Week 4

Drugs affecting the Cardiovascular and Renal Systems

Required readings:

Lilley textbook:
• Ch. 20 Adrenergic Blocking Drugs pp. 396-404
• Ch. 23 Antihypertensives
• Ch. 24 Antianginal
• Ch. 29 Diuretics
• Ch. 30 Fluids and Electrolytes
• Sodium/Potassium pp. 585-589
The Sympathetic Nervous System in Relationship to the Entire
Nervous System
Organization of the ANS
from: http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/P/PNS.html
ANS: Controls vital life activities
SNS-sympathetic PSNS-parasympathetic
• Neurotransmitters are epinephrine, • Neurotransmitter is acetylcholine (Ach)
norepinephrine and dopamine
• Receptors are centrally located nicotinic
• Receptors are alpha1 and alpha2, beta1 and beta2, and peripherally located muscarinic
and dopaminergic receptors
• Fight or flight
• Rest and digest
• Activated under stress
Adrenergic Agents: Alpha and Beta

Antagonists / Blockers
• Beta 1 Antagonist
• Selective Beta 1 Antagonist: Metoprolol
• Non-selective Beta 1 Antagonist: Propranolol
• Mixed Alpha 1 and non-selective
• Alpha 1 receptor Antagonist

Agonists
• Alpha 2 receptor Agonist
Adrenergic Blockers

Classified by the type of adrenergic receptor they block

• Alpha1- and alpha2-receptors
• Beta1- and beta2-receptors

• Block stimulation of SNS at the alpha receptor sites

• Results in vasodilation—symptoms of hypotension, bradycardia,
dizziness, headaches, CNS depression & GI distress
• Directly compete for SNS neurotransmitter norepinephrine
 Drug Effects and Indications: α-Blockers

• Cause both arterial and venous dilation, lowering BP

• Used to treat hypertension
• Effect on receptors on prostate gland and bladder decreases
resistance to urinary outflow, thus reducing urinary obstruction and
relieving the effects of benign prostatic hyperplasia (BPH).

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Question: Check your knowledge
When phentolamine is used to diagnose the presence of
pheochromocytoma, the nurse will assess for what indicative finding?

A. Rapid decrease in blood pressure

B. Steady increase in blood pressure
C. Slower heart rate
D. Reduced cardiac ectopy

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Question: Check your knowledge
When the nurse is administering an α-blocker for the first time, which
of the following is the most important development for the nurse to
assess?

A. Renal failure
B. Hypotension
C. Blood dyscrasia
D. Dysrhythmias

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Alpha-blockers Common Medication:
Drug Effects and Indications
• Phentolamine (Alpha Blocker)
• Used to control and prevent hypertension in clients with
pheochromocytoma
• Quickly reverses the potent vasoconstrictive effects of vasopressors
such as norepinephrine or epinephrine.
• Restores blood flow and prevents ischemic tissue leading to tissue
necrosis
• Causes vasodilation
Alpha-blockers Common Medication: Drug Effects and Indications

Prazosin (Minipress)
• Cause both arterial and venous dilation, reducing peripheral vascular
resistance and BP
• Used to treat hypertension

Tamsulosin (Flomax) (specific for BPH)

• Effect the receptors of prostate gland and bladder to decrease resistance
of urinary outflow, thus reducing urinary obstruction and relieving
effects of BPH (benign prostatic hyperplasia)
Alpha-Blockers: Side Effects
Body System Side/Adverse Effects
Cardiovascular Palpitations, orthostatic hypotension,
bradycardia, edema, dysrhythmias,
chest pain

CNS Dizziness, headache, drowsiness,

anxiety, vertigo,
weakness, numbness, fatigue

Gastrointestinal Nausea, vomiting, diarrhea,

constipation, abdominal pain

Other Impotence, nosebleed,

tinnitus, dry mouth, pharyngitis,
rhinitis, May mask signs and symptoms of hypoglycemia
Use with caution in patients with diabetes mellitus.
Beta1-Receptors
Beta1-receptors
• Located primarily on the heart

• Beta-blockers selective for these receptors are called cardioselective

beta-blockers

• Effective for cardiac arrhythmias and hypertension

• Effects heart contractility, heart rate and conduction—resulting in

bradycardia, decrease contractility and decrease conduction
Mechanism of Action: Cardioselective (beta1) blockers
Eg atenolol, metoprolol, bisoprolol

Negative inotropy: Reduce SNS stimulation of the heart

Negative chronotropy: Decreases heart rate
Negative dromotropy: Prolongs SA node recovery &Slows conduction rate
through the AV node

• Decreases myocardial contractility, thus decreasing myocardial oxygen

demand
• Peripheral pooling of blood due to relaxation of smooth muscles (Beta2)
leads to *orthostatic hypotension*
Beta2-Receptors
Beta2-receptors
• Located primarily on smooth muscles of bronchioles and blood
vessels

• Blocking bronchodilating effect from the smooth muscle causes

relaxation - resulting in bronchoconstrition of the lungs

• Use with caution in patients with lung disorders, asthmatics. Can

worsen the effects and put the patient at risk for respiratory distress
Mechanism of Action Nonselective (beta1 and beta2)
eg Propranolol, Sotalol
• Effects on heart: Same as cardioselective

