Bisoprolol/Fumarate (Zebeta)

• Classification- therapeutic: antihypertensives Pharmacologic: beta blockers
• Pregnancy category: C
• Indications: management of hypertension
• Action: Blocks stimulation of beta1 (myocardial)-adrenergic receptors. Does not usually effect beta2 (Pulmonary, vascular, uterine)-receptor sites.
• Therepeutic effects: Decreased BP and HR
• Contraindications: Uncompensated HF; Pulmonary edema; Cardiogenic shock; Bradycardia; or heart block.
• Use cautiously in: Renal impairment (dosage ↓ recommmended); Hepatic impairment (dosage ↓ recommended); Pulmonary disease (including asthma); DM; Thyrotoxicosis.
• Adverse Rxns/ Side effects
• CNS: fatigue, weakness
• EENT: blurred vision
• Resp: bronchospasm, wheezing
• CV: BRADYCARDIA, HF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction
• GI: constipation, ↑ liver function tests
• GU: erectile dysfunction, ↓ libido, urinary frequency
• Assessment
• Monitor BP, ECG, and pulse frequently during dosage adjustment period and periodically throughout therapy.
• Monitor intake and output ratios and daily weights. Assess routinely for signs and symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention).
• Monitor frequency of prescription refills to determine adherence.
• Lab Test Considerations:
• May cause increased BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
• Implementation
• Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional.
• Evaluation- Decrease in BP.

Amlodipine (Norvasc)

• Pregnancy Category- Category C
• Ther. Class.- antihypertensives
• Pharm. Class.- calcium channel blockers
• Indications- Alone or with other agents in the management of hypertension, angina pectoris, and vasospastic (Prinzmetal's) angina.
• Action- Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction.
• Therapeutic Effect(s):
• Systemic vasodilation resulting in decreased BP.
• Coronary vasodilation resulting in decreased frequency and severity of attacks of angina
• Contraindicated in:
• Systolic BP <90 mm Hg.
•  Use Cautiously in:
• Severe hepatic impairment (dosage reduction recommended);
• Aortic stenosis;
• History of HF;
• Adverse Rxns/Side effects:
• CNS: headache
• CV: , angina, bradycardia, hypotension, palpitations
• GI: gingival hyperplasia
• Derm: flushing
• Drug-Food Interactions: 
• Grapefruit juice ↑ serum levels and effect.
• Assessment: 
• Monitor BP. Monitor ECG periodically during prolonged therapy.
• Monitor intake and output ratios and daily weight. Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
• Angina: 
• Assess location, duration, intensity, and precipitating factors of patient's anginal pain.
• Lab Test Considerations:
• Total serum calcium concentrations are not affected by calcium channel blockers.
• Evaluation/desired outcome: 
• Decrease in BP.
• Decrease in frequency and severity of anginal attacks.
• Decrease in need for nitrate therapy.
• Increase in activity tolerance and sense of well-being.

Hydrochlorothiazide (HydroDiuril)

• Pregnancy Category- Category B
• Ther. Class.- antihypertensives; diuretics
• Pharm. Class.- thiazide diuretics
• Indications- 
• Management of mild to moderate hypertension.
• Treatment of edema associated with:
• HF
• Renal dysfunction
• Cirrhosis
• Glucocorticoid therapy
• Estrogen therapy
• Action
• Increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule.
• Promotes excretion of chloride, potassium, hydrogen, magnesium, phosphate, calcium and bicarbonate.
• May produce arteriolar dilation.
• Therapeutic Effect(s):
• Lowering of BP in hypertensive patients and diuresis with mobilization of edema.
• Contraindicated in:
• Anuria
• Lactation
• Use Cautiously in:
• Renal or hepatic impairment
• OB: Jaundice or thrombocytopenia may be seen in the newborn.
• Adverse Rxns/Side effects- 
• CNS: dizziness, drowsiness
• CV: hypotension
• GI: anorexia
• Derm: STEVENS JOHNSON SYNDROME, photosensitivity
• EENT: acute angle-closure glaucoma, acute myopia
• F and E: hypokalemia, dehydration, hypercalcemia, hypochloremic alkalosis, hypomagnesemia, hyponatremia, hypophosphatemia, hypovolemia
• Hemat: blood dyscrasias
• Metabolic: hyperuricemia(abnormally high uric acid in blood), hypercholesterolemia
• Misc: pancreatitis
• Drug-drug interactions- 
• Hypokalemia ↑ risk of digoxin toxicity.
• Assessment
• Monitor BP, intake, output, and daily weight and assess feet, legs, and sacral area for edema daily.
• Assess patient, especially if taking digoxin, for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. 
• Patients taking digitalis (cardiac) glycosides are at risk of digitalis toxicity because of the potassium-depleting effect of the diuretic.
• If hypokalemia occurs, consideration may be given to potassium supplementation or decreasing dose of diuretic.
• Assess patient for skin rash frequently during therapy. Discontinue diuretic at first sign of rash; may be life-threatening. Stevens-Johnson syndrome may develop. Treat symptomatically; may recur once treatment is stopped.
• Hypertension: 
• Monitor BP before and periodically throughout therapy.
• Lab Test Considerations:
• Monitor electrolytes (especially potassium), blood glucose, BUN, serum creatinine, and uric acid levels before and periodically during therapy.
• May cause ↑ serum and urine glucose in diabetic patients.
• Implementation-
• Administer in the morning to prevent disruption of sleep cycle.
• Intermittent dose schedule may be used for continued control of edema.
• PO: May give with food or milk to minimize GI irritation. Tablets may be crushed and mixed with fluid to facilitate swallowing.
• Evaluation/ desired outcomes-
• Decrease in BP.
• Decrease in edema.

Spironolactone (Aldactone)

• Pregnancy Category- Category C
• Ther. Class.- diuretics; potassium-sparing diuretics
• Indications- 
• Management of primary hyperaldosteronism.
• Management of edema associated with HF, cirrhosis and nephrotic syndrome.
• Management of essential hypertension.
• Treatment of hypokalemia (counteracts potassium loss caused by other diuretics).
• Action- 
• Causes loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions by antagonizing aldosterone.
• Therapeutic Effect(s):
• Increased survival in patients with severe heart failure.
• Weak diuretic and antihypertensive response when compared with other diuretics.
• Conservation of potassium.
• Contraindicated in:
• Anuria
• Acute renal insufficiency
• Significant renal impairment (CCr <30 mL/min); SCr >2.5 mg/dL (for patients with heart failure)
• Hyperkalemia.
• Use Cautiously in:
• Hepatic dysfunction
• Geriatric or debilitated patients or patients with diabetes mellitus (↑ risk of hyperkalemia)
• OB: Lactation: May cause endocrine dysfunction in infants. Is tumorigenic and should not be given to nursing mothers. Alternative method of feeding should be used if spironolactone is essential.
• Adverse Rxn/Side effect-
• CNS: dizziness
• CV: arrhythmias
• GU: erectile dysfunction, dysuria
• Endo: gynecomastia (in males)
• F and E: hyperkalemia, hyponatremia, hyperchloremic metabolic acidosis
• Hemat: agranulocytosis
• Derm: DRUG RASH WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS
• Drug-drug interaction- Use with ACE inhibitors, potassium supplements, angiotensin II receptor antagonists, or angiotensin converting enzyme inhibitors, ↑ risk of hyperkalemia.
• Assessment-
• Monitor intake and output ratios and daily weight during therapy.
• If medication is given as an adjunct to antihypertensive therapy, BP should be evaluated before administering.
• Monitor response of signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia). Assess patient frequently for development of hyperkalemia (fatigue, muscle weakness, paresthesia, confusion, dyspnea, cardiac arrhythmias). Patients who have diabetes mellitus or kidney disease and elderly patients are at increased risk of developing these symptoms.
• Periodic ECGs may be recommended in patients receiving prolonged therapy.
• Assess patient for skin rash frequently during therapy. Discontinue diuretic at first sign of rash; may be life-threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop. Treat symptomatically; may recur once treatment is stopped.
• Lab Test Considerations:
• Evaluate serum potassium levels prior to and routinely during therapy. Withhold drug and notify health care professional if patient becomes hyperkalemic.
• Monitor BUN, serum creatinine, and electrolytes prior to and periodically during therapy. May cause ↑ serum magnesium, uric acid, BUN, creatinine, potassium, plasma renin activity, and urinary calcium excretion levels. May also cause ↓ sodium levels.
• Discontinue potassium-sparing diuretics 3 days prior to a glucose tolerance test because of risk of severe hyperkalemia.
• May cause false ↑ of plasma cortisol concentrations. Spironolactone should be withdrawn 4–7 days before test.
• Implementation- 
• PO: Administer in AM to avoid interrupting sleep pattern.
• Administer with food or milk to minimize gastric irritation and to increase bioavailability.
• Evaluation/desired outcomes-
• Increase in diuresis and decrease in edema while maintaining serum potassium level in an acceptable range.
• Decrease in BP.
• Prevention of hypokalemia in patients taking diuretics.
• Treatment of hyperaldosteronism.

