Myocardial Infarction (MI)

Heart Attack

PRESENTED BY:

ANCHOS, MADELAINE G.CAPISTRANO, CRYSTAL ROSEDELOS REYES, MELISSA ASHLYN T.

Myocardial Infarction (MI)

▪ is the medical term for an event commonly known as a heart attack

▪ It happens when blood stops flowing properly to part of the heart and the heart muscle is injured due to not enough oxygen.

▪ Usually this is because one of the coronary arteries that supplies blood to the heart develops a blockage due to an unstable buildup of  white blood cells, cholesterol and fat. 

▪ The event is called "acute" if it is sudden and serious.

Myocardial Infarction (MI)

▪ A person having an acute myocardial infarction usually has sudden chest pain that is felt behind the breast bone and sometimes travels to the left arm or the left side of the neck.

▪ Additionally, the person may have shortness of breath, sweating, nausea, vomiting, abnormal heartbeats, and anxiety. 

▪ The anxiety is often described as a "sense of impending doom."

▪ Women experience fewer of these symptoms than men, but usually have shortness of breath, weakness, a feeling of indigestion, and fatigue.

Myocardial Infarction (MI)

▪ In many cases, in some estimates as high as 64 percent, the person does not have chest pain or other symptoms.

▪ These are called “silent” myocardial infarctions. Important risk factors are previous cardiovascular disease, old age, tobacco smoking, high blood levels of certain

lipids (low-density lipoprotein cholesterol, triglycerides) and low

levels of high density lipoprotein

(HDL) cholesterol, diabetes, high blood pressure, lack of physical

activity, obesity, chronic kidney disease, excessive alcohol consumption, the use of illicit drugs

(such as cocaine and

amphetamines), and chronic high stress levels.

Myocardial Infarction (MI)

▪ The two main ways to determine if a person has had a myocardial infarction are an electrocardiograms(ECGs) that trace the electrical signals in the heart and testing the blood for substances associated with damage to the heart muscle. Common blood tests are creatinekinase (CK-MB) and troponin. ECG testing is used to differentiate between two types of myocardial infarctions based on the shape of the tracing. When the ST section of the tracing is higher than the baseline it is called an ST-elevation myocardial infarction (STEMI) which usually requires more aggressive treatment. Immediate treatments for a suspected myocardial infarction include aspirin, which prevents further blood from clotting, and sometimes nitroglycerin to treat chest pain and oxygen.

▪ STEMI is treated by restoring circulation to the heart, called reperfusion therapy, and typical methods are angioplasty where the arteries are pushed opened and thrombolysis where the blockage is removed using medications.

Myocardial Infarction (MI)

▪ Non-ST elevation myocardial infarction (NSTEMI) may be managed with medication, although angioplasty may be required if the person is considered to be at high risk.▪ People who have multiple blockages of their

coronary arteries, particularly if they also have diabetes, may also be treated with bypass surgery (CABG).▪  Ischemic heart disease, which includes myocardial

infarction, angina and heart failure when it happens after myocardial infarction, was the leading cause of death for both men and women worldwide in 2011.

LABORATORY WORKS : Exercise Stress Test

▪ Determine the amount of stress that your heart can manage:▪ before developing either an abnormal

rhythm ▪ or evidence of ischemia

A physician may recommend an exercise stress test for various reasons:

▪ diagnose coronary artery disease ▪ diagnose a possible heart-related cause of

symptoms▪ To determine a safe level of exercise ▪ To check the effectiveness of procedures done ▪ To predict risk of dangerous heart-related

conditions such as a heart attack. ▪ effectiveness of medications to control angina

and ischemia.

Types of Stress Tests

▪ Dobutamine or Adenosine Stress Test: ▪ used in people who are unable to exercise. ▪ heart respond as if the person were exercising. ▪ no exercise is required.

▪ Stress echocardiogram: ▪ An echocardiogram (often called "echo") is a graphic outline

of the heart's movement. ▪ accurately visualize the motion of the heart's walls and

pumping action when the heart is stressed▪ Nuclear stress test: ▪ determine which parts of the heart are healthy and function

normally and which are not. ▪ radioactive substance is injected into the patient. ▪ These pictures are done both at rest and after exercise. ▪ a less than normal amount of thallium will be seen in those

areas of the heart that have a decreased blood supply.

