Antihypertensive

Pharmacologic Agents

NR33
K Burger, MSEd, MSN, RN, CNE
Referenced from:
Lilley et al (2005)
Pharmacology and the nursing process (4th ed). Elsevier
 Categories
 Adrenergic agents
-Alpha blockers
-Beta blockers
-Alpha/Beta blockers
 Angiotensin-converting enzyme inhibitors
 Angiotensin II receptor blockers
 Calcium channel blockers
 Vasodilators
 Diuretics
 Components of Blood Pressure

Blood pressure = CO X SVR

 CO = cardiac output
 SVR = systemic vascular resistance
 Adrenergic Agents
Alpha Blockers Alpha Blockers
(peripherally acting) (centrally acting)

 Prazosin (Minipress)  Clonidine (Catapres)

 Blocks norepinephrine  Reduces norepinephrine
at receptor sites production
 Sympathetic Nervous  Sympathetic Nervous
System not stimulated System not stimulated
 Blood vessel dilation  Blood vessel dilation
results in decreased BP results in decreased BP
 Adrenergic Agents
 Beta Blockers

 atenolol (Tenormin)
 metoprolol (Lopressor)
 propranolol (Inderal)
 Block SNS stimulation of heart; reduces SA node activity
 Reduces ventricular contraction rate
 Reduction in cardiac output results in lower BP
 Also used as: Antidysrhythmic, Antianginal
 Adrenergic Agents
 Alpha / Beta Blocker Combination

 Carvedilol ( Coreg )

 Dual antihypertensive effect on both CO and SVR

 Alpha blocker promotes vasodilation; decreased SVR
 Beta blocker reduces heart rate; decreased CO
 Overall effect = decreased BP
 Adrenergic Agents
Nursing Implications

 Orthostatic hypotension common;take alphas @ bedtime

 Other side effects:
fatigue, dizziness, sedation, constipation
 Potentiates CNS depressants (Alcohol/Opiods)
 Abrupt withdrawal of central alpha blocker causes
rebound hypertension
 Less side effects with peripheral acting and/or
combination adrenergics
 Monitor HR =>60 for beta blockers
 Angiotensin-Converting Enzyme Inhibitors
ACE Inhibitors
 Inhibit the conversion of Angiotensin I to
Angiotensin II resulting in:
Vasodilation,decreased SVR, decreased BP
Decreased aldosterone,diuresis,decreased SVR&BP
 May be combined with a thiazide diuretic
or calcium channel blocker
 Safe and effective; often used as first line Rx
 Used also for: CHF, post MI to stop LVH progress
 Renal protective effects in patients with diabetes
 ACE Inhibitors

 captopril (Capoten)
Short half-life, must be dosed more
frequently than others
 enalapril (Vasotec)
The only ACE inhibitor available in oral and
parenteral forms
 Newer agents, long half-lives, once-a-day
dosing
 ACE Inhibitors
Nursing Implications

 Dry, nonproductive cough common

 Other side effects:
fatigue,dizziness,headache, mood changes,
taste alterations, angioedema
 First-dose hypotensive effect may occur
 Additive effects when given with diuretics or other
antihypertensives
 Antagonistic effects when given with NSAIDs
 If given with K supplement may cause hyperK
 Angiotensin II Receptor Blockers
ARBs

 Losartan ( Cozaar )
 Valsartan ( Diovan )
 Block the binding of Angiotensin II to AT1
receptors on vessels & adrenal gland thereby:
- promoting vasodilation / lower aldosterone
- decreased SVR and decreased BP
 Newer class and well-tolerated
 ARB
Nursing Implications

 Possible side effects:

Upper respiratory infection
Angioedema & Headache
 Less likely to cause hyperkalemia (unlike ACE)
 Can be used in pts who cannot tolerate ACE Rx
 Do not cause coughing
 Used cautiously in geriatric pts and impaired
renal function
 Calcium Channel Blockers
CCBs

 Diltiazem (Cardizem)
 Verapamil ( Calan )
 Nifedipine ( Procardia )
 Cause smooth muscle relaxation by blocking the
binding of calcium to its receptors, preventing
muscle contraction
 This causes decreased peripheral smooth muscle
tone, decreased SVR and BP
 Slows cardiac conduction; decreases HR&CO&BP
 Also used as : antidysrythmic, antianginal
 Calcium Channel Blockers
Nursing Implications

 Considered safe with limited side-effects

 First line drug choice
 More effective in geriatric and African-American
patients
 Possible side effects:
hypotension, dysrythmias, constipation, nausea,
rash,peripheral edema, dermatitis
 Vasodilators

 hydralazine HCl (Apresoline)

 sodium nitroprusside (Nipride, Nitropress)

 Directly relaxes arteriolar smooth muscle

vasodilation; decreased SVR; decreased BP
 May be used in combination with other agents
 Sodium nitroprusside is reserved for the
management of hypertensive emergencies
 Vasodilators
Nursing Implications

 Hydralazine
Side Effects: dizziness, headache, anxiety,
tachycardia
 Sodium Nitroprusside
Side Effects: bradycardia, hypotension
Controlled administration/IV infusion pump
 CHECKPOINT
The physician has ordered prazosin
(Minipress) for Mrs. McAdams. What patient
teaching should she receive?

