Brand Name: Inoxin
Generic Name: Digoxin
Classification: Cardiac Glycosides
Recommended Dosage, Route, and Frequency:
Digitalizing Dose Adult: PO 10–15 mcg/kg (1 mg)
in divided doses over 24–48 h IV 10–15 mcg/kg
(1 mg) in divided doses over 24 h
Child: PO/IV <2 y, 40–60 mcg/kg; 2–10 y, 20–40
mcg/kg; >10 y, 10–15 mcg/kg (1.5–2 mg)
Neonate: PO/IV 30–50 mcg/kg
Premature neonate: PO/IV 20 mcg/kg
Maintenance Dose Adult: PO/IV 0.1–0.375 mg/d
Child: PO/IV <2 y, 7.5–9 mcg/kg/d; 2–10 y, 6–7.5
mcg/kg/d; >10 y, 0.125–0.25 mg/d Neonate: 6–
7.5 mcg/kg/d Premature neonate: 3.75
mcg/kg/d
Drug Action: Increases the force of myocardial
contraction. Prolongs refractory period of the
AV node. Decreases conduction through the SA
and AV nodes.
Absorption: 60– 80% absorbed after oral
administration of tablets; 70– 85% absorbed
after administration of elixir; 80% absorbed
from IM sites (IM route not recommended due
to pain/irritation).
Distribution: Widely distributed; crosses
placenta and enters breast milk.
Metabolism & Excretion: Excreted almost
entirely unchanged by the kidneys.
Half-life: 36– 48 hr (qin renal impairment).
Onset: 30-120mins
Peak: 2-8hrs
Duration: 2-4days
Drug-Drug and Drug-Food Interaction:
Drug: ANTACIDS, cholestyramine, colestipol
decrease digoxin absorption; DIURETICS,
CORTICOSTEROIDS, amphotericin B, LAXATIVES,
sodium polystyrene sulfonate may cause
hypokalemia, increasing the risk of digoxin
toxicity; calcium IV may increase risk of
arrhythmias if administered together with
digoxin; quinidine, verapamil, amiodarone,
flecainide significantly increase digoxin levels,
and digoxin dose should be decreased by 50%;
erythromycin may increase digoxin levels;
succinylcholine may potentiate arrhythmogenic
effects; nefazodone may increase digoxin levels.
Herbal: Ginseng increase digoxin toxicity; ma
huang, ephedra may induce arrhythmias.
Indications: Heart failure. Atrial fibrillation and
atrial flutter (slows ventricular rate). Paroxysmal
atrial tachycardia.
Contraindications: Digitalis hypersensitivity,
ventricular fibrillation, ventricular tachycardia
unless due to CHF. Full digitalizing dose not
given if patient has received digoxin during
previous week or if slowly excreted cardiotonic
glycoside has been given during previous 2 wk.
Side/Adverse Effects:
CNS: Fatigue, muscle weakness, headache, facial
neuralgia, mental depression, paresthesias,
hallucinations, confusion, drowsiness, agitation,
dizziness.
CV: Arrhythmias, hypotension, AV block. Special
Senses: Visual disturbances.
GI: Anorexia, nausea, vomiting, diarrhea.
Other: Diaphoresis, recurrent malaise,
dysphagia.
Nursing Responsibilities
Assessment:
 Monitor apical pulse for 1 full min before
administering. Withhold dose and notify
health care professional if pulse rate is 60
bpm in an adult, 70 bpm in a child, or <90
bpm in an infant. Also notify health care
professional promptly of any significant
changes in rate, rhythm, or quality of pulse.
 Pedi: Heart rate varies in children
depending on age, ask physician to specify
at what heart rates digoxin should be
withheld.
 Monitor BP periodically in patients receiving
IV digoxin.
 Monitor ECG throughout IV administration
and 6 hr after each dose. Notify health care
professional if bradycardia or new
arrhythmias occur.
Potential Nursing Diagnoses:
 Decreased cardiac output
Implementation:
 High Alert: Digoxin has a narrow
therapeutic range. Medication errors
associated with digoxin include
miscalculation of pediatric doses and
insufficient monitoring of digoxin levels.
Have second practitioner independently
check original order and dose calculations.
Monitor therapeutic drug levels.
 For rapid digitalization, the initial dose is
higher than the maintenance dose; 50% of
the total digitalizing dose is given initially.
The remainder of the dose will be
administered in 25% increments at 4– 8 hr
intervals.
Evaluation/Desired Outcomes:
 Decrease in severity of HF.
 Increase in cardiac output
 Decrease in ventricular response in atrial
tachyarrhythmias.
Brand Name: Primacor  Monitor platelet count during therapy.
Generic Name: Milrinone lactate Potential Nursing Diagnoses:
Classification: Inotropic Agents/  Decreased cardiac output
Phosphodiesterase Inhibitors Implementation:
Recommended Dosage, Route, and Frequency:  High Alert: Accidental overdose of milrinone
Heart Failure can cause patient harm or death. Have
Adult: IV Loading Dose 50 mcg/kg IV over 10 min second practitioner independently check
IV Maintenance Dose 0.375–0.75 mcg/kg/min original order, dose calculations, and
Drug Action: Member of a class of infusion pump settings.
inotropic/vasodilator agents. Positive inotropic  IV Administration
action and vasodilator, with little chronotropic  pH: 3.2– 4.0.
activity; mode of action and structure are  Direct IV: Diluent: Loading dose may be
different from digitalis and catecholamines as administered undiluted. May also be
well as beta-adrenergic agonists. Inhibitory diluted in 0.9% NaCl, 0.45% NaCl, or
action against cyclic-AMP phosphodiesterase in D5W for ease of administration.
cardiac and smooth vascular muscle. Increases Concentration: 1 mg/mL. Rate:
cardiac contractility. Administer the loading dose over 10
Absorption: IV administration results in min.
complete bioavailability.  Continuous Infusion: Diluent: Milrinone
Distribution: Unknown. drawn from vials must be diluted.