Holter monitoring

▪ continuous monitoring of the electrical activity of a patient's heart muscle (electrocardiography) for 24 hours, ▪ special portable

device called a Holter monitor.

TROPONIN T AND I

▪ These isoforms are very specific for cardiac injury▪ Preferred markers for

detecting myocardial cell injury▪ Rise 2-6 hours after

injury Peak in 12-16 hours Stay elevated for 5-14

days

Creatinine Kinase ( CK-MB)

▪ Creatinine Kinase is found in heart muscle (MB), skeletal muscle (MM), and brain (BB)

▪ Increased in over 90% of myocardial infraction▪ However, it can be increased in muscle trauma, physical exertion,

post-op, convulsions, and other conditions▪ Time sequence after myocardial infarction Begins to rise 4-6 hours Peaks 24 hours returns to normal in 2 days▪ MB2 released from heart muscle and converted to MB1.▪ A level of MB2 > or = 1 and a ratio of MB2/MB1 > 1.5 indicates

myocardial injury

Myoglobin

▪ Damage to skeletal or cardiac muscle release myoglobin into circulation▪ Time sequence after infarction Rises fast 2hours Peaks at 6-8 hours Returns to normal in 20-36 hours▪ Have false positives with skeletal muscle injury and

renal failure

Renal Failure and Renal Transplantation

▪ Diagnostic accuracy of serum markers of cardiac injury are altered in patients with renal failure▪ Cardiac troponins decreased diagnostic

sensitivity and specificity in patients receiving renal replacement therapy▪ Current data show levels of troponin I are

unaltered while levels of troponin T may be elevated

CBC

▪ CBC is indicated if anemia is suspected as precipitant

▪ Leukocytosis may be observed within several hours after myocardial injury and returns returns to levels within the reference range within one week

Chemistry Profile

▪ Potassium and magnesium levels should be monitored and corrected

▪ Creatinine levels must be considered before using contrast dye for coronary angiography and percutanous revascularization

C-reactive Protein (CRP)

▪ C- reactive protein is a marker of acute inflammation

▪ Patients without evidence of myocardial necrosis but with elevated CRP are at increased risk of an event

Chest X-Ray

▪ Chest radiography may provide clues to an alternative diagnosis ( aortic dissection or pneumothorax)

▪ Chest radiography also reveals complications of myocardial infarction such as heart failure

▪ Radiologic Findings Chest X-Ray▪ Normal▪ Cardiomegaly▪ Signs of CHF

Echocardiography

▪ Use 2-dimentional and M mode echocardiography when evaluating overall ventricular function and wall motion abnormalities

▪ Echocardiography can also identify complications of MI ( eg. Valvular or pericardial effusion, VSD)

Electrocardiogram

▪ A normal ECG does not exclude ACS▪ High probability include

ST segment elevation in two contiguous leads or presence of q waves ▪ Intermediate probability

ST depression▪ T wave inversions are

less specific

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

DRUG ANALYSISNAME OF

DRUGACTION INDICATOR ADVERSE

REACTIONNURSING

RESPONSIBILITY

PropranololHydrochloride

Through beta-blocking action, propranolol:

• prevents arterial dilation and inhibitsrenin secretion, resulting in decreasedblood pressure (in hypertension andpheochromocytoma) and relief ofmigraine headaches

• decreases heart rate, which helps resolveTachyarrhythmias

To manage hypertension

E.R. TABLETSAdults. Initial: 80 mg daily, increased graduallyup to 160 mg daily Maximum: 640 mgdaily.876 propranolol hydrochlorideXL TABLETS (INNOPRAN XL)Adults. Initial: 80 mg once daily at bedtime,increased, as needed, to 120 mg oncedaily at bedtime.

CNS: Anxiety, depression, dizziness, drowsiness,fatigue, fever, insomnia, lethargy,nervousness, weakness

CV: AV conduction disorders, cold limbs,heart failure, hypotension, sinus bradycardia

EENT: Dry eyes, laryngospasm, nasal congestion,pharyngitis

• Use propranolol cautiously in patientswith bronchospastic lung disease becauseit may induce asthmatic attack.

