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D.K. comes to the clinic with complaints of "dizzy spell and wheezing" His blood pressure is 86/50, pulse 46, and respirations 30. His acebutolol was stopped, and diltiazem, was ordered.

What are the correlations between D.K.'s dizziness, wheezing, and vital signs and propranolol? Explain your answer.

In what ways could diltiazem benefit D.K and what other drug regimen might be helpful to D.K.? What are the advantages and disadvantages of calcium channel blockers?

What are the nursing considerations and teaching for patients taking calcium channel blockers like diltiazem? Provide rationale for your answer.

D.K's friend was given alteplase in the emergency department while suffering from an acute myocardial infarction. D.K inquiries about why this drug was given to his friend. Explain why alteplase is given and how it works?

Explain some of the main concerns with the administration of thrombolytics.

Explanation / Answer

1. What are the correlations between D.K.'s dizziness, wheezing, and vital signs and propranolol? Explain your answer.

Asthma and other breathing problems: Propranolol and other beta-blockers may cause symptoms of asthma to worsen. Low doses of acebutolol may be used with caution by people with asthma who do not respond to or who cannot tolerate other treatment.

Heart failure: This medication may make the symptoms of congestive heart failure worse, by slowing down the heart rate and heartbeat strength. If you have congestive heart failure, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

2. In what ways could diltiazem benefit D.K and what other drug regimen might be helpful to D.K.?  

Diltiazem is a calcium channel blocker. It works by relaxing the muscles of your heart and blood vessels. Diltiazem is used to treat hypertension (high blood pressure), angina (chest pain), and certain heart rhythm disorders. Calcium-channel blockers, particularly diltiazem, may be used in cases of patients with pulmonary disease, being a simple, efficient and widely available alternative to control HR16. Calcium-channel blockers decrease conduction through the AV node and to a lesser extent, in the sinoatrial node. Due to this mechanism, they are the group of choice for pre-examination control of patients with atrial fibrillation. They do not induce bronchospasm, but have a less intense negative chronotropic effect. Among them, diltiazem should preferably be chosen, as it has a lower negative inotropic effect.

3. What are the advantages and disadvantages of calcium channel blockers?

Calcium channel blockers are recently developed antihypertensive drugs. In terms of mechanisms of action, their specificity is not so well established as that of angiotensin converting enzyme inhibitors but is better understood than that for diuretics or adrenergic-inhibiting drugs. Calcium channel blockers were originally developed for treatment of angina but were found to lower arterial pressure as well. Three of them are now in wide use in the United States; their therapeutic spectrum in regard to type of hypertension is broad. Sublingual nifedipine has replaced intravenously administered vasodilators as immediate treatment of severe hypertension, and all three drugs, given orally, have been shown to be effective in mild, moderate, and severe hypertension. The three drugs available in this country are verapamil, diltiazem, and nifedipine. Pharmacological studies have shown that verapamil has the most negative chronotropic and inotropic effects of the three, with nifedipine producing the most vasodilation and having the potential for causing reflex tachycardia. Actually in practice, these various pharmacological differences have proved to have less significance than previously thought, and the drugs seem to have about equal antihypertensive effectiveness. Comparisons of calcium entry blockers with other drugs have shown them to be equally effective in whites as propranolol but more effective in blacks. Responsiveness appears to be related, as well, to pre-treatment plasma renin activity and age. Thus, the antihypertensive effect is directly related to age and inversely related to plasma renin activity. The side effects mostly relate to vasodilation, reflex tachycardia, palpitations, headache, and edema; they are not frequent, and the drugs are well tolerated.

4. What are the nursing considerations and teaching for patients taking calcium channel blockers like diltiazem? Provide rationale for your answer.

Nursing Implications

Assessment & Drug Effects

• Check BP and ECG before initiation of therapy and monitor particularly during dosage adjustment period.

• Lab tests: Do baseline and periodic liver and renal function tests.

• Monitor for and report S&S of CHF.

• Monitor for headache. An analgesic may be required.