Metabolism & Excretion: 80– 90% excreted Dilute 10 mg (10 mL) of milrinone in 40
unchanged by the kidneys. mL of diluent or 20 mg (20 mL) of
Half-life: 2.3 hr (Increase in renal impairment). milrinone in 80 mL of diluent.
Onset: Unknown Compatible diluents include 0.45%
Peak:2 min. NaCl, 0.9% NaCl, and D5W.
Duration:2 h. Evaluation/Desired Outcomes:
Drug-Drug and Drug-Food Interaction:
 Decrease in the signs and symptoms of
Drug: Disopyramide may cause excessive
HF.
hypotension.
 Improvement in hemodynamic
Indications:
parameters.
Short-term management of CHF.
Patient/Family Teaching
Contraindications:
 Inform patient and family of reasons
Hypersensitivity to milrinone.
for administration. Milrinone is not a
Side/Adverse Effects: CV: Increased ectopic
cure but is a temporary measure to
activity, PVCs, ventricular tachycardia,
control the symptoms of HF.
ventricular fibrillation, supraventricular
arrhythmias; possible increase in angina
symptoms, hypotension.
Nursing Responsibilities
Assessment:
 Monitor heart rate and BP continuously
during administration. Slow or discontinue
if BP drops excessively.
 Monitor intake and output and daily weight.
Assess patient for resolution of signs and
symptoms of HF (peripheral edema,
dyspnea, rales/crackles, weight gain) and
improvement in hemodynamic parameters
(increase in cardiac output and cardiac
index, decrease in pulmonary capillary
wedge pressure). Correct effects of
previous aggressive diuretic therapy to
allow for optimal filling pressure.
 Monitor ECG continuously during infusion.
Arrhythmias are common and may be life
threatening. The risk of ventricular
arrhythmias is increased in patients with a
history of arrhythmias, electrolyte
abnormalities, abnormal digoxin levels, or
insertion of vascular catheters.
Brand Name: Natrecor
Generic Name: Nesiritide
Classification: Atrial Natriuretic Peptide
hormones
Recommended Dosage, Route, and Frequency:
Acute Decompensated CHF Adult: IV 2 mcg/kg
bolus administered over 60 s, followed by a
continuous infusion of 0.01 mcg/kg/min (0.1
mL/kg/h) (max: 0.03 mcg/kg/min). Monitor
blood pressure closely. If hypotension occurs,
the dose should be reduced or discontinued.
The infusion can subsequently be restarted at a
dose that is reduced by 30% (with no bolus
administration) after stabilization of
hemodynamics.
Drug Action: Nesiritide is a human B-type
natriuretic peptide (hBNP), produced by
recombinant DNA, which mimics the actions of
human atrial natriuretic hormone (ANH). ANH is
secreted by the right atrium when atrial blood
pressure increases. Nesiritide, like ANH, inhibits
antidiuretic hormone (ADH) by increasing urine
sodium loss by the kidney and triggering the
formation of a large volume of dilute urine.
Absorption: IV administration results in
complete bioavailability.
Distribution: Unknown.
Metabolism & Excretion: Cleared from
circulation by binding to cell surface clearance
receptors resulting in cellular internalization and
proteolysis, proteolytic breakdown by
endopeptidases, and renal filtration.
Half-life: 18 min
Onset: 15 min
Peak: Unknown
Duration: >60 h depending on dose.
Drug-Drug and Drug-Food Interaction:
Drug: No interaction trials conducted. No
clinically significant interactions reported.
Indications:
Acute treatment of decompensated CHF in
patients who have dyspnea at rest or with
minimal activity.
Contraindications:
Hypersensitivity to nesiritide, patients with a
systolic blood pressure <90 mm Hg, cardiogenic
shock, patients with low cardiac filling
pressures, patients who should not receive
vasodilators, such as those with significant
valvular stenosis, restrictive or obstructive
cardiomyopathy, constrictive pericarditis,
pericardial tamponade; pregnancy (category C).
Side/Adverse Effects:
Body as a Whole: Headache, back pain, catheter
pain, fever, injection site pain, leg cramps. CNS:
Insomnia, dizziness, anxiety, confusion,
paresthesia, somnolence, tremor. CV:
Hypotension, ventricular tachycardia,
ventricular extrasystoles, angina, bradycardia,
tachycardia, atrial fibrillation, AV node
conduction abnormalities. GI: Abdominal pain,
nausea, vomiting. Respiratory: Cough,
hemoptysis, apnea. Skin: Sweating, pruritus,
rash. Special Senses: Amblyopia. Renal: Renal
failure in acutely decompensated heart failure
patients.
Nursing Responsibilities
Assessment:
 Monitor BP, pulse, ECG, respiratory rate,
cardiac index, PCWP, and central venous
pressure frequently during administration.
May cause hypotension, especially in
patients with a BP <100mm Hg. Reduce
dose or discontinue nesiritide if patient
develops hypotension.
 Monitor intake and output and weigh daily.
Assess for decrease in signs of HF(dyspnea,
rales/crackles, peripheral edema, weight
gain).
 Obtain history for reactions to recombinant
peptides; may increase risk of allergic
reaction.
Potential Nursing Diagnoses:
 Decreased cardiac output
 Activity intolerance
 Excess fluid volume
Implementation:
 High Alert: Intravenous vasoactive
medications have an increased potential for
causing harm. Have second practitioner
independently check original order, dose
calculations, and infusion pump settings.
Administer only in settings where BP can be
closely monitored.
 Prime the IV tubing with an infusion of 25
mL prior to connecting to the patient’s
vascular access port and prior to
administering bolus or infusion. Flush
catheter between administration of
nesiritide and other medications. Do not
administer through a central heparin-
coated catheter as nesiritide binds to
heparin. Concomitant administration of a
heparin infusion through a separate
catheter is acceptable.
IV Administration
 pH: 4.0– 6.0.
 Direct IV: Diluent: Reconstitute 1.5-mg
vial of nesiritide by adding 5 mL of diluent
removed from a pre-filled 250-mL plastic
IV bag containing D5W, 0.9% NaCl,
D5/0.45% NaCl, or D5/0.2% NaCl
Evaluation/Desired Outcomes:
 Improvement in dyspnea and reduction in
mean PCWP in patients with
decompensated HF.