• Bronchioles: bronchoconstriction, resulting in narrowing

of airways, shortness of breath

• Peripheral Vessels: Vasodilation

BB: Indications
• migraine - beta blockers are attracted to lipids which easily enter
the CNS & brain
• Glaucoma (topical use)
• Angina-decreases demand of myocardial energy & 02
consumption - increases the supply allowing more 02 to get to
the heart.
• Post MI myocardial infarct (cardioprotective)***
• Antihypertensive
• heart failure
• antidysrhythmic
Question: Check your knowledge
A 58-year-old patient is recovering in the Critical Care Unit after an MI. The nurse
notes an order for the β-blocker metoprolol (Lopressor). The purpose of this drug is
to

A. dilate the coronary arteries.

B. inhibit stimulation of the myocardium by circulating catecholamines.
C. provide a positive inotropic effect.
D. maintain the patient’s BP.

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β-Blockers: Adverse Effects

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Beta blockers: common medication
• Cardioselective
• atenolol (Tenormin)
• metoprolol (Lopressor)
• Bisoprolol (newer, once a day dosing)

• Nonselective
• propranolol (Inderal)
Mixed alpha 1 and non selective B-Blockers
Carvedilol
• been shown to slow the progression of heart failure and to decrease
the frequency of hospitalization in patients with mild to moderate
(class II or III) heart failure

• Labetolol
• used in the treatment of severe hypertension and in hypertensive
emergencies to quickly lower blood pressure
Adrenergic-Blocking Agents: Nursing Implications

Monitor for therapeutic effects

• Decreased chest pain in patients with angina

• Return to normal BP and P

• Other specific effects, depending on the use

Adrenergic-Blocking Agents: Nursing Implications
Monitor for side effects, including:

• Hypotension • Fatigue
• Tachycardia (alpha blockers) • Lethargy
• Bradycardia • Depression
• Heart block • Insomnia
• HF • Vivid nightmares
• Increased airway resistance
Beta-Blocking Agents: Nursing Implications

Patients should report the following to

their physician:
• Weight gain of more than 2 pounds (1 kg)
within a week
• Edema of the feet or ankles
• Shortness of breath
• Excessive fatigue or weakness
• Syncope or dizziness
Antihypertensive
Agents
Chapter 23, Lilley
Blood pressure = CO x SVR
• CO = cardiac output
• amount of blood ejected from the left ventricle

• SVR = systemic vascular resistance

• Force (resistance) the left ventricular has to overcome to get its volume of blood out

• Normal CO normal 4 –8L/min

Hypertension Canadian Guidelines 2020

Figure 24-1 Normal regulation of blood pressure and corresponding medications.

Copyright © 2007 Elsevier Canada, Ltd. All rights reserved.

Hypertension
Compelling Indications
• Post-MI
• High cardiovascular risk
• Heart failure
• Diabetes mellitus
• Chronic kidney disease
• Cerebrovascular disease
Antihypertensive Agents: Categories
• Adrenergic agents
• Angiotensin converting enzyme (ACE) inhibitors
• Angiotensin II receptor blockers (ARBs)
• Calcium channel blockers (CCBs)
• Diuretics
• Vasodilators
Site and
Mechanism of
Action for
Antihypertensi
ve Drugs

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Adrenergic Agents
• Centrally and peripherally acting adrenergic neuron blockers
• Centrally acting α2-receptor agonists eg clonidine
• Peripherally acting α1-receptor blockers eg prazosin
• Cardioselective (β1-receptor blockers)- eg. metoprolol
• Nonselective (β1- and β2-receptor blockers) eg. propranolol
• Peripherally acting dual α1- and β-receptor blockers eg. Carvedilol,
labetolol
 Mechanism of Action
Work centrally: block norepinephrine (neurotransmitter causing
stimulation) in the brain thereby decreasing blood pressure (alpha 2
adrenergic agonist)

Work peripherally to lower systemic vascular resistance which causes

vasodilation thereby decreasing blood pressure (block alpha 1 adrenergic)

Work directly: heart muscle, mainly the left ventricle which decreases the
force to eject blood through the ventricle (beta 1 blocker)

Works directly: kidneys by increasing diuresis thereby decreasing plasma

volume resulting in lowered blood pressure
Adrenergic Agents: Alpha Receptors
• Alpha 1 adrenergic blocker
• Prazosin (Minipress)
• Doxazosin(Cardura)
• Terazosin (also for BPH)

• These agents cause peripheral vasodilatation

• Also reduces systemic and pulmonary venous pressure thereby
increasing cardiac output (management of severe HF)
Alpha 1 Blocker: First dose effect
*** The first dose of Minipress (Prazosin) should be given laying down
or sitting as it causes extreme dilation of the peripheral arteries
resulting in dizziness, lightheaded with the possibility of fainting
(syncope)

• Teach patients prevention of orthostatic hypotension

Alpha 2 adrenergic agonist
centrally acting adrenergic drugs stimulate the alpha2-adrenergic receptors
in the brain.-receptor stimulation actually reduces sympathetic outflow, in
this case from the central nervous system (CNS). This reduction results in a
lack of norepinephrine production, which reduces blood pressure.
• Clonidine (Catapres)
• Methyldopa (Aldomet) –commonly used to treat hypertension in
pregnancy.

