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Warfarin
Class: Anticoagulant
MOA: Blocks one of the enzymes (proteins) that uses vitamin K to produce clotting factors, this disrupts the clotting process making it longer for the blood to clot.
Drug - drug interactions: (check NIMC) Potassium, nurophen - taken together increases the risk of bleeding.
Signs & Symptoms - Hemorrhage, vomiting, diarrhea, rash
Nursing considerations to prevent, assess or manage risk: Monitor INR (International Normalized Ratio) blood test that tells you how long it takes for your blood to clot (when you initially start it and then 1-4 weeks after).

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This will be added once we get to :)

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Did you have difficulty trying to find the right words?
Consider how your patients feel when we try to provide education

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What patient education would you provide Angela?
How would you best explain this to her?

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Atorvastatin
Class: Statins
MOA: Competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (a rate-limiting enzyme in cholesterol synthesis). Increase hepatic cholesterol uptake from blood, reduce concentrations of total cholesterol, LDL and triglyceride (modest), and produce a small increase in HDL concentrations.
Drug - drug interactions: Warfin (when taken together it can increase risk of acute kidney injury as Warfarin, which uses the same enzyme pathway for metabolism - IVR monitoring
Signs & Symptoms: Mild transient GI symptoms, headache, sleep disturbances, dizziness,
Nursing considerations to prevent, assess or manage risk to: avoid stopping statin if there are symptoms of an ACS because stopping is associated with an increased rate of cardiac events (especially in the first week after stopping. Monitor aminotransferase and CK at baseline, repeat during treatment if indicated clinically. Stop statin if aminotransferase concentrations are persistently elevated to >3 times ULN. CK concentration is >10 times ULN. There is persistent unexplained muscle pain or weakness (even if CK is normal).
Educate patient that they should limit the amount of high fat foods they eat

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This will be added once we get to :)

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Ramipril
Class: ACE-Inhibitor
MOA: ACE-inhibitors act on the renin-angiotensin-aldosterone system (RAAS) by blocking the conversion of angiotensin 1 to angiotensin 2 and by inhibiting the breakdown of bradykinin. Thereby, reducing the effects of angiotensin 2 induced vasoconstriction and reducing aldosterone release and sodium retention. This results in the reduction of BP and systemic vascular resistance.

Drug - drug interactions: (check NIMC)
Spironolactone (potassium sparing diuretic) - may lead to an increase in the amount of potassium in the blood (hyperkalaemia)
Frusemide (loop diuretic) - increases the risk of severe hypotension
Nurofen (NSAID) - may reduce the anti-hypertensive effect of ramipril and increase renal impairment and hyperkalaemia

Signs & Symptoms
- Hypotension

- Dizziness

- Headache

- Renal impairment

- Hyperkalaemia – due to the decreased secretion of aldosterone which regulates potassium excretion therefore potassium elimination may be reduced

- Non-productive cough – related to the release of bradykinin

Nursing considerations to prevent, assess or manage risk:
- Monitor renal function
- Monitor electrolytes
- Review the use of NSAIDs
- Liaise in relation to ceasing potassium supplements
- Liaise with the doctor in relation to low blood pressure and whether ramipril should be withheld

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Bisoprolol
Class: Beta Bolcker
MOA:
- Blocks beta 1 & beta 2 recptors
- Beta-blockers reduce HR, BP and cardiac contractility; also depress sinus node rate and slow conduction through the AV node, and prolong atrial refractory periods.

Drug - drug interactions: (check NIMC)

Lasix - mod interaction - may lower BP & HR = dizziness, weak, fainting & arrhythmias. Ensure pt sit on edge of bed prior to ambulating.

NSAIDS - NSAIDs may impair antihypertensive effect of beta-blockers; avoid combination or monitor BP and adjust dose of beta-blocker if necessary. Low-dose aspirin may be used.