Brand Name: Imdur
Generic Name: Isosorbide Mononitrate
Classification: Nitrates
Recommended Dosage, Route, and Frequency:
Acute Decompensated CHF Prevention of
Angina
Adult: PO Regular release (ISMO, Monoket) 20
mg b.i.d. 7 h apart; Sustained release (Imdur)
30–60 mg every morning, may increase up to
120 mg once daily after several days if needed
(max: dose 240 mg)
Drug Action:
Isosorbide mononitrate is a long-acting
metabolite of the coronary vasodilator
isosorbide dinitrate. It decreases preload as
measured by pulmonary capillary wedge
pressure (PCWP), and left ventricular end
volume and diastolic pressure (LVEDV), with a
consequent reduction in myocardial oxygen
consumption.
Absorption: Completely and rapidly absorbed
from GI tract; 93% reaches systemic circulation.
Distribution: Unknown.
Metabolism: Metabolized in liver by denitration
and conjugation to inactive metabolites
Excretion: Excreted primarily by kidneys.
Half-life: 4–5 h.
Onset: 1 h.
Peak: Regular release 30–60 min; sustained
release 3–4 h.
Duration: Regular release 5–12 h; sustained
release 12 h.
Drug-Drug and Drug-Food Interaction:
Drug: Alcohol may cause severe hypotension
and cardiovascular collapse. Aspirin may
increase nitrate serum levels. CALCIUM
CHANNEL BLOCKERS may cause orthostatic
hypotension.
Indications:
Prevention of angina. Not indicated for acute
attack
Contraindications:
Hypersensitivity to nitrates; severe anemia;
closed-angle glaucoma, postural hypotension,
head trauma, cerebral hemorrhage (increases
intracranial pressure). Safe use during
pregnancy [(category C) and (category B) for
sustained form] or lactation is not established.
Side/Adverse Effects:
CNS: Headache, agitation, anxiety, confusion,
loss of coordination, hypoesthesia, hypokinesia,
insomnia or somnolence, nervousness, migraine
headache, paresthesia, vertigo, ptosis, tremor.
CV: Aggravation of angina, abnormal heart
sounds, murmurs, MI, transient hypotension,
palpitations. Hematologic: Hypochromic
anemia, purpura, thrombocytopenia,
methemoglobinemia (high doses). GI: Nausea,
vomiting, dry mouth, abdominal pain,
constipation, diarrhea, dyspepsia, flatulence,
tenesmus, gastric ulcer, hemorrhoids, gastritis,
glossitis. Metabolic: Hyperuricemia,
hypokalemia. GU: Renal calculus, UTI, atrophic
vaginitis, dysuria, polyuria, urinary frequency,
decreased libido, impotence. Respiratory:
Bronchitis, pneumonia, upper respiratory tract
infection, nasal congestion, bronchospasm,
coughing, dyspnea, rales, rhinitis. Skin: Rash,
pruritus, hot flashes, acne, abnormal texture.
Special Senses: Diplopia, blurred vision,
photophobia, conjunctivitis.
Nursing Responsibilities
Assessment:
 Assess location, duration, intensity, and
precipitating factors of anginal pain.
 Monitor BP and pulse routinely during
period of dosage adjustment.
 Lab Test Considerations: Excessive doses
mayqmethemoglobin concentrations
Potential Nursing Diagnoses:
 Ineffective tissue perfusion
 Activity intolerance
Implementation:
 PO: Extended-release tablets should be
swallowed whole. Do not break, crush, or
chew.
Evaluation/Desired Outcomes:
 Decrease in frequency and severity of
anginal attacks.
 Increase in activity tolerance.
Patient/Family Teaching:
 Instruct patient to take medication as
directed, even if feeling better. Take missed
doses as soon as remembered; doses of
isosorbide dinitrate should be taken at least
2 hr apart (6 hr with extended-release
preparations); daily doses of isosorbide
mononitrate should be taken 7 hr apart. Do
not double doses. Do not discontinue
abruptly.
 Caution patient to make position changes
slowly to minimize orthostatic hypotension.
 May cause dizziness. Caution patient to
avoid driving or other activities requiring
alertness until response to medication is
known.
 Instruct patient to take last dose of day
(when taking 2– 4 doses/day) no later than
7 pm to prevent the development of
tolerance.
Brand Name: Inderal
Generic Name: Propranolol
Classification: Non-Selective Beta Blockers
Recommended Dosage, Route, and Frequency:
Hypertension
Adult: PO 40 mg b.i.d., usually need 160–480
mg/d in divided doses; InnoPran XL dose 80 mg
q hs, may increase to 120 mg hs Child: PO 1
mg/kg/d in 2 divided doses (1–5 mg/kg/d)
Neonate: PO 0.25 mg/kg q6–8h (max: 5
mg/kg/d) IV 0.01 mg/kg slow IV push over 10
min q6–8h prn (max: 0.15 mg/kg q6–8h)
Angina Adult: PO 10–20 mg b.i.d. or t.i.d., may
need 160–320 mg/d in divided doses
Arrhythmias
Adult: PO 10–30 mg t.i.d. or q.i.d. IV 0.5–3 mg
q4h prn Child: PO 1–4 mg/kg/d in 4 divided
doses (max: 16 mg/kg/d) IV 10–20 mcg/kg/min
over 10 min
Drug Action: Nonselective beta-blocker of both
cardiac and bronchial adrenoreceptors which
competes with epinephrine and norepinephrine
for available beta-receptor sites. In higher
doses, exerts direct quinidine-like effects, which
depresses cardiac function including
contractility and arrhythmias. Lowers both
supine and standing blood pressures in
hypertensive patients. Mechanism of
antimigraine action unknown but thought to be
related to inhibition of cerebral vasodilation and
arteriolar spasms.
A: Well absorbed but undergoes extensive first-
pass hepatic metabolism.
