Ppt chapter 43

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Drugs Affecting Blood
Pressure
Chapter 43

Elements Determining Blood Pressure
• 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

Control of Blood Pressure

The Renin–Angiotensin System

Categories Rating the Severity of
Hypertension

Risks for Coronary Artery Disease Related
to Hypertension
• Thickening of the heart muscle
• Increased pressure generated by the muscle on
contraction
• Increased workload on the heart

Conditions Related to Untreated
Hypertension
• CAD and Cardiac Death
• Stroke
• Renal Failure
• Loss of Vision

Situations in Which Hypotensive States
Can Occur
• Heart muscle is damaged and unable to pump effectively
• Severe blood loss, volume drops dramatically
• Extreme stress when body’s levels of norepinephrine are
depleted
– Body is unable to respond to stimuli to raise blood
pressure

• Step 1: Lifestyle modifications are instituted
• Step 2: If the measures in step 1 are not sufficient, drug
therapy is added
• Step 3: If the patient’s response is inadequate, drug dose
or class may be changed or another drug added
• Step 4: Includes all of the above measures with the
addition of more antihypertensive agents until blood
pressure is controlled
Stepped Care Approach to Treating
Hypertension

Types of Drugs Used to Control Blood
Pressure
• Diuretic: Decreases serum sodium levels and blood
volume
• Beta-Blocker: Leads to a decrease in heart rate and
strength of contraction as well as vasodilatation
• ACE Inhibitor: Blocks the conversion of angiotensin I to
angiotensin II; an angiotensin II receptor blocker;
blocking effects of angiotensin on blood vessels
• Calcium Channel Blocker: Relaxes muscle contraction or
other autonomic blockers

Question
Please answer the following questions as true or false.
The use of a loop diuretic is the first drug used in the Step
Care Management program to treat hypertension.

Answer
False
Rationale: A somewhat controversial study, the ALLHAT
study, reported in 2002 that patients taking the less
expensive, less toxic diuretics did better and had better
blood pressure control than patients using other
antihypertensive agents. Replications of this study have
supported its findings and the use of a thiazide diuretic is
currently considered the first drug used in the Step Care
Management of Hypertension.

Sympathetic Nervous System Blockers
• Beta-Blockers
• Alpha-Blockers
• Alpha-Adrenergic Blockers
• Alpha1
-Blockers
• Alpha2
-Agonists

ACE Inhibitor
• Actions
– Blocks ACE from converting angiotensin I to angiotensin
II, leading to a decrease in blood pressure, a decrease in
aldosterone production, and a small increase in serum
potassium levels along with sodium and fluid loss
• Indications
– Treatment of hypertension, congestive heart failure (CHF),
diabetic nephropathy, left ventricular dysfunction following
an MI
• Pharmacokinetics
– Well absorbed, widely distributed, metabolized in the liver,
and excreted in the urine and feces

ACE Inhibitor (cont.)
• Contraindications
– Allergies
– Impaired renal function
– Pregnancy and lactation
• Caution
– CHF

ACE Inhibitor (cont.)
• Adverse Effects
– Related to the effects of vasodilatation and
alterations in blood flow
– GI irritation
– Renal insufficiency
– Cough
• Drug-to-Drug Interactions
– Allopurinol

Angiotensin II Receptor Blockers
– Allergy, pregnancy, and lactation
• Caution
– Hepatic or renal dysfunction, and hypovolemia
• Adverse Effects
– Headache, dizziness, syncope, weakness
– GI complaints
– Skin rash or dry skin
– Phenobarbital

Calcium Channel Blockers
• Actions
– Inhibits the movement of calcium ions across the
membranes of cardiac and arterial muscle cells,
depressing the impulse and leading to slowed conduction,
decreased myocardial contractility, and dilation of
arterioles, which lowers blood pressure and decreases
myocardial oxygen consumption
• Indications
– Treatment of essential hypertension in the extended
release form
– Well absorbed, metabolized in the liver, and excreted in
the urine

Calcium Channel Blockers (cont.)
– Allergy, heart block or sick sinus syndrome, renal or
hepatic dysfunction, pregnancy, and lactation
• Adverse Effects
– Related to effects on cardiac output
– GI symptoms
– Cardiovascular symptoms
– Cyclosporine

