Blood Pressure Agents PDF

Blood Pressure Agents Dr. Katy Challenger, EdD, MSN, FNP-C, CNE Pima Community College NRS155 1  Blood Pressure Agents Learning Outcomes/Objectives Key Terms Explain the therapeutic actions...

Blood Pressure Agents Dr. Katy Challenger, EdD, MSN, FNP-C, CNE Pima Community College NRS155 1  Blood Pressure Agents Learning Outcomes/Objectives Key Terms Explain the therapeutic actions Angiotensin-converting enzyme (ACE) and uses of agents affecting BP. inhibitor Discuss nursing implications Angiotensin II receptors related to safe administration of Baroreceptor agents affecting BP, including Cardiovascular Center related assessments, expected Essential or primary hypertension effects, safe routes and Hypotension dosages, timing of administration, adverse effects, Peripheral resistance contraindications, and relevant Renin-angiotensin-aldosterone system practice factors. Shock Stroke volume 2  Blood Pressure Control BP determined by Heart Rate Stroke Volume: Amount of blood pumped out of the ventricle with each heartbeat Total Peripheral Resistance: Resistance of the muscular arteries to the blood being pumped through Baroreceptors Renin-angiotensin-aldosterone system 3 The Renin–Angiotensin System 4 Risks Related to Hypertension If HTN remains Coronary Artery Disease untreated…. CAD and Cardiac Thickening of the heart Death muscle Stroke Increased pressure generated by the Renal Failure muscle on contraction Loss of Vision Increased workload on the heart 5 Categories Rating the Severity of Hypertension 6 Risk Factors for Hypertension Stress Obesity Chronic kidney disease Decreased physical activity Insulin resistance Diabetes Increased age High-salt diet Cigarette smoking Sleep apnea Alchohol use Genetic predisposition 7 Use Of Drugs Affecting Blood Pressure Across The Lifespan: Children National Standards- new Different drug classes May start in childhood that may be used More likely to be secondary Follow-up needed Monitor BP Use drug therapy with Monitor for adverse caution effects Lifestyle changes first Diuretic: monitor glucose Weight loss and electrolytes Increased activity 8 Use Of Drugs Affecting Blood Pressure Across The Lifespan: Adults Education Adverse effects that should be reported immediately Safety precautions Situations that may cause dehydration Drug-drug interactions Lifestyle modifications Caution with pregnancy and lactation ACEI/ARB/Renin inhibitors should not be used in pregnancy – ABSOLUTE CONTRAINDICATION If benefit outweighs risk, labetalol is the first choice if absolutely needed in pregnancy Drugs enter breastmilk and can cause serious adverse effects Use Of Drugs Affecting Blood Pressure Across The Lifespan: Older adults More susceptible to toxic effects Underlying conditions that may effect drug metabolism and excretion Reduced dose Close monitoring Drug-drug interactions including herbal therapies Safety precautions Sustained-release or extended-release medication Do not cut, crush, or chew May have a toxic dose Fall risk reduction Monitoring for dehydration Evaluating BP In institutional settings, BP should be taken immediately before administration of these drugs 10 Stepped Care Management of Hypertension Step 1: Lifestyle modifications are instituted Weight reduction, smoking cessation, moderation of alcohol intake, reduction of dietary salt, increase in aerobic physical activity Step 2: Inadequate response Drug therapy added Step 3: Inadequate response Consider change in drug dose or class, or addition of another drug for combined effect Step 4: Inadequate response Second or third agent or diuretic is added if not already prescribed 11  Antihypertensive Agents Drugs Affecting the RAAS Sympathetic Nervous System ACE Inhibitors Blockers Beta-Blockers Angiotensin II Selective/nonselective Receptor Blockers Alpha-adrenergic Blockers (ARBs) Nonselective Renin Inhibitors Alpha1-blockers Calcium Channel Blockers Alpha- and Beta- Blockers Vasodilators (a.k.a. Nonselective Adrenergic Blocking Agents) Diuretics Alpha2-agonist 12 Antihypertensive Agents: Drugs affecting the RAAS Angiotensin-Converting Enzyme Inhibitors (ACEI or ACE inhibitors) Angiotensin II Receptor Blockers (ARBs) Renin Inhibitors 13 ACE Inhibitors Actions Blocks ACE from converting angiotensin I to angiotensin