NU 221 - Diuretics & Anti-HTN (Exam 4)

What is an example of an ACE inhibitor

** Captopril (Capoten) May have a huge drop in blood pressure with first dose Initial dose should be low and gradual increase the dose until BP is in normal range Monitor blood pressure frequently ** Works very fast, think ~viper~ fast

What is Mannitol (Osmitrol) used for

** HEAD AND EYES Prevent kidney failure, decrease ICP (head pressure), and decrease IOP (eye pressure) - Cystic fibrosis (decreases stickiness of snot)

What is an example of an ARB

** Losartan (Cozaar) Used to treat HTN, heart failure, diabetic nephropathy, stroke prevention With ARBs less bradykinin produced = less cough May actually lower uric acid Adverse effects Angioedema - 8% cross-over with those that also had angioedema with ACE Fetal injury - especially 2 and 3 trimester Renal failure

What are the two subdivisions of potassium-sparing diuretics

- Aldosterone antagonists (spironolactone) - Nonaldosterone antagonists (triamterene)*

Quickie notes on ARNIs

- Combo med - Only med in its class - Super expensive - Drug for heart failure - What kills most diabetics and HTN is heart failure - Anything that has to do with an ARB has to do with this - Keeps people out of the hospital - Suppository

What are categories of medications to lower blood pressure

- Diuretics - Beta-adrenergic blockers - Alpha-adrenergic blockers - Ace Inhibitors - Angiotensin Receptor Blockers - Calcium Channel Blockers

What are classes of anti-HTN meds

- Diuretics (Thiazide, loop/lasix, potassium sparing/aldactone) - Sympatholytics/anti-adrenergic drugs (Beta & alpha blockers, calcium channel, ACE, ARBs)

What are therapeutic uses of Hydrochlorothiazide (HydroDIURIL) (HCTZ)

- Essential/primary/idiopathic HTN - Edema

What category of medication can cause permanent hearing loss

- Furosemide (Lasix) (Loop diuretics) HEARING LOSS - fairly permanent, ototoxic Develops quickly Exacerbated with more ototoxic dosages and meds First signs are tinnitus and/vertigo

What regulates potassium levels

- Mostly the kidneys - Insulin has profound effect on potassium levels

What are important nursing considerations with high-ceiling loop diuretics

- NO med errors with bumetanide (Bumex) and lasix - Bumex (another loop diuretic) is 40x stronger than Lasix - Watch out for too much diuresis, dehydration, signs of low potassium, low BP

What are examples of Alpha-adrenergic blockers

- Prazosin HCl (Minipress) - Labetalol (Trandate)

How is furosemide (Lasix) given and how fast does it work

- Rapid onset either PO, IM, IV ** IV in ER - Onset within 1 hour, lasts 6-8 hours

What kind of beta blocker should asthmatics take and why

- Selective blockers - Because those block B1, not B2 - B2 can block lung receptors too much and make lungs twitchy and trigger asthma attack - Can take a nonselective if they can handle it

Quickie notes on Verapamil (Calan)

- Works well in Black people - Cheap drug - Causes constipation and cankles

What is the ending for Beta blockers

-olol

What is the ending for ACE inhibitors

-pril

What is the ending for ARBs

-sartan

What are ARNIs

Sacubitril/valsartan (Entresto) reduces CV death rate by 25% in heart failure Only drug in this class. Can cause potassium to build up in system Do not double up with an ace or other arb All side effects of the arb apply to this medication too because there is a sartan in it. Helps with letting the heart pump better, especially a weakened heart Keeps people out of the hospital

Quickie facts on Metoprolol (Lopressor)

Second generation Beta Blocker, selective for B1 activity at typical doses Used mostly for HTN Heart failure, angina, MI Can often be used in asthma patients when needed

What are calcium channel blockers

3 kinds; one kind ends in "dipine" ie ; nifedipine (Procardia) Block calcium channels in blood vessels and in the heart Without calcium, muscle contraction does not occur and the vessel will dilate Overdose: may respond to Glucagon, Calcium

What is prevention and treatment of hypokalemia

Oral potassium chloride KCL Tablets or solutions oSustained release tablets better tolerated; regular tablets commonly cause nausea, vomiting, diarrhea, and can cause intestinal injury even death oALWAYS take KCL with full glass of H2O Intravenous potassium chloride Should be diluted and infused slowly Contraindications and complications to potassium use Hyperkalemia