Question
The mechanism of action of an ACE inhibitor is the blocking
of ACE from converting angiotensin I to angiotensin
II. What does this cause?
A. Decrease in serum potassium levels
B. Decrease in aldosterone production
C. Sodium and fluid loss
D. Increase in blood pressure

Answer
B. Decrease in aldosterone production
Rationale: Blocks ACE from converting angiotensin I to
angiotensin II, leading to a decrease in blood
pressure, a decrease in aldosterone production, and
a small increase in serum potassium levels along
with sodium and fluid loss

Vasodilators
• Diazoxide (Hyperstat): IV for hospitalized patients with
severe hypertension; increases blood glucose levels
• Hydralazine (Apresoline): Maintains increased renal
blood flow
• Minoxidil (Loniten): Used only for severe and
unresponsive hypertension
• Nitroprusside (Nitropress): Used for hypertensive
crisis; maintain hypertension during surgery

Vasodilators (cont.)
• Actions
– Acts directly on vascular smooth muscle to cause muscle
relaxation, leading to vasodilatation, and drop in blood pressure
• Indications
– Severe hypertension
– Rapidly absorbed and widely distributed, metabolized in the liver,
and primarily excreted in the urine
– Allergy, pregnancy, lactation, cerebral insufficiency

Vasodilators (cont.)
• Caution
– Peripheral vascular disease, CAD, CHF, or
tachycardia
• Adverse Effects
– Related to changes in the blood pressure
– GI upset
– Cyanide Toxicity
– Based on individual drug

Midodrine
• Actions
– Activates alpha-receptors in arteries and veins to
produce an increase in vascular tone and an increase in
blood pressure
• Indications
– Symptomatic treatment of orthostatic hypotension
– Absorbed from GI tract, metabolized in the liver, and
excreted in the urine
– Supine hypertension, CAD, pheochromocytoma, and
with urinary retention

Midodrine (cont.)
• Caution
– Pregnancy and lactation
– Visual problems
• Adverse Effects
– Related to stimulation of alpha-receptors
– Cardiac glycosides, beta blockers, alpha-adrenergic
agents, and corticosteroids

Question
The nurse is caring for a patient whose physician has just
ordered Cyclomen PO 800 mg daily in 2 divided doses.
What disease process would the physician be ordering
the Cyclomen for?
A. Fibrocystic breast disease
B. Cholestatic hepatitis
C. Endometriosis
D. Delayed male puberty

Answer
C. Endometriosis
Rationale: In women, danazol (Cyclomen) may be used to
prevent or treat endometriosis or fibrocystic breast
disease. Anabolic steroids are more often abused for
body-building purposes than used for therapeutic effects.

Use Of Drugs Affecting Blood Pressure
Across The Lifespan

Prototype ACE Inhibitors

Prototype Angiotensin II Receptor
Blockers

Prototype Calcium Channel Blockers

Prototype Vasodilators

Question
• The nurse is caring for a 27-year-old African American
woman who was just prescribed an ACE inhibitor for
management of her hypertension. What should be
advised related to contraception?
A. The use of spermicidal jellies is recommended.
B. The minipill is the contraception method of choice.
C. Use barrier contraceptives to prevent pregnancy
while taking these drugs.
D. No special precautions need to be taken.

Answer
C. Use barrier contraceptives to prevent pregnancy while
taking these drugs.
Rationale: The safety for the use of these drugs during
pregnancy has not been established. ACE inhibitors,
ARBs, and renin inhibitors should not be used during
pregnancy, and women of child-bearing age should be
advised to use barrier contraceptives to prevent
pregnancy while taking these drugs.

Nursing Considerations for ACE Inhibitors
• Assessment: History and Physical Exam
• Nursing Diagnosis
• Implementation
• Evaluation

Nursing Considerations for Angiotensin II
Receptor Blockers
• Assessment : History and Physical Exam
• Implementation
• Evaluation

Nursing Considerations for Calcium
Channel Blocker
• Implementation
• Evaluation

Nursing Considerations for Vasodilators
• Implementation
• Evaluation

Nursing Considerations for Midodrine
• Implementation
• Evaluation

Ppt chapter 43

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