II in the RAAS. This blocks aldosterone leading to “-pril” vasodilation, sodium and water Benazepril excretion, and small increase in serum potassium. Captopril Indications Enalapril HTN Lisinopril Congestive heart failure (CHF) and left ventricular dysfunction (in Ramipril conjunction with other medications) Diabetic nephropathy prevention 14 ACE Inhibitors Absolute Contraindications Adverse Effects r/t vasodilation & Allergy alterations in blood flow Pregnancy – Black Box Warning Hypotension Relative Contraindications Renal insufficiency Impaired renal function Dizziness Caution Fatigue Acute/unstable CHF Adverse Effects: Other Drug-Drug Interactions Pancytopenia Allopurinol GI irritation Other RAAS drugs Rash NSAIDs Hyperkalemia Cough 15 Nursing Considerations specific to ACE Inhibitors Assessment Labs: CBC Implementation Patient teaching regarding cough 16 Angiotensin II Receptor Blockers Actions “-sartan” Angiotensin II receptor antagonist Candesartan Blocks angiotensin II from Irbesartan binding with the receptors on the vascular smooth muscle and in Losartan the adrenal cortex Olmesartan prevents vasoconstriction prevents release of Telmisartan aldosterone Valsartan Indications HTN CHF Diabetic nephropathy prevention 17 Angiotensin II Receptor Blockers Absolute Contraindications Adverse Effects Allergy CNS: HA, dizziness, syncope, Pregnancy – Black Box weakness Warning CV: hypotension Caution GI complaints Hepatic dysfunction Skin: rash Renal dysfunction Hyperkalemia Hypovolemia Renal damage Drug-Drug Interactions NSAIDs Other RAAS drugs 18 Nursing Considerations specific to Angiotensin II Receptor Blockers Assessment Liver impairment Labs: liver function 19  Renin Inhibitor: Aliskiren Action Absolute Contraindications Inhibits renin which inhibits the Allergy RAAS Pregnancy Decreased BP Adverse Effects Decreased aldosterone Hyperkalemia Decreased sodium reabsorption Diarrhea Indications Drug-Drug Interactions HTN Other RAAS drugs 20  Drugs Affecting the RAAS: The Nursing Process Assessment Implementation History Encourage lifestyle changes Allergy, pregnancy Use of barrier contraceptives Impaired kidney function, salt/volume Comfort and safety measures depletion, heart failure Physical Monitor the patient carefully in any Baseline physical: cardiac, respiratory, situation that might lead to a drop in abdominal, skin fluid volume Vitals and weight Provide thorough patient teaching Labs: renal function tests, electrolytes, Evaluation pregnancy test Evaluate response to drug Nursing Diagnoses/Conclusions Evaluate effectiveness of teaching plan Altered tissue perfusion Evaluate effectiveness of comfort & Altered skin integrity safety measures Impaired comfort Evaluate compliance with regimen Electrolyte imbalance risk Knowledge deficit 21 Calcium Channel Blockers Actions “-dipine” Inhibits the movement of calcium ions across the cell membranes of Amlodipine cardiac and arterial muscle, Felodipine depressing the impulse and leading to slowed conduction, decreased Nifedipine myocardial contractility, and relaxing and dilating the arteries Diltiazem Decreases BP, cardiac workload, and myocardial oxygen Verapamil consumption Indications Hypertension Angina Arrhythmias 22  Calcium Channel Blockers Absolute Contraindications Adverse Effects Allergy r/t effects on cardiac output CNS Relative Contraindications CV Renal or hepatic dysfunction Other Heart block or sick sinus GI syndrome Skin Cautions Interactions CHF Drug-Drug Cyclosporine and diltiazem Drug-Food Grapefruit juice 23  Calcium Channel Blockers: The Nursing Process Assessment Implementation History Monitor the patient's blood pressure, cardiac Allergy rhythm, and cardiac output Heart block, sick sinus syndrome, Comfort measures and safety measures heart failure Provide thorough patient teaching Liver and kidney impairment EvaluationEvaluation Physical Evaluate response to drug Skin, respiratory, cardiac, neuro, Evaluate effectiveness of teaching plan abdominal Evaluate effectiveness of comfort & safety Vitals, ECG, pain measures Labs: liver and renal function tests Evaluate compliance with regimen Nursing Diagnoses/Conclusions Altered cardiac output risk Injury risk 24 Altered tissue perfusion Vasodilators Actions Acts directly on vascular smooth muscle to cause