Drugs For Hypertension (HTN)Chapter 23

Hypertension & Demographics

In the United States:• 74.5 Million adults Dx with HTN• 56,561 deaths in 2006, contributing factor in

300,000 additional deaths/year • Incidence is 1:3 adults, 77% unaware until

diagnosed• 1996-2006: death rate increased 19.5%

• Am. Heart Assn. 2010

2006 Death Rates in U.S./100,000

15.6% White males51.1% Black males14.3% White females37.7% Black females

Am. Heart Assn. 2010

Hypertension (HTN) Classification

• Normal: SBP <120 and DBP <80• PreHTN: SBP 120-139 or DBP 80-89• Stage 1 HTN: SBP 140-159 or DBP 90-99• Stage 2 HTN: SBP>159 or DBP>99

• Joint Nat’l Committee 7, 2003

Life Span and HTN

• Blood Pressure naturally changes over one’s lifetime, gradually and constantly increasing from infancy through later years. HTN is common among the elder population, occurring in:

• 64% of all Males older than 65• 75% of all Females older than 75

Pharmacology for Nurses, A Pathophysiological Approach 3rd Ed. 2011

• Widespread under-treatment for this age group.

Target Organs affected by HTN• Heart • Brain• Kidneys• Retina

• Compelling Reason For Instituting Pharmacotherapy: MI, HF, CAD,

DM, CRF, CVA.

• Pharmacology and the Nursing Process, • Mosby/Elsevier 2008 DVD-ROM• Adams, M., Leland, N., Urban, C.

Disease Progression

• Heart failure• Transient Ischemic Attack (TIA) and/or

Cerebral Vascular Accident (CVA)• Renal failure (RF)• Visual impairment and blindness

Pharmacology and the Nursing Process, Mosby/Elsevier 2008 DVD-ROM

Case Study

• Mr. F. is a 39 y.o. Black male who was admitted to the ICU from the County Clinic, diagnosed with Hypertensive Crisis. His history includes childhood Appendectomy, Obesity, newly diagnosed Hypercholesterolemia, Essential Hypertension and Alcoholism. Mr. F. had sustained BP’s of 200-210/115-120 mm/Hg while in the Emergency Department (ED) until treated with IV Nitroprusside (Nitropress). His pressure was stabilized at 140-160/80-88. Transfer orders to Telemetry Care Unit (TCU) were written.

Neuman System Model

• How deeply is the Hypertensive Stressor penetrating Mr. F.’s Lines of Resistance?

• Is the Basic Structure threatened?• At what Level of Prevention is the

administration of IV Nitroprusside?

nitroprusside sodium (Nipride or Nitropress)

• Drug Class: Direct-acting vasodilator • Actions and Uses: to lower blood pressure quickly in

a hypertensive crisis, relaxation of arterial and venous smooth muscle.

Adverse Effects: Increased intracranial pressure, bradycardia; cyanide toxicity with long term use

Dosage: initially 0.25-0.35mcg/kg/min IV then gradually titrate for effect every few minutes for max dose of 10mcg/kg/min.

Half-life: 2 minutes

Report from ICU Nurse, & Chart Review

• Unemployed auto mechanic• Completed 2 years High School • Weight 188 lbs, Height 5’5’’• Noncompliant with medications • Previously diagnosed Essential HTN• Cholesterol 244mg/dl (<200mg/dl desirable)• NKDA• 6 beers daily for 20 years

Transfer to TCU

• Mr. F.’s first set of VSS on the Unit are 97.9, 148/92, 76, 16, O2 SAT 98%. Pain 2/10 headache.

• MD has Ordered: Hydrochlorothiazide 25 mg PO BIDLisinopril 40 mg PO BID, hold for SBP < 100

VSS q2H and prn, IV Lock, NAS Cardiac Diet, Intake & Output (I&O), up ad lib, daily labs include Serum Electrolytes and CBC.

Primary Drug Therapy• Hydrochlorothiazide

(HydroDIURIL, Microzide)Drug Class: Thiazide Diuretic

Action: increases Na+ and H2O excretion by inhibiting Na+ & Cl-reabsorption in the distal nephron, causing diuresis which lowers SBP @ 10-20mmHg..