Digoxin (Lanoxin)

• Pregnancy Category- Category C
• Ther. Class.- antiarrhythmics; inotropics
• Pharm. Class.- digitalis glycosides/cardiac glycosides
• Indications- 
• Heart failure.
• Atrial fibrillation and atrial flutter (slows ventricular rate).
• Paroxysmal atrial tachycardia.
• Action- 
• Increases the force of myocardial contraction.
• Prolongs refractory period of the AV node.
• Decreases conduction through the SA and AV nodes.
• Therapeutic Effect(s):
• Increased cardiac output (positive inotropic effect) and slowing of the heart rate (negative chronotropic effect).
• Contraindicated in:
• Uncontrolled ventricular arrhythmias;
• AV block (in absence of pacemaker);
• Idiopathic hypertrophic subaortic stenosis;
• Constrictive pericarditis;
• Known alcohol intolerance (elixir only).
• Use Cautiously in:
• Hypokalemia (↑ risk of digoxin toxicity);
• Hypercalcemia (↑ risk of toxicity, especially with mild hypokalemia);
• Hypomagnesemia (↑ risk of digoxin toxicity);
• Diuretic use (may cause electrolyte abnormalities including hypokalemia and hypomagnesemia);
• Hypothyroidism;
• Myocardial infarction;
• Renal impairment (dose ↓ required);
• Obesity (dose should be based on ideal body weight);
• Adverse Rxn/side effects-
•  CNS: fatigue
• EENT: blurred vision, yellow or green vision, halos
• CV: ARRHYTHMIAS, bradycardia, ECG changes, AV block, SA block
• GI: anorexia, N.V.D
• Hemat: thrombocytopenia
• Metabolic: electrolyte imbalances with acute digoxin toxicity
• Interactions- Drug-Drug
• Thiazide and loop diuretics, and excessive use of laxatives may cause hypokalemia which may ↑ risk of toxicity.
• Some benzodiazepines, and spironolactone, may ↑ levels and lead to toxicity (serum level monitoring/dose ↓ may be required).
• Additive bradycardia may occur with beta blockers, diltiazem, and other antiarrhythmics.
• Concurrent use of sympathomimetics may ↑ risk of arrthythmias.
• 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, Also notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse.
• Monitor BP and ECG throughout IV administration and 6 hr after each dose. Notify health care professional if bradycardia or new arrhythmias occur.
• Observe IV site for redness or infiltration; extravasation can lead to tissue irritation and sloughing.
• Monitor intake and output ratios and daily weights. Assess for peripheral edema, and auscultate lungs for rales/crackles throughout therapy.
• Before administering initial loading dose, determine whether patient has taken any digitalis preparations in the preceding 2–3 wk.
• Geri: increased risk of falls.
• Lab Test Considerations:
• Evaluate serum electrolyte levels (especially potassium, magnesium, and calcium) and renal and hepatic functions periodically during therapy. Notify health care professional before giving dose if patient is hypokalemic. Hypokalemia, hypomagnesemia, or hypercalcemia may make the patient more susceptible to digitalis toxicity. 
• Geri: Older adults may be toxic even when serum concentrations are within normal range
• Toxicity Overdose:
• Therapeutic serum digoxin levels range from 0.5–2 ng/mL. Serum levels may be drawn 6–8 hr after a dose is administered, although they are usually drawn immediately before the next dose. Patients receiving erythromycin or tetracycline, which kill gut bacteria, can develop toxicity on their usual doses of digoxin.
• Observe for signs and symptoms of toxicity. In adults and older children, the first signs of toxicity usually include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias.
• Correction of arrhythmias resulting from digitalis toxicity may be attempted with lidocaine, quinidine, or propranolol. Temporary ventricular pacing may be useful in advanced heart block.
• Treatment of life-threatening arrhythmias may include administration of digoxin immune Fab (Digibind), which binds to the digitalis glycoside molecule in the blood and is excreted by the kidneys.
• Implementation- 
• High Alert: Digoxin has a narrow therapeutic range. Medication errors associated with digoxin inclyde 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.
• When changing from parenteral to oral dose forms, dose adjustments may be necessary because of pharmacokinetic variations in percentage of digoxin absorbed
• Evaluation/desired outcomes- 
• Decrease in severity of HF.
• Increase in cardiac output.
• Decrease in ventricular response in atrial tachyarrhythmias.
• Termination of paroxysmal atrial tachycardia.

Furosemide (Lasix)

• Pregnancy Category- Category C
• Ther. Class.- diuretics
• Pharm. Class.- loop diuretics
• Indications- 
• Edema due to heart failure, hepatic impairment or renal disease.
• Hypertension.
• Action- 
• Inhibits the reabsorption of sodium and chloride from the ascendng loop of Henle and distal renal tubule.
• Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.
• Effectiveness persists in impaired renal function.
• Therapeutic Effect(s):
• Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions).
• Decreased BP.
• Contraindicated in:
• Cross-sensitivity with thiazides and sulfonamides may occur
• Hepatic coma or anuria
• Some liquid products may contain alcohol, avoid in patients with alcohol intolerance.
• Use Cautiously in:
• Severe liver disease (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary)
• Electrolyte depletion
• Diabetes mellitus
• Hypoproteinemia (↑ risk of ototoxicity)
• Severe renal impairment (↑ risk of ototoxicity)
• Geri: May have ↑ risk of side effects, especially hypotension and electrolyte imbalance, at usual doses.
• Adverse Rxns/Side effects- 
• CNS: blurred vision, dizziness, headache, vertigo
• EENT: hearing loss, tinnitus
• CV: hypotension
• GI: anorexia, constipation, N.V.D., dry mouth, dyspepsia, ↑ liver enzymes, pancreatitis,
• GU: ↑ BUN, excessive urination, nephrocalcinosis
• Derm: STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity
• Endo: hypercholesterolemia, hyperglycemia, hypertriglyceridemia, hyperuricemia
• F and E: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis
• Hemat: APLASTIC ANEMIA, AGRANULOCYTOSIS, hemolytic anemia, leukopenia, thrombocytopenia
• Neuro: paresthesia
• Interactions- 
• Drug-Drug
• Hypokalemia may ↑ risk of digoxin toxicity and ↑ risk of arrhythmia in patients taking drugs that prolong the QT interval.
• NSAIDS↓ effects of furosemide.
• Assessment- 
• Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs.
• Monitor BP and pulse before and during administration. 
• Geri: increased risk for falls.
• Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia.
• Assess patient for tinnitus and hearing loss. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs.
• Assess patient for skin rash frequently during therapy. Discontinue furosemide at first sign of rash; may be life-threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop. Treat symptomatically; may recur once treatment is stopped.
• Lab Test Considerations:
• Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonly ↓ serum potassium. May cause ↓ serum sodium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, creatinine, and uric acid levels.
• Implementation- 
• If administering twice daily, give last dose no later than 5 pm to minimize disruption of sleep cycle.
• PO: May be taken with food or milk to minimize gastric irritation. Tablets may be crushed if patient has difficulty swallowing.
• Evaluation/desired outcomes- 
• Decrease in edema.
• Decrease in abdominal girth and weight.
• Increase in urinary output.
• Decrease in BP.

