember their
actions.

The Basis of Cardiac Function: Hemodynamics

All nurses assess and treat hemodynamics! The idea that hemodynamics is only for the
ICU has kept many nurses from understanding what is really happening with their
patient’s cardiac function. Fortunately, hemodynamics concepts are not difficult to
understand; the terminology is just different from what we are accustomed to using.

The concepts of hemodynamics are the same as the concepts that you use everyday while
troubleshooting an IV pump. Fluid comes to the pump; in hemodynamic terms this is
called the load before the pump (preload). The pump itself has to be functioning well
(cardiac output) and it has to be plugged in to its energy source. The resistance the pump
has to pump against, the tubing, has to be as low as possible. On the IV pump we
decrease the load after the pump (afterload) by un-kinking the tubing. The tubing in the
body is the arterial vasculature.

The diagram below illustrates the three concepts of hemodynamics, their relationship to
the heart, and the factors that need to be manipulated in order to optimize hemodynamic
function.

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 Know Your Meds: A System for Safe Medication Administration
(Excerpt)
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Anti-arrhythmics
Electrical energy conducts through the heart by changing the flow of sodium, potassium,
and calcium in and out of heart cells. Manipulating the flow of these electrolytes will
change the conduction characteristics of the heart. Antiarrhythmics change electrical
conduction through the heart by manipulating electrolytes.

Class I Anti-arrhythmics: Na+ Channel Blockers

By blocking sodium influx into the cardiac cell, Class I anti-arrhythmics decrease the
speed of firing and reloading of the heart. These drugs work well in suppressing
ventricular arrhythmias. Some examples include: Lidocaine (Xylocaine), Flecainide
(Tambocor), Quinidine (Cardioquin), and Procainamide (Procan, Pronestyl).

It is necessary for sodium to rush into the cardiac cell in order to cause firing
(depolarization), and a risk of using Class I anti-arrhythmics is that sodium inflow will be
too slow and cause blocks in conduction (AV-blocks), or even asystole. Heart rate and
blood pressure should be monitored. Remember that in order for this medication to work
effectively, electrolytes levels have to be maintained in normal limits.

Beta-Blockers as Class II Anti-arrhythmics and Antihypertensives

Beta-blockers, as the name implies, block the beta adrenergic system. This is the
sympathetic nervous system (SNS), and is composed of both alpha and beta adrenergic
receptors. Most beta-blockers block both to some extent, with the intended result of
causing vasodilation and slowing the heart. These actions are helpful to overcome the
negative effects of the SNS in the patient with heart failure, but may lead to hypotension
and bradycardia. The major effects of the SNS are outlined below.

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 Know Your Meds: A System for Safe Medication Administration
(Excerpt)
© 2006 Ed4Nurses, Inc.

The SNS is helpful in increasing cardiac output in times of crisis (fight or flight
response). However, the SNS can be activated inappropriately in patients with cardiac
dysfunction due to a low cardiac output state; in this condition the SNS makes cardiac
output worse by increasing heart rate and causing vasoconstriction. It’s like turning up
the rate on the IV pump and kinking the tubing when the pump reads “low battery.” It
doesn’t help, and in fact makes the patient worse.

As an anti-arrhythmic, B-blockers decrease the automaticity of cardiac cells by

decreasing the SNS effect of cardiac stimulation. They are most effective against atrial
and supraventricular tachyarrhythmias where decreasing the automaticity of the SA and
AV nodes is effective in controlling the arrhythmia.

The sympathetic nervous system is also responsible for increasing blood glucose and
stimulating bronchodilation. Blocking the SNS can result in hypoglycemia in diabetics
and bronchoconstriction in asthmatics.

Examples of beta-blockers include: propanolol (Inderal), metoprolol (Lopresor), and

esmolol (Brevibloc).

Class III Anti-arrhythmics: K+ Channel Blockers

Potassium flows into the cardiac cells during the reloading (repolarization) process.
Blocking potassium channels slows the reloading process and decreases the rapid
ventricular response in life-threatening ventricular arrhythmias and refractory atrial
arrhythmias.

