Hypertension

-increase in blood pressure

90 % of the contributing factor

family history hyperlipidemia African American background Diabetes Obesity Aging Stress Smoking and Alcohol intake

10 % of the contributing factor

2nd degree hypertension -related to the renal and endocrine disorder.

Diuretics
-promotes Sodium Depletion (decreases excessive intracellular fluid volume) -effective as first line drugs for treating mild hypertension. -NOT USE if hypertension is caused by RAAS (Renin-Angiotensin-Aldosterone System).

Sympatholytics (sympathetic depressants)

1. 2. 3. 4. 5. Beta-Adrenergic blockers Centrally acting alpha2 agonists Alpha-Adrenergic blockers Adrenergic neuron blockers Alpha, and beta, adrenergic blockers

Beta-Adrenergic blockers (Beta-blockers)

-antihypetensive (used with diuretics) -antianginal + antidysrhythmic -more effective in lowering blood pressure of clients with elevated serum renin level -should not be used by clients with second/third degree atrioventricular (AV) block or sinus bradycardia. -noncardioselective (ex. Propranolol) should not be given to client with Chronic Obstructive Pulmonary Disease (COPD)

Types of Beta-blockers
1. Nonselective beta blockers -inhibit beta 1(heart) and beta 2(bronchial) receptors. Heart Rate slows (BP decreases secondary to the decrease of heart rate) and bronchoconstriction occurs because of unopposed parasympathetic tone. Example: Propranolol (Inderal) 2. Cardioselective beta blockers -are preferred, because they act mainly on the beta 1 receptor rather than beta2 receptor and bronchoconstriction is less likely to occur. Example: Acebutolol (Sectral), Atenolol (Tenormin), Betaxol (Kerlone), Bisoprolol (Zebeta), and Metaprolol (Lopressor)

Pharmacokinetics
Well absorbed from the gastrointestinal tract. Its half life is short and its proteinbinding power is low Ex. metoprolol

Pharmacodynamics
Cardioselective -decreases heart rate and bp. Nonselective -can result to bronchial constriction.
Oral Onset of Action: 30mins or less Duration of Action: 6 -12hrs. Intravenous Onset of Action: immediate Peak time: is 20mins. Duration of Action: 4 10hrs.

Side Effects and Adverse Effects

Decrease pulse rate, markedly decreased bp, and bronchospasm (with non cardioselective beta 1 and beta 2 blcokers) Should not abruptly discontinued because these can result to: rebound hypertension, angina, dysrhythmias and myocardial infarction. Fatigue, weakness, dizziness, nausea, vomiting, diarrhea, mental changes, nasal stuffiness, impotence, decreased libido and depression. Noncardioselective beta-blockers inhibits the livers ability to convert glycogen to glucose in response to hypoglycemia. Should be used with caution in clients with DM

Assessment
-obtain a medication and herbal hx from client (report if drug-drug /drug-herbal interaction) -obtain vital signs (report abnormal bp) -check laboratory values related to renal and liver function.

Nursing Diagnosis
-decreased cardiac output related to hypertension -noncompliance with drug regimen related to multiple drugs ordered -sexual dysfunction related to beta blockers (side effect)

Planning
-clients bp will be decreased or will return to normal value -client takes the medication prescribed.

Implementation
-monitor v/s (especially bp and pulse) -monitor laboratory results (especially BUN, serum, creatinine, AST and LDH) Client teaching -instruct to comply with drug regimen -inform that herbs can interfere with beta-blocker -avoid OTC drugs w/o checking with the health care provider. -instruct client/family members how to take pulse and bp -advise client the side effects like: dizziness (advice to rise slowly from lying) -alert client with DM to possible hypoglycemic symptoms. -low-fat and low salt diet, weight control, relaxation tech., exercise, avoid smoking and drinking. -Report constipation Foods high in fiber and increased water intake are indicated

Evaluation
-evaluate the effectiveness of drug therapy -determine that the client adheres to the drug regimen

Generic (Brand)

Type

Dosage A-dult and C-hild

1.
2. 3. 4. 5. 6. 7. 8.

