Pharmacology for Nurses Chapter 26

• cardiac output

• peripheral resistance

• blood volume

• vasomotor center

• baroreceptros

• chemoreceptors in the aorta and internal carotid arteries

• renin-angiotensin system

primary (idiopathic or essential) or secondary

chronic and debilitating disorders like stroke, heart attack, and HF

• lifestyle

• proper diet

• exercise should eb implemented

low doses of a single med. if this med proves ineffective, a second drug from a different class may be added to the regimen

diuretics

renin-angiotensin-aldosterone system (RAAS)

calcium channel blockers

Answer: 3

Rationale: Hydrochlorothiazide (Microzide) was prescribed as an adjunct treatment for HTN. Blood pressure decrease toward normal limits indicates that the use of this treatment has been effective.

Options 1, 2,and 4 are incorrect. Although absence of edema, weight loss, and frequency of voiding are related to fluid status and are other effects of furosemide, they are not related to the primary reason this drug was given (adjunctive therapy in HTN). Cognitive Level: Analyzing. Nursing Process: Evaluation. Client Need: Physiological Integrity.

Answer: 2

Rationale: Nifedipine (Procardia XL) may cause hypotension with reflex tachycardia.

Options 1, 3, and 4 are incorrect. Rash, chills, increased urine out-put, and weight loss are not adverse effects of CCBs. \n Cognitive Level: Applying. Nursing Process: Planning. \n Client Need: Physiological Integrity.

Answer: 2

Rationale: The advantage of using a combi nation of two drugs such as atenolol (Tenormin; a beta blocker) and doxazosin (Cardura; an alpha-1 antago-nist) is that lower doses of each may be used, resulting in fewer side effects.

Options 1, 3, and 4 are incorrect. \n With careful dosing, the BP should be gradually lowered to a safe limit. The number of doses per day is dependent on the half-life of the drug, not the combina-tion. Other conditions may be treated, but the primary reason to combine antihypertensives is not in treatment of additional conditions. Cognitive Level: Applying. \n Nursing Process: Implementation. Client Need: Physiological Integrity.

Answer: 4

Rationale: Nadolol (Corgard) may increase the risk of orthostatic hypotension, and the patient should be taught to rise slowly to standing from a sitting or lying position.

Options 1, 2, and 3 are incorrect. \n The drug does not cause constipation, and extra fluids and fiber are not required. A weight gain of over 1 kg per day should be reported but a gain of 1 kg per month may be insignificant or unrelated to the drug. The drug should never be stopped abruptly because of possible HIN and tachycardia. Cognitive Level: Applying. \n Nursing Process: Implementation. Client Need: Health Promotion and Maintenance.

Answer: 2, 4, 5

Rationale: Adverse effects of ARBs such as losartan (Cozaar) include dizziness, fatigue, hypoglycemia, urinary tract infections, and anemia. Though rare, angioedema and acute kidney injury may occur.

Option 1 and 3 are incorrect. Drowsiness and tremors are not expected adverse effects of losartan. Cognitive Level: Analyzing. Nursing Process: Evaluation. Client Need: Physiological Integrity.

Answer: 2

Rationale: Propranolol (Inderal) and other beta-blocking drugs are used to prevent reflex tachycardia that may occur as a result of treatment with direct-acting vasodilators. Giving two antihypertensive drugs together may also lower blood pressure further; how-ever, the beta-blocking drugs also lower the heart rate and are given in this case to reduce the chance for reflex tachycardia.

Options 1, 3, and 4 are incorrect. Propranolol has not been demonstrated to have effects in preventing lupus and is not a diuretic, although judicious diuretic therapy may be necessary if excessive fluid gain is an adverse effect of direct-acting vasodilator therapy. Cognitive Level: Analyzing. Nursing Process:

Implementation. Client Need: Physiological Integrity.

