Chapter 28 Drugs Affecting Blood Pressure

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Physiology
The heart is composed of four chambers: the left atrium, the right atrium, the left ventricle, and the right ventricle. The two phases of the cardiac cycle are: systole and diastole. Contractions of the heart propel blood through the vessels The formula for measuring blood pressure is:

Blood pressure = cardiac output peripheral resistance

BP = CO PR:
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Regulation of Blood Pressure

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Role of Adrenergic Receptors

Adrenergic receptors affect blood pressure causing a Sympathomimetic effect
Sympathomimetic effect (one that mimics the effect of the sympathetic system). Alpha-1 receptors : Stimulated Blocked peripheral constriction dilates arterioles and veins (blood pressure increases)

( blood pressure drops)

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Role of Adrenergic Receptors

Alpha-2 receptor sites are located within the brain

Stimulation inhibits sympathetic system

( sympathetic outflow from the CNS) Results in : heart rate, vasoconstriction

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Role of Adrenergic Receptors

Beta-1 receptor sites located in the heart
Stimulation - heart rate speed of conduction force of contraction Blocking causes the opposite effect,

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Role of Adrenergic Receptors

Beta 2 receptors are in the: bronchial and vascular musculatue Stimulation causes : bronchial and peripheral dilation

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Role of Renin-Angiotensin-Aldosterone System

Another mechanism involved in blood pressure regulation is the renin-angiotensin-aldosterone system. Renin, which is synthesized by the kidneys, produces angiotensin I. Angiotensin I is an inactive substance until it is converted to the active angiotensin II Angiotensin II is a potent vasoconstrictor. {It also stimulates secretion of aldosterone from the adrenal medulla}

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Pathophysiology
In the United States, hypertension is a chronic disorder that affects all age groups.
Hypertension is common in all racial groups, {although some groups are more prone to hypertension than others}. The American Heart Association defines adult hypertension as : persistent elevation of 140/90 mm Hg.

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Classification of Hypertension

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Lifestyle Modification and Hypertension

In prehypertension, therapy usually consists of lifestyle changes, which include reducing weight and adopting the Dietary Approaches to Stop Hypertension (DASH). DASH recommends a diet rich in fruits, vegetables, and nonfat dairy, along with reduced intake of saturated and total fat, but higher potassium and calcium intake. Lifestyle modifications also include: limiting alcohol intake, regular exercise, and stopping smoking.

Lifestyle changes also are believed to be essential in preventing hypertension.

Lifestyle modification remains an important aspect of therapy for patients in stage 1 or stage 2 hypertension. Lifestyle modifications may decrease the required drug therapy dosage.
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Angiotensin-Converting Enzyme Inhibitors (ACE inhibitors)

In the renin-angiotensin-aldosterone sequence, a special enzyme is needed to convert the inactive angiotensin I to the active angiotensin II. Angiotensin II is a potent vasoconstrictor. Its presence increases secretion of aldosterone. The ACE inhibitors prevent the conversion of angiotensin I to angiotensin II. ACE inhibitors are used as first-line antihypertensives if the patient has comorbidities. Prototype drug: captopril (Capoten)

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Captopril: Core Drug Knowledge

Pharmacotherapeutics Hypertension, Congestive Heart failure, diabetic nephropathy, and left ventricular dysfunction. Pharmacokinetics Administered: Oral ( rapid onset of action)

Metabolism: liver. Excreted: kidneys.

Pharmacodynamics Inhibits the ACE(enzyme) needed to change the inactive angiotensin I to the active form angiotensin II. Decreasing Angiotensin II decreases aldosterone secretion {which prevents Na and H2O retention}
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Captopril: Core Drug Knowledge (cont.)

Contraindications and precautions 2nd and 3rd trimester of pregnancy (cause injury to the fetus) {Black Box Warning category D }

Hypersensitivity and cross sensitivity with other ACE inhibitors

Adverse effects Persistent nonproductive cough, rash, hypotension Hyperkalemia ; Hyponatremia Drug interactions

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Captopril: Core Patient Variables

Health status
Assess blood pressure before starting therapy. Life span and gender Determine pregnancy status.

Lifestyle, diet, and habits

Assess normal dietary habits Environment Assess environment where drug will be given. Culture and inherited traits Assess patients ethnic and cultural background. {smaller antihypertensive response in African Americans than Caucasions}
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Captopril: Nursing Diagnoses and Outcomes

Risk for Injury from first-dose hypotension related to effect of drug therapy Desired outcome: the patient will not sustain injury from hypotensive event

Ineffective Therapeutic Regimen Management, Nonadherence, related to persistent dry cough secondary to drug therapy
Desired outcome: adherence to drug therapy will be unaffected by chronic cough.

Disturbed electrolyte imbalance, hyperkalemia, and hyponatremia, related to effects of captopril

Desired outcome: the patients electrolyte levels will remain within normal ranges.
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Captopril: Planning & Interventions

Maximizing therapeutic effects Administer captopril 1 hour before meals because food decreases absorption.

Minimizing adverse effects

Monitor the patient for at least 2 hours after the initial dose and until blood pressure stabilizes. Assess lab values for: hyperkalemia, hyponatremia, neutropenia, proteinuria.
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Captopril: Teaching, Assessment & Evaluations

Patient and family education Teach purpose of drug therapy and any adverse reactions.

Teach signs and symptoms to report.

Ongoing assessment and evaluation Monitor blood pressure throughout captopril therapy.

Blood pressure that decreases to a normal range is indicative of successful drug therapy.

