Anti-Hypertensives

HYPERTENSIVE
Hypertension is an increase in blood pressure such that the systolic pressure is greater
than 140 mm Hg and the diastolic pressure is greater than 90 mm Hg.
There are two types of Hypertension:
(a) Essential hypertension
- Most common type of hypertension
- This affects 90% of persons with high blood pressure
- Origin: Unknown
- Contributing factors: include family history of hypertension, hyperlipidemia, African-
American background, diabetes, aging, stress, excessive alcohol ingestion, smoking, and
obesity.
(b) Secondary Hypertension
- This affects 10% of the persons with high blood pressure.
- Origin: These are cases related to renal end endocrine disorders.
There are selected regulators of the blood pressure which are the kidneys and blood
vessels strive to regulate and maintain a “normal” blood pressure. With the help of the renin-
angiotensin-aldosterone system and the control of the fluid volume, the kidneys help regulate
the blood pressure.
Kidneys control sodium and water elimination/retention, which affects cardiac output and
systemic arterial blood pressure. Renin (from the renal cells) stimulates production of
angiotensin II (a potent vasoconstrictor), which causes the release of aldosterone (adrenal
hormone that promotes sodium retention and thereby water retention). Retention of sodium and
water causes fluid volume to increase, elevating blood pressure.
The baroreceptors in the aorta and carotid sinus and the vasomotor center in the medulla
also assist in the regulation of blood pressure. Catecholamines such as norepinephrine, released
from the sympathetic nerve terminals, and epinephrine, released from the adrenal medulla,
increase blood pressure through vasoconstriction activity.
There are also other hormones that contribute to blood pressure regulation which are the
antidiuretic hormone (ADH), atrial natriuretic peptide (ANP) hormone, and brain natriuretic
peptide (BNP) hormone. The hypothalamus produces the ADH and it is stored and released by
the posterior pituitary gland (neurohypophysis). This hormone stimulates the kidneys to conserve
and retain water when there is a fluid volume deficit. When there is fluid overload, ADH
secretion is inhibited, and the kidneys then excrete more water.
Many physiological risk factors may affect the blood pressure of a person like having a
diet which is high in saturated fat and simple carbohydrates, alcohol ingestion, and obesity.
 Women are more prone to have hypertension by the age of 65 because of different factors
like menopause, obesity, and diet. Menopause increase the blood pressure because of the
increase of hormones once menstruation stop which lead to weight gain and make your blood
pressure more sensitive to salt in your diet. So, it is very important to maintain a healthy lifestyle
most importantly before and after menopause.
There are also some side effects and adverse effects when taking anti-hypertensives. One
of the troublesome side effects of the use of antihypertensive agents in older adults, especially
frail or institutionalized persons, is orthostatic hypotension. This episode of sudden low blood
pressure presents dizziness due to blood pooling in lower extremities when an individual change
to an upright position. If orthostatic hypotension occurs, the antihypertensive drug dose may
need to be decreased or another antihypertensive drug used.

Antihypertensive drugs, used either singly or in combination with other drugs, are
classified into six categories:
(1) diuretics
(2) sympatholytics (sympathetic depressants),
(3) direct-acting arteriolar vasodilators
(4) ACE inhibitors,
(5) angiotensin II receptor blockers (ARBs)
(6) calcium channel blockers
A. SYMPHATOLYTICS DRUGS
These medications depress or inhibit the activity of the sympathetic nervous system (SNS).

1. BETA-ADRENERGIC BLOCKERS
- Also known as BETA BLOCKERS
- These are used as anti-hypertensive drugs, in combination with diuretics, antianginals and
antidysrhythmics.
- These reduce cardiac output by diminishing the SNS response to decrease basal sympathetic tone
This diminish the vascular resistance therefore lowering the blood pressure.
- This reduces the heart rate, contractility and renin release.
- There are two types of beta-blockers. The Nonselective beta blockers and the Cardioselective beta
blockers. Nonselective beta blockers inhibit B1 and B2 receptors, slows the heart rate, the blood
pressure, and bronchoconstriction occurs because of the unopposed parasympathetic tone.
Propranolol and carvedilol are some of these drugs. While the Cardioselective beta blockers act
directly on the B1 therefore lowering the occurrence of vasoconstriction, hence this is more
preferred since the airway will not be affected. Some of these drugs are acebutolol, atenolol and
metoprolol.