Lidocaine

• Pregnancy Category- Category B
• Ther. Class.- anesthetics (topical/local), antiarrhythmics (class IB)
• Indications- 
• IV: Ventricular arrhythmias.
• IM: Self-injected or when IV unavailable (during transport to hospital facilities).
• Local: Infiltration/mucosal/topical anesthetic.
• Patch: Pain due to post-herpetic neuralgia.
• Action- 
• IV: IM: Suppresses automaticity and spontaneous depolarization of the ventricles during diastole by altering the flux of sodium ions across cell membranes with little or no effect on heart rate.
• Local: 
• Produces local anesthesia by inhibiting transport of ions across neuronal membranes, thereby preventing initiation and conduction of normal nerve impulses.
• Therapeutic Effect(s):
• Control of ventricular arrhythmias.
• Local anesthesia.
• Contraindicated in:
• Hypersensitivity; cross-sensitivity may occur
• Third-degree heart block.
• Use Cautiously in:
• Liver disease, HF, patients weighing <50 kg, and geriatric patients (↓ bolus and/or maintenance dose)
• Respiratory depression
• Shock
• Heart block
• OB: Lactation: Safety not established
• Pedi: Safety not established for transdermal patch.
• Adverse Rxns/Side effects- 
• CNS: SEIZURES, confusion, drowsiness, blurred vision, dizziness, nervousness, slurred speech, tremor
• EENT: mucosal use: ↓ or absent gag reflex
• CV: CARDIAC ARREST, arrhythmias, bradycardia, heart block, hypotension
• GI: nausea, vomiting
• Resp: bronchospasm
• Local: stinging, burning
• MS: chondrolysis
• Misc: ALLERGIC REACTIONS, INCLUDING ANAPHYLAXIS
• Interactions- 
• Drug-Drug
• Beta blockers may ↓ metabolism and ↑ risk of toxicity.
• Assessment- 
• Antiarrhythmic: 
• Monitor ECG continuously and BP and respiratory status frequently during administration.
• Anesthetic: 
• Assess degree of numbness of affected part.
• Lab Test Considerations: 
• Serum electrolyte levels should be monitored periodically during prolonged therapy.
• IM administration may cause ↑ CPK levels.
• Toxicity Overdose:
• Serum lidocaine levels should be monitored periodically during prolonged or high-dose IV therapy. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/mL.
• Signs and symptoms of toxicity include confusion, excitation, blurred or double vision, nausea, vomiting, ringing in ears, tremors, twitching, seizures, difficulty breathing, severe dizziness or fainting, and unusually slow heart rate.
• If symptoms of overdose occur, stop infusion and monitor patient closely.
• 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.
• IM: IM injections are recommended only when ECG monitoring is not available and benefits outweigh risks. Administer IM injections only into deltoid muscle while frequently aspirating to prevent IV injection.
• Transdermal: When used concomitantly with other products containing local anesthetic agents, consider amount absorbed from all formulations.
• Infiltration: 
• Lidocaine with epinephrine may be used to minimize systemic absorption and prolong local anesthesia.
• Transdermal: When used concomitantly with other products containing local anesthetic agents, consider amount absorbed from all formulations.
• Evaluation/Desired outcome- 
• Decrease in ventricular arrhythmias. 
• Local anesthesia.

Acebutolol (Sectral)

• Pregnancy Category- Category B
• Ther. Class.- antiarrhythmics (class II), antihypertensives

Pharm. Class.- beta blockers

• Indications- 
• Treatment of hypertension (single agent or with other antihypertensives).
• Treatment of ventricular tachyarrhythmias.
• Unlabeled Use(s):
• Prophylaxis of MI, treatment of angina pectoris, management of anxiety, tremors, thyrotoxicosis, mitral valve prolapse, idiopathic hypertrophic subaortic stenosis.
• Actions- 
• Blocks stimulation of beta₁–(myocardial)-adrenergic receptors. Does not usually affect beta₂ (pulmonary, vascular, or uterine) receptor sites.
• Mild intrinsic sympathomimetic activity (ISA).
• Therapeutic Effect(s):
• Decreased heart rate.
• Decreased AV conduction.
• Decreased BP.
• Contraindicated in:
• Uncompensated HF
• Pulmonary edema
• Cardiogenic shock
• Bradycardia or heart block
• Obstructive airway disease including asthma.
• Use Cautiously in:
• Renal or hepatic impairment (dosage reduction recommended if CCr <50 mL/min/1.73 m2)
• Thyrotoxicosis (may mask symptoms)
• Diabetes mellitus (may mask symptoms of hypoglycemia)
• Adverse rxns/ side effects- 
• CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, nightmares
• EENT: blurred vision
• Resp: bronchospasm, wheezing
• CV: BRADYCARDIA, HF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction
• GI: constipation, N.V.D
• GU: erectile dysfunction, diminished libido, urinary frequency
• Endo: hyperglycemia, hypoglycemia
• Drug-drug interactions- 
• Concurrent use with digoxin may increase bradycardia.
• Antihypertensives, acute ingestion of alcohol, or nitrates may cause additive hypotension.
• Use with epinephrine may result in unopposed alpha-adrenergic stimulation.
• Assessment- 
• Monitor BP, ECG, and pulse frequently during dosage adjustment period and periodically throughout therapy.
• Monitor intake and output ratios and daily weights. Assess routinely for signs and symptoms of HF(dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention).
• Lab Test Considerations:
• May cause increased BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
• May cause increased serum alkaline phosphatase, LDH, AST, and ALT levels.
• May cause increase in blood glucose levels.
• Implementations- 
• PO: Take apical pulse prior to administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional.
• Evaluation/desired outcomes
• Decrease in BP.
• Control of arrhythmias without appearance of detrimental side effects.

Nitroglycerin (SL and Transderm)

