Let me say SORRY to all my dear readers…This very gap in my posts was really unexpected. Firstly, even though in vacation my plans to continue to write was a big fail, as we were stuck in the Flood that hit my homeland…our gods own country…Kerala.

Kerala is a calm and serene destination in south India. We the people of Kerala are always blessed with the finest climates, and the rainy season – the monsoon- on which agricultural Kerala relays on, is a time of blend emotions, that Keralites always cherish. The school reopenings, all the busy rainy mornings, playful kids at the roadside puddles, that patting sounds of rain at the window sills…

But, the rainy season of 2018, was not like the previous years. It was as if GOD had plans, not a single, but many many plans to each individual Keralites…and that’s why each one of us have our own stories to share, stories of horror, and sleepless nights, prayers and religious harmony, cooperation and compassion, moreover the stories of acceptance of the unavoidable, acceptance of the supernatural power above .

Here is the front view of my house during the flood. A picture captured by my relative who took shelter on the first floor of our house. Later they were rescued by the helicopter rescue team.

My House

The aftermath of the devastating flood…

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Days of cleaning and chlorination followed and still some more electrical and plumbing works pending.

All those flood days taught many valuable lessons.

Firstly, only a neighbor worth more than a distant relative.

Then, we understood the warmth of family bonds, as many of us took shelter in those relatives house, we haven’t been in touch for long.

We came to understand, how to live with minimal resources.

We learned to be in harmony irrespective of religion, financial or social status.

Now, after three months, our Kerala is almost back on track. And once again is open to the world with her natural beauty…..

Bonus: You could watch a documentary on 12th Nov 2018 on Discovery Channel at  9 pm (IST ) ‘KERALA FLOODS – THE HUMAN STORY’



A case of chest pain in the emergency department always go for the protocol of angina and/or MI. The MI protocol primarily focuses on relief of pain with antianginal medications.

What are Antianginal Medications?

Those medicines which reduce the oxygen demand of the myocardium or increases the oxygen supply to the heart are known as The Antianginal Drugs.


Here I will discuss the details of Nitrates




Indications of NITRATES

  • Acute Angina – Prophylaxis and Treatment
  • Chronic Angina treatment
  • Hypertension associated with MI or CHF
  • Raynaud’s disease (NTG ointment)

Mechanism of Action

Antianginals mainly work either by decreasing the Oxygen demand or by increasing oxygen supply.


  • ONSET – 2min (S/L); 3min (PO); 30min (Topical)
  • HALF LIFE – 5-7min
  • METABOLISM – In Liver


  • Sensitivity to Nitrates
  • Severe Anemia
  • Hepatic or Renal dysfunction
  • Hypotension
  • Head Trauma
  • Cerebral Haemorrhage

Side Effects

  • Dizziness (especially at the beginning of the treatment)
  • Orthostatic Hypotension
  • Topical application may lead to dermatitis
  • A throbbing Headache
  • Flushing of face
  • Reflex tachycardia

Drug Interaction

Additive hypotension with other ANTIHYPERTENSIVES

SILDENAFIL (Viagra) can cause additive hypotension

Intake of ALCOHOL along with NTG also cause hypotension


About the nurse’s responsibility, there is a lot to discusses. So I am dealing with it as a separate post. You can read it  NURSING CONSIDERATIONS WHILE ADMINISTERING NITRATES

Are you administering Inj Clexane safely?


On physical examination of a newly admitted case of bedridden elderly patient I noticed circular red patches around 3-4 cm radius over right and left lateral thighs. I  recognised it as the local damage due to the improper administration of Injection Clexane, a subcutaneously administered antithrombotic, which is a Low Molecular Weight Heparin. This led me to the thought,” How can we administer inj clexane properly?”. ” How safely we are administering it daily?”. In this post, I will share my knowledge about inj Clexane and the recommendations for its safe administration.


It is an Antithrombotic.

The active ingredient of Inj Clexane is Enoxaparin Sodium. It is a low molecular weight heparin (LMWH).

LMWH is produced by chemically splitting heparin into one-third of its original size. Has fewer side effects than heparin and has more predictable anticoagulant action. 