NONSELECTIVE BETA BLOCKERS

DRUG INDICATION
This drug works by blocking the action of certain
natural chemicals in your body (such as
Propanolol epinephrine) that affect the heart and blood
vessels. This effect reduces heart rate, blood
pressure, and strain on the heart.
A mixture of nonselective alpha- and beta-
adrenergic blocking activity, decreasing cardiac
Carvedilol output, exercise-induced tachycardia, reflex
orthostatic tachycardia, causes vasodilation and
reduction in peripheral vascular resistance.

CARDIOSELECTIVE BETA BLOCKERS

DRUG INDICATION
To control hypertension by promoting blood
Metoprolol
pressure reduction via beta1 blocking effect.
For Mild to moderate hypertension, prophylaxis
Atenolol of anginal pectoris, and suspected or known
myocardial infraction (TIV)
For mild to moderate hypertension and
Acebutolol management of PVC (premature ventricular
contraction).
For hypertension and cardiac dysrhythmia. Used
 alone or with a thiazide diuretic.

Contraindications

The use of Beta- Adrenergic blockers are used with caution with patients with preexisting
bronchospasm or other pulmonary disease. These drugs are contraindicated to patients with second- or
third-degree atrioventricular (AV) block or sinus bradycardia and patients with COPD especially the
nonselective beta blockers.

Side effects and Adverse Effects

Side effects and adverse reactions include decreased pulse rate, markedly decreased blood
pressure, and (with noncardioselective beta 1 and beta2 blockers) bronchospasm. Beta blockers should
not be abruptly discontinued, because rebound hypertension, angina, dysrhythmias, and myocardial
infarction can result. Beta blockers can cause dizziness, insomnia, depression, fatigue, nightmares, and
sexual dysfunction.

Nursing Considerations

NONSELECTIVE BETA BLOCKERS

Assessment:

 Assess for contraindications or cautions (e.g. history of allergy to drug, heart blocks,
asthma, pregnancy or lactation status, etc.) to avoid adverse effects.
 Establish baseline physical assessment to monitor for any potential adverse effects.
 Assess the level of orientation and for any complaints of dizziness, paresthesias, or
vertigo to monitor CNS drug effects.
 Assess vital signs, especially pulse and blood pressure to monitor for possible excess
stimulation of the cardiac system.
 Note respiratory rate and auscultate lungs for adventitious sounds to evaluate effects
on bronchi and respirations.
 Monitor laboratory test results (e.g. liver and renal function tests) to determine need for
possible dose adjustment, serum electrolyte levels to evaluate fluid loss and
appropriateness of therapy, and blood glucose to evaluate for hyper- or hypoglycemia.

Diagnosis:

 Decreased cardiac output related to CV effects

 Ineffective airway clearance related to lack of bronchodilating effects
 Risk for injury related to CNS effects
 Diarrhea related to increased parasympathetic activity

Implementation:

 Do not discontinue abruptly after chronic therapy because hypersensitivity to

catecholamines may develop and patient could have severe reaction; taper drug slowly
over two weeks, monitoring the patient.
  Educate patient about positive lifestyle changes (e.g. diet, exercise, smoking cessation)
to aid in lowering blood pressure.
 Assess heart rate for changes that might suggest arrhythmia. Obtain blood pressure in
various positions to assess for orthostatic hypotension.
 Monitor GI function and need for increased access to bathroom facilities and need for
increased fluid intake related to diarrhea.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
knowledge about drug therapy and promote compliance.

Evaluation:

 Monitor patient response to therapy (improvement in blood pressure and heart failure).
 Monitor for adverse effects (e.g. CV changes, headache, GI upset, liver failure).
 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.