• Pregnancy Category- Category C
• Ther. Class.- antianginals
• Pharm. Class.- nitrates
• Indications- 
• Acute (translingual, SL, ointment) and long-term prophylatic (oral, transdermal) management of angina pectoris.
• PO: Adjunct treatment of HF.
• IV: Adjunct treatment of acute MI.
• Production of controlled hypotension during surgical procedures.
• Treatment of HF associated with acute MI.
• Actions- 
• Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions.
• Produces vasodilation (venous greater than arterial).
• Decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload).
• Reduces myocardial oxygen consumption.
• Therapeutic Effect(s):
• Relief or prevention of anginal attacks.
• Increased cardiac output.
• Reduction of BP.
• Contraindicated in:
• Severe anemia
• Pericardial tamponade (build up of pericardial fluid)
• Constrictive pericarditis
• Alcohol intolerance (large IV doses only)
• Use Cautiously in:
• Head trauma or cerebral hemorrhage
• Glaucoma
• Hypertrophic cardiomyopathy
• Severe liver impairment
• Malabsorption or hypermotility (PO)
• Hypovolemia (IV)
• Normal or ↓ pulmonary capillary wedge pressure (IV)
• Cardioversion (remove transdermal patch before procedure)
• Adverse rxns/side effects-
•  CNS: dizziness, headache
• EENT: blurred vision
• CV: hypotension, tachycardia, syncope
• GI: abdominal pain
• Drug-drug interactions- 
• Agents having anticholinergic properties (tricyclic antidepressants, antihistamines, phenothiazines) may ↓ absorption of translingual or sublingual nitroglycerin.
• Assessment- 
• Assess location, duration, intensity, and precipitating factors of patient's anginal pain.
• Monitor BP and pulse before and after administration. Patients receiving IV nitroglycerin require continuous ECG and BP monitoring. Additional hemodynamic parameters may be monitored.
• Lab Test Considerations:
• May cause falsely ↑ serum cholesterol levels.
• Implementations- 
• PO: Administer dose 1 hr before or 2 hr after meals with a full glass of water for faster absorption. Sustained-release preparations should be swallowed whole; do not break, crush, or chew.
• SL: Tablet should be held under tongue until dissolved. Avoid eating, drinking, or smoking until tablet is dissolved.
• Translingual spray: 
• Spray Nitrolingual under tongue. Spray Nitromist on or under tongue.
• Topical: Sites of topical application should be rotated to prevent skin irritation. Remove patch or ointment from previous site before application.
• Doses may be increased to the highest dose that does not cause symptomatic hypotension.
• Apply ointment by using dose-measuring application papers supplied with ointment. Squeeze ointment onto measuring scale printed on paper. Use paper to spread ointment onto nonhairy area of skin (chest, abdomen, thighs; avoid distal extremities) in a thin, even layer, covering a 2–3-in. area. Do not allow ointment to come in contact with hands. Do not massage or rub in ointment; this will increase absorption and interfere with sustained action. Apply occlusive dressing if ordered.
• Transdermal patches may be applied to any hairless site (avoid distal extremities or areas with cuts or calluses). Apply firm pressure over patch to ensure contact with skin, especially around edges. Apply a new dose unit if the first one becomes loose or falls off. Units are waterproof and not affected by showering or bathing. Do not cut or trim system to adjust dosage. Do not alternate between brands of transdermal products; dose may not be equivalent. Remove patches before MRI, cardioversion or defibrillation to prevent patient burns. Patch may be worn for 12–14 hr and removed for 10–12 hr at night to prevent development of tolerance.
• Evaluation/desired outcome- 
• Decrease in frequency and severity of anginal attacks.
• Increase in activity tolerance. During long-term therapy, tolerance may be minimized by intermittent administration in 12–14 hr or 10–12 hr off intervals.
• Controlled hypotension during surgical procedures.
• Treatment of HF associated with acute MI.

Isosorbide dinitrate (Isordil)

• Pregnancy Category- Category C
• Ther. Class.- antianginals
• Pharm. Class.- nitrates
• Indications- 
• Acute treatment of anginal attacks (SL only).
• Prophylactic management of angina pectoris.
• Unlabeled Use(s):
• Treatment of chronic heart failure (unlabeled).
• Action- 
• Produce vasodilation (venous greater than arterial).
• Decrease left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload). Net effect is reduced myocardial oxygen consumption.
• Increase coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions.
• Therapeutic Effect(s):
• Relief and prevention of anginal attacks.
• Use Cautiously in:
• Volume depleted patients
• Right ventricular infarction
• Hypertrophic cardiomyopathy
• Adverse rxns/side effects- 
• CNS: dizziness, headache
• CV: hypotension, tachycardia, paradoxic bradycardia, syncope
• GI: nausea, vomiting
• Misc: flushing, tolerance
• Assessment- 
• Assess location, duration, intensity, and precipitating factors of anginal pain.
• Monitor BP and pulse routinely during period of dosage adjustment.
• Implementations- 
• SL: tablets should be held under tongue until dissolved.
• Avoid eating, drinking, or smoking until tablet is dissolved. Replace tablet if inadvertently swallowed.
• Evaluation/desired outomes- 
• Decrease in frequency and severity of anginal attacks.
• Increase in activity tolerance.

Isosorbade/Isosorbide mononitrate (Imdur)

• Pregnancy Category- Category C
• Ther. Class.- antianginals
• Pharm. Class.- nitrates
• Indications- 
• Acute treatment of anginal attacks (SL only).
• Prophylactic management of angina pectoris.
• Unlabeled Use(s):
• Treatment of chronic heart failure (unlabeled).
• Action- 
• Produce vasodilation (venous greater than arterial).
• Decrease left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload). Net effect is reduced myocardial oxygen consumption.
• Increase coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions.
• Therapeutic Effect(s):
• Relief and prevention of anginal attacks.
• Use Cautiously in:
• Volume depleted patients
• Right ventricular infarction
• Hypertrophic cardiomyopathy
• OB: May compromise maternal/fetal circulation
• Lactation: No data available
• Pedi: Safety not established
• Geri: Initial dose ↓ required due to ↑ potential for hypotension.
• Adverse rxns/side effects- 
• CNS: dizziness, headache
• CV: hypotension, tachycardia, paradoxic bradycardia, syncope
• GI: nausea, vomiting
• Misc: flushing, tolerance
• Assessment- 
• Assess location, duration, intensity, and precipitating factors of anginal pain.
• Monitor BP and pulse routinely during period of dosage adjustment.
• Implementations- 
• PO: Extended-release tablets should be swallowed whole. Do not break, crush, or chew.
• Evaluation/desired outomes- 
• Decrease in frequency and severity of anginal attacks.
• Increase in activity tolerance.

Diltiazem (Cardizem)

• Pregnancy Category- Category C
• Ther. Class.- antianginals; antiarrhythmics (class IV); antihypertensives
• Pharm. Class.- calcium channel blockers
• Indications- 
• Hypertension.
• Angina pectoris and vasospastic (Prinzmetal's) angina.
• Supraventricular tachyarrhythmias and rapid ventricular rates in atrial flutter or fibrillation.
• Actions- 
• Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction.
• Therapeutic Effect(s):
• Systemic vasodilation resulting in decreased BP.
• Coronary vasodilation resulting in decreased frequency and severity of attacks of angina.
• Reduction of ventricular rate in atrial fibrillation or flutter.
• Contraindicated in:
• Sick sinus syndrome
• 2nd- or 3rd-degree AV block (unless an artificial pacemaker is in place)
• Systolic BP <90 mm Hg
• Recent MI or pulmonary congestion
• Use Cautiously in:
• Severe hepatic impairment (↓ dose recommended)
• Severe renal impairment
• Serious ventricular arrhythmias or HF
• Adverse rxns/side effects-
•  CNS: anxiety, dizziness
• EENT: blurred vision, epistaxis(nose bleed), tinnitus
• Resp: cough, dyspnea
• CV: ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia
• GI: ↑ liver enzymes, anorexia, constipation, dry mouth, dysgeusia(disorder of taste), dyspepsia, N.V.D.
• GU: dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency
• Derm: STEVENS-JOHNSON SYNDROME, erythema multiforme, flushing, sweating, photosensitivity.
• Endo: gynecomastia, hyperglycemia
• Hemat: anemia, leukopenia, thrombocytopenia
• Metabolic: weight gain
• Neuro: paresthesia, tremor
• Misc: gingival hyperplasia
• Interactions- 
• Drug-Drug
• May ↑ digoxin levels.
• Concurrent use with beta blockers or digoxin may result in bradycardia, conduction defects, or HF.
• Drug-Food:
• Grapefruit juice ↑ levels and effect.
• Assessment- 
• Monitor BP and pulse prior to therapy, during dose titration, and periodically during therapy. Monitor ECG periodically during prolonged therapy. May cause prolonged PR interval.
• Monitor intake and output ratios and daily weight. Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
• Patients receiving digoxin concurrently with calcium channel blockers should have routine serum digoxin levels checked and be monitored for signs and symptoms of digoxin toxicity.
• Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions,conjunctivitis, hepatitis and/or eosinophilia.
• Angina: 
• Assess location, duration, intensity, and precipitating factors of patient's anginal pain.
• Arrhythmias: 
•  Monitor ECG continuously during administration. Report bradycardia or prolonged hypotension promptly. Emergency equipment and medication should be available. Monitor BP and pulse before and frequently during administration.
• Lab Test Considerations:
• Total serum calcium concentrations are not affected by calcium channel blockers.
• Monitor serum potassium periodically. Hypokalemia ↑ the risk of arrhythmias and should be corrected.
• Monitor renal and hepatic functions periodically during long-term therapy. May cause ↑ in hepatic enzymes after several days of therapy, which return to normal on discontinuation of therapy.
• Implementation- 
• Do not open, crush, break, or chew sustained-release capsules or tablets. Empty tablets that appear in stool are not significant. Crush and mix diltiazem with food or fluids for patients having difficulty swallowing.
• Evaluation/Desired outcomes- 
• Decrease in BP.
• Decrease in frequency and severity of anginal attacks.
• Decrease in need for nitrate therapy.
• Increase in activity tolerance and sense of well-being.
• Suppression and prevention of tachyarrhythmias.