Microzide

Adverse Effects: Common: minor Hypokalemia, fatigueSerious: severe hypokalemia, electrolyte

depletion, hyponatremia, cardiac arrhythmias, dehydration, hypotension, hyperglycemia, coma, blood dyscrasias.

Drug Therapy Continued

Lisinopril (Prinivil, Zestril)Drug Class: Angiotensin Converting

Enzyme (ACE) Inhibitor• Action and use: ACE Inhibitors block angiotensin

II, which lowers peripheral resistance and decrease blood volume by lowering aldosterone secretion. This drug action decreases blood pressure and increases cardiac output. Valued use in treating both HTN and Heart Failure (HF).

Lisinopril • Adverse effects: mostly well tolerated:

Common: H/A, dizziness, orthostatic hypotension, cough, n/v/d, rash.

Serious: severe hypotension (1st dose phenomenon), syncope, angioedema, blood dyscrasias, hyperkalemia, Chest Pain

Contraindications: Hx of angioedema from ACE-I, hyperkalemia, 2nd & 3rd Trimesters of Pregnancy

Drug Action

• ACE Inhibitors prevent vasoconstriction by blocking the formation of Angiotensin II (a potent naturally occurring vasoconstrictor) in the body. Also, ACE Inhibitors decrease the secretion of Aldosterone which decreases Na+ and H2O absorption.

Nursing Process

• Potential / Actual Nursing Diagnosis for clients receiving diuretics & antihypertensives:– Fluid Volume , Deficient, Risk for– Falls/Injury/Activity Intolerance, Risk for, related to

orthostatic hypotension– Knowledge, Deficient, related to drug therapy

Nursing Process Cont’ed

– Risk for Imbalanced Nutrition, More than Body requirements (K+ intake)

– Noncompliance, Risk for, related to adverse drug effects : sexual dysfunction, lifestyle habits, income/insurance coverage, etc.

– Decreased Cardiac Output-disease process– Altered Tissue Perfusion due to drug therapy

» Adams, M., Leland, N., Urban, C.

Planning: Client Goals & Expected Outcomes

• Reduction in Systolic & Diastolic BP• Free of/minimal adverse effects• Lab values WNL • Verbalize/Demonstrate understanding of drug

actions, dosing/self administration, side effects and precautions of medications

• Adams, M., Leland, N., Urban, C.

Implementation:Intervention/Rationales

Observe for hypersensitivity reactions (angioedema)

Client to report any dyspnea, throat tightness, stridor, muscle cramps, hives, rash, tremors

Intervention/Rationales

Monitor Lab Values: Neutropenia/infections

ACE-Inhibitors can lower WBC’sClient to report any s/s of flu/infections

• Hyperkalemia due to low aldosterone levels(esp. with CHF, Renal insufficiency & Diabetes)

– Report nausea, irregular or slow heart beat, profound fatigue or weakness, avoid high K+ beverages/salt substitutes/nutritional supplements

Intervention/Rationales

Monitor for persistent dry cough or change in cough pattern

Encourage appropriate lifestyle changes ETOH, smoking, saturated fat, exercise

Client to expect cough, elevate head of bed (HOB), sugar-free lozenges, antihistamines, report any change in character/frequency of cough associated with shortness of breath (SOB) or chest pain (CP).

Intervention/Rationales

Monitor Liver ( drug metabolism) & Kidney (drug excretion) FunctionClient to report N/V/D, anorexia, rash, jaundice, abd

pain/tenderness/distention/change in stool. Contact Health Care Provider immediately if jaundice develops, keep all medical and lab appointments, carry ID Medication Card

Measure I&O and record daily weight. Observe for severe SOB/frothy sputum, profound fatigue

Intervention/Rationales

• 1st dose phenomenon : Monitor for safe activity until response to drug is known.– Accompany client first time out of bed– Provide dose at bed time– Instruct client when getting up to raise slowly to

sitting then standing position– Client to report

faintness/dizziness/numbness/tingling

Intervention/Rationales

Orthostatic B/P’s, hold meds if SBP<90keep 2 side rails up, call bell in reach

Avoid activities that require much mental alertness (driving)

Use opportunities to instruct client during medication pass or assessments (rationales for drug, desired outcomes, common side effects, when to contact provider).