  • Prophylaxis of Venous thromboembolic diseases in Surgical patients(orthopaedic and general surgeries) and in Medical patients(rheumatic disease)
  • Treatment of DVT and Pulmonary Embolism (PE)
  • Acute STEMI
  • Unstable Angina and NSTEMI
  • In Haemodialysis – To prevent thrombus formation in Extracorporeal Circulation


  • Active significant bleeding
  • Hypersensitivity
  • Thrombocytopenia
  • Vascular aneurysms
  • Oesophageal varices
  • Hyperkalemia


  • Haemorrhage
  • Haematoma
  • Anaemia
  • Ecchymosis
  • Confusion
  • Diarrhoea
  • Haematuria


  • Aspirin
  • NSAIDs
  • Dextran
  • Warfarin

Interaction with these drugs increase the risk of bleeding



Should NOT BE  administered by IM route. IM CAUSES HAEMATOMA.

Preferred injection method is subcutaneous

In special cases, IV routes are used



  • Patient must be preferably in a lying position.
  • DO NOT expel the air bubble from the syringe. {This is to avoid the loss of drug while using prefilled syringes}
  • PREFERRED SITE: The subcutaneous tissue of the anterolateral or posterolateral ABDOMINAL WALL
  • It is administered as a DEEP S/C INJECTION
  • The whole length of the needle should be introduced PERPENDICULARLY, not from sides, into the skinfold gently held between the thumb and the index finger. SKINFOLD SHOULD BE HELD THROUGHOUT THE INJECTIONInjection_subcutaneous_insulinsyringe_angle_EQUIP_ILL_EN


  • DO NOT rub the injection site after administration


  • Initiate the treatment with single dose IV bolus injection, followed by  s/c injection
  • For IV, Multidose Vials or Prefilled syringes can be used



clexane multidose vial


  • IV administration should not be mixed or coadministered  with any other medications
  • Safely administered with NS (normal saline .9%) solution or 5%D in water.


  • Lab monitorings include

Baseline coagulation studies: aPTT, PT, INR, clotting time

periodic CBC for blood counts

periodic urine and stool examination for occult blood

  • apply direct pressure for venipuncture site for long durations
  • Assess for any history of allergy for the patient
  • Monitor for any signs of side effects


  • Educate regarding the increased risk of bleeding while taking inj clexane, monitoring for bleeding and management of bleeding
  • Instruct not to take any OTC medications without the consultation of the doctor
  • Patients who will self-administer it must be instructed on correct s/c administration technique
  • Instruct not to breastfeed while taking inj clexane

Let us join hands for safe administration of antithrombotics, to ensure the full benefit of the therapy with minimal potential harm.






while discussing the antianginal drugs, especially Nitrates I found there is a lot to tell you. Mainly, on the precautions that you must take while administering IV nitroglycerine. So I thought to write a separate post on the nursing considerations. I believe this would be useful for you throughout your nursing career and while preparing for any international nursing licence exams.

I arranged the points under two headings. First,  points to remember on administering all preparations other than IV and  Second,  points to remember on administering IV Nitroglycerine.



Oral Sustained-Release Tablets of NTG should be taken on an empty stomach with full glass of water

GTN tablet

Carry S/L tablets in the glass bottle, tightly capped. Nitroglycerin can lose potency if exposed to light, moisture, or heat. Also to discard the tablets and get a new supply every 8 weeks. Now, NTG sprays are prefered over the tablets due to the longer shelf life when compared to its S/L form.

Cartoon Ambulance Car Stock Animation | 10496218 for Ambulance Animation

If the chest pain is not relieved by 1 S/L tab, give 2 more tabs with a 5-minute interval. even after the third tablet (within 15 minutes), the pain persists, shift the client to the emergency department as the chest pain can be an MI and not Angina. your chest pain… is it simply a chest pain or a heart attack???

tablet intake sitting position

S/L tabs or sprays to be taken in sitting position to avoid postural hypotension



Explain that slight stinging, burning, or tingling under the tongue indicates the potency of the drug. Get a new supply if these sensations are not present.

avoid alcoho

Avoid alcohol, hot baths, saunas, and whirlpools, as they can cause vasodilatation and lead to hypotension and fainting.