Acebutolol HCl (Sectral)

Atenolol (tenormin) Betaxolol hcl (kerlone) Bisoprolol fumarate (zebeta) Carteolol hcl (cartrol) Carvedilol (coreg) Metoprolol (lopressor) Nadolol (corgard)

Cardioselective B1
Cardioselective B1 Cardioselective B1 B1 Nonselective B1,B2 Nonselective B1, B2 Cardioselective B1 Nonselevtive B1, B2

A PO: 400-800 mg/d

A PO: 25-100mg/d A PO: 10-20mg/d A PO: initial (5mg/d) maint. (2.520mg/d) A PO: 2.5-5.0 mg/d A PO: 3.125-6.25mg bid A PO: 50-100mg/d in div. doses maint. 100-450mg in div. doses A PO: 40-80 mg/d

9.
10. 11. 12.

Penbutolol so4 (levatol)

Pindolol (visken) Propranolol (inderal) Timolol maleate (blocadren)

Nonselevtive B1, B2
Nonselevtive B1, B2 Nonselevtive B1, B2 Nonselevtive B1, B2

A PO: 10- 20mg/d

A PO: 5mg BID/TID maint. 10-30 mg in div. doses A PO: 40mg BID C PO: 1mg/kg/d in 2 div. doses A PO: initial (10mg BID) maint. 20-

Renin-angiotensinaldosterone System (RAAS) Renin, an enzyme located in the Juxtaglomerular cells of the kidney, is released when BP decreases.

Angiotensin-Converting Enzyme (ACE) Inhibitors

-Drugs in this group inhibit ACE, which in turn inhibits the formation of Angiotensin II (vasoconstrictor) and blocks the release of Aldosterone. -used to treat hypertension and some of these agents are also effective in treating heart failure. -they lower peripheral resistance -can be used in clients who have elevated serum renin levels. -is taken with diuretic for African Americans and older adults. -Clients with renal insufficiency, reduce of drug dose. -Moexipril (univasc) should be taken with empty stomach

Side Effects and Adverse Reaction

Primary side effect is constant irritated cough Nausea, vomiting, diarrhea, headached, dizziness, fatigue, insomnia, serum potassium excess (hyperkalemia) and tachycardia Major adverse effect are first-dose hypotention and hyperkalemia. -hypotenstion results because of the vasodilating effect. And this is common to clients also taking diuretics

Contraindication
Should not be given during PREGNANCY (causes harm to the fetus because it can reduce in placental blood flow) Should not be taken with Potassium-sparing diuretics such as Spironolactone or salt substitutes that contrain potassium, because of the risk of hyperkalemia.

Assessment
-obtain a medication and herbal hx from client (report if drug-drug /drug-herbal interaction) -obtain vital signs (report abnormal bp) -check laboratory values for serum protein, albumin, BUN, creatinine and WBC.

Nursing Diagnosis
-Deficienct knowlegde related to drug regimen -Anxiety related to hypertensive state

Planning
-Clients BP will be within desired range -Client is free of moderate to severe side effects

Intervention
-monitor lab tests related to renal function (BUN, creatinine, protein) and blood glucose levels. *watch for hypoglycemic reaction in clients with DM -report to HCP bruising, petechiae, and bleeding -do not abruptly discontinue -do not take OTC meds with in this medication -do not let pregnant women take this med -teach client how to take and record BP -explain side effects -instruct to take captopril 20mins 1 hour before meal. -inform taste of food may be diminished during the first month -African Americans do not respond well unless taken with diuretic

Evaluation
-evaluate the effectiveness of the drug therapy

# 1. 2. 3.

Generic (brand) Benazepril HCl (lotensin) Captopril (capoten)

Route and Dosage A PO: initially: 10mg/d ;maint:20-40mg/d in 2 div. doses A PO: initially: 12.5 -23mg BID/TID ; maint: 25-100mg BID/TID

Enlapril maleate (vasotec) A PO: initially 5mg/d ; maint: 10-40mg/d in 1-2 div. doses IV: 1.25 mg q6h infuse in 5min Emergencies: IV: 5mg q6h prn PO: 5-40mg/d Fosinopril (monopril) Lisinopril (prinivil, zestril) A PO: 5-40mg/d A PO: initially: 10mg/d ; maint: 20-40mg/d

4. 5.