Mannitol

• Pregnancy Category- Category C
• Ther. Class.- diuretics
• Pharm. Class.- osmotic diuretics
• Indications- 
• IV: Adjunct in the treatment of:
• Acute oliguric renal failure,
• Edema,
• Increased intracranial or intraocular pressure,
• Toxic overdose.
• GU irrigant: 
• During transurethral procedures (2.5–5% solution only).
• Actions- 
• Increases the osmotic pressure of the glomerular filtrate, thereby inhibiting reabsorption of water and electrolytes.
• Causes excretion of:
• Water,
• Sodium,
• Potassium,
• Chloride,
• Calcium,
• Phosphorus,
• Magnesium,
• Urea,
• Uric acid.
• Therapeutic Effect(s):
• Mobilization of excess fluid in oliguric renal failure or edema.
• Reduction of intraocular or intracranial pressure.
• Increased urinary excretion of toxic materials.
• Decreased hemolysis when used as an irrigant after transurethral prostatic resection.
• Contraindicated in:
• Anuria
• Dehydration
• Active intracranial bleeding
• Severe pulmonary edema or congestion.
• Adverse rxns/side effects- 
• CNS: headache
• EENT: blurred vision, rhinitis
• CV: transient volume expansion, chest pain, HF, pulmonary edema, tachycardia
• GI: thirst
• GU: renal failure, urinary retention
• F and E: dehydration, hyperkalemia, hypernatremia, hypokalemia, hyponatremia
• Local: phlebitis at IV site
• Drug-drug interactions-
• Hypokalemia ↑ the risk of digoxin toxicity.
• Assessment- 
• Monitor vital signs, urine output, CVP, and pulmonary artery pressures (PAP) before and hourly throughout administration. Assess patient for signs and symptoms of dehydration (decreased skin turgor, fever, dry skin and mucous membranes, thirst) or signs of fluid overload (increased CVP, dyspnea, rales/crackles, edema).
• Assess patient for anorexia, muscle weakness, numbness, tingling, paresthesia, confusion, and excessive thirst. Report signs of electrolyte imbalance.
• Increased Intracranial Pressure: 
• Monitor neurologic status and intracranial pressure readings in patients receiving this medication to decrease cerebral edema.
• Increased Intraocular Pressure: 
• Monitor for persistent or increased eye pain or decreased visual acuity.
• Lab Test Considerations:
• Renal function and serum electrolytes should be monitored routinely throughout course of therapy.
• Implementation- 
• Observe infusion site frequently for infiltration. Extravasation may cause tissue irritation and necrosis.
• Do not administer electrolyte-free mannitol solution with blood. If blood must be administered simultaneously with mannitol, add at least 20 mEq NaCl to each liter of mannitol.
• Confer with physician regarding placement of an indwelling Foley catheter (except when used to decrease intraocular pressure).
• IV: Administer by IV infusion undiluted. If solution contains crystals, warm bottle in hot water and shake vigorously. Do not administer solution in which crystals remain undissolved. Cool to body temperature. Use an in-line filter for 15%, 20%, and 25% infusions.
• Test Dose: 
• Administer over 3–5 min to produce a urine output of 30–50 mL/hr. If urine flow does not increase, administer 2nd test dose. If urine output is not at least 30–50 mL/hr for 2–3 hr after 2nd test dose, patient should be re-evaluated.
• Oliguria: 
• Administration rate should be titrated to produce a urine output of 30–50 mL/hr.
• Increased Intracranial Pressure: 
• Infuse dose over 30–60 min in adults and children.
• Intraocular Pressure: 
• Administer dose over 30 min. When used preoperatively, administer 60–90 min before surgery.
• Evaluation/desired outcomes- 
• Urine output of at least 30–50 mL/hr or an increase in urine output in accordance with parameters set by physician.
• Reduction in intracranial pressure.
• Reduction of intraocular pressure.
• Excretion of certain toxic substances.
• Irrigation during transurethral prostate resection.

Digoxin immune fab

• Pregnancy Category- Category C
• Ther. Class.- antidotes
• Pharm. Class.- antibody fragments
• Indications- 
• Serious life-threatening overdosage with digoxin.
• Actions- 
• An antibody produced in sheep that binds antigenically to unbound digoxin in serum.
• Therapeutic Effect(s):
• Binding and subsequent removal of digoxin, preventing toxic effects in overdose.
• Use Cautiously in:
• Known hypersensitivity to sheep proteins or products
• Adverse rxns/side effect
• CV: re-emergence of atrial fibrillation, re-emergence of HF
• F and E: HYPOKALEMIA
• Drug-drug interactions-
•  Prevents therapeutic response to digoxin.
• Assessment- 
• Monitor ECG, pulse, BP, and body temperature before and during treatment. Patients with atrial fibrillation may develop a rapid ventricular response as a result of decreased digoxin levels.
• Assess patient for increase in signs of HF (peripheral edema, dyspnea, rales/crackles, weight gain).
• Lab Test Considerations:
• Monitor serum digoxin levels before administration.
• Monitor serum potassium levels frequently during treatment. Before treatment, hyperkalemia usually coexists with toxicity. Levels may decrease rapidly; hypokalemia should be treated promptly.
• Free serum digoxin levels fall rapidly after administration. Total serum concentrations rise suddenly after administration but are bound to the Fab molecule and are inactive. Total serum concentrations will decrease to undetectable levels within several days. Serum digoxin levels are not valid for 5–7 days after administration.
• Implementation-
•  Cardiopulmonary resuscitation equipment and medications should be available during administration.
• Delay redigitalization for several days until the elimination of digoxin immune Fab from the body is complete.
• Evaluation/desired effects-
• Resolution of signs and symptoms of digoxin toxicity.
• Decreased digoxin or level without major side effects.

Captopril (Capoten)

