1. health and fitness
2. disease

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 males
51.1% Black males
14.3% White females
37.7% 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 BID
Lisinopril 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, fatigue
Serious: 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’s
Client 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) Function
Client 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<90
keep 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 Photosensitivity
limit 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 ones
Caution: 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 Diuretic
Actions 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 spasms
Serious: hypokalemia, electrolyte
imbalances, blood dyscrasias, ototixicity,
volume depletion, pancreatitis, (hyperglycemia 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. 2011
Circulation: Journal of the AHA Jan 2010
Joint Nat’l Committee 7
Lab Tests & Diagnostic Procedures with Nursing Diagnosis 6th
Ed. 2004 Pearson Education
Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. 2007,
Quality and safety education for nurses, Nursing Outlook,
55(3)122-131.