Slowing potassium influx into cardiac cells will cause the heart to slow and the strength
of contraction to diminish; these effects can worsen heart failure and cardiogenic shock.
Examples of Class III anti-arrhythmics include: amiodarone (Cordarone), and sotalol
(Betapace).

Amiodarone is considered to be superior to lidocaine or

bretylium in suppressing lethal ventricular arrhythmias.

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 Know Your Meds: A System for Safe Medication Administration
(Excerpt)
© 2006 Ed4Nurses, Inc.

Calcium-Channel Blockers as Class IV Anti-arrhythmics and

Antihypertensives
Calcium-channel blockers block calcium uptake into cells. Calcium is necessary for
contraction of the heart and blood vessels. Therefore, administering calcium-channel
blockers will lead to vasodilation and lowered blood pressure, and slowing of the heart
rate. Examples of Class IV antiarrhythmics include: diltiazem (Cardizem), and verapamil
(Isoptin, Calan).

Diuretics
Diuretics stimulate the kidneys to excrete more fluid by
wasting sodium. The kidneys also control electrolyte levels by
constant filtration. Giving diuretics will therefore cause
wasting of water and electrolytes.

The desired effects of diuretics are to decrease total water

volume in the body. A hemodynamic assessment must be
made on any patient to determine where the extra fluid is, and
how much is in excess. In addition, every attempt should be
made to keep intake from exceeding output that leads to fluid
overload again requiring more diuretic therapy.

Nitrates
Nitrates convert to nitrous oxide in the blood stream and cause a direct vasodilatory
effect. You can thin of them as being topical in their action. As nitrates flow through the
bloodstream, they cause an effect on the vasculature that leads to vasodilation. So
everywhere the nitrate goes, it does this. Nitrates are not selective, they will case
vasodilation everywhere.

Vasodilation will increase blood flow through atherosclerotic vessels and improve
perfusion to those areas, but may cause venous pooling of blood leading to hypotension
and decreased blood flow to the brain. Watch for hypotension, tachycardia, dizziness,
and syncope.

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 Know Your Meds: A System for Safe Medication Administration
(Excerpt)
© 2006 Ed4Nurses, Inc.

David’s Top 10 Resources:

1. The best way to get the most up-to-date information about your patient’s
medications is to use a Palm Pilot® equipped with drug reference software. See:
www.PDAs4Nurses.com for more information.
2. Use your “Know Your Meds” pocket reference at work, and get a few for your
colleagues at www.Ed4Nurses.com/products.htm
3. Stay up-to-date and get tips on how to prevent medication administration errors
by subscribing to the ISMP’s Medication Safety Alert at:
www.ismp.org/Newsletters/default.asp
4. Use a simple analogy to understand how hemodynamics affects all of your
patients. You can Understand Hemodymanics Today by using this program:
www.ed4nurses.com/hemotoday.htm
5. The National Coordinating Council for Medication Error Reporting and
Prevention (NCC MERP) is an independent group of 22 organizations dedicated
to reducing medication errors. Find out more at: www.nccmerp.org/
6. Get the latest information about managing your patient’s cardiac and pulmonary
conditions by using CardioPulmonary Update 2006. Find more information at:
www.ed4nurses.com/cp_update.htm
7. Check you patient’s medications against the Medscape Drug Interaction Checker
at: www.medscape.com/druginfo/druginterchecker?cid=med
8. Get evidence-based practice reviews and tips for FREE, subscribe to the Nurses’
NewsWire at: www.nurses-newswire.com
9. Learn more about the new ACLS and CPR guidelines from the American Heart
Association by reading the article in Circulation at:
http://circ.ahajournals.org/content/vol112/24_suppl/
10. Get everything you want out of your life and your career. Find out how to lead an
extraordinary life at www.Million-Dollar-Nurse.com

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