CARDIOSELECTIVE BETA BLOCKERS

Assessment:

 Assess for contraindications or cautions (e.g. history of allergy to drug, bradycardia,

pregnancy or lactation status, etc.) to avoid adverse effects.
 Establish baseline physical assessment to monitor for any potential adverse effects.
 Assess orientation, affect, and reflexes to monitor for CNS changes related to drug
therapy.
 Monitor CV status (blood pressure, pulse rate, peripheral perfusion) to determine
changes in function.
 Assess abdomen, including auscultating bowel sounds to monitor GI effects.
 Monitor renal and hepatic function tests to evaluate potential need for dose
adjustment, as well as electrolyte levels to monitor for risks for arrhythmias.

Diagnosis:

 Acute pain related to CNS, GI, and systemic

 Decreased cardiac output related to CV effects

 Ineffective tissue perfusion related to CNS effects

Implementation:

 Do not stop these drugs abruptly after chronic therapy, but taper gradually over 2 weeks
because long-term use of these drugs can sensitize the myocardium to catecholamines,
and severe reactions could occur.

 Continuously monitor any patient receiving an intravenous form of these drugs to avert
serious complications caused by rapid sympathetic blockade.
  Give oral forms of metoprolol with food to facilitate absorption.

 Provide comfort measures to help patient cope with drug effects.

 Provide patient education about drug effects and warning signs to report to enhance
knowledge about drug therapy and promote compliance.

Evaluation:

 Monitor patient response to therapy (lowered blood pressure, fewer angina episodes,
lowered intraocular pressure).

 Monitor for adverse effects (e.g. GI upset, CNS, or CV changes).

 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.

 Monitor patient compliance to drug therapy.

2. CENTRALLY ACTING ALPHA2 AGONIST

- These drugs decrease the sympathetic response from the brainstem to the peripheral vessels. They
decrease the sympathetic activity by stimulating the Alpha 2 receptors. It increases the Vagus activity,
decreases the cardiac output and decrease the serum epinephrine, norepinephrine, and renin
release. All these happen because of vasodilation and the reduced peripheral resistance.
- Beta blockers are not given with centrally acting alpha 2 agonists because it can cause bradycardia
during therapy and rebound hypertension.

CENTRALLY ACTING ALPHA2 AGONISTS

DRUG INDICATION
One of the first drugs widely used to control
hypertension. It can be used alone or with a
Methyldopa thiazide diuretic. It can be given TIV. This can
cause sodium and water retention when given in
high doses.
For hypertension, long duration of action. It is
well absorbed in the GI tract and can be used
alone or with thiazide diuretics. It decreases
Clonidine
sympathetic effects and can cause drowsiness,
dizziness and dry mouth. This can cause sodium
and water retention when given in high doses.
For hypertension, with long duration of action. It
Guanfacine can be used alone or with thiazide diuretics. This
is usually taken once a day.

Contraindications
 The use of these drugs is contraindicated when patients are hypersensitive to clonidine and has
a liver disease. It is also contraindicated to use clonidine in pregnancy since it crosses the placental
barrier and small amounts may enter the breast milk of a lactating patient These group of drugs should
not be abruptly discontinued for it can cause rebound hypertension, instead is they are usually
prescribed with another antihypertensive drug to avoid rebound hypertension symptoms like
restlessness, tachycardia, tremors, headache and increase blood pressure.

Side Effects and Adverse Effects

Some common side effects of these drugs are drowsiness, dry mouth, dizziness, and slow heart
rate (bradycardia). Since these group of drugs may cause sodium and water retention, peripheral edema
may occur.

Nursing Considerations

CENTRALLY ACTING ALPHA2 AGONISTS

Assessment:

 Record baseline vital signs for future comparison.

 Assess the patient’s drug history.
 Determine patient’s health history. Most adrenergic agonists are contraindicated if the
patient has cardiac dysrhythmias, narrow-angle glaucoma, or cardiogenic shock.
 Determine baseline glucose level.

3. SELECTIVE ALPHA1 ADRENERGIC BLOCKERS

- These are used mainly to reduce the blood pressure, but it can also be used to treat benign prostatic
hypertrophy.