Signs & Symptoms
- Bradycardia
- HoTN
- Orthostatic hypotension
- Transient worsening of heart failure - at start of Tx
- GIT - nausea, diarrhoea
- Bronchospasm
- Dyspnoea
- Cold extremities
- Fatigue
- Dizziness
- Abnormal vision
- Alteration of glucose and lipid metabolism

Nursing considerations to prevent, assess or manage risk:

Educate pt's on drug interactions and importance of disclosing all drug incl. OTC & CAMS when asked about med Hx.

When commencing Tx, ensure pt's are haemodynamically stable

Start at lowest dose and gradually increase to the highest tolerable maintenance dose, carefully monitoring BP, heart rate and clinical status with each dose increase

If there is transient worsening of heart failure, optimise dosage of other drugs before changing bisoprolol dose, eg:

if increasing congestion, increase diuretic dose, then halve bisoprolol dose if necessary

if symptomatic hypotension, first stop or reduce the dose of diuretics or vasodilators as appropriate

When stopping Tx, reduce dosage gradually (2 weeks). Avoid abrupt withdrawal as it may exacerbate angina, or precipitate rebound hypertension, MI or arrhythmias.

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Frusemide
Class: loop diuretic
MOA: Inhibit reabsorption of sodium and chloride in the ascending limb of the loop of Henle. Which accounts for retention of approximately 20% of filtered sodium; therefore, these are potent diuretics.
Indication: Oedema associated with heart failure, hepatic cirrhosis, renal impairment and nephrotic syndrome
Drug - drug interactions: (check NIMC):
Prescribing a NSAID(paracetamol/ nurofen) concurrently with an ACE inhibitor/ARB (Ramipril) and a diuretic increases the risk of AKI considerably. Therefore, care is needed whenever a prescriber is considering the use of a NSAID in a patient already taking the “double whammy”
Pt taking potassium
Signs & Symptoms: muscle cramps, weakness, unusual tiredness, confusion, severe dizziness, fast/irregular heartbeat
Nursing considerations to prevent, assess or manage risk:
urinary  chart- to monitor out put as pt will be losing electrolytes
fluid balance - to monitor input
Regular obs - monitor BP,HR
Monitor electrolytes
Assess renal function - lab test
Provide pt education concerning, potential sided effects, diet (low sodium diet), purchasing OTC NSAID
Assess skin turgor

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Spironalactone
Class: Aldosterone receptor antagonists
MOA: Inhibit sodium absorption in the distal tubule by antagonising aldosterone, increasing sodium and water excretion and reducing potassium excretion; they are weak diuretics.

Aldosterone may contribute to the pathophysiology of heart failure; by reducing aldosterone activity, aldosterone antagonist improve outcome.

Drug - drug interactions: (check NIMC)

Treatment with Drugs that can increase potassium concentration exmple trimethoprim, NSAIDS- increases the risk of hyperkalaemia.

Signs & Symptoms
Feeling dizzy
Muscle or leg cramps
feeling tired or low in energy
breast pain or breast enlargement

Risk or Adverse Effect:
Hyperkalemia
contraindicated when starting treatment; for advice about hyperkalaemia developing treatment of heart failure .

Nursing considerations to prevent, assess or manage risk:

Avoid combination or monitoy potassium concentration

Avoid foods that are rich in potassium
Report weight change of more than 3 pounds in 1 day, sweelling of ankles or fingers, trembling, nymbness

Increased thirst used mouth wash
Avoid rapid position changes since it can cause dizziness

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Note: Always consider:
Is there anything in the patient's condition/ past history that may increase the risks?

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What would they be for this medication chart?

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How / why does it occur?
What are they and what signs and symptoms would we see?
What do we as nurses do;
- prevent and/ or manage these?
Its not only the prescribed medication that needs to be considered; over the counter (OTC) needs to be also included when considering drug interactions

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Compare and contrast the significant risks for each of the drug classes. How might you identify these in your patient?

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Compare and contrast the significant risks for each of the drug classes. How might you identify these in your patient?

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What were your significant risks? Are they significant?
Do you understand the MoA of how the patient might develop the risk?
What assessments would you need to do help you identify the risks?
Did you need to go and look them up again?