• Supervise ambulation as indicated.

Patient & Family Education

• Make position changes slowly and in stages; light-headedness and dizziness (hypotension) are possible.

• Do not drive or engage in other potentially hazardous activities until reaction to drug is known.

• Keep follow-up appointments and physician informed.

• Do not breast feed while taking this drug without consulting physician.

5. D.K's friend was given alteplase in the emergency department while suffering from an acute myocardial infarction. D.K inquiries about why this drug was given to his friend. Explain why alteplase is given and how it works?

Activase (alteplase) is an effective treatment for Acute Myocardial Infarction (AMI). Activase is indicated for use in acute myocardial infarction (AMI) for the reduction of mortality and reduction of the incidence of heart failure.

Administer as soon as possible after onset of symptoms. Recommended total dose for AMI is based on patient weight, not to exceed 100 mg, regardless of the selected administration regimen (accelerated or 3 hr)

Tissue type plasminogen activator is available, through recombinant technology, for thrombolytic use as alteplase. Alteplase is relatively clot specific and should cause less bleeding side effects than the non-specific agents such as streptokinase. Alteplase has been used successfully in evolving myocardial infarction (MI) to reopen occluded coronary arteries. It is probably equally effective or superior to streptokinase in opening arteries and reducing mortality in MI. Alteplase is most effective when given early in MI and is probably ineffective when given 12 h after the onset of symptoms. The effectiveness of alteplase in MI can be increased by front loading with a bolus of 15 mg, followed by an infusion of 50 mg over 30 min and 35 mg over 60 min. Percutaneous transluminal coronary angioplasty or stenting is associated with a greater patency and lower rates of serious bleeding, recurrent ischaemia and death than alteplase in MI and is likely to take over from alteplase as the standard MI treatment. A reduced dose of alteplase to increase coronary artery patency prior to angioplasty may be useful in MI. An exciting new indication for the use of alteplase is in stroke, where it has become the first beneficial intervention. Alteplase is used to reopen occluded cerebral vessels but is associated with an increased risk of intracerebral haemorrhage. Alteplase is beneficial if given within 3 h of the onset of stroke but not after this time period. Therefore, the next challenge is to increase the percentage of people being diagnosed and treated within this period. Clinical trials have not established a role for alteplase in the treatment of acute coronary syndromes or deep vein thrombosis. However, alteplase is useful in treating pulmonary thromboembolism and peripheral vascular disease.

6. Explain some of the main concerns with the administration of thrombolytics.

Understanding the clinical risks of intravenous thrombolytic therapy is critical to appropriate patient selection. The major risks can be classified into 5 major categories: intracranial hemorrhage, systemic hemorrhage, immunologic complications, hypotension, and myocardial rupture. Although theoretical concern exists about thromboembolic complications, they rarely occur. Although cardiac rhythm disturbances are somewhat more likely to occur at the time of reperfusion, the clinical significance of "reperfusion arrhythmias" is minimal. Intracranial hemorrhage, the most devastating complication, occurs in 0.2-1% of patients treated with thrombolytic therapy. Factors associated with incremental risk are now being identified from large clinical trials. Systemic hemorrhage is uncommon in patients without major vascular punctures and seldom leads to serious adverse outcomes. Immunologic complications--including anaphylaxis, which is rare, and immune complex disease, which is more common--occur only with streptokinase or agents with a streptokinase moiety, including anistreplase (anisoylated plasminogen--streptokinase activator complex, APSAC). Hypotension, which can be managed easily in most patients, is also observed much more frequently with streptokinase and anistreplase. Myocardial rupture is increasingly being recognized as a possible complication of late thrombolysis. A proper perspective on clinical risk can only be gained in the context of potential benefit of therapy. In many cases individual patients considered to be at highest risk for complications also stand to gain the most from treatment. Many of the questions raised by currently available data about bleeding risk are being addressed in the ongoing Global Utilization of t-PA and Streptokinase (GUSTO) Trial. A paradigm for considering this decision making problem is presented.

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