SELECTIVE ALPHA ADRENERGIC

DRUG INDICATION
Used alone or with another antihypertensive.
Dizziness and headache may occur. This is a
commonly prescribed drug.
Prazosin
When prazosin is taken with alcohol or other
antihypertensives, the hypotensive state can
be intensified.
This decreases the total vascular resistance which
is responsible for a decrease of blood pressure.
Terazosin Terazosin and doxazosin have longer half-lives
than prazosin, and they are normally given once
at bedtime.
Used alone or with another antihypertensive.
Orthostatic hypotension, headache, dizziness,
Doxazosin Mesylate and GI upset may occur. Terazosin and doxazosin
have longer half-lives than prazosin, and they are
normally given once at bedtime.
Contraindications

These drugs are contraindicated when:

 Allergy to any component of the drug. To prevent hypersensitivity reaction

 Lactation. Drugs cross into breast milk

 Heart or renal failure. Can be exacerbated by blood pressure-lowering effects of the drug

 Hepatic impairment. Can alter drug metabolism.

 Pregnancy. Potential adverse effects to the fetus.

Side effects and Adverse effects

Some adverse effects of Selective Alpha1 Adrenergic blockers are headache, weakness, dizziness,
fatigue, drowsiness, depression, arrhythmia, hypotension, edema, HF, angina, nausea, vomiting,
diarrhea, abdominal pain, flushing, rhinitis, reddened eyes, nasal congestion, and priapism.

Nursing considerations

Assessment:

 Assess for contraindications or cautions (e.g. history of allergy to drug, heart or renal
failure, pregnancy or lactation status, etc.) to avoid adverse effects.

 Establish baseline physical assessment to monitor for any potential adverse effects.

 Assess orientation, affect, and reflexes to monitor for CNS changes related to drug
therapy.

 Monitor CV status (blood pressure, pulse rate, peripheral perfusion) to determine

changes in function.

 Assess renal function, including urinary output, to evaluate effects on the renal system
and assess benign prostatic hypertrophy and its effects on urinary output.

 Monitor renal and hepatic function tests to evaluate potential need for dose
adjustment.

Diagnosis:

 Acute pain related to headache, GI upset, flushing, nasal congestion

 Decreased cardiac output related to blood pressure changes, arrhythmias, vasodilation

 Risk for injury related to CNS or CV effects of the drug

Implementation:
  Monitor blood pressure, pulse, rhythm, and cardiac output regularly to evaluate for
changes that may indicate a need to adjust dose or discontinue the drug if CV effects are
severe.

 Establish safety precautions if CNS effects or orthostatic hypotension occurs to prevent

patient injury.

 Arrange for small, frequent meals if GI upset is severe to relieve discomfort and
maintain nutrition.

 Provide comfort measures to help patient cope with drug effects.

 Provide patient education about drug effects and warning signs to report to enhance
knowledge about drug therapy and promote compliance.

Evaluation:

 Monitor patient response to therapy (lowering of blood pressure, improved urine flow
with BPH).

 Monitor for adverse effects (e.g. GI upset, CNS, or CV changes).

 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.

 Monitor patient compliance to drug therapy.

4. ALPHA ADRENERGIC BLOCKERS

- These drugs block the alpha-adrenergic receptors, resulting in vasodilation and decreased blood
pressure. They also help maintain the renal blood flow rate.
- Alpha blockers are useful in treating hypertension in patients with lipid abnormalities since they
decrease the very low-density lipoproteins and the low-density lipoproteins that are responsible for
the fatty plaques in the arteries (Atherosclerosis).
- These are safe for patients with diabetes since it does not affect the glucose level and it does not
affect the respiratory function.
- hypertrophy.

ALPHA ADRENERGIC BLOCKERS

DRUG INDICATION
For diagnosis of pheochromocytoma and
Phentolamine prevention of tissue necrosis after
norepinephrine or epinephrine extravasation.
Are used primarily for hypertensive crisis and
Phenoxybenzamine severe hypertension resulting from
catecholamine secreting tumors of the adrenal
medulla (pheochromocytomas). This Lowers
peripheral resistance and has a long duration of
 action.