D: Moderate CNS penetration. Crosses the
placenta; enters breast milk.
Protein Binding: 93%.
M & E: Almost completely metabolized by the
liver.
Half-life: 3.4– 6 hr
Onset: 30mins.
Peak: 60-90mins.
Duration: 6-12hrs
Drug-Drug and Drug-Food Interaction:
Drug: PHENOTHIAZINES have additive
hypotensive effects. BETA-ADRENERGIC
AGONISTS (e.g., albuterol) antagonize effects.
Atropine and TRICYCLIC ANTIDEPRESSANTS
 High Alert: IV vasoactive medications are
block bradycardia. DIURETICS and other
HYPOTENSIVE AGENTS increase hypotension.
High doses of tubocurarine may potentiate
neuromuscular blockade. Cimetidine decreases
clearance, increases effects. ANTACIDS may
decrease absorption.
Indications:
Management of cardiac arrhythmias, myocardial
infarction, tachyarrhythmias associated with
digitalis intoxication, anesthesia, and
thyrotoxicosis, hypertrophic subaortic stenosis,
angina pectoris due to coronary atherosclerosis,
pheochromocytoma, hereditary essential
tremor; also treatment of hypertension alone,
but generally with a thiazide or other
antihypertensives.
Contraindications:
Greater than first-degree heart block; CHF, right
ventricular failure secondary to pulmonary
hypertension; ventricular dysfunction; sinus
bradycardia, cardiogenic shock, significant aortic
or mitral valvular disease; bronchial asthma or
bronchospasm, severe COPD, pulmonary
edema, allergic rhinitis during pollen season;
concurrent use with adrenergic-augmenting
psychotropic drugs or within 2 wk of MAO
inhibition therapy; abrupt discontinuation;
major depression; peripheral vascular disease,
Raynaud's disease; pregnancy (category C).
Side/Adverse Effects:
Body as a Whole: Fever; pharyngitis; respiratory
distress, weight gain, LE-like reaction, cold
extremities, leg fatigue, arthralgia, anaphylactic
Urogenital: Impotence or decreased libido. Skin:
Erythematous, psoriasis-like eruptions; pruritus,
Stevens-Johnson syndrome, Reversible alopecia,
hyperkeratoses of scalp, palms, feet; nail
changes, dry skin. CNS: depression, confusion,
agitation, giddiness, light-headedness, fatigue,
vertigo, syncope, weakness, drowsiness,
insomnia, vivid dreams, visual hallucinations,
delusions, reversible organic brain syndrome.
CV: Palpitation, profound bradycardia, AV heart
block, cardiac standstill, hypotension, angina
pectoris, tachyarrhythmia, acute CHF, peripheral
arterial insufficiency resembling Raynaud's
disease, myotonia, paresthesia of hands. Special
Senses: Dry eyes (gritty sensation), visual
disturbances, conjunctivitis, tinnitus, hearing
loss, nasal stuffiness.
Nursing Responsibilities
Assessment:
 Monitor BP and pulse frequently during
dose adjustment period and periodically
during therapy.
Potential Nursing Diagnoses:
 Decreased cardiac output
 Non-compliance
Implementation:
inherently dangerous. Before administering
intravenously, have second practitioner
independently check the original order, dose
calculations, and infusion pump settings.
Evaluation/Desired Outcomes:
 Decrease in BP.
 Control of arrhythmias without appearance
of detrimental side effects.
Brand Name: Cardiosel Nursing Responsibilities
Generic Name: Metoprolol Tartrate Assessment:
Classification: Selective Beta Blockers  Monitor BP, ECG, and pulse frequently
Recommended Dosage, Route, and Frequency: during dosage adjustment period and
Hypertension periodically throughout therapy.
Adult: PO 50–100 mg/d in 1–2 divided doses,  Monitor intake and output ratios and daily
may increase weekly up to 100–450 mg/d weights. Assess routinely for HF (dyspnea,
Geriatric: PO 25 mg/d (range: 25–300 mg/d) rales/crackles, weight gain, peripheral
Angina Pectoris Adult: PO 100 mg/d in 2 divided edema, jugular venous distention).
doses, may increase weekly up to 100–400 mg/d  Monitor frequency of prescription refills to
Myocardial Infarction Adult: IV 5 mg q2min for 3 determine adherence
doses, followed by PO therapy PO 50 mg q6h for Potential Nursing Diagnoses:
48 h, then 100 mg b.i.d.
 Decreased cardiac output
A: 50% of PO dose absorbed
 Non-compliance
D: Does not readily cross blood–brain barrier
Implementation:
M: No hepatic metabolism
 PO: Take apical pulse before administering
E: 40–50% excreted in urine; 50–60% excreted
drug. If 50 bpm or if arrhythmia occurs,
in feces
withhold medication and notify physician or
Half-life: 6–7 h.
other health care professional.
Onset: N/A
Evaluation/Desired Outcomes:
Peak: 2–4 h PO; 5 min IV
 Decrease in BP.
Duration: 24hrs
 Reduction in frequency of angina.
Drug-Drug and Drug-Food Interaction:
 Increase in activity tolerance.
Drug: Atropine and other ANTICHOLINERGICS
may increase atenolol absorption from GI tract;  Prevention of MI.
NSAIDS may decrease hypotensive effects; may
mask symptoms of a hypoglycemic reaction
induced by insulin, SULFONYLUREAS; may
increase lidocaine levels and toxicity;
pharmacologic and toxic effects of both atenolol
and verapamil are increased. Prazosin, terazocin
may increase severe hypotensive response to
first dose of atenolol.
Indications:
Management of hypertension as a single agent
or concomitantly with other antihypertensive
agents, especially a diuretic, and in treatment of
stable angina pectoris, MI.
Contraindications:
Sinus bradycardia, greater than first-degree AV
heart block, uncompensated heart failure,
cardiogenic shock, peripheral vascular disease,
Raynaud's disease, hypotension; abrupt
discontinuation, pulmonary edema. Safety
during pregnancy (category D), or lactation is
not established.