1. Unless the provider sets different parameters, anti-hypertensive medication is usually held if the blood pressure is 90/60 or below. The provider should be contacted if the blood pressure is below the set parameter or any time there are other symptoms, such as a weight gain of over 1 kg (2 pounds) in a 24-hour period, chest pain, or shortness of breath.

2. Because the BP is above 90/60, the nurse should give the dose of benazepril (Lotensin). Mr. Marshall should be cautioned about orthostatic hypotension and the appropriate safety measures taken (e.g., rising slowly to standing).

3. Mr. Marshall is on a low-sodium, low-protein diet, which may contribute to hypotension. Because the patient has CKD, the excretion of the drug may be prolonged and also contribute to the hypotensive effects. The nurse should recheck the BP more frequently (e.g., 30 and 60 minutes after giving the dose, then every 4 hours to assess for hypotension. Assessing ortho-static blood pressures as the patient rises from lying to sitting to standing will also provide valuable data. The serum creatinine and protein levels may also be checked to assess renal status. Finally, because this drug is an ACE inhibitor, the nurse should assess for the development of a cough or angioedema. Both are potential adverse effects of this drug classification that may require additional treatment.

Atenolol (Tenormin) is a beta,-adrenergic blocker that works directly on the heart. The nurse and the patient need to be aware that despite increased activity or stress, the patient's heart rate may not increase significantly because of the action of the medication. Tachycardia is one of the adrenergic signs of hypoglycemia that would not be readily evident in this patient. Both the nurse and patient need to be aware of the more subtle signs of hypoglycemia such as nervousness, irritability, or sweating that would not be evident with a patient on beta-blocking medications.

The nurse must ensure that the patient's blood pressure is not lowered too rapidly or too significantly because hypotension and reflex tachycardia may occur. The blood pressure should be lowered gradually and to parameters set by the healthcare provider. The patient is reevaluated frequently for decrease in blood pres-sure, reflex tachycardia, urine output, and other signs of cardiac output and tissue perfusion. This drug is light sensitive and must remain covered with foil or an amber protective wrapper during infusion. Once prepared, the drip is stable for only 24 hours.

cardiac output (CO); the higher the CO is the higher the BP

• dizziness

• lack of adequate urine formation

blood vessels to rupture or restrict blood flow to critical organs

antidiuretic hormone (ADH)

primary HTN

secondary HTN

to treat or remove the underlying condition that is causing the BP elevation

• limit intake of alcohol

• restrict Na consumption

• increase K intake

• reduce intake of saturated fat and cholesterol and increase consumption of fresh fruits and veggies

• increase physical activity

• discontinue use of tobacco products

• reduce sources of stress

• maintain optimal weight

alpha 2 agonist

beta blockers

alpha 1 blockers

direct vasodilators

calcium channel blockers

angiotensin receptor blockers

ACE inhibitors (ACEI)

diuretics

lower doses of each may be used, resulting in fewer side effects and better patient adherence to the therapy

• angiotensin converting enzyme (ACE) inhibitors

• angiotensin receptor blockers (ARBs)

• calcium channel blockers (CCBs)

• thiazide diuretics

• alpha 1 adrenergic blockers

• alpha 2 adrenergic agonist

• beta adrenergic blockers

• centrally acting alpha and beta blockers

• direct-acting vasodilators

• direct renin inhibitors

• grape seed extract

thiazide and thiazide-like diuretics

potassium-sparing diuretics; also a primary concern is retaining too much potassium

• dysrhythmias (from hyperK)

• dehydration

• hyponatremia

• agranulocytosis

• other blood dyscrasia

• significant hypokalemia

• electrolyte depletion

• dehydration

• hypotension

• hyponatremia

• hyperglycemia

• coma

• blood dyscrasias

• serious hypokalemia

• blood dyscrasias

• dehydration

• ototoxicity

• electrolyte imbalance

• circulatory collapse

renin-angiotensin-aldosterone system (RAAS)

renin-angiotensin-aldosterone system (RAAS)

aldosterone

aldosterone

direct vasoconstriction and increase water retention

• angioedema

• acute renal failure

• first-dose phenomenon

• fetal toxicity

• hyperkalemia

• angioedema

• acute renal failure

• first-dose phenomenon

• fetal toxicity

• hyperkalemia

• nephrotoxicity

losartan (Cozaar)