Intervention/Rationales

Monitor Nutritional Status– For K+ wasting diuretics: Eat foods high in

Potassium: bananas, apricots, beans, etc.,– For K+ sparing diuretics: avoid foods high in K+

Monitor for Photosensitivitylimit sun exposure, wear sun glasses

Adams, M., Leland, N., Urban, C.

Evaluation of Outcome Criteria

• BP WNL• Lab values WNL• Client verbalizes and demonstrates an

understanding of drug action, dosing, side effects and precautions.

• Adams, M., Leland, N., Urban, C.

Case Study Cont’d

• Mr. F.’s BP over the next 24 hours has slowly climbed to the 170’s/100’s. His Serum K+ is 5.1, WBC’s 4.3, Bun 16 and Cr 0.8.

• The MD adds Atenolol 50 mg PO at HS, hold for SBP < 100

Drug Therapy

• Atenolol (Tenormin)• Drug Class: Beta-Adrenergic Antagonist

Action: slows heart rate and reduces cardiac contractility which reduces cardiac output. Also, inhibits Renin secretion and the formation of Angiotension II. Thus, systemic BP drops.

Atenolol

Adverse Effects:Common: fatigue, insomnia, drowsiness,

impotence or decreased libido, bradycardia, confusion

Serious: Agranulocytosis, laryngospasm, Stevens-Johnson Syndrome, anaphylaxis. Abrupt withdraw: palpitations, rebound HTN, arrhythmias, MI

Nurse & Patient

Mr. F. is asking some questions regarding what happened to him and what does it mean. As the nurse, you determine that Mr. F. is receptive to education so you describe HTN, what the long term effects may involve and what can be done about it. Mr. F. is appreciative.

Quality & Safety Education for Nurses

• Patient Centered Care– Mr F. is in control/full partner– Provide compassionate and coordinated care– Respect for preferences, values, needs

• Cronenwett, L., Sherwood, G., Barnsteiner, J.

QSEN

• Knowledge:– Information, communication, education– Understand concepts of pain and suffering– Examine barriers to active involvement and

strategies to empower pt. in his own health care process

QSEN

• Skills:– Elicit pt. values, preferences and expressed needs– Collaborate with and Communicate these needs to

other health care team members– Assess level of physical and emotional comfort– Assess level of pt.’s decisional conflict and provide

access to resources

QSEN

• Attitudes– Value seeing pt.’s situation through ‘his eyes’– Respect/encourage expression of values,

preferences and needs– Respect pt. preference in degree of his active

involvement in care process• Cronenwett, L., Sherwood, G., Barnsteiner, J.

More Nurse & Patient

You review with Mr. F.:Medications: actions, adverse effects, need for compliance.Lifestyle Issues: diet, Etoh, smoking, obesity, exercise, unemployment.

Mr. F. admits he lost his job due to his drinking and would like to return to work.

Next Morning

• The MD discontinued (D’ced) Microzide and atenolol and began Verapamil 240 mg PO daily & Furosemide 40mg BID due to Mr. F.’s poor response. (His SBP had remained in the 170’s.) The nurse continues to monitor his BP carefully. The noon time VSS are: 98.8, 88, 18, 143/88, O2 Saturation (O2 SAT) is 97% on room air (R/A).

Calcium Channel Blockers (CCB’s)

• Verapamil (Calan, Isoptin)• Drug Class: Nonselective CCB

Actions: inhibits flow of Ca++ ions into both cardiac and vascular smooth muscle, slowing heart rate (HR) and conduction velocity which can stabilize dysrhythmias. Dilates coronary arteries as well as arterioles, thus lowering the BP and cardiac workload.

Nursing Drug Book 2008

Adams, M., Leland, N. Urban, C.