Side/Adverse Effects:
CNS: Dizziness, vertigo, light-headedness,
syncope, fatigue or weakness, lethargy,
drowsiness, insomnia, mental changes,
depression. CV: Bradycardia, hypotension, CHF,
cold extremities, leg pains, dysrhythmias. GI:
Nausea, vomiting, diarrhea. Respiratory:
Pulmonary edema, dyspnea, bronchospasm.
Other: May mask symptoms of hypoglycemia;
decreased sexual ability.
Brand Name: Diadipine Nursing Responsibilities
Generic Name: Amlodipine Assessment:
Classification: Calcium-Channel Blockers  Monitor BP and pulse before therapy,
Recommended Dosage, Route, and Frequency: during dose titration, and periodically
Hypertension Adult: PO 5–10 mg once daily during therapy. Monitor ECG periodically
Geriatric: Start with 2.5 mg, adjust dose at
during prolonged therapy.
intervals of not less than 2 wk
 Monitor intake and output ratios and daily
Hepatic Impairment Start with 2.5 mg, adjust
weight. Assess for signs of HF (peripheral
dose at intervals of not less than 2 wk
edema, rales/crackles, dyspnea, weight
Drug Action:
gain, jugular venous distention).
Amlodipine is a calcium channel blocking agent
that selectively blocks calcium ion reflux across  Angina: Assess location, duration, intensity,
cell membranes of cardiac and vascular smooth and precipitating factors of patient’s anginal
muscle without changing serum calcium pain.
concentrations. It predominantly acts on the  Lab Test Considerations: Total serum
peripheral circulation, decreasing peripheral calcium concentrations are not affected by
vascular resistance, and increases cardiac calcium channel blockers
output. Potential Nursing Diagnoses:
A: 50% of PO dose absorbed>90% absorbed  Ineffective tissue perfusion
from GI tract.  Acute pain
D:>95% protein bound. Implementation:
M: Extensively metabolized in the liver to  Do not confuse amlodipine with amiloride.
inactive metabolites. Do not confuse Norvasc with Navane.
E: Inactive metabolites primarily excreted in  PO: May be administered without regard to
urine (<5–10% excreted unchanged), 20–25% meals
excreted in feces Evaluation/Desired Outcomes:
Half-life: <45 y: 28–69 h; >60 y: 40–120 h  Decrease in BP.
Onset: Gradual.  Decrease in frequency and severity of
Peak: 6–9 h anginal attacks.
Duration: 24hrs  Decrease in need for nitrate therapy.
Drug-Drug and Drug-Food Interaction:  Increase in activity tolerance and sense of
Drug: Adenosine may increase the risk of well-being.
bradycardia; bosentan may decrease efficacy of
amlodipine; additive hypotensive effects with
other ANTIHYPERTENSIVE AGENTS; AZOLE
ANTIFUNGALS (e.g., fluconazole, itraconazole)
may inhibit metabolism of amlodipine;
itraconazole may increase edema. Food:
Grapefruit juice may increase amlodipine levels.
Herbal: Ephedra, Ma Huang, melatonin may
antagonize antihypertensive effects.
Indications:
Treatment of mild to moderate hypertension
and angina.
Contraindications:
Hypersensitivity to amlodipine; pregnancy
(category C).
Side/Adverse Effects:
CV: Palpitations, flushing tachycardia, peripheral
or facial edema, bradycardia, chest pain,
syncope, postural hypotension. CNS: Light-
headedness, fatigue, headache. GI: Abdominal
pain, nausea, anorexia, constipation, dyspepsia,
dysphagia, diarrhea, flatulence, vomiting.
Urogenital: Sexual dysfunction, frequency,
nocturia. Respiratory: Dyspnea. Skin: Flushing,
rash. Other: Arthralgia, cramps, myalgia.
Brand Name: Pronestyl nausea, vomiting, diarrhea, anorexia, (all mostly
Generic Name: Procainamide PO). Hematologic: Agranulocytosis with
Classification: Sodium Channel Blockers IA repeated use; thrombocytopenia. Body as a
Recommended Dosage, Route, and Frequency: Whole: Fever, muscle and joint pain,
Arrhythmias angioneurotic edema, myalgia, SLE-like
Adult: PO 1 g followed by 250–500 mg q3h or syndrome (50% of patients on large doses for 1
500 mg–1 g q6h sustained release (b.i.d. for y): Polyarthralgias, pleuritic pain, pleural
Procanbid) IM 0.5–1 g q4–6h until able to take effusion. Skin: Maculopapular rash, pruritus,
PO IV 100 mg q5min at a rate of 25–50 mg/min erythema, skin rash.
until arrhythmia is controlled or 1 g given, then Nursing Responsibilities
2–6 mg/min Assessment:
Child: PO 40–60 mg/kg/d divided q4–6h IV 3–6  Monitor ECG, pulse, and BP continuously
mg/kg q 10–30 min (max: 100 mg/dose), then throughout IV administration. Parameters
0.02–0.08 mg/kg/min should be monitored periodically during
Drug Action: oral administration.
Amide analog of procaine hydrochloride with  Lab Test Considerations: Monitor CBC every
cardiac actions similar to those of quinine. Class 2 wk during the first 3 mo of therapy.
IA antiarrhythmic agent. Depresses excitability Potential Nursing Diagnoses:
of myocardium to electrical stimulation, reduces  Decreased cardiac output.
conduction velocity in atria, ventricles, and His- Implementation:
Purkinje system. Increases duration of refractory
 IM: Used only when IV route is not feasible.
period, especially in the atria
IV Administration
A: 75–95% absorbed from GI tract.
 pH: 4.0– 6.0.
D: Distributed to CSF, liver, spleen, kidney,
 Direct IV: (only to be used for life-
brain, and heart; crosses placenta; distributed
threatening arrhythmias).Diluent: Dilute
into breast milk.
each 100 mg of procainamide with 10 mL of
M; Metabolized in liver to N-acetylprocainamide
0.9% NaCl. Rate: Not to exceed 25 mg/min.