•Monitor blood pressure, apical and radialpulses, fluid intake and output, dailyweight, respiration, and circulation inextremities before and during therapy.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY• improves myocardial contractility, whichhelps ease symptoms of hypertrophic cardiomyopathy

• decreases myocardial oxygen demand,which helps prevent anginal pain anddeath of myocardial tissue. In addition, peripheral beta-adrenergicblockade may play a role in propranolol’sability to alleviate tremor.

ORAL SOLUTION, TABLETSAdults. Initial: 40 mg b.i.d., increased graduallyto 120 to 240 mg daily, as needed.Maximum: 640 mg daily.Children. Initial: 0.5 to 1 mg/kg daily individed doses b.i.d. to q.i.d., adjusted asneeded. Maintenance: 2 to 4 mg/kg daily individed doses b.i.d.

To treat chronic anginaE.R. TABLETSAdults. Initial: 80 mg daily, increased every

GI: Abdominal pain, constipation, diarrhea,nausea, vomiting

GU: Impotence, peyronie’s disease, sexualdysfunction

HEME: Agranulocytosis

MS: Muscle weakness

RESP: Bronchospasm, dyspnea, respiratorydistress, wheezing

• Give I.V. injection at no more than 1 mg/minute.

WARNING Monitor ECG continuously, asordered, when giving I.V. injection. Haveemergency drugs and equipment availablein case of hypotension or cardiac arrest

• Protect injection solution from light..

• Because drug’s negative inotropic effectcan depress cardiac output, monitor cardiacoutput in patients

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY3 to 7 days, as prescribed. Maximum:320 mg/day.ORAL SOLUTION, TABLETSAdults. 80 to 320 mg daily in divided dosesb.i.d., t.i.d., or q.i.d.

To treat supraventricular arrhythmiasand ventricular tachycardiaORAL SOLUTION, TABLETSAdults. 10 to 30 mg t.i.d. or q.i.d., adjustedas needed.

SKIN: Alopecia, erythema multiforme,erythematous rash, exfoliative dermatitis,psoriasiform rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticaria

Other: Anaphylaxis, flulike symptoms, systemiclupuslike reaction

with heart failure.,particularly those with severely compromisedleft ventricular dysfunction.

• Be aware that propranolol can mask tachycardiain hyperthyroidism and that abruptwithdrawal in patients with hyperthyroidismor thyrotoxicosis can cause thyroidstorm.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYI.V. INJECTIONAdults. 1 to 3 mg at a rate not to exceed1 mg/min; repeated after 2 min and againafter 4 hr, if neededChildren. 0.01 to 0.1 mg/kg at a rate not toexceed 1 mg/min; repeated every 6 to 8 hr,as needed. Maximum: 1 mg/dose.

To control tremorORAL SOLUTION, TABLETSAdults. Initial: 40 mg b.i.d., adjusted asneeded and prescribed. Maximum: 320 mgdaily.

•Monitor diabetic patient taking an antidiabeticbecause propranolol can prolonghypoglycemia or promote hyperglycemia.It also can mask signs of hypoglycemia,especially tachycardia, palpitations, and tremor, but it doesn’t suppress diaphoresisor hypertensive response to hypoglycemia.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY To prevent vascular migraine headachesE.R. TABLETSAdults. Initial: 80 mg daily, increased gradually,as needed. Maximum: 240 mg daily.ORAL SOLUTION, TABLETSAdults. Initial: 20 mg q.i.d., increased gradually,as needed. Maximum: 240 mg daily.

As adjunct to treat hypertrophic cardiomyopathyORAL SOLUTION, TABLETSAdults. 20 to 40 mg t.i.d. or q.i.d.,

WARNING Be aware that stopping drugabruptly may cause myocardial ischemia,MI, ventricular arrhythmias, or severehypertension, especially in patients withcardiac disease. It also m increasedintraocular pressure to return. Dosageshould be reduced gradually.ay cause

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYadjustedas needed.

As adjunct to manage pheochromocytomaORAL SOLUTION, TABLETSAdults. For operable tumors, 20 mg t.i.d. to40 mg t.i.d. or q.i.d. for 3 days before surgery,concurrently with an alpha blocker.For inoperable tumors, 30 to 160 mg dailyin divided doses.

