The patient is a 70 years old man, admitted in Clinton Cardiology Center for repeated chest pain, fainting, hypotension, thoracic discomfort and cough, which appeared suddenly the same day. The clinical exam showed: cold, pale, sweated skin, dyspnea, tachycardia, a diastolic murmur in the third intercostal space near the sternum edge, a third degree systolic murmur above the lower sternum, and a blood pressure of 80/60 mmHg. The electrocardiogram showed signs of right ventricular overload.
The patient was known with arterial hypertension form 2009, had an episode of atrial fibrillation and deep vein thrombosis of the right calf in 2005 and had a hip replacement in 2010. An echocardiographic exam in 2006 noted an ascending aorta aneurism. He had been treated with Betaxolol 20 mg/day for hypertension, Amlodipine 5 mg/day, Indapamide 1. 5 mg/day and Trimetazidine 35 mg x 2/day.
He was also treated for a severe depression (Olanzapine). The patient states having worked as an accountant at some point in his life has the occasional beer but never smoked; he doesn’t exercise at all and cannot stand for long period of time.
The patient is a high fall risk. LEARNING STYLE English is the patient’s first language and he can read and write; he states having a degree in accounting. He is both an auditory and verbal learner who loves to talk and crack jokes. He speaks clearly and has no trouble communicating at all.
He is however feeling discouraged, depressed and is anxious of his current situation but is not eager to learn how to manage his diet and weight as he is not able to exercise due to dyspnea; he is also partially weight bearing on his left leg and is seeing PT as a result from his hip surgery and is still non-compliant with his therapy.
The doctor has put him on new medication Reteplase (Retevase) after the doctor diagnosed him with acute myocardium infarction. RETEPLASE (RETEVASE) Reteplase is a thrombolytic drug that is used to dissolve and break the blood clots that cause a heart attack. It works by activating a substance that helps to break up blood clots. Blood clots can prevent oxygen and nutrients from getting to the heart, which causes tissue death and long-term damage to the heart.
It’s indicated for use in the management of acute myocardial infarction (AMI) in adults for the improvement of ventricular function following AMI, the reduction of the incidence of congestive heart failure and the reduction of mortality associated with AMI. Reteplase is given by injection into a vein (IV). Generally, it is given as 10 + 10 unit double bolus injection. EACH BOLUS GIVEN OVER 2 MINUTES. WITH THE 2ND BOLUS GIVEN, AN INITIAL DOSE follows by a second dose 30 minutes later. Two 10 unit bolus injections are required for a complete treatment. CONTRAINDICATIONS.
•Active internal bleeding •Recent intracranial or intraspinal surgery or trauma •Severe uncontrolled hypertension •Known bleeding diathesis ADVERSE REACTIONS •hypersensitivity reactions, bleeding •GI upset, hypotension, fever •cardiogenic shock, arrhythmias, AV block, pulmonary edema.
• Heart failure, cardiac arrest, ischemia, myocardial rupture, mitral regurgitation, pericardial effusion, venous thrombosis, cholesterol embolism SIDE EFFECTS The most frequent adverse reaction associated with Retavase is bleeding. Other side effects include •Pain, redness, or swelling at the injection site •Nausea and vomiting •Severe headache, eye pain or vision changes •Sudden numbness or weakness, especially on one side of the body •Sudden headache, confusion, problems with speech, or balance INTERACTIONS •Anticoagulants “blood thinners” (e. g. , warfarin or heparins)
•Antiplatelet drugs (e. g. , clopidogrel, dipyridamole, ticlopidine) •NSAIDs (e. g. , ibuprofen, naproxen) •Drugs that alter platelet function (such as aspirin ) may increase the risk of bleeding if administered prior to or after Retavase (reteplase) therapy DOSAGE Reteplase is for intravenous administration only. Reteplase is administered as a 10 + 10 unit double-bolus injection.
Two 10 unit bolus injections are required for a complete treatment. Each bolus is administered as an intravenous injection over 2 minutes. The second bolus is given 30 minutes after initiation of the first bolus injection. Each bolus injection should be given via an intravenous line in which no other medication is being simultaneously injected or infused. No other medication should be added to the injection solution containing reteplase. There is no experience with patients receiving repeat courses of therapy with reteplase. Nursing Implications
Monitor vital signs, especially blood pressure and pulse. (Decreasing blood pressure, increase in pulse may indicate internal bleeding). Protect patient from injury by maintaining limited mobility during drug therapy. Monitor all possible sites of bleeding during infusion. Ensure that cardiac rhythm is monitored during therapy. (Dysrhythmias may occur with reperfusion of myocardium). Monitor CBC during and after therapy for indications of blood loss due to internal bleeding. (Patient has increased risk of bleeding for 2-4 days post therapy. )
Lab test considerations •Plasminogen (Administration of Retavase(reteplase) may cause decreases in plasminogen and fibrinogen •Degradation of fibrinogen in blood samples removed for analysis NURSING PROCESS Assessment Prior to administration: •Obtain complete health history including allergies, drug history and possible drug interactions •Obtain a baseline ECG and electrolytes, ABG, blood urea nitrogen and cardiac enzyme levels •Assess lab values; obtain CBC, PT, Hgb, Hct, platelet count.
•Asses vital signs and neurological status •Assess for recent surgery or trauma, bleeding disorders, or history of
hemorrhagic stroke or GI bleeding Nursing Diagnoses •Tissue perfusion, Ineffective related to adverse effects of medication •Injury, Risk for (bleeding) related to adverse effects of medication •Knowledge, Deficit related to drug therapy, action, and side effects Planning Patient teaching and demonstrate understanding of risks and benefits of drug therapy. Inform patient that activity will be limited during infusion and pressure dressing may be needed to prevent any active bleeding. Patient will remain free of unusual and excessive bleeding. Maintain effective tissue perfusion.
Continuously monitor cardiac rhythm and explain to patient that cardiac rhythm will be monitored during treatment. Instruct patient of increased risk of bleeding, activity restriction, and frequent monitoring during this time.
Teach patient regarding need for frequent vital signs. Take and record vital signs every 15minutes during infusion and for 2 hours following. Intervention Continue to monitor for adherence and compliance. At start of therapy watch for any signs of hypersensitivity, shortness of breath and a feeling of tightness and pressure in the chest.
Check patient vital signs frequently and monitor his skin color and sensory of function of extremities every hour. Evaluation Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met.
Protect patient from injury by maintaining limited mobility during drug therapy this helped to prevent any falls since he’s a high risk for falls. By monitoring his vital signs, especially blood pressure and pulse (Decreasing blood pressure, increase in pulse may indicate internal bleeding) this reduced risks for any internal bleeding. Patient understands the risks and benefits of the drug therapy.
The teaching plan is reasonable and effective as well and if implemented today would serve to teach the patient and assist him to better manage the MI and prevent other related complications such as hypertension, embolisms, dyspnea and circulation. REFERENCES ?2009 Edition Delmar’s Nurse’s Drug Handbook By George R. Spratto, Ph. D. , Adrienne L. Woods pages 1394-1395 ?http://www. rxlist. com/retavase-drug/patient-images-side-effects. htm ?http://www. drugs. com/cons/retavase. html ?http://reference. medscape. com/drug/retavase-reteplase-342289 ?http://www. mayoclinic. com/health/drug-information/DR602387.