(NAPA), an active metabolite (30–60%
Rapid administration may cause ventricular
metabolized to NAPA).
fibrillation or asystole.
E: Excreted in urine
Evaluation/Desired Outcomes:
Half-life: 3 h procainamide, 6 h NAPA
 Resolution of cardiac arrhythmias without
Onset: Unknown
detrimental side effects.
Peak: 15–60 min IM; 30–60 min PO
Duration: 3 h; 8 h with sustained release
Drug-Drug and Drug-Food Interaction:
Drug: Other ANTIARRHYTHMICS add to
therapeutic and toxic effects; ANTICHOLINERGIC
AGENTS compound anticholinergic effects;
ANTIHYPERTENSIVES add to hypotensive effects;
cimetidine may increase procainamide and
NAPA levels with increase in toxicity.
Indications:
Prophylactically to maintain normal sinus
rhythm following conversion of atrial flutter or
fibrillation by other methods. Also to prevent
recurrence of paroxysmal atrial fibrillation and
tachycardia, paroxysmal AV junctional rhythm,
ventricular tachycardia, ventricular and atrial
premature contractions. Also cardiac
arrhythmias associated with surgery and
anesthesia.
Contraindications:
Myasthenia gravis; hypersensitivity to
procainamide or procaine; blood dyscrasias;
complete AV block, second and third degree AV
block unassisted by pacemaker.
Side/Adverse Effects:
CNS: Dizziness, psychosis. CV: Severe
hypotension, pericarditis, ventricular fibrillation,
AV block, tachycardia, flushing. GI: Bitter taste,
Brand Name: Xylocaine
Generic Name: Lidocaine
Classification: Sodium Channel Blockers IB
Recommended Dosage, Route, and Frequency:
Ventricular Arrhythmias Adult: IV 50–100 mg
bolus at a rate of 20–50 mg/min, may repeat in
5 min, then start infusion of 1–4 mg/min
immediately after first bolus IM/SC 200–300 mg
IM, may repeat once after 60–90 min Child: IV
0.5–1 mg/kg bolus dose, then 10–50
mcg/kg/min infusion Anesthetic Uses
Adult: Infiltration 0.5–1% solution Nerve Block
1–2% solution Epidural 1–2% solution Caudal 1–
1.5% solution Spinal 5% with glucose Saddle
Block 1.5% with dextrose Topical 2.5–5% jelly,
ointment, cream, or solution Post-Herpetic
Neuralgia Adult: Topical Apply up to 3 patches
over intact skin in most painful areas once for
up to 12 h per 24 h period
Drug Action:
Similar to those of procainamide and quinidine,
but has little effect on myocardial contractility,
AV and intraventricular conduction, cardiac
output, and systolic arterial pressure in
equivalent doses. Exerts antiarrhythmic action
(Class IB) by suppressing automaticity in His-
Purkinje system and by elevating electrical
stimulation threshold of ventricle during
diastole. Action as local anesthetic is more
prompt, more intense, and longer lasting than
that of procaine.
A: Topical application is 3% absorbed through
intact skin.
D: Crosses blood–brain barrier and placenta;
distributed into breast milk.
M: Metabolized in liver
E: Excreted in urine
Half-life: 1.5–2 h
Onset: 45–90 sec IV; 5–15 min IM; 2–5 min
topical.
Peak: Unknown
Duration: 10–20 min IV; 60–90 min IM; 30–60
min topical; >100 min injected for anesthesia.
Drug-Drug and Drug-Food Interaction:
Drug: Lidocaine patch may increase toxic effects
of tocainide, mexiletine; BARBITURATES
decrease lidocaine activity; cimetidine, BETA
BLOCKERS, quinidine increase pharmacologic
effects of lidocaine; phenytoin increases cardiac
depressant effects; procainamide compounds
neurologic and cardiac effects.
Indications:
Rapid control of ventricular arrhythmias
occurring during acute MI, cardiac surgery, and
cardiac catheterization and those caused by
digitalis intoxication. Also as surface and
infiltration anesthesia and for nerve block,
including caudal and spinal block anesthesia and
to relieve local discomfort of skin and mucous
membranes. Patch for relief of pain associated
with post-herpetic neuralgia.
Contraindications:
History of hypersensitivity to amide-type local
anesthetics; application or injection of lidocaine
anesthetic in presence of severe trauma or
sepsis, blood dyscrasias, supraventricular
arrhythmias, Stokes-Adams syndrome,
untreated sinus bradycardia, severe degrees of
sinoatrial, atrioventricular, and intraventricular
heart block. Safe use during pregnancy
(category B), lactation, or in children is not
established.
Side/Adverse Effects:
CNS: Drowsiness, dizziness, light-headedness,
restlessness, confusion, disorientation,
irritability, apprehension, euphoria, wild
excitement, numbness of lips or tongue and
other paresthesias including sensations of heat
and cold, chest heaviness, difficulty in speaking,
difficulty in breathing or swallowing, muscular
twitching, tremors, psychosis. With high doses:
convulsions, respiratory depression and arrest.
CV: With high doses, hypotension, bradycardia,
conduction disorders including heart block,
cardiovascular collapse, cardiac arrest.
Nursing Responsibilities
Assessment:
 Antiarrhythmic: Monitor ECG continuously
and BP and respiratory status frequently
during administration.
 Anesthetic: Assess degree of numbness of
affected part.
 Transdermal: Monitor for pain intensity in
affected area periodically during therapy.
 Lab Test Considerations: Serum electrolyte
levels should be monitored periodically
during prolonged therapy.
Potential Nursing Diagnoses:
 Decreased cardiac output.
Implementation:
 High Alert:Lidocaine is readily absorbed
through mucous membranes.Inadvertent
overdosage of lidocaine jelly and spray has
resulted in patient harm or death from
neurologic and/or cardiac toxicity. Do not
exceed recommended doses.
 Throat Spray: Ensure that gag reflex is intact
before allowing patient to drink or eat
Evaluation/Desired Outcomes:
 Decrease in ventricular arrhythmias.
 Local anesthesia.