To prevent MIORAL SOLUTION, TABLETSAdults. 180 to 240 mg daily in divideddoses.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY

Metoprolol Inhibits stimulation of beta1-receptor sites,located mainly in the heart, resulting indecreased cardiac excitability, cardiac output,and myocardial oxygen demand.

DOSAGEADJUSTMENT Dosage increased ordecreased for elderly patients, depending onsensitivity to propranolol.

Route: P.O. Onset: UnknownPeak: 1–1.5hr*Duration: Unknown

To manage hypertension, alone or withother antihypertensivesE.R. TABLETS (METOPROLOL SUCCINATE)Adults. Initial: 25 to 100 mg daily, adjusted weekly as prescribed.

CNS: Anxiety, confusion, depression, dizziness,drowsiness, fatigue, hallucinations,headache, insomnia, weaknessCV: Angina, arrhythmias (including AVblock and

• Use metoprolol with extreme caution inpatients with bronchospastic disease whodon’t respond to or can’t tolerate otherantihypertensives. Expect to give smaller

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYTheseeffects help relieve angina.Metoprolol alsohelps reduce blood pressure by decreasingrenal release of renin.

Maximum: 400 mgdaily.E.R. TABLETS (METOPROLOL TARTRATE)Adults.Maintenance: 100 to 400 mg dailyto maintain blood pressure control aftertherapeutic level has been achieved withimmediate-release tablets.TABLETS (METOPROLOL TARTRATE)Adults. Initial: 100mg daily, adjustedweeklyas prescribed. Maximum: 450 mg daily asa single dose or in divided doses.

bradycardia), chest pain,decreased HDL levelincreased triglyceridelevels, gangrene of extremity, heart failure,hypertension, orthostatic hypotension

EENT: Nasal congestion, rhinitis, taste disturbance

GI: Constipation, diarrhea, hepatitis, nausea,Vomiting

GU: Impotence

HEME: Leukopenia, thrombocytopenia

doses more often to avoid the higher plasmalevels in longer dosage intervals.

• Use cautiously in patients with hypertensionor angina who have congestive heartfailure because beta blockers such asmetoprolol can further depress myocardialcontractility, worsening heart failure.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY To treat acute MI or evolving acute MITABLETS (METOPROLOL TARTRATE), I.V. INJECTION(METOPROLOL TARTRATE)Adults. Initial: 5 mg by I.V. bolus every2 min for 3 doses followed by 50 mgP.O. for patients who tolerate total I.V. dose(25 to 50 mg P.O. for patients who can’t toleratetotal I.V. dose) every 6 hr for 48 hr,starting 15 min after final I.V. dose; after48 hr, 100 mg b.i.d. followed by maintenanceDosage.

MS: Arthralgia, back pain, myalgia

RESP: Bronchospasm, dyspnea

SKIN: Diaphoresis, photosensitivity, rash, urticaria, worsening of psoriasis

• For patient with acute MI who can’t tolerateinitial dosage or who delays treatment,start with maintenance dosage, as prescribedand tolerated.

• Before starting therapy for heart failure,expect to give a diuretic, an ACE inhibitor,and digoxin to stabilize patient.• If patient has pheochromocytoma, alphablocker therapy should start first, followed by metoprolol to

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYMaintenance: 100 mg P.O.b.i.d. for at least 3 mo.

To treat angina pectoris and chronicstable anginaE.R. TABLETS (METOPROLOL SUCCINATE)Adults. 100 mg daily, increased weekly asprescribed. Maximum: 400 mg daily as asingle dose or in divided doses.E.R. TABLETS (METOPROLOL TARTRATE)Adults. Initial: 100 mg daily, adjusted weekly as prescribed.Maximum: 450 mg daily.

prevent paradoxicalIncrease vasodilation inskeletal muscle.

• Be aware that metoprolol dosage for heart failure is highly individualized.Monitor patient for evidence of worsening heartfailure during dosage increases. If heart failure worsens, expect to increase diureticdosage and possibly decrease metoprololdosage or temporarily discontinue drug, asprescribed. Metoprolol dosage shouldn’t be increased until

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYTABLETS (METOPROLOL TARTRATE)Adults. Initial: 50 mg b.i.d., adjusted weeklyas prescribed. Maximum: 450 mg daily.

