NitroglycerinNursing considerations

Side effects by what to assess

Sources: [1][2][3][4][5][6]

Blood pressure

Why

Hypotension, especially when upright

When

Before and after each dose in the hospital

Act on

Do not give in shock or circulatory failure; for severe hypotension lay the patient flat, raise the legs, and give IV fluids

Normal

Below 120/80 mm Hg.

Sources: [1][2][3][4]

Heart rate

Why

Reflex tachycardia or paradoxical bradycardia

When

With each dose

Normal

60 to 100 beats per minute in adults at rest.

Sources: [1][2][3]

High-alert status

Sublingual nitroglycerin is not on the ISMP acute care list. The only nitrate-type vasodilator listed is nitroprusside sodium for injection.

Sources: [1]

Narrow therapeutic index

The label does not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.

Sources: [1]

Boxed warning

None on the current Nitrostat label. Severe hypotension and tolerance are labeled warnings instead.

Sources: [1]

Antidote or reversal

No specific antagonist. Treat hypotension by raising central volume: lay the patient flat in a shock position with legs elevated and give IV normal saline. Epinephrine does not reverse it and is not recommended. For methemoglobinemia, give IV methylene blue 1 to 2 mg/kg unless the patient has G-6-PD deficiency.

Sources: [1]

Patient teaching

• Sit down before taking a tablet, and stand up slowly afterward to avoid falls
• Take 1 tablet at the first sign of chest pain; repeat every 5 minutes if needed
• Call emergency help if pain continues after 3 tablets in 15 minutes
• Never combine with erectile dysfunction drugs such as sildenafil or tadalafil
• Avoid alcohol, which deepens the drop in blood pressure
• Headache is common and usually fades; use the smallest dose that relieves pain
• Burning or tingling under the tongue is not a sign of whether the tablet works
• Keep tablets in the original glass bottle, capped tightly

Sources: [1][2][3][4][5]

Sound-alike and look-alike names

None listed in the ISMP list of confused drug names.

Sources: [1]

Adult dose

Acute angina attack

1 tablet (0.3, 0.4, or 0.6 mg) sublingually at onset; repeat every 5 minutes as needed, no more than 3 tablets in 15 minutes.

Acute prophylaxis

1 tablet sublingually 5 to 10 minutes before activity that may trigger angina.

Sources: [1][2]

Renal adjustment

No labeled renal adjustment. Elimination is mainly by metabolism in the liver, blood cells, and vessel walls.

Sources: [1]

Hepatic adjustment

No labeled hepatic adjustment. A liver reductase is the main metabolic route, so use the smallest effective dose.

Sources: [1][2]

Mechanism

Releases nitric oxide, which raises cyclic GMP in vascular smooth muscle and relaxes it. Venous dilation dominates: blood pools in the veins, preload falls, and myocardial oxygen demand drops. It also lowers afterload and widens large coronary arteries. Onset is about 1 to 3 minutes, with peak effect by 5 minutes and effects lasting at least 25 minutes.

Sources: [1][2]