Contraindications

Alpha Adrenergic Blockers and Selective Alpha 1 Adrenergic Blockers both are contraindicated
when there’s known allergies or hypersensitivity to alpha-1 blockers or any of the active ingredient, that
includes angioedema induced by the drug. Patients with a history of orthostatic hypotension or severe
hepatic impairment

Side Effects and Adverse Effects

The side effects of both Alpha 1 Adrenergic Blockers and Selective Alpha 1 Adrenergic Blockers
include orthostatic hypotension (dizziness, faintness, lightheadedness, and increased heart rate, which
may occur with first dose), nausea, headache, drowsiness, nasal congestion caused by vasodilation,
edema, and weight gain.

Nursing Considerations

Assessment:

 Assess for contraindications or cautions (e.g. history of allergy, pheochromocytoma,

fatal arrhythmias, etc.) to avoid adverse effects.

 Establish baseline physical assessment to monitor for any potential adverse effects.

 Assess vital signs, especially pulse and blood pressure to monitor for possible excess
stimulation of the cardiac system.

 Note respiratory rate and auscultate lungs for adventitious sounds to evaluate effects
on bronchi and respirations.

 Monitor urine output to evaluate perfusion of the kidneys and therapeutic effects.

 Monitor laboratory test results (e.g. liver and renal function tests) to determine need for
possible dose adjustment, and serum electrolyte levels to evaluate fluid loss and
appropriateness of therapy.

Diagnosis:

 Decreased cardiac output related to CV effects

 Ineffective tissue perfusion related to CV effects

Implementation:

 Use extreme caution in calculating and preparing doses of these drugs because even
small errors could have serious effects.

 Use proper, aseptic technique when administering ophthalmic or nasal agents (alpha-
and beta- adrenergic agonists) to prevent injection and assure the therapeutic
effectiveness of the drug.
  Monitor patient response closely (vital signs, ECG, urine output) to ensure the most
benefit with the least amount of toxicity.

 Maintain phentolamine on standby in case extravasation occurs. Save the area by

infiltrating 10 mL of saline containing 5-10 mg of phentolamine.

 Provide comfort measures (e.g. light control, encouragement to void, monitoring bowel
functions, support and relaxation measures) to help patient cope with the
sympathomimetic effects of the drug.

 Provide patient education about drug effects and warning signs to report.

Evaluation:

 Monitor patient response to therapy (improvement in blood pressure, ocular pressure,

bronchial airflow).

 Monitor for adverse effects (e.g. CV changes, decreased urine output, headache, GI
upset).

 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.

 Monitor patient compliance to drug therapy. 

5. ALPHA1 AND BETA1 BLOCKERS

- These drugs block the Alpha1 receptors that causes vasodilation, decreasing the resistance to blood
flow. Since the effect on the alpha receptor is stronger than the effect on the beta receptor, the
blood pressure is lowered, and the pulse rate is moderately decreased.
- By blocking the cardiac beta1 receptor, both heart rate and the atrioventricular (AV) contractility are
decreased.
- Large doses of alpha/beta blockers could block beta2-adrenergic receptors, thus increasing airway
resistance. Patients who have severe asthma should not take large doses of labetalol.

ALPHA1AND BETA1 BLOCKERS

DRUG INDICATION
For hypertension. Used alone or with a thiazide
Labetalol diuretic. May cause orthostatic hypotension,
palpitations, and syncope.

Contraindication

Patients who have severe asthma should not take large doses of labetalol.

Side Effects and Adverse Effects

Common side effects of these drugs include orthostatic hypotension, GI disturbances,

nervousness, dry mouth, and fatigue. Large doses of labetalol may cause AV heart block.
Nursing Considerations

Assessment:

 Assess for contraindications or cautions (e.g. history of allergy to drug, heart blocks,
asthma, pregnancy or lactation status, etc.) to avoid adverse effects.
 Establish baseline physical assessment to monitor for any potential adverse effects.
 Assess the level of orientation and for any complaints of dizziness, paresthesias, or
vertigo to monitor CNS drug effects.
 Assess vital signs, especially pulse and blood pressure to monitor for possible excess
stimulation of the cardiac system.
 Note respiratory rate and auscultate lungs for adventitious sounds to evaluate effects on
bronchi and respirations.
 Monitor laboratory test results (e.g. liver and renal function tests) to determine need for
possible dose adjustment, serum electrolyte levels to evaluate fluid loss and
appropriateness of therapy, and blood glucose to evaluate for hyper- or hypoglycemia.