• Pregnancy Category- 
• Category C: first trimester
• Category D: second and third trimesters
• Ther. Class.- antihypertensives
• Pharm. Class.- ace inhibitors
• Indications- 
• Alone or with other agents in the management of hypertension.
• Management of heart failure.
• Reduction of risk of death, heart failure-related hospitalizations, and development of overt heart failure following myocardial infarction.
• Treatment of diabetic nephropathy in patients with Type 1 diabetes mellitus and retinopathy.
• Action- 
• Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also ↑ plasma renin levels and ↓ aldosterone levels. Net result is systemic vasodilation.
• Therapeutic Effect(s):
• Lowering of BP in patients with hypertension.
• Improved survival and reduced symptoms in patients with heart failure.
• Improved survival and reduced development of overt heart failure after myocardial infarction.
• Decreased progression of diabetic nephropathy with decreased need for transplantation or dialysis.
• Contraindicated in:
• History of angioedema with previous use of ACE inhibitors
• OB: Can cause injury or death of fetus – if pregnancy occurs, discontinue immediately
• Lactation: Appears in breast milk; patient must discontinue drug or provide alternate to breast milk.
• Use Cautiously in:
• Patients with collagen vascular disease, renal impairment, hypovolemia, hyponatremia, and concurrent diuretic therapy
• Surgery/anesthesia (hypotension may be exaggerated)
• [image]Black patients (monotherapy for hypertension less effective, may require additional therapy; higher risk of angioedema)
• Exercise Extreme Caution in:
• History of angioedema.
• Adverse rxns/side effects-
• CNS: dizziness, fatigue, headache, insomnia
• Resp: cough (nagging)
• CV: hypotension, chest pain, palpitations, tachycardia
• GI: taste disturbances, abdominal pain, anorexia, constipation, diarrhea, nausea, vomiting
• GU: proteinuria, impaired renal function
• Derm: ANGIOEDEMA, rash, pruritis
• F and E: hyperkalemia
• Hemat: AGRANULOCYTOSIS, neutropenia
• Interactions-
• Drug-Drug
• NSAIDs and selective COX-2 inhibitors may blunt the antihypertensive effect and ↑ the risk of renal dysfunction.
• Drug-Natural Products:
• Avoid natural licorice (causes sodium and water retention and increases potassium loss).
• Drug-Food:
• Food significantly ↓ absorption. Administer captopril 1 hr before meals.
• Assessment- 
• Hypertension: 
• Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes.
• Monitor frequency of prescription refills to determine compliance.
• Assess patient for signs of angioedema (dyspnea, facial swelling).
• Heart Failure: 
• Monitor weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
• Lab Test Considerations:
• Monitor renal function. May cause ↑ BUN and serum creatinine. If ↑ BUN or serum creatinine concentrations occur, may require dose reduction or withdrawal.
• May cause hyperkalemia.
• May cause ↑ AST, ALT, alkaline phosphatase, and serum bilirubin.
• Assess urine protein prior to and periodically during therapy for up to 1 yr in patients with renal impairment or those receiving > 150 mg/day of captopril. If excessive or increasing proteinuria occurs, re-evaluate ACE inhibitor therapy.
• Monitor CBC with differential prior to initiation of therapy, every 2 wk for the first 3 mo, and periodically for up to 1 yr in patients at risk for neutropenia (patients with renal impairment, or collagen-vascular disease) or at first sign of infection. Discontinue therapy if neutrophil count is <1000/mm3.
• May cause false-positive test results for urine acetone.
• Implementation- 
• Correct volume depletion, if possible, before initiation of therapy due to possible precipitous drop in BP during first 1–3 hr following first dose. Risk of hypotension may be decreased by discontinuing diuretics or cautiously increasing salt intake 2–3 days prior to beginning captopril. Monitor BP closely. Resume diuretics if BP is not controlled.
• PO: Administer 1 hr before meals or 2 hr after meals. May be crushed if patient has difficulty swallowing. Tablets may have a sulfurous odor.
• An oral solution may be prepared by crushing the tablets.
• Evaluation/desired outcomes- 
• Decrease in BP without appearance of excessive side effects.
• Improvement in survival and reduction of symptoms in heart failure.
• Reduction of risk of death or development of heart failure following myocardial infarction.
• Decrease in progression of diabetic nephropathy.

Metolazone (Zaroxolyn)

• Pregnancy Category- Category B
• Ther. Class.- antihypertensives; diuretics
• Pharm. Class.- thiazide like diuretics
• Indications- 
• Mild to moderate hypertension.
• Edema associated with HF or the nephrotic syndrome.
• Action- 
• Increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule.
• Promotes excretion of chloride, potassium, magnesium, and bicarbonate.
• May produce arteriolar dilation.
• Therapeutic Effect(s):
• Lowering of BP in hypertensive patients.
• Diuresis with subsequent mobilization of edema. Effect may continue in renal impairment.
• Contraindicated in:
• Anuria
• Lactation
• Use Cautiously in:
• Severe hepatic impairment
• Adverse rxns/side effect-
•  CNS: drowsiness
• CV: chest pain, hypotension, palpitations
• GI: anorexia, bloating, cramping, drug-induced hepatitis, pancreatitis,
• Derm: photosensitivity, rashes
• Endo: hyperglycemia
• F and E: hypokalemia, dehydration, hypercalcemia, hypochloremic alkalosis, hypomagnesemia, hyponatremia, hypophosphatemia, hypovolemia
• Hemat: blood dyscrasias
• Metabolic: hyperuricemia
• Interactions- 
• Drug-Drug
• May ↑ the risk of digoxin toxicity.
• Stimulant laxatives (including aloe, senna) may ↑ risk of potassium depletion.
• Drug-Food:
• Food may ↑ extent of absorption.
• Assessment- 
• Monitor BP, intake and output, and daily weight, and assess feet, legs, and sacral area for edema daily.
• Assess patient, especially if taking digoxin, for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Notify health care professional if these signs of electrolyte imbalance occur. Patients taking digoxin are at risk of digoxin toxicity because of the potassium-depleting effect of the diuretic.
• Hypertension: 
• Monitor BP before and periodically during therapy.
• Lab Test Considerations:
• Monitor electrolytes (especially potassium), blood glucose, BUN, and serum creatinine and uric acid levels before and periodically during therapy.
• May cause ↑ in serum and urine glucose in diabetic patients.
• May cause an ↑ in serum bilirubin, calcium, creatinine, and uric acid, and a ↓ in serum magnesium, potassium, and sodium and urinary calcium concentrations.
• May cause ↓ serum protein-bound iodine (PBI) concentrations.
• May cause ↑ serum cholesterol, low-density lipoprotein, and triglyceride concentrations.
• Implementations- 
• Administer in the morning to prevent disruption of sleep cycle.
• Intermittent dose schedule may be used for continued control of edema.
• Evaluation/desired outcomes- 
• Decrease in BP.
• Increase in urine output.
• Decrease in edema.

nadolol (Corgard)

• Pregnancy Category- Category C
• Ther. Class.- antianginals; antihypertensives
• Pharm. Class.- beta blockers
• Indications- 
• Management of hypertension.
• Management of angina pectoris.
• Unlabeled Use(s):
• Arrhythmias.
• Migraine prophylaxis.
• Tremors (essential, lithium-induced, parkinsonian).
• Aggressive behavior.
• Antipsychotic-associated akathisia.
• Situational anxiety.
• Esophageal varices.
• Reduction of intraocular pressure.
• Action- 
• Blocks stimulation of beta₁ (myocardial) and beta₂ (pulmonary, vascular, and uterine) receptor sites.
• Therapeutic Effect(s):
• Decreased heart rate and BP.
• Contraindicated in:
• Uncompensated HF
• Pulmonary edema
• Cardiogenic shock
• Bradycardia or heart block.
• Use Cautiously in:
• Renal impairment (CCr <50 mL/min)
• Hepatic impairment
• Pulmonary disease (including asthma)
• Diabetes mellitus (may mask signs of hypoglycemia)
• Thyrotoxicosis (may mask symptoms)
• Adverse rxns/side effects-
•  CNS: fatigue, weakness, anxiety, depression, dizziness, insomnia, memory loss, mental status changes, nightmares
• EENT: blurred vision, dry eyes
• Resp: bronchospasm, wheezing
• CV: ARRHYTHMIAS, BRADYCARDIA, HF, PULMONARY EDEMA, orthostatic hypotension, peripheral vasoconstriction
• GI: constipation, diarrhea, nausea
• GU: erectile dysfunction, ↓ libido
• Derm: itching, rashes
• Endo: hyperglycemia, hypoglycemia
• Neuro: paresthesia
• Drug-Drug interactions
• General anesthesia, diltiazem, and verapamil may cause additive myocardial depression.
• Concurrent use with amphetamines, cocaine, ephedrine, epinephrine, or norepinephrine, may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia).
• Concurrent use with clonidine ↑ hypotension and bradycardia.
• May alter the effectiveness of insulins or oral hypoglycemic agents (dosage adjustments may be necessary).
• Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).
• Concurrent NSAIDs may ↓ antihypertensive action.
• Assessment-
• Monitor BP and pulse frequently during dose adjustment and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position.
• Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, jugular venous distention).
• Hypertension: 
• Check frequency of refills to determine compliance.
• Angina: 
• Assess frequency and characteristics of angina periodically during therapy.
• Lab Test Considerations:
• May cause increased BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
• May cause increase in blood glucose levels.
• Toxicity Overdose:
• Monitor patients receiving beta blockers for signs of overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails or palms, seizures). Notify physician or other health care professional immediately if these signs occur.
• Implementation-
•  Discontinuation of concurrent clonidine should be done gradually, with beta blocker discontinued first; then, after several days, discontinue clonidine.
• PO: Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional.
• May be administered with food or on an empty stomach.
• Tablets may be crushed and mixed with food.
• Evaluation/desired outcomes- 
• Decrease in BP.
• Reduction in frequency of angina.
• Increase in activity tolerance. May require up to 5 days before therapeutic effects are seen.