Brand Name: Tambocor (peripheral edema, rales/crackles, dyspnea,
Generic Name: Flecainide weight gain,jugular venous distention).
Classification: Sodium Channel Blockers IC  Lab Test Considerations: Evaluate renal,
Recommended Dosage, Route, and Frequency: pulmonary, and hepatic functions and CBC
Life-threatening Ventricular Arrhythmias periodically on patients receiving long-term
Adult: PO 100 mg q12h, may increase by 50 mg therapy. Flecainide should be discontinued
b.i.d. q4d (max: 400 mg/d) if bone marrow depression occurs.
Child: PO 1–3 mg/kg/d in 3 divided doses (max: Potential Nursing Diagnoses:
8 mg/kg/d)  Decreased cardiac output
Drug Action: Implementation:
Local (membrane) anesthetic and  Do not confuse Tambocor with Pamelor.
antiarrhythmic with electrophysiologic
 Previous antiarrhythmic therapy (except
properties similar to other class IC
lidocaine) should be withdrawn 2– 4 half-
antiarrhythmic drugs. Slows conduction velocity
lives before starting flecainide.
throughout myocardial conduction system,
 Therapy should be initiated in a hospital
increases ventricular refractoriness; little effect
setting to monitor for increase in
on repolarization. Prolongs His-ventricular (HQ)
arrhythmias.
and QRS intervals at therapeutic doses.
 Dose adjustments should be at least 4 days
A: Readily absorbed from GI tract.
apart because of the long half-life of
D: Crosses placenta; distributed into breast milk
flecainide.
M: Metabolized in liver
 PO: May be administered with meals if GI
E: Excreted mainly in urine
irritation becomes a problem.
Half-life: 7–22h
Evaluation/Desired Outcomes:
Onset: days
 Decrease in frequency of life-threatening
Peak: 2–3 h
ventricular arrhythmias.
Duration: 12hrs
 Decrease in supraventricular
Drug-Drug and Drug-Food Interaction:
tachyarrhythmias.
Drug: Cimetidine may increase flecainide levels;
may increase digoxin levels 15–25%; BETA
BLOCKERS may have additive negative inotropic
effects.
Indications:
Life-threatening ventricular arrhythmias.
Contraindications:
Hypersensitivity to flecainide; preexisting
second- or third-degree AV block, right bundle
branch block when associated with a left
hemiblock unless a pacemaker is present;
cardiogenic shock, significant hepatic
impairment. Safety during pregnancy (category
C), lactation, or in children <18 y is not
established.
Side/Adverse Effects:
CNS: Dizziness, headache, light-headedness,
unsteadiness, paresthesias, fatigue. CV:
Arrhythmias, chest pain, worsening of CHF.
Special Senses: Blurred vision, difficulty in
focusing, spots before eyes. GI: Nausea,
constipation, change in taste perception. Body
as a Whole: Dyspnea, fever, edema.
Nursing Responsibilities
Assessment:
 Monitor ECG or Holter monitor prior to and
periodically during therapy. May cause QRS
widening, PR prolongation, and QT
prolongation.
 Monitor BP and pulse periodically during
therapy.
 Monitor intake and output ratios and daily
weight. Assess patient for signs of HF
Brand Name: Inderal
Generic Name: Propranolol Hydrochloride
Classification: Class II Beta Adrenergic Blockers
Recommended Dosage, Route, and Frequency:
Hypertension
Adult: PO 40 mg b.i.d., usually need 160–480
mg/d in divided doses; InnoPran XL dose 80 mg
q hs, may increase to 120 mg hs Child: PO 1
mg/kg/d in 2 divided doses (1–5 mg/kg/d)
Neonate: PO 0.25 mg/kg q6–8h (max: 5
mg/kg/d) IV 0.01 mg/kg slow IV push over 10
min q6–8h prn (max: 0.15 mg/kg q6–8h)
Angina Adult: PO 10–20 mg b.i.d. or t.i.d., may
need 160–320 mg/d in divided doses
Arrhythmias
Adult: PO 10–30 mg t.i.d. or q.i.d. IV 0.5–3 mg
q4h prn Child: PO 1–4 mg/kg/d in 4 divided
doses (max: 16 mg/kg/d) IV 10–20 mcg/kg/min
over 10 min
Drug Action:
Nonselective beta-blocker of both cardiac and
bronchial adrenoreceptors which competes with
epinephrine and norepinephrine for available
beta-receptor sites. In higher doses, exerts
direct quinidine-like effects, which depresses
cardiac function including contractility and
arrhythmias. Lowers both supine and standing
blood pressures in hypertensive patients.
Mechanism of antimigraine action unknown but
thought to be related to inhibition of cerebral
vasodilation and arteriolar spasms.
A: Well absorbed but undergoes extensive first-
pass hepatic metabolism.
D: Moderate CNS penetration. Crosses the
placenta; enters breast milk.
Protein Binding: 93%.
M & E: Almost completely metabolized by the
liver.
Half-life: 3.4– 6 hr
Onset: 30mins.
Peak: 60-90mins.
Duration: 6-12hrs
Drug-Drug and Drug-Food Interaction:
Drug: PHENOTHIAZINES have additive
hypotensive effects. BETA-ADRENERGIC
AGONISTS (e.g., albuterol) antagonize effects.
Atropine and TRICYCLIC ANTIDEPRESSANTS
block bradycardia. DIURETICS and other
HYPOTENSIVE AGENTS increase hypotension.
High doses of tubocurarine may potentiate
neuromuscular blockade. Cimetidine decreases
clearance, increases effects. ANTACIDS may
decrease absorption.
Indications:
Management of cardiac arrhythmias, myocardial
infarction, tachyarrhythmias associated with
digitalis intoxication, anesthesia, and
thyrotoxicosis, hypertrophic subaortic stenosis,
angina pectoris due to coronary atherosclerosis,
pheochromocytoma, hereditary essential
tremor; also treatment of hypertension alone,
but generally with a thiazide or other
antihypertensives.