Diagnosis:

 Decreased cardiac output related to CV effects

 Ineffective airway clearance related to lack of bronchodilating effects
 Risk for injury related to CNS effects
 Diarrhea related to increased parasympathetic activity

Implementation

 Do not discontinue abruptly after chronic therapy because hypersensitivity to

catecholamines may develop and patient could have severe reaction; taper drug slowly
over two weeks, monitoring the patient.
 Educate patient about positive lifestyle changes (e.g. diet, exercise, smoking cessation)
to aid in lowering blood pressure.
 Assess heart rate for changes that might suggest arrhythmia. Obtain blood pressure in
various positions to assess for orthostatic hypotension.
 Monitor GI function and need for increased access to bathroom facilities and need for
increased fluid intake related to diarrhea.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance
knowledge about drug therapy and promote compliance.

Evaluation:

 Monitor patient response to therapy (improvement in blood pressure and heart failure).
 Monitor for adverse effects (e.g. CV changes, headache, GI upset, liver failure).
 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.
B. DIRECT-ACTING VASODILATORS
These drugs are potent hypertensive drugs. They act by relaxing the smooth muscles of the blood
vessels which are mainly the arteries, therefore causing vasodilation. With vasodilation, this
promotes an increase in the blood flow to the brain and kidneys. This lowers the blood pressure and
retains sodium and water, resulting in peripheral edema. These drugs are usually prescribed with
diuretics to decrease the peripheral edema.

DIRECT-ACTING VASODILATORS

DRUG INDICATION
For moderate or severe hypertension. Short
duration of action. May be used with a diuretic to
Hydralazine HCL
decrease edema and a beta blocker to prevent
tachycardia. Closely monitor the vital signs.
For moderate or severe hypertension. May be
used with a diuretic to reduce edema and with a
beta blocker to prevent tachycardia. Long
Minoxidil
duration of action. Do not discontinue drug
abruptly; withdraw drug slowly to avoid rebound
hypertension. Closely monitor vital signs.
For hypertensive crisis. Potent antihypertensive.
Drug decomposes in light; container must be
wrapped in aluminum foil. Good for 24 h. Discard
drug if red or blue. Cyanide toxicity may occur.
Measure cyanide and thiocyanate levels. May
Sodium Nitroprusside
cause profound hypotension.
This is prescribed for acute hypertensive
emergencies since this is a very potent
vasodilator that rapidly decreases the blood
pressure.

Contraindications

These drugs are contraindicated when there’s known Hypersensitivity to the drugs. Some
products contain tartrazine and should be avoided in patients with known intolerance. These drugs must
be used Cautiously in patients with Cardiovascular or cerebrovascular disease, Severe renal and hepatic
impairment (dose modification may be necessary);

Side Effects and Adverse Effects

The effects of hydralazine are numerous and include reflex tachycardia, palpitations, edema, nasal
congestion, headache, dizziness, GI bleeding, lupus-like symptoms, and neurologic symptoms (tingling,
numbness). Minoxidil has similar side effects, as well as tachycardia, edema, and excess hair growth. It
can precipitate an anginal attack. Nitroprusside can cause reflex tachycardia, palpitations, restlessness,
agitation, nausea, and confusion.

Nursing Considerations
 Assessment:

 Assess for the mentioned contraindications to this drug (e.g. drug allergy, CAD, cerebral
insufficiency etc.) to prevent potential adverse effects.
 Obtain baseline status for weight, vital signs, overall skin condition, and laboratory tests
like renal and hepatic function tests, and serum electrolyte to assess patient’s response
to therapy.