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Angiotensin II Receptor Blocker

Losartan is the prototype drug ( a monopotassium salt) Pharmacotherapeutics used to treat hypertension Pharmacokinetics- has a high first pass metabolism converted in liver to an active metabolite highly protein bound Pharmacodynamics- inhibits the pressor effect of Angiotensin II by preventing binding to receptor sites

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Angiotensin II Blocker
Contraindications - hypersensitivity to the drug Pregnancy Category C 1st trimester Pregnancy Category D 2nd, 3rd trimester { Black Box warning for this} Maximimize Therapeutic Effectdoes not cause the cough that ACE inhibitors do Adverse effects hypotension, dizzyness, fatigue, diarrhea, upper respiratory infections
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Angiotensin II Blocker
Drug Interactions lithium, rifampin and indomethacin { if taken with K or K sparing medications can cause increased K levels} Food Interactions grapefruit juice may drug effectiveness

Core Patient Variables- not for use in patients with severe congestive heart failure
Increases in BUN / creatinine in the elderly If hepatic disease; give lower starting dose Safety and efficacy in children < 18 yrs of age unknown
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Angiotensin II Receptor Blocker

Minimize adverse effects help the patient out of bed Nursing diagnosis : Risk for injury related to fall, secondary to adverse effect of dizzyness Desired outcome : patient will not fall Provide Patient and Family Education related to :

dizzyness
caution with OTC drugs

pregnancy category
upper respiratory infection

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Alpha-Beta Blockers
Alpha Beta Blocker:
slow heart rate decrease cardiac output lower blood pressure. Prototype drug: labetalol (Normodyne)

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Labetalol: Core Drug Knowledge

Pharmacotherapeutics Treatment of hypertension. Pharmacokinetics

Administered: oral.
Peak: 2-4 hours. Crosses the bloodbrain barrier. Pharmacodynamics

Adrenergic non specific blocking agent at:

the beta-1 and beta-2 receptor sites selective alpha-1 blocking action.
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Labetalol: Core Drug Knowledge (cont.)

Contraindications and precautions Bradycardia, heart block, asthma, and cardiogenic shock

Adverse effects
Diarrhea, dizziness, elevations in BUN and serum creatinine levels, tingling of scalp, and fatigue Drug interactions

Beta-adrenergic agonists, cimetidine, halothane, and nitroglycerin

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Labetalol: Core Patient Variables

Health status Assess for the underlying pathology of the hypertension. Life span and gender Assess age; safety has not been established in children. Lifestyle, diet, and habits Assess lifestyle changes. Environment Assess environment where drug will be given.

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Labetalol: Nursing Diagnoses and Outcomes

Decreased Cardiac Output related to effect of drug therapy Desired outcome: the patient will not develop decreased cardiac output substantial enough to alter cardiac perfusion. Risk for Injury related to orthostatic hypotension secondary to adverse effects of drug therapy

Desired outcome: the patient will not sustain injury if transient orthostatic hypotension develops.

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Labetalol: Planning & Interventions

Maximizing therapeutic effects Administer oral labetalol with food to increase absolute bioavailability.

Minimizing adverse effects

Prepare IV infusions of labetalol carefully. Observe the patient closely for signs of heart failure.

Monitor closely the blood pressure of patients receiving IV infusions of labetalol.

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Labetalol: Teaching, Assessment & Evaluations

Patient and family education Explain the purpose of the drug. Explain the importance of not stopping drug therapy abruptly. Ongoing assessment and evaluation Monitor blood pressure throughout labetalol therapy.

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Question
Labetalol is contraindicated for the treatment of hypertension in which of the following patients? A. 23 y/o male with diabetes mellitus type I

B. 55 y/o female how just had her third heart attack

C. 34 y/o male with history of bronchial asthma D. 75 y/o female with congestive heart failure

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Rationale
Labetalol is contraindicated for the treatment of hypertension in which of the following patients? C. 34 y/o male with history of bronchial asthma

Labetalol blocks both beta-1 and beta-2 stimulation. The result of blocking beta-2 stimulation is bronchoconstriction. For that reason, labetalol would not be given to a patient with asthma.

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Hydralazine: Core Drug Knowledge

Direct acting vasodilators Hydralazine (prototype) Pharmacotherapeutics Adjunct to other antihypertensives. Pharmacokinetics Absorbed: orally. Peak: 1 to 2 hours. Metabolized: liver. Excreted: kidneys. Pharmacodynamics Produces direct smooth muscle relaxation of the arterioles peripheral resistance BP
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Hydralazine: Core Drug Knowledge (cont.)

Contraindications and precautions Hypersensitivity, CAD, and mitral valvular disease Adverse effects Arthralgia, dermatoses, fever, splenomegaly, and glomerular nephritis Drug interactions

Metoprolol, propranolol, furosemide, and indomethacin

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Hydralazine: Core Patient Variables

Health status Blood pressure and drug history. Life span and gender Pregnancy category C. Lifestyle, diet, and habits Explore lifestyle modification. Environment

Assess environment where drug will be given.

Culture and inherited traits Assess genetic background.
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Hydralazine: Nursing Diagnoses and Outcomes

Ineffective Therapeutic Regimen Management related to adverse effects of drugs Desired outcome: the patient will not experience adverse effects severe enough to stop drug therapy.

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Hydralazine: Planning & Interventions

Maximizing therapeutic effects Administering hydralazine with food promotes bioavailability.

Minimizing adverse effects

Administer hydralazine with a beta blocker (preferably) or clonidine to decrease reflex tachycardia and with a diuretic to offset fluid retention.

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