Propranolol (Inderal)

• Pregnancy Category- Category C
• Ther. Class.-
• antianginals
• antiarrhythmics (Class II)
• antihypertensives
• vascular headache suppressants
• Pharm. Class.- beta blockers
• Indications- 
• Management of hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma.
• Also used in the prevention and management of MI, and the prevention of vascular headaches.
• Unlabeled Use(s):
• Also used to manage alcohol withdrawal, aggressive behavior, antipsychotic-associated akathisia, situational anxiety, and esophageal varices.
• Post-traumatic stress disorder (PTSD)(Ongoing clinical trials at National Institute for Mental Health [NIMH]).
• Action-
• Blocks stimulation of beta₁(myocardial) and beta₂ (pulmonary, vascular, and uterine)-adrenergic receptor sites.
• Therapeutic Effect(s):
• Decreased heart rate and BP.
• Suppression of arrhythmias.
• Prevention of MI.
• Contraindicated in:
• Uncompensated HF
• Pulmonary edema
• Cardiogenic shock
• Bradycardia, sick sinus syndrome, or heart block (unless pacemaker present).
• Use Cautiously in:
• Renal or hepatic impairment
• Pulmonary disease (including asthma)
• Diabetes mellitus (may mask signs of hypoglycemia)
• Thyrotoxicosis (may mask symptoms)
• Skeletal muscle disease (may exacerbate myopathy)
• OB: Crosses the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression. May also ↓ blood supply to the placenta, increase the risk for premature birth or fetal death, and cause intrauterine growth retardation. May ↑ risk of cardiac and pulmonary complications in the infant during the neonatal time frame. 
• Lactation: Appears in breast milk; use formula if propranolol must be taken
• Adverse rxns/sode effects- 
• CNS: fatigue, weakness, anxiety, dizziness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares
• EENT: blurred vision, dry eyes,
• Resp: bronchospasm, wheezing
• CV: ARRHYTHMIAS, BRADYCARDIA, HF, PULMONARY EDEMA, orthostatic hypotension, peripheral vasoconstriction
• GI: constipation, diarrhea, nausea
• GU: erectile dysfunction, ↓ libido
• Derm: ERYTHEMA MULTIFORME, EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, itching, rash
• Endo: hyperglycemia, hypoglycemia (↑ in children)
• Neuro: paresthesia
• Misc: ANAPHYLAXIS
• Drug-Drug interactions
• General anesthesia and verapamil may cause additive myocardial depression.
• Levels may be ↓ with chronic alcohol use.
• Concurrent use with amphetamines, cocaine, epinephrine, and norepinephrine may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia).
• May alter the effectiveness of insulin or oral hypoglycemics (dose adjustments may be necessary).
• Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).
• Concurrent NSAIDs may ↓ antihypertensive action.
• Smoking ↑ metabolism and ↓ effects; smoking cessation may ↑ effects.
• Assessment-
• Monitor BP and pulse frequently during dose adjustment period and periodically during therapy.
• Abrupt withdrawal of propranolol may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia. Drug should be tapered over a 2-week period before discontinuation. Assess patient carefully during tapering and after medication is discontinued. Consider that patients taking propranolol for non-cardiac indications may have undiagnosed cardiac disease. Abrupt discontinuation or withdrawal over too-short a period of time (less than 9 days) should be avoided.
• Patients receiving propranolol IV must have continuous ECG monitoring and may have pulmonary capillary wedge pressure (PCWP) or central venous pressure (CVP) monitoring during and for several hours after administration.
• Assess for orthostatic hypotension when assisting patient up from supine position.
• Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, jugular venous distention).
• Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
• Angina: 
• Assess frequency and characteristics of anginal attacks periodically during therapy.
• Vascular Headache Prophylaxis: 
• Assess frequency, severity, characteristics, and location of vascular headaches periodically during therapy.
• PTSD: 
• Assess frequency of symptoms (flashbacks, nightmares, efforts to avoid thoughts or activities that may trigger memories of the trauma, and hypervigilance) periodically throughout therapy.
• Lab Test Considerations:
• May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
• May cause ↓ or ↑ in blood glucose levels. In labile diabetic patients, hypoglycemia may be accompanied by precipitous ↑ of BP.
• Toxicity Overdose:
• Monitor patients receiving beta blockers for signs of overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails or palms, seizures). Notify health care professional immediately if these signs occur.
• Hypotension may be treated with modified Trendelenburg position and IV fluids unless contraindicated. Vasopressors (epinephrine, norepinephrine, dopamine, dobutamine) may also be used. Hypotension does not respond to beta agonists.
• Glucagon has been used to treat bradycardia and hypotension.
• Implementations-
• 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. Also, patient harm or fatalities have occurred when switching from oral to IV propranolol; oral and parenteral doses are not interchangeable. IV dose is 1/10 of the oral dose. Change to oral therapy as soon as possible.
• PO: Take apical pulse prior to administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional.
• Administer with meals or directly after eating to enhance absorption.
• Swallow extended release tablets whole; do not crush, break, or chew. Propranolol tablets may be crushed and mixed with food.
• Mix propranolol oral solution with liquid or semisolid food (water, juices, applesauce, puddings). To ensure entire dose is taken, rinse glass with more liquid or have patient consume all of the applesauce or pudding. Do not store after mixing.
• Evaluation/desired outcome-
• Decrease in BP.
• Control of arrhythmias without appearance of detrimental side effects.
• Reduction in frequency of anginal attacks.
• Increase in activity tolerance.
• Prevention of MI.
• Prevention of vascular headaches.
• Management of thyrotoxicosis.
• Management of pheochromocytoma.
• Decrease in tremors.
• Management of hypertrophic cardiomyopathy.
• Decrease in symptoms associated with PTSD.

