Pharmacology for Nurses: A Pathophysiologic Approach, Ch. 26: Drugs for Hypertension

A patient has been prescribed nifedipine (Adalat CC) as treatment for hypertension. The nurse would evaluate medication instruction as effective if the patient makes which statements?

2. "I should stop taking my melatonin sleep medication." 3. "I should no longer drink grapefruit juice."

The nurse educator is reviewing the body's control of blood pressure. In which order will the nurse explain the steps of this process?

Liver produces angiotensinogen Renin acts Angiotension I is produced Angiotension II is produced Vasoconstriction occurs

Does medications that affect blood volume affect blood pressure and what type of medication if so?

Yes, medications that affect blood volume may lower or raise blood pressure and diuretics is a type of medication.

The patient is receiving hydrochlorothiazide (Microzide) as well as digoxin (Lanoxin). Which lab result would the nurse recognize as most significant?

Potassium level of 2.9 mEq/L

Which laboratory test would be the priority for a patient with hypertension who takes a thiazide diuretic?

Potassium. Sodium and potassium are the electrolytes of most concern. A patient on thiazide diuretics should be monitored for hypokalemia.

digitalization

rapid administration of digitalis to reach a therapeutic level

peripheral vascular resistance

resistance of blood flow through the arterial vascular system, especially arterioles and capillaries

intermittent claudication

severe pain in the calf muscles that occurs during exercise because of inadequate blood supply to the lower extremities

very-low-density lipoprotein (VLDL)

simple protein that is combined with lipid-cholesterol, phospholipids, and triglycerides; a high level of these proteins is undesirable

high-density lipoprotein (HDL)

simple protein that is combined with lipids-cholesterol, phospholipids and triglycerides; a high level of HDL is desirable

low-density lipoprotein (LDL)

simple protein that is combines with lipids-cholesterol, phospholipids, and triglycerides; a high level of LDL is undesirable

Cardiac output is determined by

stroke volume and heart rate

True or False: Medications that affect cardiac output, stroke volume, and heart rate will affect blood pressure

true

The patient receives hydrochlorothiazide (Microzide). He tells the nurse he is urinating a lot and questions how this drug affects his blood pressure. What is the best response by the nurse?

"Hydrochlorothiazide (Microzide) decreases the fluid in your bloodstream and this lowers your blood pressure."

Primary Factors affecting blood pressure: Cardiac output

1. Stoke volume > preload > contractility > afterload 2. Heart Rate > sympathetic nervous system activity > Parasympathetic nervous system activity > Epinephrine

Emotions Affect Blood Pressure

1. Stress and anger increase 2. Depression and lethargy decrease

Primary Factors affecting blood pressure: peripheral resistance/ diameter of arterioles

1. Sympathetic nervous system activity 2. Renin/angiotensin II 3. Increase in blood viscosity

Primary Factors affecting blood pressure:

1. fluid loss > dehydration 2. Fluid retention > aldosterone > ADH

What organs are affected by untreated hypertension

1. heart 2. brain 3. kidneys 4. retina

The nurse is taking the initial history of a patient admitted to the hospital for hypertension. The physician has ordered a beta-adrenergic blocker. Which statement by the patient does the nurse recognize as most significant?

"I have always had problems with my asthma." With increased doses, beta-adrenergic blockers can slow the heart rate and cause bronchoconstriction. They should be used with caution in patients with asthma.

The nurse is teaching the patient about lifestyle modifications to help manage the patient's hypertension. The nurse determines that teaching has been effective when the patient makes which statement?

"I know I need to give up my cigarettes and alcohol." Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological methods for controlling hypertension.

The nurse completed medication education with the patient who receives hydrochlorothiazide (Microzide). The nurse determines that teaching has been effective when the patient makes which statement?

"I take my medication early in the morning."

The patient is receiving doxazosin (Cardura) for hypertension. He asks the nurse how the medication works. What is the nurse's best response?

"It works by making your blood vessels expand." Doxazosin (Cardura) is selective for blocking alpha1-receptors in vascular smooth muscle, which results in dilation of arteries and veins.

How does hormones affect blood pressure?