• Stimulation of the alpha2-adrenergic receptors also reduces the activity

of renin. Renin is the hormone and enzyme that converts the protein
precursor angiotensinogen to the protein angiotensin I, the precursor of
angiotensin II, a potent vasoconstrictor that raises blood pressure
Question: Check your knowledge
When administering an α-adrenergic drug for hypertension, it is most
important for the nurse to assess the patient for the development of:

A. Hypotension
B. Hyperkalemia
C. Oliguria
D. Respiratory distress

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Adrenergic Agents: Beta-blockers
Common Drugs: Mechanism of Action
• Propranolol (Inderal)
• These agents act peripherally
• Atenolol (Tenormin)
• Metoprolol • They reduce heart rate due to
• Bisoprolol the beta receptor blockade
• Timolol • Decrease myocardial
contractility and conduction
• Dual alpha 1 and beta receptor • Some have a dual action on both
blockers
• Eg. Labetolol, Carvedilol
alpha and beta receptors
 Adrenergic Agents: Beta-blockers
Indications
• Hypertension
• Glaucoma (topical)
• Benign prostate hypertrophy (BPH) as it relaxes the smooth muscles
• Widely used, more effective in the elderly population and especially for those
resistant to ACE inhibitors

• Most serious side effect is peripheral pooling of blood (due to relaxation of smooth
muscles) which causes orthostatic hypotension

• These agents should never be stopped abruptly as they will cause rebound
hypertension patients need to be weaned
Angiotensin • Large group of safe and effective drugs
Converting • Often used as first-line agents for heart
Enzyme failure and hypertension
Inhibitors • Inhibits angiotensin converting enzyme
(ACE which is a potent vasoconstrictor
Inhibitors)
ACE Inhibitors: Mechanism of action
• Block ACE, thus preventing the Common Angiotensin Converting
formation of angiotensin II Enzyme Inhibitors (ACE inhibitors)

• Prevent the breakdown of the • Ramipril (Altace)

vasodilating substance bradykinin • Enalapril (Vasotec)
• Captopril (Capoten)- short T1/2, not
• Ability to decrease SVR (a measure of prodrug
afterload) and preload
• Newer, longer T1/2
• Can stop the progression of left
• Lisinopril (Zestril)- not prodrug
ventricular hypertrophy
• Quinapril (Accupril)
• Lower BP
ACE Inhibitors: Indications
• Hypertension - diuresis- < preload
• HF (either alone or in combination with diuretics or other agents)
• reduces workload for the heart, Decreases preload, or the left ventricular
end-diastolic volume, diuresis- more of both

• Slows progression of left ventricular hypertrophy after an MI (cardio-

protective)

• Renal protective effects in patients with diabetes

– Drugs of choice in hypertensive patients with HF
ACE Inhibitors: Cardioprotective Effects
• ↓SVR (a measure of afterload) and preload.
• Used to prevent complications after MI
• Ventricular remodeling: left ventricular hypertrophy, which is
sometimes seen after MI
• Have been shown to decrease morbidity and mortality in patients
with HF
• Drugs of choice for hypertensive patients with HF

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ACE Inhibitors: Renal Protective Effects

• Reduce glomerular filtration pressure

• Cardiovascular drugs of choice for patients with diabetes
• Reduce proteinuria
• Standard therapy for diabetic patients to prevent the progression of
diabetic nephropathy

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ACE Inhibitors: Adverse Effects
• Fatigue, dizziness, headache, impaired taste
• Mood changes
• First-dose hypotensive effect
• Possible hyperkalemia
• Biggest draw back and side effect is that they cause a persistent dry,
nonproductive cough, which reverses when therapy is stopped
• Angioedema: rare but potentially fatal
• Others

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ACE • ACE inhibitors can cause renal impairment,
Inhibitors which can be identified by serum creatinine.
and • ACE inhibitors can also cause hyperkalemia,
so potassium levels need to be monitored.
Laboratory • Monitor serum sodium during therapy.
Values

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 Question: Check your Knowledge

A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. The
patient questions this order because the patient’s health care provider has never
said that the patient has hypertension. What is the best explanation for this order?

A. The health care provider knows best.

B. The patient is confused.
C. This medication has cardioprotective properties.
D. This medication has a protective effect on the kidneys for patients with
diabetes.

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Angiotensin II Receptor Blockers (ARBs)
• Known as (A-II blockers, or ARBs)
• Newer class of antihypertensives
• Well tolerated
• Do not cause a dry cough (as with the ACEI’s) therefore better
tolerated
• Allow angiotensin I to be converted to angiotensin II, but block the
receptors that receive angiotensin II
• Block vasoconstriction and release of aldosterone
Angiotensin II Receptor Blockers: Indications
Common medications:
• Losartan (Cozaar, Hyzaar)
• Valsartan (Diovan)
• Candesartan (Atacand)
• Telmisartan (Micardis)
Indications:
• Hypertension
• Adjunctive agents for the treatment of HF
• May be used alone or with other agents such as diuretics
• Used primarily in patients who cannot tolerate ACE inhibitors
 Known as (CCB)
Causes smooth muscle relaxation by
Calcium blocking the binding of calcium to its
Channel receptors thereby preventing muscle
contraction (effective for hypertension and
Blockers: angina)
Mechanism This causes decreased peripheral smooth
of Action muscle tone and decreased systemic
vascular resistance
Dihydropyridines and non-dihydropyridines
Calcium Channel Blockers
Agents
dihydropyridine CCBs: amlodipine and nifedipine
Non- dihydropyridine CCBs: verapamil hydrochloride and diltiazem
Indications
• Angina
• Hypertension
• Dysrhythmias
• Migraine headaches (vasodilatation effect)
• Raynaud’s disease (constriction of peripheral vessels causing cyanosis, CCB
cause a vasodilatation effect)
 Common medication:
Diuretics • Hydrochlorothiazide - HCTZ
• Indapamide
Diuretics
• Decreases the plasma and extracellular fluid volumes
• Results:
• Decreased preload
• Decreased cardiac output
• Decreased total peripheral resistance