Metoprolol (Lopressor)

• Pregnancy Category- Category C
• Ther. Class.
• antianginals
• antihypertensives
• Pharm. Class.- beta blockers
• Indications- 
• Hypertension.
• Angina pectoris.
• Prevention of MI and decreased mortality in patients with recent MI.
• Management of stable, symptomatic (class II or III) heart failure due to ischemic, hypertensive or cardiomyopathc origin (may be used with ACE inhibitors, diuretics and/or digoxin; Toprol XL only).
• Unlabeled Use(s):
• Ventricular arrhythmias/tachycardia.
• Migraine prophylaxis.
• Tremors.
• Aggressive behavior.
• Drug-induced akathisia.
• Anxiety.
• Action- 
• Blocks stimulation of beta₁(myocardial)-adrenergic receptors. Does not usually affect beta₂(pulmonary, vascular, uterine)-adrenergic receptor sites.
• Therapeutic Effect(s):
• Decreased BP and heart rate.
• Decreased frequency of attacks of angina pectoris.
• Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure.
• Contraindicated in:
• Uncompensated HF;
• Pulmonary edema;
• Cardiogenic shock;
• Bradycardia, heart block, or sick sinus syndrome (in absence of a pacemaker).
• Use Cautiously in:
• Renal impairment;
• Hepatic impairment;
• Pulmonary disease (including asthma; beta₁ selectivity may be lost at higher doses);
• Diabetes mellitus (may mask signs of hypoglycemia);
• Thyrotoxicosis (may mask symptoms);
• Untreated pheochromocytoma (initiate only after alpha blocker therapy started);
• Adverse rxns/side effects-
•  CNS: fatigue, weakness, anxiety, depression, dizziness, insomnia, memory loss, mental status changes, nightmares
• EENT: blurred vision
• Resp: bronchospasm, wheezing
• CV: BRADYCARDIA, HF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction
• GI: constipation, N.V.D., drug-induced hepatitis, dry mouth, flatulence, gastric pain, heartburn, ↑ liver enzymes
• GU: erectile dysfunction, ↓ libido, urinary frequency
• Endo: hyperglycemia, hypoglycemia
• Drug-Drug interactions-
• General anesthesia, and verapamil may cause ↑ myocardial depression.
• Concurrent use with amphetamines, cocaine,  epinephrine, or norepinephrine may result in unopposed alpha-adrenergic stimulation (excessive hypertension,bradycardia).
• May alter the effectiveness of insulins or oral hypoglycemic agents (dose adjustments may be necessary).
• Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).
• Assessment-
• Monitor BP, ECG, and pulse frequently during dose adjustment and periodically during therapy.
• Monitor frequency of prescription refills to determine compliance.
• Monitor vital signs and ECG every 5–15 min during and for several hours after parenteral administration. If heart rate <40 bpm, especially if cardiac output is also decreased, administer atropine 0.25–0.5 mg IV.
•  Monitor intake and output ratios and daily weights. Assess routinely for signs and symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention).
• Angina: 
• Assess frequency and characteristics of anginal attacks periodically during therapy.
• Lab Test Considerations:
• May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
• May cause ↑ in blood glucose levels.
• May cause ↑ serum alkaline phosphatase, LDH, AST, and ALT levels.
• Implementation-
• High Alert: IV vasoactive medications are inherently dangerous. Before administering intravenously, have second practitioner independently check original order and dose calculations.
• PO: Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify health care professional.
• Administer metoprolol with meals or directly after eating.
• Extended-release tablets should be swallowed whole; do not break, crush, or chew.
• Evaluation/desired outcomes
• Decrease in BP.
• Reduction in frequency of anginal attacks.
• Increase in activity tolerance.
• Prevention of MI.

Atenolol (Tenormin)

• Pregnancy Category- Category D
• Ther. Class.-
• antianginals
• antihypertensives
• Pharm. Class.- beta blockers
• Indications- 
• Management of hypertension.
• Management of angina pectoris.
• Prevention of MI.
• Action- 
• Blocks stimulation of beta₁(myocardial)-adrenergic receptors. Does not usually affect beta₂(pulmonary, vascular, uterine)-receptor sites.
• Therapeutic Effect(s):
• Decreased BP and heart rate.
• Decreased frequency of attacks of angina pectoris.
• Prevention of MI.
• Contraindicated in:
• Uncompensated HF;
• Pulmonary edema;
• Cardiogenic shock;
• Bradycardia or heart block.
• Use Cautiously in:
• Renal impairment (dosage ↓ recommended if CCr ≤35 mL/min);
• Hepatic impairment;
• Pulmonary disease (including asthma; beta selectivity may be lost at higher doses);
• Diabetes mellitus (may mask signs of hypoglycemia);
• Thyrotoxicosis (may mask symptoms);
• Adverse rxns/side effects-
• CNS: fatigue, weakness, anxiety, depression, dizziness, insomnia, memory loss, mental status changes, nightmares
• EENT: blurred vision
• Resp: bronchospasm, wheezing
• CV: BRADYCARDIA, HF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction
• GI: constipation, N.V.D., ↑ liver enzymes,
• GU: erectile dysfunction, ↓ libido, urinary frequency 
• Endo: hyperglycemia, hypoglycemia
• Drug-Drug interactions
• General anesthesia, and verapamil may cause additive myocardial depression.
• Concurrent use with amphetamine, cocaine, ephedrine, epinephrine, or norepinephrine may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia).
• May alter the effectiveness of insulins or oral hypoglycemic agents (dosage adjustments may be necessary).
• Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).
• Assessment- 
• Monitor BP, ECG, and pulse frequently during dosage adjustment period and periodically throughout therapy.
• Monitor intake and output ratios and daily weights. Assess routinely for HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention).
• Angina: 
• Assess frequency and characteristics of angina periodically throughout therapy.
• Lab Test Considerations:
• May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.
• May cause ↑ in blood glucose levels.
• Toxicity Overdose:
• Monitor patients receiving beta blockers for signs of overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails or palms, seizures). Notify physician immediately if these signs occur.
• Implementation- 
• PO: Take apical pulse before administering drug. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional.
• Evauation/desired outcomes- 
• Decrease in BP.
• Reduction in frequency of angina.
• Increase in activity tolerance.
• Prevention of MI.

Nesiritide (Natrecor)

• Pregnancy Category- Category C
• Ther. Class.- none assigned
• Pharm. Class.- vasodilators (human B-type natriuretic peptide)
• Indications-
• Acutely decompensated HF in hospitalized patients who have dyspnea at rest or with minimal activity; has been used with digoxin, diuretics, and ACE inhibitors. Should not be used for intermittent outpatient infusion, scheduled repetitive use, as a diuretic or to improve renal function.
• Action-
•  Binds to guanyl cyclase receptors in vascular smooth muscle and endothelial cells, producing increased intracellular guanosine 3'5'-cyclic monophosphate (cGMP) and smooth muscle cell relaxation. cGMP acts as a "second messenger" to dilate veins and arteries.
• Therapeutic Effect(s):
• Dose-dependent reduction in pulmonary capillary wedge pressure (PCWP) and systemic arterial pressure in patients with heart failure with resultant decrease in dyspnea.
• Contraindicated in:
• Cardiogenic shock
• Systolic BP <90 mm Hg
• Low cardiac filling pressure, significant valvular stenosis, restrictive/subtractive cardiomyopathy, constrictive pericarditis/cardiac tamponade, or other conditions in which cardiac output is dependent on venous return.
• Use Cautiously in:
• Heart failure where renal function is dependent on activity of the renin/angiotensin/aldosterone system (may cause azotemia)
• Cardiogenic shock (should not be used as primary therapy)
• Adverse rxns/side effects-
•  CNS: anxiety, confusion, dizziness, headache, hypotension (dose related), insomnia
• EENT: amblyopia
• Resp: APNEA, cough, hemoptysis
• CV: hypotension, arrhythmias, bradycardia
• GI: abdominal pain, nausea, vomiting
• GU: ↑ creatinine, renal failure
• Derm: itching, rash, sweating
• Hemat: anemia
• Neuro: paresthesia, tremor
• 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 <100 mm Hg. Reduce dose or discontinue nesiritide if patient develops hypotension. Hypotension may cause renal compromise. Use IV fluids and changes in body position to support BP if symptomatic hypotension occurs. Nesiritide may be restarted at a dose reduced by 30% with no bolus administration once patient is stabilized. Hypotension may be prolonged for hours, requiring a period of monitoring prior to restarting administration.
• Monitor intake and output and weigh daily. Assess for decrease in signs of HF (dyspnea, rales/crackles, peripheral edema, weight gain).
• Lab Test Considerations:
• Monitor BUN and serum creatinine. May cause ↑ in serum creatinine; ↑ serum creatinine may be dose-related.
• Implementations-
• 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.
• Evaluation/desired effects-
• Improvement in dyspnea and reduction in mean PCWP in patients with decompensated HF.