- Natural hormones affect blood pressure daily > Epinephrine and norepinephrine injections raise B/P > Antidiuretic hormone (A D H) raises B/P by raising blood volume - Renin-angiotensin-aldosterone system is a primary homeostatic mechanism for controlling blood pressure

A patient says, "Since I started taking metoprolol (Lopressor), I have been having problems having sex. I think I am going to stop taking it." What nursing responses are indicated?

1. "Sexual dysfunction is a common problem with this drug." 4. "Stopping the drug all at once may make your blood pressure get higher."

The nurse is caring for an African American male who has just been diagnosed with hypertension and mild heart failure. The nurse anticipates that this patient will be started on which medications?

1. A combination drug like hydralazine and isosorbide dinitrate 2. A calcium channel blocker like nifedipine (Adalat) The combination drug BiDil, a fixed dose combination of hydralazine and isosorbide dinitrate is used to treat heart failure African American patients appear to show an enhanced response to this medication. Calcium channel blockers seem to provide the greatest blood pressure reduction in this population

What disease could develop from untreated hypertension in relation to organs

1. Heart- Heart failure 2. Brain- T I A and/or cerebral vascular accident 3. Kidneys- Renal failure 4. Retina- Visual impairment and blindness

Pharmacologic Management of Hypertension

1. Individualized to patient's risk factors, medical conditions, degree of blood pressure elevation 2. Clinician experience plays role in choice of therapy

The patient has been recently diagnosed with hypertension with a sustained blood pressure of 144/90 mmHg. The patient is concerned about effects on the body. What effects of hypertension on the body will the nurse include in her education of this patient?

1. Kidney damage 2. Stroke 4. Heart failure 5. Blindness

Nonpharmacologic Methods to Control Hypertension

1. Limit alcohol intake 2. Restrict sodium consumption 3. Reduce saturated fat and cholesterol; increase fresh fruit and vegetable intake 4. Increase aerobic physical activity 5. Discontinue tobacco use 6. Reduce stress 7. Maintain optimum weight

What are the types of hypertension?

1. Primary hypertension 2. Secondary hypertension

For the last 3 months, the nurse has been working with a group of patients who have been using nonpharmacological methods to try to manage their hypertension. The nurse anticipates that which patients will require the addition of a pharmacological intervention?

2. A 61-year-old man whose blood pressure is 144/90 mmHg who also has type 2 diabetes. 5. A 61-year-old woman whose blood pressure is 153/92 mmHg who is otherwise healthy.

A patient who is in hypertensive crisis will be given the calcium channel blocker clevidipine (Cleviprex). The nurse should prepare for which interventions?

2. Administering the drug intravenously 3. Continuous blood pressure monitoring

The nurse is educating a patient whose blood pressure is 140/90 mmHg on ways to lower blood pressure and avoid hypertension. Which lifestyle choices may eliminate the need for pharmacotherapy in this patient?

2. Restricting salt intake 4. Increasing activity 5. Stopping smoking

The nurse is conducting the initial group education session for patients who have hypertension. What is the most important information to include?

2. The aorta has sensors that help regulate blood pressure. 3. Anger can result in hypertension.

A hospitalized patient has been started on enalapril (Vasotec). The nurse would hold this drug and discuss which findings with the prescriber?

3. Swelling around the eyes 5. Difficulty swallowing

Continue with the prescribed rate.

A patient is receiving 1400 units of heparin/hour on an IV pump. The aPTT time is 54. The laboratory control is 25. Which action by the nurse is accurate?

Stop the heparin drip

A patient is receiving IV heparin therapy. The aPTT is 90; the laboratory control is 30 seconds. Which nursing intervention is most accurate?

"Heparin does not dissolve blood clots but neutralizes clotting factors, preventing extension of the clot and the possibility of it traveling elsewhere in your body."

A patient receiving IV heparin therapy for a deep vein thrombosis (DVT) in his right calf asks why his calf remains painful, edematous, and warm to touch after 2 days of anticoagulant therapy. Which response by the nurse is most accurate?

Protamine sulfate

A trauma patient arrives in the emergency department via EMS. He is bleeding profusely. A medical alert bracelet indicates that he is on heparin therapy. The nurse will most likely administer which medication that counteracts the action of heparin?