What are side effects of alpha-adrenergic blockers

Orthostatic hypotension, nausea, headache, drowsiness, nasal congestion caused by vasodilation, edema, and weight gain

Who takes oral potassium (KCL) pills

People on dialysis

What is the normal range of potassium

3.5-5.0 mEq/L ** Want a "4.0"

What is the antidote to ACE OD

Possibly Narcan

If there is a cardiac question, which lab value is most likely the answer

Potassium

What are ACE inhibitors and ARBs

Drugs Acting on the Renin-Angiotensin-Aldosterone System - RAA system ** Pit viper venom ** RAA regulates BP through angiotensin II and aldosterone ** ACE inhibitors block ACE in lungs and blocks aldosterone ** Take one or the other

What do diuretics do

Drugs that increase urinary output Decrease blood pressure Decrease edema Prevent fluid retention for a wide variety of diseases such as heart failure, acute pulmonary edema, liver disease, HTN, renal disease and glaucoma

What are ways to promote adherence to pharmacological therapy

Educate the patient Teach self-monitoring Minimize side effects Establish a collaborative relationship Simplify the regimen Minimize costs - Consider Walmart med list Schedule office visits at convenient times Involve SOs

What is the "new" drug and only drug in its class

ARNIs * Angiotensin-neprilysin receptor blocker

What is furosemide (Lasix) mechanism of action

Acts on the ascending loop of Henle to block reabsorption

What is furosemide (Lasix) used for

Acute Pulmonary edema Edematous states Severe Hypertension Heart failure

What is the #1 selling calcium blocker in the US

Amlodipine (Norvasc)

What drug category should all diabetics be taking

An ACE inhibitor

What are adverse effects of ARBs

Angioedema Fetal harm Renal failure Annoying cough ** Less bradykinin so less cough

A patient with heart failure is prescribed furosemide (Lasix). The nurse should instruct the patient to consume: A. oranges, spinach, and potatoes. B. baked fish, chicken, and cauliflower. C. tomato juice, skim milk, and cottage cheese. D. oatmeal, cabbage, and bran flakes.

Answer: A Rationale: Furosemide may have the adverse effect of hypokalemia. Hypokalemia can be reduced by consuming foods that are high in potassium such as nuts, dried fruits, spinach, citrus fruits, potatoes, and bananas.

A patient has a serum potassium level of 3.1 mEq/L. The nurse plans to administer: A. sustained-release potassium tablets (K-Dur). B. foods that are deficient in potassium. C. furosemide (Lasix). D. sodium polystyrene sulfonate (Kayexalate).

Answer: A Rationale: Normal serum potassium levels range from 3.5 to 5.0 mEq/L. Appropriate treatment for hypokalemia would be potassium supplements and foods high in potassium such as 6 prunes, avocado, carrots, potatoes, broccoli and cantaloupe. Furosemide is a loop diuretic that causes hypokalemia. Sodium polystyrene sulfonate is administered for hyperkalemia.

A patient is prescribed spironolactone (Aldactone) for treatment of hypertension. Which foods should the patient be taught to avoid? A. Baked fish B. Low-fat milk C. Salt substitutes D. Green beans

Answer: C Rationale: Spironolactone is a potassium-sparing diuretic. Medications that are potassium sparing, potassium supplements, and salt substitutes should be avoided. High-potassium foods should also be avoided. ** Salt substitutes are usually high in potassium

Info on HTN

Estimated that 20% of adults in the US have HTN Many are unaware they have it 90% have "essential HTN" - no known cause We do know that diet, sedentary lifestyle, body weight all play a significant role in the development of HTN Isolated systolic hypertension is the stronger predictor of CV disease

True or false: it is safe to abruptly stop taking your HTN meds

FALSE

True or false: It is ok to double up with an ACE and an ARB

False; drop the ACE and increase the ARB

What are adverse effects of ACE inhibitors

First-dose hypotension Fetal injury- Cat. C first trimester, Cat. D second and third trimesters Cough- chronic, persistent, 1 in 6 get the cough: 1/3 have it go away, 1/3 tolerate it, 1/3 can't tolerate it More likely in women In no way fatal, does not interfere with breathing at all, just real annoying Angioedema- rare and potentially fatal with edema of tongue and throat. Treat with epi; NEVER use drug again. Starts with Jaw pain No hives, no pruritis Hyperkalemia Rash Renal failure

What are side effects of Mannitol (Osmitrol)