Diagnosis:

 Decreased tissue perfusion related to changes in volume of blood pumped out by the
heart
 Acute pain related to GI distress, headache, and skin effects of the drug

Implementation:

 Educate patient on importance of healthy lifestyle choices which include regular

exercise, weight loss, smoking cessation, and low-sodium diet to maximize the effect of
antihypertensive therapy.
 Monitor blood pressure and heart rate and rhythm closely to evaluate for effectiveness
and ensure quick response if blood pressure falls rapidly or too much.
 Provide comfort measures for the patient to tolerate side effects (e.g. small frequent
meals for nausea, limiting noise and controlling room light and temperature to prevent
aggravation of stress which can increase demand to the heart, etc.)
 Monitor patient for any manifestations that could decrease fluid volume inside the body
(e.g. vomiting, diarrhea, excessive sweating, etc.) to detect and treat excessive
hypotension.
 Educate patient and family members about drug’s effect to the body and manifestations
that would need reporting to enhance patient knowledge on drug therapy and promote
adherence.
 Emphasize to the client the importance of strict adherence to drug therapy to ensure
maximum therapeutic effects.

Evaluation:

 Monitor patient response to therapy through blood pressure monitoring.

 Monitor for presence of mentioned adverse effects (e.g. hypotension, GI distress, skin
reactions, etc.)
 Monitor for effectiveness of comfort measures.
 Monitor for compliance to drug therapy regimen.
 Monitor laboratory tests.

C. RAA SYSTEM ANTAGONIST

Renin Angiotensin Aldosterone Antagonists are group of drugs that act by inhibiting the renin-
angiotensin-aldosterone system (RAAS) and include angiotensin-converting enzyme (ACE) inhibitors.
 1. ACE INHIBITORS
- These inhibit the Angiotensin-Converting Enzymes which in turn inhibits the formulation of the
angiotensin II (vasoconstrictor) and blocks the release of aldosterone. Since aldosterone promotes
sodium retention and protein secretion, when it is blocked, the sodium is excreted along with the
water and potassium is retained.
- These drugs cause little change in the cardiac output or heart rate and they lower peripheral
resistance.
- These drugs can be used in patients who have elevated serum renin levels.
- These are used primarily to treat hypertension, but some agents are also effective in treatment of
heart failure.

ANGIOTENSIN-COVERTING ENZYMES INHIBITORS

DRUG INDICATION
For hypertension and HF. Inhibits conversion of
Captopril angiotensin I to angiotensin II. Irritating cough
may occur; retains potassium.
For hypertension and HF. Usually given with a
Lisinopril
diuretic. Long duration of action (24 h).
For hypertension and HF. Potent ACE inhibitor.
Quinapril Reduces systemic vascular resistance and
increases cardiac output.
For mild to moderate hypertension. Reduces
Perindopril
vasoconstriction. Cough may occur.

Contraindications

ACE inhibitors should not be given during pregnancy; harm to the fetus due to reduction in
placental blood flow could occur. This group of drugs should not be taken with potassium-sparing
diuretics such as spironolactone (Aldactone) or salt substitutes that contain potassium, because of the
risk of hyperkalemia (serum potassium excess).

Side Effects and Adverse Effects

The primary side effect of ACE inhibitors is a constant, irritated cough. Other side effects include
nausea, vomiting, diarrhea, headache, dizziness, fatigue, insomnia, serum potassium excess
(hyperkalemia), and tachycardia. The persistent, nonproductive “ACE cough” may be relieved upon
discontinuance of the drug. The major adverse effects are first-dose hypotension and hyperkalemia.
Hypotension results because of the vasodilating effect.

Nursing Considerations

Assessment:

 Assess for the mentioned contraindications to this drug (e.g. renal impairment,
hyponatremia, hypovolemia, etc.) to prevent potential adverse effects.
  Obtain baseline status for weight, vital signs, overall skin condition, and laboratory tests
like renal and hepatic function tests, serum electrolyte, and complete blood count (CBC)
with differential to assess patient’s response to therapy.

Diagnosis:

 Decreased cardiac output related to effect of drug in increasing fluid volume excretion
 Impaired skin integrity related to dermatological effects of the drug
 Increased risk for infection related to potential decreasing effect of drug to circulating
blood cells

Implementation:

 Educate patient on importance of healthy lifestyle choices which include regular

exercise, weight loss, smoking cessation, and low-sodium diet to maximize the effect of
antihypertensive therapy.
 Administer drug on empty stomach one hour before or two hours after meal to ensure
optimum drug absorption.
 Monitor renal and hepatic function tests to alert doctor for possible development of
renal and/or hepatic failure as well as to signal need for reduced drug dose.
 Monitor for presence of manifestations that signal decreased in fluid volume (e.g.
diarrhea, vomiting, dehydration) to prevent exacerbation of hypotensive effect of drug.
 Educate patient and family members about drug’s effect to the body and manifestations
that would need reporting to enhance patient knowledge on drug therapy and promote
adherence.