To prevent stroke in patients at high risk Following a myocardial infarction Following total hip or knee joint replacement surgery With DVT To prevent thrombosis in immobilized patients

Anticoagulant therapy may be used for which situation(s)? (Select all that apply.)

How many deaths is hypertension associated with in the U.S. per year?

Associated with more than 348,000 deaths in U.S. per year

The patient with hypertension has experienced heart failure. The nurse notes that the patient is receiving nifedipine (Procardia). What is a priority assessment for the nurse?

Auscultate breath sounds for crackles. Some calcium channel blockers can reduce myocardial contractility and can worsen heart failure. Crackles in the lungs can indicate pulmonary edema, which could indicate heart failure.

Changes in which level would be sensed by baroreceptors and relayed to the vasomotor center?

Blood pressure

What three factors are responsible for blood pressure?

Cardiac output Peripheral resistance Blood volume

Which lists include the three factors that make up blood pressure?

Cardiac output, blood volume, and peripheral vascular resistance

What is hypertension

Consistent elevation of systemic arterial blood pressure - High blood pressure - "Normal" B/P varies with age; abnormal as we age

What are some causes of secondary hypertension

Cushing's syndrome Hyperthyroidism Chronic renal disease Certain drugs

Cardiac valve replacement

Dipyridamole (Persantine) has been used extensively in combination with warfarin to prevent the formation of thromboembolism after which type of event?

The patient with hypertension is receiving nifedipine (Procardia XL). The nurse determines that the patient needs additional medication education when the patient selects which menu for breakfast?

Eggs, whole-wheat toast with butter, cereal, milk, and grapefruit juice

A young female patient is being treated for hypertension. The nurse would be most concerned if the patient became pregnant while taking which drug?

Enalapril (Vasotec). Enalapril is a Pregnancy Category D drug that has a higher fetal risk than do the other drugs listed.

True or False: Resistance in arteries do not yield any effect on blood pressure.

False. Greater Resistance in arteries yields higher blood pressure

What is peripheral resistance is?

Friction in arteries as blood flows through vascular system

The patient comes to the emergency department with a blood pressure of 200/120 mmHg. The physician orders hydralazine (Apresoline) IV. What will the nurse's priority assessment include?

Hypotension and tachycardia. Direct vasodilators produce reflex tachycardia, a compensatory response to the sudden decrease in blood pressure caused by the drug.

How does blood volume affect the blood pressure?

Increased blood volume increases blood pressure

Which statement is accurate in regard to secondary hypertension?

It can result from chronic renal impairment.

The patient has been recently diagnosed with hypertension. Assessment data include Wt: 200 pounds Ht: 5' 4" Diet: Mostly starches Alcohol intake: 3 beers/week Stressors: Works 60 hours/week In planning care with this patient, what is the priority outcome?

Patient will achieve and maintain optimum weight.

First-Line Antihypertensive Drugs

Primary Antihypertensive Agents - Diuretics (especially thiazide and thiazide-like diuretics, potassium-sparing diuretics) - Angiotensin-converting enzyme (A C E) inhibitors Angiotensin receptor blockers (A R Bs) - Direct renin inhibitors - Calcium channel blockers (C C Bs)

Peripheral Resistance: Central and Autonomic Nervous Systems

Regulate blood pressure - Vasomotor center - Baroreceptors - Chemoreceptors

for 12 days postsurgically.

Rivaroxaban (Xarelto) is ordered on a patient following knee replacement surgery. When providing education on this medication to the patient, the nurse conveys that treatment will continue

Which interventions would be indicated and take highest priority for a 30-year-old female with a BMI of 20 who smokes and has a blood pressure of 137/88?

Smoking-cessation program

What is a priority nursing intervention for a patient who has just begun antihypertensive treatment with enalapril (Vasotec)?

Take the patient's blood pressure. Enalapril (Vasotec) may produce a first-dose phenomenon resulting in profound hypotension, which may result in syncope.

"I will rinse my mouth with mouthwash instead of brushing my teeth."

