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I. Drug Information

1. Generic Name: Digoxin

2. Brand Name: Lanoxin, Digox

3. Stock Dosage:

Caps 0.05, 0.1, 0.2 mg

tabs 0.0625 mg, 0.125 mg, 0.25mg

Injection:0.25 mg/ml

4. Drug Classification: Cardiac Glycoside, Digitalis Preparation

5. Mechanism of Action: Inhibits sodium-potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output; increases force of contraction (positive inotropic effect); decreases heart rate (negative chronotropic effect); decreases AV conduction speed.

Therapeutic Outcome: Decreased edema, pulse, respiration, crackles

6. Specific Client Indication:

Heart failure, rapid digitalization

TABLET: Adults and children older than age 10: Total loading dose is 10 to 15 mcg/kg PO. Initially, give half the total loading dose followed by one-quarter of the loading dose every 6 to 8 hours twice. Carefully assess clinical response and toxicity before each dose. Recommended starting maintenance dose for patients with normal renal function is 3.4 to 5.1 mcg/kg/day PO once daily. May increase every 2 weeks based on clinical response, serum drug levels, and toxicity. Refer to manufacturer's instructions for once-daily maintenance dose recommendations based on renal function and lean body weight.

Heart Failure, Gradual Digitalization

Tablet: More gradual attainment of digoxin levels can also be accomplished by beginning an appropriate maintenance dosage without a loading dose in patients with normal renal function. Adults and children older than age 10: Give starting maintenance dose of 3.4 to 5.1 mcg/kg PO once daily.

Atrial Fibrillation (Chronic)

PO, IV: Adults: If a loading dose is used, total loading dose is 10 to 15 mcg/kg PO (tablets, elixir). Initially, give half the total loading dose followed by one-quarter of the loading dose every 6 to 8 hours twice. Carefully assess clinical response and toxicity before each dose. Recommended starting maintenance dosage for patients with normal renal function is 3.4 to 5.1 mcg/kg (tablets) PO once daily or3 to 4.5 mcg/kg (elixir) PO once daily.

7. Contraindications:

Hypersensitivity to digoxin, ventricular fibrillation, ventricular tachycardia, carotid sinus syndrome, 2nd- or 3rd-degree heart block

8. Side Effects and Adverse Effects:

CNS: Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations

CV: Dysrhythmias, hypotension, bradycardia, AV block

EENT: Blurred vision, yellow-green halos, photophobia, diplopia

GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea

II. Drug-Related Nursing Responsibilities

Drug-induced arrhythmias may increase the severity of HF and hypotension.

Monitor patient for toxicity. Toxic effects on the heart may be life-threatening and require immediate attention. Signs and symptoms of toxicity include anorexia, nausea, vomiting, visual changes, and cardiac arrhythmias. Patients with low body weight, advanced age, renal impairment, and electrolyte disturbances are at increased risk.

Monitor digoxin level. Therapeutic level ranges from 0.5 to 2 nanograms/mL. Obtain blood for digoxin level at least 6 to 8 hours after last oral dose, preferably just before next scheduled dose.

Assess and document apical pulse for 1 min before giving product. Excessively slow pulse rate (60 beats/minute [bpm] or less) may be a sign of digitalis toxicity. Withhold drug and notify prescriber.

Monitor potassium level carefully. Take corrective action before hypokalemia occurs. Hyperkalemia may result from digoxin toxicity.

Reduce dose or discontinue drug for 1 or 2 days before elective cardioversion. Adjust dosage after cardioversion.

Monitor ECG continuously during parenteral loading doses and for patients with suspected toxicity; provide hemodynamic monitoring for patients with heart failure or administer multiple cardiac products.

Advise patient not to stop abruptly; teach all aspects of product (drug action, dosage regimen, how to take pulse, reportable signs, and follow-up care).

Tell patient to report pulse rate less than 60 bpm or more than 110 bpm or skipped beats or other rhythm changes.

Instruct patient to report all adverse reactions promptly. Nausea, vomiting, diarrhea, appetite loss, and visual disturbances may indicate toxicity.

Encourage patient to eat a consistent amount of potassium-rich foods.

Tell patient not to substitute one brand for another.

Advise patient to avoid using herbal supplements and to consult prescriber before taking one.

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I. Drug Information

1. Generic Name: Clopidogrel bisulfate

2. Brand Name: Plavix, Plogrel

3. Stock Dosage: Tablet: 75 mg, 300 mg

4. Drug Classification: Antiplatelet drugs

5. Mechanism of Action: Inhibits first and second phases of ADP-induced effects in platelet aggregation.

6. Specific Client Indication:

To reduce rate of MI and stroke in patients with established peripheral arterial disease or history of recent MI or stroke

Adults: 75 mg PO daily with aspirin

To reduce rate of MI and stroke in patients with unstable angina/non-ST-elevation MI (NSTEMI), including those managed medically and those managed with coronary revascularization; to reduce rate of MI and stroke in patients with acute ST-elevation MI (STEMI) who are to be managed medically.

Adults: Initially, a single 300-mg PO loading dose; then 75 mg PO once daily. Start and continue aspirin with clopidogrel. Initiating clopidogrel without a loading dose will delay (by several days) establishing antiplatelet effects.

7. Contraindications:

Hypersensitive to drug or its components.

Active bleeding, those with pathologic bleeding (peptic ulcer, intracranial hemorrhage)

8. Side Effects and Adverse Effects:

CNS: Headache, dizziness, depression, syncope, hyperesthesia, neuralgia, confusion, hallucinations

CV: Edema, hypertension, chest pain

GI: Nausea, vomiting, diarrhea, GI discomfort, GI bleeding, pancreatitis, hepatic failure

GU: Glomerulonephritis

HEMA: Epistaxis, purpura, bleeding (major/minor from any site), neutropenia, aplastic anemia, agranulocytosis, thrombotic thrombocytopenic purpura

INTEG: Rash, pruritus

MISC: UTI, hypercholesterolemia, chest pain, fatigue, intracranial hemorrhage, toxic epidermal necrolysis, Stevens-Johnson syndrome, flu-like syndrome, anaphylaxis

MS: Arthralgia, back pain

RESP: Upper respiratory tract infection, dyspnea, rhinitis, bronchitis, cough, bronchospasm

II. Drug-Related Nursing Responsibilities

Assess for symptoms of stroke, MI during treatment

Monitor liver function tests: AST, ALT, bilirubin, creatinine if patient is on long-term therapy (4 mo or more)

Monitor blood studies: CBC, Hct, Hgb, protime, cholesterol if patient is on long-term therapy; thrombocytopenia, neutropenia may occur

Advise patient that it may take longer than usual to stop bleeding and to refrain from activities in which trauma and bleeding may occur. Encourage patient to wear a seat belt when in a car.

Instruct patient to notify prescriber if unusual bleeding or bruising occurs.

Tell patient to inform all health care providers, including dentists, before undergoing procedures or starting new drug therapy, about taking drug.

Inform patient that drug may be taken without regard to meals.

Caution patient to report diarrhea, skin rashes, subcutaneous bleeding, chills, fever, sore throat.

Positive Therapeutic Outcome: Absence of Stroke