• Overall effect: Decreased workload of the heart, and decreased

blood pressure
 • Nitroglycerine
• Diazoxide (IV for emergencies)
• Minoxidil (also for hair loss)
Vasodilators
• Sodium Nitroprusside (IV for hypertensive
emergencies)
• Hydralazine
Vasodilators
• Act directly on arteriole smooth muscle which causes
relaxation resulting in dilatation

• Reduces SVR (systemic vascular resistance)

Vasodilator: Nursing Implication
Educate patient: • Patients should report:
• the importance of not missing a • shortness of breath;
dose and take the medications
exactly as prescribed • difficulty breathing;
• never double up on doses if a • swelling of the feet, ankles, face,
dose is missed; check with or around the eyes;
physician for instructions • weight gain or loss;
• Do not stop medication abruptly - • chest pain; palpitations; or
risk of rebound hypertensive crisis excessive fatigue
(stroke or MI)
• Take medication with meals for
gradual absorption
 • Men should be aware that impotence is an
expected effect (due to vasodilatation). This may
influence compliance

• Hot tubs, hot showers or baths, hot weather,

Vasodilator: prolonged sitting or standing; physical exercise;
Nursing and alcohol ingestion may aggravate low blood
pressure, leading to fainting and injury. Patients
Implication should sit or lie down until symptoms subside.

• not take any other medications, including OTC

drugs, without first getting the approval of their
physician
Antianginal Agents
 • Chronic stable angina Types of Angina

(also called classic or effort angina)

• Unstable angina
(also called preinfarction or
crescendo angina)

• Vasospastic angina
(also called Prinzmetal’s or variant
angina)

• Mainly due to ischemic heart disease

leading to coronary artery disease

http://medicalassessmentonline.com/john/Angina_mechanisms_20142.png
 •Nitrates/nitrites
•Beta-blockers (BB)
•Calcium channel blockers(CCB)

Overall Goals
• Increase blood flow to ischemic heart muscle
• Decrease myocardial oxygen demand
Antianginal • Decrease frequency, duration and intensity of
Agents anginal attacks
• Improve the patient’s functional capacity with
as few side effects as possible
• Prevent or delay the worst possible outcome,
MI
 • Causes vasodilation due to relaxation of smooth
Nitroglycerin muscles

Available Forms: • Potent dilating effect on coronary arteries (small and

large vessels)
• Sublingual
• Buccal • Used for prevention angina, treat acute angina
• Translingual spray
• Transdermal • Main drug of choice for angina due to rapid dilatation
patches
 Nitroglycerin has large first-pass effect with oral forms
• Ointments
• IV solutions  IV form used for BP control in perioperative
• Isosorbide hypertension, treatment of HF, ischemic pain,
pulmonary edema associated with acute MI, and
dinitrate tablets hypertensive emergencies
 • Patients should report blurred vision, persistent headache,
dry mouth, dizziness, edema, fainting episodes, weight gain
of 2 pounds in 1 day or 5 or more pounds in 1 week
• Pulse rates less than 60, and any dyspnea

Nitroglycerin: • Avoid: Alcohol consumption, whirlpools, hot tubs, or

saunas will result in vasodilation, hypotension, and the
Nursing possibility of fainting

Implications • Teach patients to change positions slowly to avoid postural

BP changes
• Encourage patients to keep a record of their anginal attacks,
including precipitating factors, number of pills taken, and
therapeutic effects
 • Take up to 3 doses 5 minutes apart, if no improvement call 911
• Instruct patients:
• Never chew or swallow the SL form
• Burning sensation with SL forms indicates that the drug is still potent
• They can get a headache with NTG
• Their blood pressure will drop so need to lie down when taking NTG
Nitroglycerin • Proper storage

: Nursing • Instruct patients to keep a fresh supply of NTG on hand; potency is lost in
about 3 months after the bottle has been opened
implications
• Medications should be stored in an airtight, dark glass bottle with a metal cap
and no cotton filler to preserve potency

• Instruct patients in the proper application of nitrate topical ointments and

transdermal forms, including site rotation and removal of old medication

• To reduce tolerance, remove transdermal patch overnight, allow for an 8hour

nitrate-free period
 • Instruct patients to take prn nitrates at the first hint of anginal pain

• If experiencing chest pain, the patient taking SL NTG should be lying

down to prevent or decrease dizziness and fainting that may occur due
to hypotension