6.
7. 8. 9. 10.

Moexipril (univasc)
Perindopril (aceon) Quinapril HCl (accupril) Ramipril (Altace) Trandolapril (mavik)

A PO: 7.5mg/d
A PO: 2-8mg/d A PO: 10-20mg/d E.A. PO:2.5-5 mg/d A PO: 2.5-5 mg/d A PO: 1 mg/d may increase weekly to 2-4mg/d

Combination of ACE with Calcium Blockers

# 1. Generic ( brand ) Benazepril with amlodipine (lotrel) Route and Dosage A PO: amlodipine/benazepril (2.5/10mg) ; (5/10mg) ; (5/20mg) d A PO: enalapril/diltiazem ER: 5/180 mg/d A PO: felodipine/enalapril 5/5 mg ; 2.5/5 mg/d A PO: trandolapril /verapamil SR: (2/180 mg) ; (1/240mg) ; (2/240mg) ; (4/240mg)

2.

Enalapril with diltiazem (teczem)

3.

Enalapril with felodipine (lexxel)

4.

Trandolapril with verapamil (tarka)

Angiotensin II Receptor Blockers (ARBs)

-antihypertensive drugs -similar to ACE (prevent the release of aldosterone) -they act on the RAAS -block angiotensin II from the AT1 receptors. -cause vasodilation and decrease peripheral resistance

Pharmacokinetics
It is rapidly absorbed in the GI tract and undergoes first-pass metabolism in the liver to form active metabolism It is highly-protein bound and should not be given during pregnancy (especially 2nd and 3rd trim) The half-life is 1.2 to 2hrs and the half-life of the metabolite is 6-9hrs. Drug is excreted in he urine and feces

Pharmacodynamics
these agents can be taken with or without food and are suitable for clients with mild hepatic insufficiency.

#
1.

Generic (brand)
Candesartan (atacand)

Route and Dosage

A PO: 16mg/d ; maint: 8-32mg/d

2.

Eprosartan (teveten)

A PO: initially 200mg/d 400-800 mg/d or in 2 dived doses

3.

Irbesartan (avapro)

A PO: 150mg/d ; maint: 150-300mg/d

4.

Losartan Potassium (cozaar)

A PO: 25-50 mg/d. in single dose or in 2 divided doses A PO: 20mg/d ; may increase 40mg/d Elderly same as adult A PO: 40-80 mg/d

5.

Olmesartan medoxomil (benicar) Telmisartan (micardis)

6.

7.

Valsartan (diovan)

A PO: 80mg/d

Calcium Channel Blockers

-also called calcium antagonists and calcium blockers. -it blocks the calcium channel in the VSM (vascular smooth muscle), promoting vasodilation. -are normally not prescribed with beta-blockers because both drugs decrease myocardium contractility. -can lower the BP of African Americans more better than other drugs

Groups
Phenylalkylamines Benzothiazepines Dihydropyridines -are the largest group of calcium channel blockers.

Pharmacokinetics
it is highly protein-bound. it is gradually absorbed via GI tract

Side Effects and Adverse Reactions

Include flush, headache, dizziness, ankle edema, bradycardia and AV shock.

Generic (brand)

Route and Dosage

1.

Phenylalkylamines Verapamil (calan sr, isoptin sr)

A PO: 40-80mg/d TID A PO SR: 120-240 mg/d in 2 divided doses

2.

Benzothiazepines A PO SR: initially 60-120mg BID Diltiazem HCl (cardizem, cardizem cd/sr) Dihydropyridines Amlodipine ( norvasc) Felodipine (plendil) Isradipine (dynacirc) Nicardipine (cardene, cardene sr)

3. 4. 5. 6.

A PO: 5-10mg/d ; Elderly: 2.5-5.0 mg/d A PO: initially 5mg ; maint 5-10mg/d A PO: 1.25 -10mg BID A PO: 20-40mg TID ; SR: 30-60mg BID A IV: 5mg/h increase dose PRN C IV: 1-3 mcg/kg/min A PO: 10-20 mg TID A PO SR: 30-90mg/d

7.

Nifedipine (procardia)

8.

Nisoldipine (sular, nisocor)

A PO: 10-20mg/d in 2 divided doses