muscle relaxation which leads to vasodilation and Hydralazine decrease in BP Also results in decreased peripheral Minoxidil vascular resistance which increases cardiac output Nitroprusside Indications Nitroglycerin Severe hypertension Refractory hypertension Hypertensive emergencies Malignant hypertension 25 Vasodilators Absolute Contraindication Adverse Effects Allergy Related to changes in BP Cautions CNS Conditions exacerbated by CV decreased BP Skin Peripheral vascular disease, GI upset CAD, CHF, cerebral Cyanide toxicity with insufficiency, or tachycardia nitroprusside Drug-Drug Interactions pink/cherry-red skin Based on individual drug headache dizziness dyspnea vomiting 26 Vasodilators: The Nursing Process Assessment Implementation History Encourage lifestyle changes Allergy, CV dysfunction Monitor BP closely Physical Monitor patient carefully in any Skin, cardiac, respiratory, situation that might lead to a abdominal drop in fluid volume Vitals, ECG, weight Comfort and safety measures Labs: renal and hepatic function Provide thorough patient Nursing Diagnoses/Conclusions teaching Altered tissue perfusion Evaluation Altered skin integrity Evaluate response to drug Impaired comfort Evaluate effectiveness of Knowledge deficit teaching plan Evaluate effectiveness of comfort & safety measures 27 Diuretics Thiazide and thiazide-like Increase the excretion of diuretics sodium and water from the kidney to lower blood Chlorothiazide pressure chlorthalidone Review Chapter 51 for hydrochlorothiazide detailed information Potassium-sparing diuretics spironolactone triamterene 28 Sympathetic Nervous System Blockers Beta-Blockers Selective/ Nonselective Alpha-Adrenergic Blockers Nonselective Alpha1-blockers Alpha- and Beta- Blockers a.k.a. Nonselective Adrenergic Blocking Agents Alpha2-Agonist 29 Sympathetic Nervous System Blockers: Beta-Blockers Actions Blocks beta receptors in the “-olol” heart Decreases heart rate and Atenolol cardiac muscle contraction Metoprolol Vasodilates which increases Propranolol blood flow to the kidneys, Nonselecti leading to a decrease in the ve release of renin Indications Hypertension, angina, tachyarrhythmias, migraine headache, MI, glaucoma, 30 Sympathetic Nervous System Blockers: Beta-Blockers Absolute Contraindication Allergy Relative Contraindications Acute/unstable heart failure, bradycardia and heart block Bronchospasm, COPD, acute asthma Cautions Renal and hepatic dysfunction Diabetes 31 Sympathetic Nervous System Blockers: Beta-Blockers Adverse Effects CNS: HA, fatigue, dizziness, depression, sleep issues, disorientation, memory loss CV: bradycardia, hypotension Resp: Bronchospasm, dyspnea, pulmonary edema GI: N/V/D, pain GU: decreased libido and impotence Alterations in glucose levels Drug-Drug Interactions Clonidine NSAIDs Insulin/hypoglycemic agents 32 Nursing Considerations Specific to Beta-Blockers Assessment History of lung conditions or diabetes Implementation Take apical pulse prior to administering and hold if below 60 bpm Do not abruptly stop medication Patients with diabetes should monitor blood glucose closely 33  Sympathetic Nervous System Blockers Alpha-adrenergic blocker (non-selective) Actions Phentolamine Blocks Alpha1 receptors: Administered IM or IV vasodilation resulting in only decreased BP Blocks Alpha2 receptors: prevents norepinephrine feedback loop resulting in increase in reflex tachycardia Indications Diagnose and manage 34 episodes of Sympathetic Nervous System Blockers Alpha-adrenergic blocker (non-selective) Absolute Contraindication Allergy Relative Contraindications CAD MI Drug-drug Interactions Alcohol 35  Sympathetic Nervous System Blockers Alpha-adrenergic blocker (non-selective): Adverse Effects CV Hypotension Angina; MI Arrhythmia Increased reflex tachycardia Flushing CNS CVA HA Weakness Dizziness 36 Sympathetic Nervous System Blockers: Alpha1-blockers Actions “-azosin” Blocks alpha1-receptor sites Doxazosin Decreases vascular tone Prazosin resulting in vasodilation Terazosin Decreases blood pressure Indications: Hypertension 37 Sympathetic Nervous System Blockers: Alpha1-blockers Absolute Contraindication Allergy Cautions Heart failure Renal failure or hepatic impairment Adverse Effects CNS, CV, GU, Skin Drug-Drug Interactions Drugs used for erectile dysfunction (ED) 38 Sympathetic Nervous System Blockers: Alpha- and Beta- blockers (Nonselective Adrenergic Blocking Agents) Actions Indications Blocks norepinephrine at Hypertension all alpha and beta Drugs receptors in the SNS Carvedilol Lower BP and HR Labetalol Increased renal perfusion Decreased renin 39 Sympathetic Nervous System Blockers: Alpha- and Beta- blockers Absolute Contraindications Allergy Relative Contraindications Heart block Bradycardia Liver disease Cautions Lung disease/bronchospasm Diabetes 40 Sympathetic Nervous System Blockers: Alpha- and Beta- blockers Adverse Effects CNS Cardiovascular Respiratory Hypoglycemia Skin: Rash GI/GU issues Liver failure Drug-Drug Interactions Antidiabetic agents 41  Sympathetic Nervous System Blocker Alpha2-agonist: Clonidine Actions Absolute Contraindications: Allergy Stimulates the alpha2 Relative Contraindications receptors in the CNS and Narrow angle glaucoma inhibits the CV centers, Severe HTN leading to a decrease in Hypotension sympathetic outflow from the CNS resulting in a drop in BP Bradycardia Indications Cautions CV disease Hypertension Diabetes Oral and transdermal Hyperthyroidism formulations Renal/hepatic impairment 42  Sympathetic Nervous System Blocker Alpha2-agonist: Clonidine Adverse Effects CNS CV GU Drug-Drug Interactions Beta-blockers Adrenergic-antagonists CNS depressants/alcohol 43  Sympathetic Nervous System Blockers: The Nursing Process Assessment Nursing History Diagnoses/Conclusions Contraindications and Impaired comfort cautions Altered tissue perfusion Physical Altered cardiac output CNS, cardiac/perfusion, Altered breathing pattern respiratory, abdominal, urinary Injury risk Vitals and ECG Activity intolerance Labs: electrolytes, renal and Altered sensory perception hepatic function, glucose Knowledge deficit 44 Sympathetic Nervous System Blockers: The Nursing Process - Implementation Take apical pulse prior to administering and hold if below 60 bpm Prepare medication carefully Monitor blood pressure Do not abruptly stop medication Encourage patient to make lifestyle modifications Change position slowly Safety and comfort measures Patients with diabetes should monitor blood glucose closely Do not crush ER formulations Patient teaching Consult a healthcare professional before taking any OTC medication or herbal/alternative therapies Emphasize importance of follow-up exam 45 Sympathetic Nervous System Blockers: The Nursing Process - Evaluation Evaluate response to drug Evaluate effectiveness of the teaching plan Evaluate effectiveness of comfort and safety measures Evaluate compliance with the regimen 46 Hypotension Blood pressure becomes too low When the heart muscle is damaged and unable to pump effectively With severe blood or fluid loss, when volume drops dramatically When there is extreme stress and the body’s levels of norepinephrine are depleted, leaving the body unable to respond to stimuli to raise BP 47  Antihypotensive Agents: Vasopressors Sympathetic adrenergic agonists / Sympathomimetics / Alpha- and Beta- adrenergic agonists Action Dobutamine Stimulate all adrenergic receptors/SNS Dopamine HR and myocardial contractility Epinephrine increases Blood vessels constrict and BP Norepinephrine increases Bronchi dilate and rate/depth of breathing increases Indications Hypotensive states: Shock, Heart failure Anaphylaxis Bronchospasm/Acute Asthma 48 Antihypotensive Agents: Vasopressors Absolute Contraindications: Allergy, Pheochromocytoma Relative Contraindications: Hypovolemia Cautions Tachycardia Hypertension Disease that limits blood flow Adverse Effects CV, CNS Drug-Drug Interactions Any drug or substance that increases HR or BP 49 Antihypotensive Drugs: The Nursing Process Nursing Assessment Diagnoses/Conclusions History Altered tissue perfusion Contraindications and cautions Altered sensory Physical perception Respiratory, cardiac/perfusion, Impaired comfort abdominal, skin Knowledge deficit Weight, vitals Labs: kidney and liver function 50 Antihypotensive Drugs: The Nursing Process Implementa Evaluati tion on Monitor BP and HR Evaluate response to drug Safety and comfort Evaluate effectiveness of measures teaching plan Provide thorough patient Evaluate effectiveness of teaching comfort & safety measures Evaluate compliance with regimen 51