To treat stable, symptomatic (New York Heart Association [NYHA] Class II or III), ischemic, hypertensive, or cardiomyopathic heart failureE.R. TABLETS (METOPROLOL SUCCINATE)Adults. Initial: 25 mg daily (NYHA ClassII) or 12.5 mg daily (NYHA Class III ormore severe heart failure)

worsening heart failure has been stabilized.

• If patient with heart failure developssymptomatic bradycardia, expect to decrease the metoprolol dosage.WARNING If dosage exceeds 400 mg daily, monitor patient for bronchospasm anddyspnea because metoprolol competitivelyblocks beta2-adrenergic receptors in bronchial and vascular smooth muscles.WARNING When substituting metoprolol for

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYfor 2 wk. Thendosage doubled every 2 wk as tolerated.Maximum: 200 mg daily.

Route : P.O. P.O.(E.R.) I.V.Onset : 60 min Unknown UnknownPeak : 1–2 hr 6–12 hr 20 minDuration: Unknown Unknown Unknown

clonidine, expect to gradually reduceclonidine and increase metoprololDosage over several days. Given together, these drugs have additive hypotensive effects.

• Patients who take metoprolol may be at risk for AV block. If AV block results from depressed AV node conduction, prepare to give appropriate drug, as ordered, or assistwith insertion of temporary pacemaker.

• Check for signs of poor glucose control in patient with diabetes mellitus.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYMetoprolol may interfere with therapeutic effects of insulin and oral antidiabetic drugs.It also may mask evidence of hypoglycemia, suchas palpitations, tachycardia, and tremor.

•Monitor patient with peripheral vasculardisease for evidence of arterial insufficiency(pain, pallor, and coldness in affectedextremity) Metoprolol can precipitate oraggravate peripheral vascular disease.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY

Nitroglycerin(glyceryl trinitrate)

May interact with nitrate receptors in vascularsmooth-muscle cell

To prevent or treat anginaE.R. BUCCAL TABLETS

CNS: Agitation, anxiety, dizziness,headache, insomnia,

WARNING Expect to taper dosage over 1 to 2 weeks when drug is discontinued; stoppingabruptly can cause myocardialischemia,MI, ventricular arrhythmias, or severe hypertension, especially in patientswith cardiac disease. Abrupt withdrawalalso may cause thyroid storm in a patientwith hyperthyroidism or thyrotoxicosis.

• Use nitroglycerin cautiously in elderlypatients, especially those who are

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYmembranes. Thisinteraction reduces nitroglycerin to nitric oxide, which activates theenzyme guanylatecyclase, increasing intracellular formation of cGMP. Increased cGMP level may relaxvascular smooth muscle by forcing calciumout of muscle cells, causing vasodilation. Venous dilation decreases venous return tothe heart, reducing left ventricular enddiastolicpressure and pulmonary arterywedge pressure.

Adults. 1 mg every 5 hr while awake.E.R. CAPSULESAdults. 2.5, 6.5, or 9 mg every 12 hr.Frequency of doses increased to every 8 hrbased on patient’s response.E.R. TABLETSAdults. 2.6 or 6.5 mg every 12 hr.Frequency of doses increased to every 8 hr based on patS.L. TABLETSAdults. 0.3 to 0.6 mg, repeated every 5 min.Maximum: 3 tabs in 15 min or 10 mg daily.ient’s response.

restlessness, syncope,Weakness

CV: Arrhythmias (including tachycardia),edema, hypotension, orthostatic hypotension,Palpitations

EENT: Blurred vision, burning or tinglingin mouth (buccal, S.L. forms), dry mouth

GI: Abdominal pain, diarrhea, indigestion,nausea, vomiting

GU: Dysuria, impotence, urinary frequency

volume depleted or taking several medications, because of the increased risk of hypotension and falls. Hypotension may beaccompanied by angina and paradoxicalslowing of the heart rate. Notify prescriber if these occur, and provide appropriatetreatment, as ordered.