Verapamil

• Adverse Effects: Common: dizziness, H/A, facial flushing,

dyspnea, hypotension, constipation Serious: new dysrhythmias or worsening

of existing onesCaution: renal & hepatic impairment

Nursing Process-Implementation

• Monitor for signs of Heart Failure (HF)– Increasing dyspnea, postural nocturnal dyspnea,

rales, frothy pink sputum. (CCB’s may cause decreased myocardial contractility, which increases risk of HF)

– Instruct pt. to report any above symptoms/signs as well as fatigue or edema of extremities

– Monitor Constipation-(CCB’s may cause decreased peristalsis). Enc. Fluids, fiber, stool softener PRN

Furosemide (Lasix)

Drug Class: Loop DiureticActions and Uses: strong inhibition of Na+ and

Cl- re-absorption at the proximal and distal tubules and ascending Loop of Henle (Loop Diuretic). Beneficial when cardiac output and renal blood flow are compromised.

Caution: review serum K+ levels prior to administration, if low- hold dose and notify the provider.

Furosemide (Lasix)

Adverse Effects:Common: mild hypokalemia, postural hypotension, tinnitus, N/V/D, dizziness, fatigue, muscle spasmsSerious: hypokalemia, electrolyte imbalances, blood dyscrasias, ototixicity, volume depletion, pancreatitis, (hyper-glycemia in Diabetics).

Adams, M., Leland, N., Urban, C.

Nursing Drug Book 2008

Other Primary Antihypertensive Drugs

• Angiotensin II Receptor Blockers (ARB’s) losartan (Cozaar), valsartan (Diovan) block the reception of Angiotensin II in arteriole smooth muscle and Adrenal Gland, causing BP to fall. (No cough and less angioedema)

Alternative AntiHypertensives

• Alpha 1 Adrenergic Antagonists: Doxazosin (Cardura), block sympathetic receptors in arterioles; hypotension, fatigue, nausea.

Alpha 1 & Beta Blockers: nonselective blockade of α & β adrenergic receptors; carvedilol (Coreg), labetalol (Trandate)

Alternative Antihypertensive

• Alpha 2 Adrenergic Agonists: decrease CNS stimulation to heart and arterioles; CNS side effects (sedation, etc.) Clonidine (Catapres) methyldopa (Aldomet)

• Adrenergic Neuron Blockers: many significant side effects, Reserpine rarely used today

Mr. F.Mr. F. is tolerating the new medication

regimen of Lisinopril, Verapamil and Lasix, which is maintaining his BP in the range of 120-130/80-88. He has mild dizziness when first sitting up which passes and he then tolerates mild activity. His Lab Values are WNL except his K+ of 3.2. The MD ordered IV K+ 40meq over 4 hours then 20meq PO BID. Now his K+ is 4.3. He is tolerating his diet well.

Implementation/Interventions

The Nurse confers with fellow staff nurses and the MD, resulting in: Clinical Social Worker (CSW) consult to explore financial aid options during unemployment, help create a more supportive home environment. CSW will provide Community Information on Alcoholics Anonymous (A.A)., Employment Development Dept.(EDD), local fitness centers, smoking cessation.Nutritional Consultation to explore alternative dietary options that may reduce saturated fat/excess caloric intake.

Mr. F. Goes Home

• Mr. F. feels encouraged by the Health Care Team and understands that lifestyle modifications are designed to be instituted gradually and one at a time. His personal preferences have remained central in the discharge plan. The goal or outcome is his improved quality of life and health. Mr. F. expresses his desire to be medication compliant and will explore A.A. and begin seeking employment.

References

Pharmacology and the Nursing Process, Mosby/Elsevier 2008 DVD-ROM

Nursing Drug Book 2008 Pharmacology for Nurses, A Pathophysiological Approach, Adams,

M., Leland, N., Urban, C., 3rd Ed. 2011Circulation: Journal of the AHA Jan 2010Joint Nat’l Committee 7Lab Tests & Diagnostic Procedures with Nursing Diagnosis 6th Ed.

2004 Pearson EducationCronenwett, L., Sherwood, G., Barnsteiner, J., et al. 2007, Quality

and safety education for nurses, Nursing Outlook, 55(3)122-131.