• Monitor VS frequently during acute exacerbations of angina and during

Nitroglycerin: IV administration

Nursing • IV forms of NTG must be contained in glass IV bottles and must be given
with infusion pumps
implications • Discard parenteral solution that is blue, green, or dark red

• Follow specific manufacturer’s instructions for IV administration; use

special IV tubing provided or non-PVC (polyvinyl chloride) tubing (causes
absorption of the drug through the plastic)

• NTG is stable for 96hrs after preparation

Beta Blockers Mechanism of action
• Decrease HR
Common drugs: • resulting in decreased myocardial oxygen
• atenolol (Tenormin) demand and increased oxygen delivery to the
heart
• metoprolol (Lopressor) • Decrease myocardial contractility
• propranolol (Inderal) • helping to conserve energy or decrease demand
• nadolol (Corgard)
Indications
• Treatment of angina, hypertension, and
supraventricular tachycardia (SVT)
• Antihypertensive
• Cardioprotective effects, especially after MI
(Metoprolol best tolerated)
• Some used for migraine headaches
 • Bradycardia
• hypotension
Beta- second- or third-degree heart block; heart
failure
Blockers: • Dyspnea
Side effects • Hyperglycemia
• Impotence
• Depression
 B eta-B lo ck Ners: u rsin gim p licati o n s

• Patients taking beta-blockers should monitor pulse rate daily and report any rate
lower than 60 beats per minute

• Constipation is a common problem; instruct patients to take in adequate fluids and

eat high-fiber foods

• Never abruptly stop due to risk of rebound hypertension

• Inform patients that these medications are for long-term prevention of angina, not
for immediate relief (immediate relief use NTG)
 Drug Examples:
• verapamil (Calan)
• diltiazem (Cardizem)
• Amlodipine (Norvasc)

Calcium • Blocks or prevents calcium from entering into

the cardiac cells thereby resulting in relaxation
Channel of the heart muscles which will decrease blood
pressure and heart rate.
Blockers • Slows the AV node conduction and prolongs the
refractory period
Calcium Channel Blockers: Mechanism of action
Mechanism of action
• Cause peripheral arterial vasodilation
• Reduce myocardial contractility
(negative inotropy)
• Result: decreased myocardial oxygen demand

Indications
• Treatment of angina, hypertension, and supraventricular tachycardia
(SVT)
• Short-term management of atrial fibrillation and flutter
• Several other uses
 Calcium Channel Blockers
Nursing Implications:
Side effects:
• Blood levels should be monitored to
• hypotension
ensure they are therapeutic
• palpitations
• tachycardia or bradycardia
• constipation • Medication should never be
discontinued abruptly, may cause
• nausea
rebound hypertension
• dyspnea
Diuretics

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Diuretics

• Drugs that accelerate the rate of urine formation

• Result in the removal of sodium and water

• Supportive therapy for the treatment of hypertension and

heart failure and for prevention of kidney damage during
acute kidney injury

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The Nephron and Diuretic Sites of Action

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Question: Check your knowledge
Which location is the area where the highest
percentage of sodium and water are resorbed back into
the bloodstream?
A. Glomerulus
B. Proximal tubule
C. Ascending loop of Henle
D. Distal tubule

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 Diuretics Mechanism of Action:
• Cause direct arterial dilation, decreasing
Types of Diuretic Drugs: peripheral vascular resistance
• Carbonic anhydrase inhibitors
• Loop diuretics • Reduce:
• Osmotic diuretics • extracellular fluid volume
• Potassium-sparing diuretics • plasma volume
• Thiazide and thiazide-like • cardiac output
diuretics
• Therefore the heart doesn’t have to
work so hard
Loop Diuretics
Common drug:
• furosemide (Lasix)

• Primarily used for pulmonary edema, heart failure,

liver disease, nephrotic syndrome and ascites

• Used when rapid diuresis is necessary

Loop Diuretics:
Drug Examples: Mechanism of Action
• bumetanide •Possess kidney, cardiovascular, and metabolic
• ethacrynic acid (rarely used effects
clinically) •Act directly on the ascending limb of the
• furosemide (Lasix®) loop of Henle to block chloride and sodium
resorption
•Increase kidney prostaglandins, resulting in the
dilation of blood vessels and reduced kidney,
pulmonary, and systemic vascular resistance
•Useful in treatment of edema

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 Loop Diuretics: Drug Effects

• Rapid onset; last at least 2 hours

• Potent diuresis and subsequent loss of fluid
• Decreased fluid volume causes a reduction in:
• Blood pressure
• Pulmonary vascular resistance
• Systemic vascular resistance
• Central venous pressure
• Left ventricular end-diastolic pressure
• Potassium and sodium depletion
• Small calcium loss Copyright © 2017 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 80
Loop Diuretics: Indications
• Edema associated with heart failure and liver or kidney disease
• Hypertension (to control)
• Kidney excretion of calcium in patients with hypercalcemia (to increase
excretion)
• Heart failure resulting from diastolic dysfunction

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 Loop Diuretics: Adverse Effects
Body System Adverse Effects