To minimise the tolerance to NTG the patches are removed after 12 hours. And a 12-hour gap is given before the next patch

  •  Instruct client to not take sildenafil (Viagra) within 24 hours after taking
    nitrates, and wait 24 hours after taking Viagra to resume nitrate therapy



Use glass containers and tubings or PVC tubings to administer IV GTN. (other materials absorb it and reduce potency)

syringe n infusion pump

Administer  using an infusion pump that can maintain constant infusion rate


Strictly maintain BP CHART. Monitor the BP every 5 -15 minutes

NTG patch

Remove topical forms when starting IV infusion

  • Administer nitroglycerine diluted in 5% dextrose. Do not mix it with any other drugs
  • Nitrates can develop a tolerance to the drug. May need 10-12 hr/day nitrate-free interval to avoid tolerance development
  • Sudden cessation of the therapy may cause withdrawal reactions. Gradually reduce the dose and withdraw the therapy.
  • Intravenous Drip:  Begin at 5 mcg/min and titrate every 3-5 minutes to therapeutic response and stable vital signs. Titrate NTG infusion until relief of chest pain or a maximum of 200 mcg/min dose is achieved.


your chest pain… is it simply a chest pain or a heart attack???

Image result for images angina pectoris

It’s a common topic of discussion these days,  about the chest pain and heart attack. Several videos and writings regarding the topic and how to manage it is flying through the social media daily. Yes, it is a serious thing. But, do you think every chest pain of yours is a heart attack?. I thought to share with you what is my knowledge on the topic.


A chest pain which is felt like pressing, squeezing, choking or bursting and radiating to the left hand, shoulders, and left side of neck and jaw could be a serious symptom of a heart attack. At the same time, it could be a minor attack of angina pectoris. So,

what is the difference between Angina Pectoris and Myocardial Infarction(MI)?


  • Angina Pectoris is a symptom
  • Anginal pain is expressed as squeezing, chocking type felt at the Sternum
  • Angina can be different types
  • Caused by a decrease in oxygen supply to the heart muscles or an increased demand of oxygen
  • Maybe precipitated by activity or can occur during rest
  • ECG change noticed – ST depression
  • Investigated with the help of Stress Test
  • Relieved by rest or administration of Nitroglycerine


  • MI is a medical emergency
  • The chest pain is expressed to be crushing and typically spreads from the heart to the left arm, shoulders, jaw, neck, and back
  • Caused by the damaged myocardial cells resulting from  myocardial infarction (lack of oxygen supply to myocardium)
  • ECG shows a T wave inversion and an ST segment depression or elevation
  • Investigated mainly by labs – cardiac enzyme levels
  • Not relieved by rest or any medicines. Needed supportive therapy with Oxygen, analgesics, and positioning


Do you get additional points to add? .Please comment in the comment box.

Have a happy, pain-free life …

All About Antihypertensive Series 4 – Diuretics

Hello all nursing students there,

This is the fourth topic in All About Antihypertensive Series… You can read other topics in this series here… Diuretics are primarily those drugs help in the diuresis or increased production of urine. These drugs mainly affect the renal mechanism for tubular secretion and reabsorption of water and electrolytes. Diuretics are classified as follows

Classification and Examples

Thiazide and Thiazide-like diuretics

  • Chlorothiazide
  • Hydrochlorothiazide
  • Metolazone
  • Chlorthalidone
  • Indapamide

Last two are the examples for Thiazide-like diuretics.

Loop Diuretics

  • Furosemide
  • Torsemide
  • Bumetanide

Potassium-sparing Diuretics

  • Amiloride
  • Spironolactone
  • Triamterene

Osmotic Diuretics

  • Mannitol

Carbonic Anhydrase Inhibitors

  • Acetazolamide
  • Methazolamide

Mechanism of  action

The action of the diuretics varies depending on the agents. Generally, all affect on the renal mechanism for tubular secretion and reabsorption and enhance the selective excretion of various electrolytes and water.

In the management of hypertension, the diuretic of choice is the Thiazide and the Thiazide-like diuretics and the loop diuretics. Other groups have only a weak Antihypertensive property and are used in different conditions too. For instance, potassium-sparing diuretics are to conserve potassium in patients receiving  Thiazide and loop diuretics, whereas, osmotic diuretics are a major choice in treating cerebral edema.