• Plan a nitroglycerin-free period of about10 hours each day, as prescribed, to maintaintherapeutic effects and avoid tolerance.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYArterial dilation decreasessystemic vascular resistance, systolic arterialpressure, and mean arterial pressure. Thus,nitroglycerin reduces preload and afterload,Decreasing myocardial workload and oxygendemand. It also dilates coronary arteries,increasing blood flow to ischemicmyocardial tissue.

TRANSDERMAL OINTMENTAdults. 1" to 2" (15 to 30 mg) every 8 hr.Frequency of doses increased to every 6 hrif angina occurs between doses.Maximum:5" (75 mg)/application.TRANSDERMAL PATCHAdults. 0.1 to 0.8 mg/hr, worn 12 to 14 hr.TRANSLINGUAL SPRAY Adults. For treatment, 1 or 2 metered doses(0.4 or 0.8 mg) onto or under tongue,repeated every 5 min as needed. For prevention,

HEME: Methemoglobinemia

MS: Arthralgia

RESP: Bronchitis, pneumonia

SKIN: Contact dermatitis (transdermalforms), flushing of face and neck, rash

• Place E.R. buccal tablets in buccal pouchwith patient in sitting or lying position.

• Don’t break or crush E.R. tablets or capsules. Have patient swallow them wholewith a full glass of water.

• Place S.L. tablet under patient’s tongueand make sure it dissolves completely.

• Be sure to remove cotton from S.L. tablet container to allow quick access to drug.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYRoute: P.O. * P.O.† I.V. S.L. Trans- dermal‡ Trans- dermal§ Trans- lingualOnset: 3 min 20–45 min 1–2 min 1–3 min In 30 min In 30 min 2 to 4 minPeak: UnknownDuration:5 hr 8–12 hr 3–5 min 30–60 min 4–8 hr 8–24 hr 30–60 min

1 or 2 metered doses (0.4 or0.8 mg) onto or under tongue 5 to 10 minutesbefore activities that could lead to acute attack.

To prevent or treat angina, to managehypertension or heart failureI.V. INFUSIONAdults. 5 mcg/min, increased by 5 mcg/minevery 3 to 5 min to 20 mcg/min, as prescribed,and then by 10 to 20 mcg/minevery 3 to 5 min until desired effect occurs.

•When applying transdermal ointment,apply correct amount on dose-measuring paper. Then place paper on hairless area of body and spread in a thin, even layer over an area at least 2 inches by 3 inches. Don’t place on cuts or irritated areas. Wash your hands after application. Rotate sites. Storeat room temperature.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYHeparin calciumHeparin sodium

Binds with antithrombin III, enhancingantithrombin III’s inactivation of the coagulationenzymes thrombin (factor IIa) and factors Xa and XIa. At low doses, heparin inhibits factor Xa and prevents conversionof prothrombin to thrombin. Thrombin is needed for conversion of fibrinogen to fibrin;without fibrin, clots can’t form. At highdoses, heparin inactivates thrombin, preventingfibrin formation and existing clotextension.

To prevent and treat deep vein thrombosis and pulmonary embolism, to treatperipheral arterial embolism, and toPrevent thromboembolism before and after cardioversion of chronic atrial fibrillationI.V. INFUSION OR INJECTIONAdults. Loading: 35 to 70 units/kg or5,000 units by injection. Then 20,000 to40,000 units infused over 24 hr.Children. Loading: 50 units/kg by injection.

CNS: Chills, dizziness, fever, headache,peripheral neuropathy

CV: Chest pain, thrombosis

EENT: Epistaxis, gingival bleeding, rhinitis

GI: Abdominal distention and pain, hematemesis,melena, nausea, vomiting

GU: Hematuria, hypermenorrhea

HEME: Easy bruising, excessive bleedingfrom wounds, thrombocytopenia

• Use heparin cautiously in alcoholics; menstruatingwomen; patients over age 60,especially women; and patients with Mild hepatic or renal disease or a history of allergies, asthma, or GI ulcer.