A. She should weigh herself daily, and report any

weight loss to the physician.
B. She must increase her potassium intake by eating
more bananas and apricots.
C. The impaired taste associated with the medication
usually goes away in 2 to 3 weeks.
D. She should take her first dose while lying down,
because there is a first-dose effect with the
prazosin.
 Antihypertensive Agents
General Nursing Implications
 Educate patients about the importance of not missing a
dose, taking the medications exactly as prescribed,
never doubling up on doses, and not stopping abruptly

 Patients should not take any OTC drugs without first

checking with MD

 PO meds should be taken with meals

 Educate patient on concurrent lifestyle modifications:

Diet, Exercise, Stress Reduction

 Instruct patients on how to monitor their own BP

 Antihypertensive Agents
Nursing Implications
 Instruct patients that these drugs should not be
stopped abruptly, as this may cause a rebound
hypertensive crisis, and perhaps lead to CVA.

 Oral forms should be given with meals so that

absorption is more gradual and effective.

 Administer IV forms with extreme caution and

use an IV pump.
 Antihypertensive Agents
General Nursing Implications
 Instruct patients to change positions slowly

 Hot showers, tubs, weather, exercise, alcohol,

prolonged sitting/standing may cause hypotension,
dizziness, fainting

 Patients should report: SOB, dyspnea, peripheral

and/or angioedema, excessive weight gain, chest
pain, palpitations

 Men may experience impotence as expected SE

 Diuretics

Main classifications:
 Thiazide and thiazide-like
 Loop
 Potassium-sparing

Others:
 Osmotic
 Carbonic Anhydrase Inhibitors
 Thiazide Diuretics
 Hydrochlorothiazide ( HydroDIURIL )
 Inhibits Na reabsorption at distal tubule
resulting in diuresis; decreased SVR & BP
 Also acts to relax arterioles;decrease SVR
 First line medication regimen for HTN
 Safe for most patients; inexpensive
 Often used in combination w/ other drugs
 Loop Diuretics
 Furosemide (Lasix)
 Blocks Cl and Na reabsorption at Loop of
Henle resulting in diuresis; decreased SVR
and decreased BP
 Stimulate prostaglandins; vasodilation of
renal, lung, system vessels
 Rapid onset and most potent diuretic
 Can be given once daily
 Effective even in renal impaired patients
 Thiazide and Loop Diuretics
Nursing Implications
 Monitor K levels closely for hypokalemia
 Teach patient to eat high K foods
 Cross allergies may exist to sulfonamides
 Concurrent digoxin Rx may lead to digoxin
toxicity
 NSAIDS may decrease diuretic effect
 Concurrent antiglycemic Rx may lead to
hyperglycemia
 Monitor for I & O.
 NCLEX QUESTION

A 66 y.o. client who is taking several

medications including Digoxin and Diuril comes
to the clinic complaining of not feeling well.
Which of the following assessment data would
indicate a potential diagnosis of digoxin toxicity?
A. chest pain, hypotension, and paresthesia
B. constipation, dry mouth, and sleep disorder
C. double vision, loss of appetite, and nausea
D. dyspnea, edema, and palpitations
 Potassium-sparing Diuretics
 Spironlactone ( Aldactone )
 Works in the collecting duct
 Binds and blocks aldosterone receptors
resulting in blocked Na water reabsorption;
decreased SVR and BP
 Considered a weak diuretic
 Often used in conjunction with more potent
K depleting diuretics
 Potassium-sparing Diuretic
Nursing Implications
 Monitor K levels closely for hyperkalemia
Especially with renal impairment, use of
potassium supplements, or ACE drugs
 May cause gynecomastia, impotence in
men; amenorrhea, and post-menopausal
bleeding in women.
 Other side effects: dizziness, ha, cramps,
nausea,diarrhea.
 Diuretics
General Nursing Implications
 Instruct patient to take early in the day to
avoid sleep disturbances
 Geriatric patients more sensitive to fluid
balance changes; caution for postural
hypotension
 Monitor weights, potassium levels as well
as Na and Cl
 Instruct patients to notify MD if ill with
vomiting and/or diarrhea