The nurse has provided instruction to a patient recently prescribed warfarin (Coumadin). Which statement by the patient indicates to the nurse the need for further teaching?

implement deep breathing and coughing exercises.

The nurse is caring for a 27-year-old woman on the postpartum unit one day following a C-section. To prevent clot formation, the nurse will

"Do not make any major changes to your diet without discussing it with your health care provider." "Keep outpatient laboratory appointments for monitoring of therapy." "Report signs of bleeding to your health care provider, including observing skin for bruising; petechiae; blood in emesis, urine, or stools; bleeding gums; cold, clammy skin; faintness; or altered sensorium." "Avoid aspirin products."

The nurse is preparing discharge education for a patient who will be receiving warfarin (Coumadin) at home. Which important point(s) will the nurse include? (Select all that apply.)

inject slowly alternate injection sites every 24 hours.

The nurse is preparing to administer dalteparin (Fragmin) to a patient in order to prevent DVT following a hip replacement. When providing this medication to the patient, the nurse will (Select all that apply.)

Spinach

The nurse is teaching a patient about dietary implications while on warfarin (Coumadin) therapy. Which salad is highest in vitamin K?

Prevent platelet aggregation. Prevent the extension of existing clots. Inhibit steps in the fibrin clot formation cascade. Prolong bleeding time.

The pharmacologic agents used to treat DVT may act in which way(s)? (Select all that apply.)

Can medications affecting the vascular smooth lower or raise blood pressure?

Yes, mediation affecting the vascular smooth may lower or raise blood pressure

Blood Volume is

Total amount of blood in vascular system

What is cardiac output

Volume of blood pumped per minute

Preventing platelet aggregation and inhibiting clot formation

What is the mechanism of action of drugs used to treat thromboembolic disease?

Lyses the blood clot

What is the rationale for administering fibrinolytic agents, such as streptokinase, within hours of the onset of myocardial infarction?

Encourage passive leg exercises

Which action will the nurse implement to decrease the risk of clot formation in an older patient on bed rest?

Leave the needle in place for 10 seconds after injection.

Which is an accurate nursing action when administering subcutaneous enoxaparin, a low-molecular-weight heparin product?

Documenting ecchymotic areas Monitoring of vital signs

Which nursing intervention(s) would be accurate when administering heparin subcutaneously? (Select all that apply.)

Petechiae

Which symptom is indicative of bleeding in a patient taking warfarin (Coumadin)?

glycoside

active plant substance that yields a sugar plus an active ingredient

sympatholytic agent

adrenergic blocking agent; agent that blocks the action of the sympathetic nervous system

vasodilator

agent that increases size or dilates blood vessels by relaxation of vascular smooth muscles

vasoconstrictor

agent that narrows or constricts blood vessels

hemostasis

arrest of bleeding

automaticity

automatic spontaneous initiation of a heart impulse

thrombus

blood clot that obstructs the lumen of a blood vessel

myocardial infarction (MI)

deprivation of the myocardium of blood supply to the heart caused by blockage of the coronary arteries with resultant necrosis of the myocardium; heart attack

dysrhythmia

disturbance or abnormality in normal rhythmic pattern as with heart rhythm

orthostatic hypotension

drop in blood pressure that a person experiences when changing from a supine to an upright position

hypertension

elevation of blood pressure above normal limits

thromboembolism

embolus; the blocking of a blood vessel by a detached embolus

atherosclerosis

form of arteriosclerosis characterized by buildup of fatty plaques on the walls of arteries and arterioles

Secondary hypertension

has an identifiable cause

What is the most common form of cardiovascular disease?

hypertension

dromotropic effect

increase or decrease in the conduction of cardiac electrical impulses

inotropic effect

increase or decrease in the force of myocardial contraction

chronotropic effect

increase or decrease in the heart rate

angina pectoris

insufficient blood flow to the heart, with resultant spasm of the cardiac muscle, causing chest pain

arrhythmia

irregular rhythm; i.e., irregular heart beat

Primary hypertension

is has no identifiable cause

point of maximum impulse (PMI)

landmark in the fifth intercostal space, 2 inches to the left of midline, where the pulse of the heart can be felt most strongly

embolus

obstruction of a blood vessel by a foreign substance or a blood clot