Contraindications:
Greater than first-degree heart block; CHF, right
ventricular failure secondary to pulmonary
hypertension; ventricular dysfunction; sinus
bradycardia, cardiogenic shock, significant aortic
or mitral valvular disease; bronchial asthma or
bronchospasm, severe COPD, pulmonary
edema, allergic rhinitis during pollen season;
concurrent use with adrenergic-augmenting
psychotropic drugs or within 2 wk of MAO
inhibition therapy; abrupt discontinuation;
major depression; peripheral vascular disease,
Raynaud's disease; pregnancy (category C).
Side/Adverse Effects:
Body as a Whole: Fever; pharyngitis; respiratory
distress, weight gain, LE-like reaction, cold
extremities, leg fatigue, arthralgia, anaphylactic
Urogenital: Impotence or decreased libido. Skin:
Erythematous, psoriasis-like eruptions; pruritus,
Stevens-Johnson syndrome, Reversible alopecia,
hyperkeratoses of scalp, palms, feet; nail
changes, dry skin. CNS: depression, confusion,
agitation, giddiness, light-headedness, fatigue,
vertigo, syncope, weakness, drowsiness,
insomnia, vivid dreams, visual hallucinations,
delusions, reversible organic brain syndrome.
CV: Palpitation, profound bradycardia, AV heart
block, cardiac standstill, hypotension, angina
pectoris, tachyarrhythmia, acute CHF, peripheral
arterial insufficiency resembling Raynaud's
disease, myotonia, paresthesia of hands. Special
Senses: Dry eyes (gritty sensation), visual
disturbances, conjunctivitis, tinnitus, hearing
loss, nasal stuffiness.
Nursing Responsibilities
Assessment:
 Monitor BP and pulse frequently during
dose adjustment period and periodically
during therapy.
Potential Nursing Diagnoses:
 Decreased cardiac output; Non-compliance
Implementation:
 High Alert: IV vasoactive medications are
inherently dangerous. Before administering
intravenously, have second practitioner
independently check the original order,
dose calculations, and infusion pump
settings
Evaluation/Desired Outcomes:
 Decrease in BP.
 Control of arrhythmias without appearance
of detrimental side effects.
Brand Name: Adenocard Other: Irritability in children.
Generic Name: Adenosine Nursing Responsibilities
Classification: Class III Drugs That Prolong Assessment:
Repolarization  Monitor heart rate frequently (every 15– 30
Recommended Dosage, Route, and Frequency: sec) and ECG continuously during therapy. A
Supraventricular Tachycardia
short, transient period of 1st-, 2nd-, or 3rd-
Adult: IV 6 mg rapid IV bolus (over 1–2 s); may
degree heart block or asystole may occur
repeat in 1–2 min with 12 mg IV push, 2 times
(total of 3 doses with max: 12 mg dose) following injection; usually resolves quickly
Neonate/Infant/Child: IV 0.05 mg/kg; may due to short duration of adenosine. Once
increase dose by 0.05 mg/kg q2 min (max: 0.25 conversion to normal sinus rhythm is
mg/kg/dose or 12 mg/dose) achieved, transient arrhythmias (premature
Stress Thallium Test ventricular contractions, atrial premature
Adult: IV 140 mcg/kg/min x 6 min (max: 0.84 contractions, sinus tachycardia, sinus
mg/kg total dose) bradycardia, skipped beats, AV nodal block)
Drug Action: may occur, but generally last a few seconds.
Slows conduction through the atrioventricular  Monitor BP during therapy.
(AV) and sinoatrial (SA) nodes. Can interrupt the  Assess respiratory status (breath sounds,
reentry pathways through the AV node. rate) following administration. Patients with
Depresses left ventricular function, but effect is history of asthma may experience
transient due to short half-life. bronchospasm.
A: Rapid uptake by erythrocytes and vascular Potential Nursing Diagnoses:
endothelial cells after IV administration.  Decreased cardiac output
D: Taken up by erythrocytes and vascular Implementation:
endothelium IV Administration
M: Rapid uptake into cells; degraded by  pH: 4.5– 7.5.
deamination to inosine, hypoxanthine, and
 IV: Crystals may occur if adenosine is
adenosine monophosphate
refrigerated. Warm to room temperature to
E: Route of elimination unknown
dissolve crystals. Solution must be clear
Half-life: 10 s
before use. Do not administer solutions that
Onset: 20–30 s
are discolored or contain particulate
Peak: Unknown
matter. Discard unused portions.
Duration: 1-2mins.
 Direct IV: Diluent: Administer undiluted.
Drug-Drug and Drug-Food Interaction:
Concentration: 3 mg/mL. Rate: Administer
Drug: Dipyridamole can potentiate the effects of
over 1– 2 seconds via peripheral IV as
adenosine; theophylline will block the
proximal as possible to trunk. Slow
electrophysiologic effects of adenosine;
administration may cause increased heart
carbamazepine may increase risk of heart block.
rate in response to vasodilation. Follow
Indications:
each dose with 20 mL rapid saline flush to
Conversion to sinus rhythm of paroxysmal
ensure injection reaches systemic
supraventricular tachycardia (PSVT) including
circulation.
PSVT associated with accessory bypass tracts
Evaluation/Desired Outcomes:
(Wolff-Parkinson-White syndrome). "Chemical"
 Conversion of supraventricular tachycardia
thallium stress test.
to normal sinus rhythm.
Contraindications:
 Diagnosis of myocardial perfusion defects
AV block, preexisting second- and third-degree
heart block or sick sinus rhythm without
pacemaker, since a heart block may result. Also
contraindicated in atrial flutter, atrial fibrillation,
and ventricular tachycardia because the drug is
ineffective.
Side/Adverse Effects:
CNS: Headache, lightheadedness, dizziness,
tingling in arms (from IV infusion),
apprehension, blurred vision, burning sensation
(from IV infusion). CV: Transient facial flushing,
sweating, palpitations, chest pain, atrial
fibrillation or flutter. Respiratory: Shortness of
breath, transient dyspnea, chest pressure. GI:
Nausea, metallic taste, tightness in throat.