Central nervous system Dizziness, headache, tinnitus, blurred vision

Gastrointestinal Nausea, vomiting, diarrhea

Hematological Agranulocytosis, neutropenia, thrombocytopenia

Metabolic Hypokalemia, hyperglycemia, hyperuricemia

Question: Check your knowledge
When administering a loop diuretic to a patient, it is most
important for the nurse to determine if the patient is also taking
which drug?
A.lithium
B.acetaminophen (Tylenol®)
C.penicillin
D.theophylline

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Potassium-Sparing Diuretics
Mechanism of Action
Also known as • Work in collecting ducts and
aldosterone-inhibiting distal convoluted tubules
diuretics
• amiloride (Midamor®)
• Interfere with sodium–
• spironolactone
potassium exchange
(Aldactone®) • Competitively bind to
• triamterene aldosterone receptors
• triamterene in • Block resorption of sodium and
combination with
hydrochlorothiazide
water usually induced by
aldosterone secretion

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Potassium-Sparing Diuretics: Adverse Effects
Body System Adverse Effects
• Dizziness, headache
Central nervous system

Gastrointestinal • Cramps, nausea, vomiting, diarrhea

• Urinary frequency,
Other weakness, hyperkalemia

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Thiazide and Thiazide-Like Diuretics
Common drugs: Mechanism of Action:
• Thiazide diuretics • Inhibit tubular resorption of sodium,
• hydrochlorothiazide chloride, and potassium ions
(Urozide®) • Action primarily in the distal
convoluted tubule
• Thiazide-like • Result in osmotic water loss
diuretics • Dilate the arterioles by direct
• metolazone relaxation
(Zaroxolyn®)
• chlorthalidone • Decrease preload and afterload
• indapamide
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 Thiazide and Thiazide-Like Diuretics: Adverse
Effects
Body System Adverse Effects
Central nervous Dizziness, headache, blurred vision

Gastrointestinal Anorexia, nausea, vomiting, diarrhea

Genitourinary Erectile dysfunction

Hematological Jaundice, leukopenia, agranulocytosis

Integumentary Urticaria, photosensitivity

Metabolic Hypokalemia, glycosuria, hyperglycemia, hyperuricemia, hypochloremic

alkalosis
 Nursing Implications
• Perform a thorough patient history and physical examination.
• Assess baseline fluid volume status, intake and output, serum electrolyte
values, weight, and vital signs (especially postural blood pressure).
• Assess for disorders that may contraindicate or necessitate cautious use
of these drugs.
• Instruct patients to take the medication in the morning if possible to
avoid interference with sleep patterns.
• Monitor serum potassium levels during therapy.

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 Nursing Implications (cont.)
• Teach patients to maintain proper nutritional and fluid volume status.
• Teach patients to eat more potassium-rich foods when taking any
diuretics but the potassium-sparing drugs.
• Foods high in potassium include bananas, oranges, dates, apricots,
raisins, broccoli, green beans, potatoes, tomatoes, meats, fish, wheat
bread, and legumes.
• Patients taking diuretics along with digoxin should be taught to watch for
digoxin toxicity.
• Patients with diabetes mellitus who are taking thiazide or loop diuretics
should be told to monitor blood glucose and watch for elevated levels.
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 Nursing Implications (cont.)
• Teach patients to change positions slowly and to rise slowly after sitting
or lying, to prevent dizziness and fainting related to orthostatic
hypotension.
• Encourage patients to keep a log of their
daily weight.
• Remind patients to return for follow-up visits and laboratory work.

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 Nursing Implications (cont.)
• Patients who have been ill with nausea, vomiting, or diarrhea should
notify their primary care provider because fluid and electrolyte
imbalances can result.
• Signs and symptoms of hypokalemia include anorexia, nausea, lethargy,
muscle weakness, mental confusion, and hypotension.
• Instruct patients to notify their primary care provider immediately if they
experience rapid heart rates or syncope (reflects hypotension or fluid
loss).
• Excessive consumption of licorice can lead to additive hypokalemia in
patients taking thiazides.

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 Nursing Implications (cont.)
• Monitor for adverse effects:
• Metabolic alkalosis, drowsiness, lethargy, hypokalemia, tachycardia, hypotension,
leg cramps, restlessness, decreased mental alertness
• Monitor for hyperkalemia with potassium-sparing diuretics.

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Case study: Check your knowledge
A patient with a creatinine clearance of 20 mL/min is admitted to the
medical–surgical unit. The patient is in need of rapid diuresis. Which class of
diuretic does the nurse anticipate administering?

A.Potassium sparing
B.Thiazide
C.Osmotic
D.Loop

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Case Study (cont.)
The patient is ordered furosemide (Lasix). Before administering furosemide,
it is most important for the nurse to assess the patient for allergies to which
drug class?

A.Aminoglycosides
B.Sulphonamides
C.Macrolides
D.Penicillins

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Case Study (cont.)
Two days after admission, the nurse is reviewing the patient’s laboratory
results. Which is the most common electrolyte finding resulting from the
administration of furosemide?

A.Hypocalcemia
B.Hypophosphatemia
C.Hypokalemia
D.Hypomagnesemia

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Case Study (cont.)
The patient is being discharged home with furosemide. When providing
discharge teaching, which will the nurse instruct the patient to do?

A. Avoid prolonged exposure to the sun.

B. Avoid foods high in potassium content.
C. Stop taking the medication if you feel dizzy.
D. Weigh yourself once a week, and report a gain or loss
of more than 0.5 kg.