• may produce dizziness and fainting; patient should change position slowly

• dont give to preggy women

• hypoglycemia

• dizziness

• UTI

• fatigue

• anemia

Serous A/E:

• angioedema

• AKI

fetal injury and death during pregnancy

• hypersensitivty

• concurrent use with aliskiren is contraindicated

may increase:

• BUN

• potassium

• creatinine

• ALT

• AST

• signs of overdose include severe dizziness and fainting due to hypotensiojn

• treated with IV infusion of normal saline solution

calcium channel blockers (CCBs)

clevidipine (Cleviprex) and nicardipine (Cardene)

clevidipine

nicardipine

• nicardipine

• nifedipine

• amlodipine

• dilitiazem

• verapamil

• hepatotoxicity

• MI

• HF

• confusion

• mood changes

• angioedema

nifedipine

• dont give immediate-release formulation if an impending MI is suspected or within 2 wks following confirmed MI

• give capsules or tablets whole

may increase:

• a;la;ome phsophatase

• ALT

• CPK

• AST

• sign of overdose: hypotension

• treated with vasopressors

• calcium infusion may be indicated

For most patients, thiazide diuretics, ACE inhibitors, ARBs, or CCBs are the most commonly recommended drug classifications for the initial treatment of HTN, per the INC-8 guidelines.

• fatigue

• insomnia

• drowsiness

• impotence or decreased libido

• angranulocytosis

• stevens-johnson syndrome

• anaphylaxis

• rebound HTN

• MI

• dysrhythmias

• orthostatic hypotension

• dizziness

• HA

• fatigue

• first-dose phenomenon

• tachycardia

• dyspnea

• peripheral edema

• sedation

• depression

• HA

• dry mouth

• decreased libido

• hepatotoxicity

• hemolytic anemia

• granulocytopenia

• dizziness

• fatigue

• weight gain

• hyperglycemia

• diarrhea

• bradycardia

• may worsen HF and mask symptoms of hypoglycemia

lower BP directly by blocking sympathetic receptors in arterioles. causing the vessels to dilate

decrease the outflow of sympathetic nerve impulses from the CNS to the heart and arterioles

• sedation

• dizziness

• other CNS effects

• leukopenia

• thrombocytopenia

• lupus

doxazosin

• monitor patients closely for profound hypotension, possible syncope 2-6 hrs following first few doses due to first-dose phenomenon

• first-dose phenomenon can recur when med is resumed after period of withdrawal and dosage increases

• dizziness

• dyspnea

• asthenia

• HA

• hypotension

• orthostatic hypotension

• somnolence

• sign of overdose is hypotension

• treated with vasopressor or IV infusion of fluids

direct vasodilators

The drop in blood pressure caused by antihypertensive medication may trigger the RAAS mechanism and the release of aldosterone, increasing sodium and, thus, water retention and edema.

• systolic: >180

• diastolic: >120

• with evidence of impending end-organ damage, usually to the heart, kidney, or brain

uncontrolled or poorly controlled primary HTN

nitroprusside (nitro press)

• with a half-life of only 2 min, has the ability to lower BP almost instantaneously on IV

hydralazine

abrupt withdrawal of drug may cause rebound HTN and anxiety

• HA

• reflex tachycardia (take beta-adrenergic blocker to counter)

• palpitations

• flusing

• nausea

• diarrhea

• in patients with angina or rheumatic mitral valve heart disease

• patient with lupus can’t take this as it worsen symptoms

• sign of overdose is hypotension

• treated with a vasopressor or an IV infusion of fluids