WARNING Be aware that the new standardfor manufacturing heparin in the U.S. has decreased its I.V. potency by about 10%. When using this route, determine if theheparin has been manufactured under the new standard by

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYThen 100 units/kg infused every 4 hr or20,000 units/m2 infused over 24 hr.I.V. INJECTIONAdults. Initial: 10,000 units. Maintenance:5,000 to 10,000 units every 4 to 6 hr. Children. Initial: 50 units/kg. Maintenance:100 units/kg/dose every 4 hr.I.V. OR SUBCUTANEOUS INJECTIONAdults. Loading: 5,000 units I.V. Then10,000 to 20,000 units subcutaneously.Maintenance: 8,000 to 10,000 units subcutaneouslyevery 8 hr or 15,000

MS: Back pain, myalgia, osteoporosis

RESP: Dyspnea, wheezing

SKIN: Alopecia, cyanosis, petechiae, pruritus,Urticaria

Other: Anaphylaxis; injection sitehematoma, irritation, pain, redness, andulceration

looking for the letter “N” in the lot number or after the expiration date (or, if made by Hospira, the number “82” or higher at the start of the lot number). If giving such heparin, be aware thatmore drug may be required than in thepast to achieve desired level of anticoagulationin some patients. The change inpotency also may require more frequent orintensive APTT or ACT monitoring. Change in potency doesn’t appear problematicusing subcutaneous route.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYto 20,000 unitssubcutaneously every 12 hr.

To diagnose and treat disseminatedintravascular coagulation (DIC)I.V. INFUSION OR INJECTIONAdults. 50 to 100 units/kg every 4 hr. Drugmay be discontinued if no improvementoccurs in 4 to 8 hr.Children. 25 to 50 units/kg every 4 hr.Drug may be discontinued if no improvementoccurs in 4 to 8 hr.

To prevent postoperative thromboembolism

WARNING Give heparin only by subcutaneousor I.V. route; I.M. use causeshematoma, irritation, and pain

• Avoid injecting any drugs by I.M. routeduring heparin therapy, to decrease risk of bleeding and hematoma.

WARNING Don’t use heparin sodium injectionas a catheter-lock flush because fatalerrors have occurred in children when1-ml heparin sodium injection vials wereconfused with 1-ml catheter-lock flushvials. Always

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYSUBCUTANEOUS INJECTIONAdults. 5,000 units 2 hr before surgery andthen 5,000 units every 8 to 12 hr for 7 daysor until patient is fully ambulatory.

To prevent clots in patients undergoingopen-heart and vascular surgeryI.V. INFUSION OR INJECTIONAdults. 300 units/kg for procedures thatlast less than 60 min; 400 units/kg for proceduresthat last longer than 60 min. Minimum: 150 units/kg.

examine vial labels closely to ensure correct product is being used.

• Administer subcutaneous heparin into anterior abdominal wall, above the iliaccrest, and 5 cm (20) or more away fromthe umbilicus. To minimize subcutaneoustissue trauma, lift adipose tissue awayfrom deep tissues; don’t aspirate for blood before injecting drug; don’t move needle while injecting drug; and don’t massageinjection site before or after injection.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYChildren. 300 units/kg for procedures thatlast less than 60 min. Then dosage basedon coagulation test results. Minimum:150 units/kg.

To maintain heparin lock patencyI.V. INJECTIONAdults. 10 to 100 units/ml heparin flush solution (enough to fill device) after each use of device.DOSAGE ADJUSTMENT Increased dosage may be needed if patient needs aggressive anticoagulation

You can apply gentle pressure to the site after withdrawing needle.

• Alternate injection sites, and watch for signs of bleeding and hematoma.

• To prepare heparin for continuous infusion,invert container at least six times toprevent drug from pooling. Anticipateslight discoloration of prepared solution;this doesn’t indicate a change in potency.

• During continuous I.V. therapy, expect to obtain APTT after 8 hours of therapy. Use the arm

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYto treat or prevent life-threateningthromboses, if heparin will be givenI.V., and if heparin has been manufacturedunder the new standard implemented inOctober, 2009. (The letter “N” appears inthe lot number or after the expiration date on heparin products made under the newstandard. An exception is Hospira, which identifies its new-standard products using alot number starting with “82” or higher.)

Route: I.V. SubQ

opposite the infusion site.

• For intermittent I.V. therapy, expect to adjust dose based on coagulation testresults performed 30 minutes earlier Therapeutic range is typically 1.5 to 2.5 times the control.