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Sodium and Potassium

p. 585-589 Lilley
 • Potassium is responsible for:
• Muscle contraction
Potassium • Transmission of nerve
impulses
K = 3.5-5.0 • Regulation of heartbeat
mmol/L or • Maintenance of acid–base
mEq/L balance
• Isotonicity
• Electrodynamic
characteristics of the cell

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Potassium : K < 3.5 mmol/L
• Hypokalemia: deficiency of potassium
• Excessive potassium loss (rather than poor dietary intake)

• Burns
• Alkalosis
• Corticosteroids • Thiazide, thiazide-like, and loop
• Diarrhea diuretics
• Ketoacidosis
• Vomiting
• Hyperaldosteronism
• Increased secretion of • Malabsorption
mineralocorticoids
• Others

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 •Adverse effects:
• Oral preparations
• Diarrhea, nausea, vomiting,
gastrointestinal bleeding, ulceration
• IV administration
Potassium • Pain at injection site
agents • Phlebitis
• Excessive administration
• Hyperkalemia
• Toxic effects
• Cardiac arrest
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Question: Check your knowledge
Which condition does the nurse identify as a late manifestation of
hypokalemia?

A. Muscle weakness
B. Hypotension
C. Cardiac dysrhythmias
D. Lethargy

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Potassium
Hyperkalemia: excessive serum potassium;
serum potassium level over 5.5 mmol/L

• Potassium supplements
• Angiotensin-converting enzyme • Burns
inhibitors • Trauma
• Kidney failure • Metabolic acidosis
• Excessive loss from cells • Infections
• Potassium-sparing diuretics

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Potassium: K > 5.0
• Hyperkalemia manifestations
• Muscle weakness, paresthesia, paralysis, cardiac rhythm irregularities (leading to
possible ventricular fibrillation and cardiac arrest)
• Treatment of severe hyperkalemia – “shift” potassium
• IV sodium bicarbonate, calcium gluconate or calcium chloride, dextrose with
insulin BIG-K
• Sodium polystyrene sulphonate (Kayexalate®)
• Salbutamol (Ventolin)
• Severe: hemodialysis to remove excess potassium

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 Sodium: Na 135-145 mmol/L

•Sodium is responsible for:

• Control of water distribution
• Fluid and electrolyte balance
• Osmotic pressure of body fluids
• Participation in acid–base balance
•Main indication
• Sodium depletion when dietary measures are inadequate (treatment or prevention)
• Mild
• Treated with oral sodium chloride or fluid restriction or both
• Severe
• Treated with IV NS or lactated Ringer’s solution

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 Sodium: Na < 135 mmol/L

• Hyponatremia: sodium loss or deficiency

• Lethargy, stomach cramps, hypotension, vomiting, diarrhea, seizures
• Causes
• Some of the same conditions that cause hypokalemia
• Also, excessive perspiration (during hot weather or physical work),
prolonged diarrhea or vomiting, kidney disorders, and adrenocortical
impairment

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Sodium : Na > 145 mmol/L
• Hypernatremia: sodium excess
• Symptoms
• Water retention (edema), hypertension
• Red, flushed skin; dry, sticky mucous membranes; increased thirst; elevated temperature; decreased
or absent urinary output
• Causes
• Poor kidney excretion stemming from kidney malfunction; inadequate water consumption and
dehydration

• Treatment -increased fluid intake and dietary restrictions.

• serious cases: diuretics may be required to enhance urinary sodium excretion. IV
administration of dextrose in water solution (e.g., 5% dextrose in water [D5W] or 10%
dextrose in water [D10W]) may also be helpful by producing both intravascular sodium
dilution and enhanced urine volume output.
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Electrolytes: Nursing Implications
• Assess baseline fluid volume and electrolyte status.
• Assess baseline vital signs.
• Assess skin, mucous membranes, daily weights, and input and output.
• Before giving potassium, assess electrocardiogram.
• Assess for contraindications to therapy.
• Assess transfusion history.
• Establish venous access as needed.
• Monitor serum electrolyte levels during therapy.
• Monitor infusion rate, appearance of fluid or solution, and infusion site.
• Observe for infiltration and other complications of IV therapy.

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Electrolytes: Nursing Implications (cont.)
• Parenteral infusions of potassium must be monitored closely.
• IV potassium must not be given at a rate faster than 10 mmol/hr to patients who
are not on cardiac monitors. For critically ill patients on cardiac monitors, rates of
20 mmol/hr may be used.
• Never give as an IV bolus or undiluted
• Oral forms of potassium
• Must be diluted in either water or fruit juice (100 to 250 mL) and taken with food
or immediately after meals to minimize gastrointestinal distress or irritation and
to prevent too rapid absorption
• Monitor reports of nausea, vomiting, gastrointestinal pain, and gastrointestinal
bleeding.