  • Hypersensitivity
  • Sulfa agents allergies
  • Gout
  • Pregnancy

Adverse effects

Thiazide and loop diuretics have the following side effects

  • Orthostatic hypotension
  • Metabolic alkalosis
  • Ototoxicity
  • They decrease levels of Na+, K+, and Mg+
  • They increase the levels of serum calcium, uric acid, glucose, cholesterol, and triglycerides

potassium-sparing diuretics specially Triamterene has the following side effects

  • Nausea
  • Flatulence
  • Skin Rashes
  • Nephrolithiasis

Drug Interactions

  • Additive hypokalemia with CORTICOSTEROIDS
  • Additive Hypotension with OTHER ANTIHYPERTENSIVES
  • Hyperkalemia with potassium-sparing diuretics and  ACEIs, ARBs, or Aliskiren
  • Lithium toxicity with potassium-sparing diuretics and LITHIUM as the combo reduce lithium excretion.

Nursing considerations

  • Fluid status must be monitored by, daily weight checks, maintenance of I/O chart, and assessment for any edema, lung sounds, skin turgor, and condition of the mucous membrane.
  • Assess any electrolyte imbalances by assessing for anorexia, muscle weakness, numbness, confusion, excessive thirst
  • Monitor pulse and BP before and during the therapy
  • Monitor lab values for electrolytes, especially K+, blood glucose, BUN, serum uric acid.
  • Administer oral diuretics in the morning to prevent sleep disturbances
  • Instruct to continue the Antihypertensive dose as prescribed even if the symptoms relieved.
  • Advise to change positions slowly to manage Orthostatic hypotension
  • Instruct to monitor weight weekly and to report significant changes.
  • Teach self-monitoring of pulse and BP
  • Caution on photosensitive reactions -instruct to use protective clothing and to use protective sunscreens

Hope you find it easy to follow and useful. Give your suggestions for further improvement…

Have a concentrated study time…

All About Antihypertensive series 3 – Calcium channel blockers, CCBs

Hi to all student nurses…

This is the 3rd topic in the All about Antihypertensive series. Calcium Channel Blockers or Calcium antagonist are drugs with multiple roles, which makes it the most widely used cardiovascular medicine. This multifunction (which you can find below) property makes these drugs effective not only in hypertension but also in angina, cardiac arrhythmias, some type of a headache etc.


CCBs includes drugs in three classes

  1. Phenylalkylamines ( verapamil)
  2. Benzothiazepines ( Diltiazem)
  3. Dihydropyridines ( Nifedipine and other alike drugs with the suffix  -dipine)

sometimes, phenylalkylamines and Benzothiazepines together is known under the class Nondihydropyridines

How CCBs act ( mechanism of action) 

These drugs inhibit or block the flow of extracellular  Ca2+ ions through the “L- type” Ca2+ channel, that is located on the vascular smooth muscles. This blocking results in the relaxation of smooth muscle cells, resulting in vasodilation and lowering of BP.

  • L-type Ca2+ channels, located on vascular smooth muscles, cardiac myocytes, and nodal tissue (SA and AV node). It regulates Ca2+ influx into the muscle cells and stimulates smooth muscle and cardiac myocytes contraction .once these channels are blocked,
  • Vascular smooth muscle relaxation – Vasodilation
  • Decrease myocardial force generation –  -ve inotropy
  • Decrease heart rate –  -ve chronotrophy
  • Decrease conduction velocity within the heart –  -ve dromotrophy

(If we consider the calcium channel as a mountain passage and the membrane as the mountain itself, CCBs act as a closed check post preventing the entry of ca2+ ions into the cells.)



Mainly used in the following  cases

  1. Hypertension
  2. Arrhythmia
  3. Angina
  4. Raynaud’s disease
  5. Cluster headache.


  • Hypersensitivity
  • Pregnancy and lactation

Side Effects

Serious side effects are rare for CCBs. Major side effects may include-

  • Flushing
  • Headaches
  • Hypotension
  • Peripheral oedemas
  • Bradycardia

Grapefruit intake is not recommended along with CCBs, as it alters the effects of the drug.

Beta blockers are not given with CCBs, as both groups depress cardiac electrical and mechanical activities 

Nursing Considerations

  • Monitor BP and pulse before therapy, and in between the therapy
  • Monitor ECG periodically for prolonged period  therapy
  • Administer along with meals or milk to reduce the gastric irritation
  • Teach the patient self-monitoring of  Pulse and BP, and ask to inform any alteration
  • Advise to change position slowly to minimize the effects of Orthostatic hypotension.
  • Advise to inform any signs of side effects

These are the important points in CCBs. Have a happy and enthusiastic study time.