McKenna's Pharmacology for Nursing, 2e

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P A R T 8  Drugs acting on the cardiovascular system

medication from heat and light because these drugs are volatile and lose their potency. ■ ■ Instruct the person that a sublingual dose may be repeated in 5 minutes if relief is not felt, for a total of three doses, if pain persists. They should go to an emergency department to ensure proper medical support if an MI should occur. ■ ■ Give sustained-release forms with water, and caution the person not to chew or crush tablets/ capsules because these preparations need to reach the GI tract intact. ■ ■ Rotate the sites of topical forms to decrease the risk of skin abrasion and breakdown ; monitor for signs of skin breakdown to arrange for appropriate skin care as needed. ■ ■ Make sure that sublingual spray is used under the tongue and not inhaled to ensure that the therapeutic effects can be achieved. ■ ■ Break an amyl nitrate capsule and wave it under the nose of the person with angina to provide rapid relief using the inhalation form of the drug ; this may be repeated with another capsule in 3 to 5 minutes if needed. ■ ■ Keep a record of the number of sprays used if a sublingual spray form is used, to prevent running out of medication and episodes of untreated angina. ■ ■ Have emergency life support equipment readily available in case of severe reaction to the drug or myocardial infarction. ■ ■ Taper the dose gradually (over 4 to 6 weeks) after long-term therapy because abrupt withdrawal could cause a severe reaction, including MI. ■ ■ Provide comfort measures to help the person tolerate drug effects. These include small, frequent meals to alleviate GI upset ; access to bathroom facilities if GI upset is severe or the person experiences incontinence; environmental controls such as temperature, controlled lighting and noise reduction to decrease stresses that could aggravate cardiac workload ; safety precautions such as

lying or sitting down after taking the drug and assistance with ambulation to reduce the risk of injury ; reorientation; and appropriate skin care as needed. ■ ■ Offer support and encouragement to help the person deal with the diagnosis and the drug regimen. ■ ■ Provide thorough teaching, including the name of the drug; dosage prescribed; proper technique for administration (oral, sublingual, transbuccal, transdermal, inhalation spray or topical); need for removal of transdermal or topical drug before application of the next dose; the importance of having an adequate supply of drug (e.g. teaching the individual to count the number of sprays used for a translingual spray so as not to run short); measures to prevent anginal attacks and actions to take when an attack occurs; use of medication during an attack (such as the number of tablets and time span that the person can take sublingual tablets); measures to avoid adverse effects, warning signs of problems and signs and symptoms to report immediately; and the need for periodic monitoring and evaluation to enhance knowledge about drug therapy and to promote compliance. ■ ■ Monitor response to the drug (alleviation of signs and symptoms of angina, prevention of angina). ■ ■ Monitor for adverse effects (hypotension, cardiac arrhythmias, GI upset, skin reactions, headache). ■ ■ Evaluate the effectiveness of the teaching plan (person can name drug, dosage, proper administration, adverse effects to watch for, specific measures to avoid them and the importance of continued follow-up). ■ ■ Monitor the effectiveness of comfort measures and compliance with the regimen. See the Critical thinking scenario for measures for handling an angina attack. Evaluation

CRITICAL THINKING SCENARIO Handling an angina attack

THE SITUATION S.W. is a 48-year-old Caucasian woman with a 2-year history of angina pectoris. She was given sublingual glyceryl trinitrate to use when she had chest pain. For the past 6 months, she has been stable, experiencing little chest pain. This morning after her exercise class, S.W. had an argument with her daughter and experienced severe chest

pain that was unrelieved by four glyceryl trinitrate tablets taken over a 20-minute period. S.W.’s daughter rushed her to the hospital, where she was given oxygen through nasal cannula and placed on a cardiac monitor, which showed a sinus tachycardia of 110 beats/min. A 12-lead electrocardiogram (ECG) showed no changes from her previous ECG of 7 months ago.