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Question: Check your knowledge
A patient is hypokalemic and will be receiving IV potassium. The patient
is not on a heart monitor. How should the nurse administer the
potassium replacement?
A. IV push
B. No more than 10 mmol/hr
C. No more than 20 mmol/hr
D. 100 mmol/hr

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Question: Check your knowledge
A patient with a serum potassium level of 6.0 mmol/L is
ordered polystyrene sulphonate (Kayexalate) via the
nasogastric tube. When administering the medication,
with what should the nurse administer the medication?
A. Sorbitol
B. Water
C. An antacid
D. A laxative

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Question: Check your knowledge

Which solution should the nurse administer with

packed red blood cells?
A.Lactated Ringer’s solution
B.0.9% sodium chloride
C.D5W
D.0.45% sodium chloride

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Class activity
• Using the nursing process, develop a collaborative plan of care and
identify associated documentation and health teaching required for
clients receiving antihypertensives, antianginals, diuretics, and
electrolytes
Hypertension
• Gloria, a 35-year-old lawyer, has been diagnosed with hypertension. Both her mother and sister have
hypertension, and both were in their 40s when it was diagnosed. Gloria’s most current blood pressure reading is
150/96 mm Hg, and for this reason the nurse practitioner has recommended drug therapy with captopril, light
exercise in the form of walking, and relaxation therapy. After 1 month of therapy, Gloria’s blood pressure is
145/86 mm Hg. Stress reduction has been the biggest obstacle in her treatment because of her work at a
prominent law firm. She has found that her blood pressure is consistently elevated (160/100 mm Hg) whenever
she measures it at work. At this follow-up visit, she is also given a prescription for a diuretic to help with her
blood pressure control.
• 1. What type of diuretic was probably prescribed for Gloria at this time? Explain your answer.
• 2. What possible adverse effects does Gloria need to be aware of while taking captopril?
• 3. Gloria tells you that she uses an over-the-counter (OTC) pain reliever for occasional headaches. What potential
interaction is of concern?
• 4. Gloria states that she and her husband are planning to start a family in 1 year. What will you, as her nurse, tell
her about pregnancy and therapy with these drugs?
• 5. What lifestyle changes would you, as her nurse, recommend that she make, and, even more important, what
information would you give her to help her change her lifestyle and more effectively reduce the stress in her life?
Antianginal
• Sherman, a 68-year-old accountant, has been diagnosed with CAD after experiencing chest pain at
times when he jogs. After undergoing a thorough physical examination, including cardiac
catheterization, he is given a prescription for a low-dose beta blocker, metoprolol 25 mg by mouth,
once a day. He also has a prescription for 0.4-mg sublingual nitroglycerin tablets to take as needed
for chest pain.
• 1. What type of angina is Sherman experiencing, and what are the therapeutic goals of the drug
therapy he has received?
• 2. Sherman asks you, “Why do I have to take two prescription drugs? It doesn’t make sense to me!”
What is the best answer to his question?
• 3. Two days after he begins the nitroglycerin, Sherman calls the office and says, “I’m having awful
headaches. What is wrong?” What is the best explanation, and what can he do about the
headaches?
• 4. Two months later, Sherman calls and says, “I don’t think these drugs are working. I’m having
more episodes of chest pain now when I jog.” What could be the explanation for this, and what can
be done?
Diuretics
• Glenda, a 62-year-old university professor, has been diagnosed with primary hypertension and will be taking
50 mg of hydrochlorothiazide (Urozide) daily. There is no evidence of renal insufficiency or cardiac damage at
this time, nor is there evidence of retinopathy or other signs or symptoms of end-organ disease. She is anxious
because the fall semester is starting and she has a heavy teaching load, but she is willing to take the steps
needed for better health.
• At her 1-month follow-up appointment, Glenda reports “feeling so tired” and asks whether the medication
causes sleepiness. When questioned, she says that she takes the hydrochlorothiazide at dinnertime because
she is afraid it will “interfere with her classes.”
• 1. What do you suspect is happening with Glenda, and what would you recommend?
• 2. During this follow-up appointment, you ask Glenda if she is eating foods high in potassium. She looks
embarrassed and answers, “I lost that pamphlet about the foods with potassium, but I try to drink orange
juice every day.” What foods should she eat for their potassium content?
• 3. The report on Glenda’s potassium levels comes back from the laboratory, and the results are 3.4 mmol/L.
She asks, “Am I going to be put on a potassium pill, too?” What is your answer?
• 4. Six months later, Glenda is diagnosed with type 2 diabetes mellitus and is started on oral antihyperglycemic
therapy. What will you teach her about managing her diabetes while taking the hydrochlorothiazide?
Electrolyte Imbalance
• Ivan, an 85-year-old retired chemist, seems somewhat confused when his daughter
comes home from work. When she brings him to the emergency department, his blood
pressure is 90/62 mm Hg, his heart rate is 114 beats per minute, and his skin is dry but
cool. His daughter says that he seems “much weaker” than usual, and he is unable to
answer questions clearly. His daughter reports that he has “lost his appetite” lately and
has not taken in much food or drink. The nurse starts an IV infusion of 0.9% sodium
chloride (NS) at 100 mL/hr via a gravity drip infusion.
• 1. What do you think is Ivan’s main medical problem at this time? The emergency
department is extremely busy, and when the nurse returns, she is shocked to see that
almost the entire 500-mL bag of NS has infused within an hour’s time.
• 2. What will the nurse do first? What will the nurse watch for at this time?
• 3. When monitoring Ivan’s fluid status, which indicators will the nurse consider the most
reliable?