• Bleeding is major adverse effect of heparin therapy. Take safety precautions to prevent bleeding, such as having patient use a softbristledtoothbrush and an electric razor. Bleeding may occur at any site and alsomay indicate an

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY

Aspirin(acetylsalicylic acid,ASA)

Blocks the activity of cyclooxygenase, theenzyme needed for prostaglandin synthesis.Prostaglandins, important mediators in theinflammatory response, cause local vasodilationwith swelling and pain.With blockingof cyclooxygenase and inhibition of

Onset: Immediate 20–60 minPeak: Minutes UnknownDuration: Unknown Unknown

To relieve mild pain or feverCHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASETABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults and adolescents. 325 to

CNS: Confusion, CNS depression

EENT: Hearing loss, tinnitus

GI: Diarrhea, GI bleeding, heartburn, hepatotoxicity,nausea, stomach pain, vomiting

HEME: Decreased blood iron level,leukopenia,

underlying problem, such as GI or urinary tract bleeding. Other sites of bleeding that could be fatal and requireimmediate attention includes adrenal,ovarian, and retroperitoneal hemorrhage.

• Don’t crush timed-release or controlled release Aspirin tablets unless directed.

• Ask about tinnitus. This reaction usuallyoccurs when blood aspirin level reaches or exceeds maximum for therapeutic effect.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYprostaglandins, inflammatory symptomssubside. Pain is also relieved becauseprostaglandins play a role in pain transmissionfrom the periphery to the spinal cord. Aspirin inhibits platelet aggregation by interfering with production of thromboxaneA2, a substance that stimulates plateletaggregation. Aspirin acts on the heatregulatingcenter in the hypothalamus andcauses peripheral vasodilation, diaphoresis, and heat loss.

650 mgevery 4 hr, p.r.n., or 500 mg every 3 hr,p.r.n., or 1,000 mg every 6 hr, p.r.n.Children ages 2 to 14. 10 to 15 mg/kg/doseevery 4 hr, p.r.n., up to 80 mg/kg daily.

To relieve mild to moderate pain frominflammation, as in rheumatoid arthritisand osteoarthritisCHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASETABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIES

prolonged bleeding time, shortenedlife span of RBCs, thrombocytopeniaSKIN: Ecchymosis, rash, urticariaOther: Angioedema, Reye’s syndrome, salicylism(dizziness, tinnitus, difficulty hearing,vomiting, diarrhea, confusion, CNSdepression, diaphoresis, headache, hyperventilation,and lassitude) with regular useof large doses

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYAdults and adolescents. 3.2 to 6 g daily in divided doses. Maximum: 6 g daily.Children. 10 to 15 mg/kg daily, up to 80 mg/kg daily, in divided doses every 4 to 6 hr.

To treat juvenile rheumatoid arthritisCHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASE TABLETS, ENTERIC-COATED TABLETS, SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESChildren. 60 to 110 mg/kg daily in divided doses every 6 to 8 hr.

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY To treat acute rheumatic feverCHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASETABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults and adolescents. 5 to 8 g daily in divided doses.Children. Initial: 100 mg/kg daily in divideddoses for first 2 wk. Maintenance: 75 mg/ kg/day in divided doses for next 4 to 6 wk.

To reduce the risk

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TYof recurrent transient ischemic attacks or stroke in men CHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASE TABLETS, ENTERIC-COATED TABLETS, SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults. 650 mg b.i.d. or 325 mg q.i.d.

To reduce the severity of or prevent acute MICHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASE TABLETS, ENTERIC-COATED TABLETS, SOLUTION, TABLETS, TIMED-

NAME OF DRUG

ACTION INDICATOR ADVERSE REACTION

NURSING RESPONSIBILI

TY-RELEASE TABLETS,SUPPOSITORIESAdults. Initial: 160 to 162.5 mg (half of a325-mg tablet or two 80- or 81-mg tablets) as soon as MI is suspected. Maintenance:160 to 162.5 mg daily for 30 days.

To reduce risk of MI in patients withprevious MI or unstable anginaCHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASE TABLETS, ENTERIC-COATED TABLETS, SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults. 325 mg daily.

NURSING CARE PLAN (Actual)

NURSING CARE PLAN (Potential)

DISCHARGE PLAN

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