Evaluation:

 Monitor patient response to therapy through blood pressure monitoring.

 Monitor for adverse effects (e.g. hypotension, arrhythmias, renal failure, cough, and
pancytopenia).
 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.

2. ANGIOTENSIN II RECEPTOR BLOCKERS

- These group of drugs prevent the release of aldosterone and they act on the renin-angiotensin-
aldosterone system.
- Major difference between this and the ACE inhibitors: They block angiotensin II from Angiotensin I
receptors found in many tissues.
- They cause vasodilation and decreases the peripheral resistance.
- They also do not cause constant irritated cough like ACE inhibitors can. Though like ACE inhibitors,
they cannot be taken during pregnancy.

ANGIOTENSIN II RECEPTOR BLOCKERS

 DRUG INDICATION
For hypertension and HF. May be used when
patient does not respond to or tolerate ACE
Candesartan inhibitors. May be combined with calcium blocker
amlodipine for more effective response in
decreasing high blood pressure.
For hypertension. May be used alone or with
Irbesartan
other antihypertensives.

For hypertension. May be used alone or with

Losartan
other antihypertensives.
For mild to moderate hypertension. Does not
Telmisartan causes cough associated with ACE inhibitors.
Angioedema rarely occurs.
For hypertension as monotherapy or with other
Valsartan
antihypertensives.

Contraindications

These group of drugs are contraindicated to patients with Hypersensitivity to the drugs, during
pregnancy and breastfeeding. These drugs should be used with caution when there are Renal and
hepatic impairments, hypotension, hypovolemia and hyperkalemia.

Side Effects and Adverse Effects

The side effects of these drugs include dizziness, drowsiness, cough (rare), blurred vision,
headache, diarrhea, insomnia, arthralgia and fatigue. While the adverse effects of these drugs are
orthostatic hypotension, hypoglycemia and hyperkalemia. The life-threatening adverse effect of these
group of drugs may cause renal dysfunction.

Nursing Considerations

Assessment:

 Assess for the mentioned contraindications to this drug (e.g. drug allergy, hypovolemia,
renal impairment, etc.) to prevent potential adverse effects.
 Obtain baseline status for weight, vital signs, overall skin condition, and laboratory tests
like renal and hepatic function tests, and serum electrolyte to assess patient’s response
to therapy.

Diagnosis:

 Ineffective tissue perfusion related to fluid excretory effect of the drug

 Impaired skin integrity related to dermatological effects of the drug
 Risk for injury related to CNS side effects of the drug

Implementation:
  Educate patient on importance of healthy lifestyle choices which include regular
exercise, weight loss, smoking cessation, and low-sodium diet to maximize the effect of
antihypertensive therapy.
 Administer drug with food to prevent GI distress associated with drug intake.
 Monitor renal and hepatic function tests to alert doctor for possible development of
renal and/or hepatic failure as well as to signal need for reduced drug dose.
 Provide comfort measures (e.g. quiet environment, relaxation techniques, etc.) to help
patient tolerate drug effects.
 Educate patient and family members about drug’s effect to the body and manifestations
that would need reporting to enhance patient knowledge on drug therapy and promote
adherence.

Evaluation:

 Monitor patient response to therapy through blood pressure monitoring.

 Monitor for adverse effects (e.g. skin reactions, cough, headache, etc.)
 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.

References:

Kee, J. L. F., Hayes, E. R., & McCuistion, L. E. (2012). Pharmacology: a nursing process approach. St. Louis,
MO: Elsevier / Saunders.

https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/51383/all/hydrALAZINE

https://en.wikipedia.org/wiki/Alpha-1_blocker

https://www.amboss.com/us/knowledge/Renin-angiotensin-aldosterone_system_inhibitors

https://nurseslabs.com/adrenergic-antagonists-sympatholytics/

https://nurseslabs.com/adrenergic-agonists-sympathomimetics/