Fluid and electrolyte imbalance, pulmonary edema, nausea, vomiting, tachycardia, and acidosis

What kinds of foods should be avoided when taking Spironolactone (Aldactone)

Foods high in potassium

What are ACE inhibitors used for

Prevent stroke, MI and death in high-risk patients Overdose - may respond to Narcan Myocardial infarction - MI Reduce mortality Decrease chance of getting heart failure Give ACE right after MI for about 6 weeks Prevents re-modeling of heart post-MI (Saves rhythm)

What is an example of a NON-selective Beta blocker

Propranolol (Inderal) ** 1st gen, beta-adrenergic antagonist

What does grapefruit juice do to medications

Raises levels in body so they become toxic and aren't excreted

Which statement will the nurse include when teaching a patient about loop (high-ceiling) diuretics? A.Take the medication at bedtime. B.Take the medication on an empty stomach. C.Rise slowly from a lying or sitting to standing position to prevent dizziness. D.Avoid fruit and vegetables in the diet.

Answer: C Rationale: The medication should be taken in the morning, not at bedtime, to prevent sleep disturbances and nocturia; taking the medication at mealtime or with a snack, not on an empty stomach, can prevent nausea from developing, and patients receiving this medication should eat a diet high in fruits and vegetables to prevent hypokalemia.

What are therapeutic uses of Beta blockers

Atrial fibrillation, HTN, Supraventricular tachydysrhythmias Slowing of ventricular rate Stage fright to migraine prophylaxis to PTSD prevention Used for Glaucoma at times when client can't do drops well

How do you treat hyperkalemia

Withhold foods that contain potassium Withhold medicines that promote potassium accumulation - Aldactone Management Counteract potassium-induced cardiotoxicty Infusion of glucose and insulin to drive potassium into cells and decrease potassium in the serum thereby lowering extracellular levels of potassium Kayexalate - enema Infusion of sodium bicarbonate Dialysis

Who should you watch for saying they have numbness and tingling of hands, feet, & lips

Young people, can "OD" on sports drinks

What is patient teaching associated with Captopril (Capoten)

Avoid potassium supplements and potassium-containing salt substitutes Monitor BP for 2 hours following first dose. Instruct patient to lie down if hypotension develops (feel dizzy, weakness) DO NOT TAKE WITH FOOD (most ACEs don't matter) Can have 2-3 doses a day (most ACEs are fewer than this)

What are contraindications for Mannitol (Osmitrol)

Be very careful giving to patients with heart and renal failure

Why do diabetics need to be watched especially on beta blockers

Because Beta blockers mask the signs of hypoglycemia ** Won't be as tachy, tremory, twitchy, or sweaty ** Chills out all the systems so signs of low blood sugar just aren't there

What is the action of alpha-adrenergic blockers

Block the alpha-adrenergic receptors, resulting in vasodilation and decreased blood pressure ** More of a neuro drug

What is the mechanism of action with Spironolactone (Aldactone)

Blocks aldosterone in the distal nephron Retention of potassium Increased excretion of sodium and water ** HOLDS ONTO POTASSIUM, GETS RID OF ALDOSTERONE

How does a NON-selective Beta blocker work

Blocks both B1(mostly cardiac) and B2 receptors (lung, skeletal, liver, uterus ((check for sexual dysfunction....)) Remember B1 in one heart, B2 mostly in two lungs

What do calcium channel blockers do and what to watch out for

Blocks calcium channels in blood vessels and in the heart Given PO or IV, Watch out for Grapefruit Juice effect, consult book ** do not give to elderly bc of the constipation

What are adverse effects of Verapamil (Calan)

Constipation (most common side effect, "stop sh!t in mid-air") - blocks smooth muscle in the GI tract as well; not for elderly Dizziness, facial flushing, headache Edema of ankles and feet from increased peripheral edema Gingival hyperplasia (overgrowth of gum tissue) Bradycardia or heart block ** hypotension

What are the 5 major categories of diuretics

High ceiling (loop)—(furosemide) Thiazide and thiazide-like—(hydrochlorothiazide) Osmotic—(mannitol) Carbonic anhydrase inhibitor (chronic glaucoma)* Potassium-sparing

What is an example of a Thiazide diuretic

Hydrochlorothiazide (HydroDIURIL) (HCTZ)

What are causes of hypo-magnesemia

Diarrhea, hemodialysis, kidney disease Prolonged intravenous feeding Chronic alcoholics Hypermagnesemia overcorrection ** Pregnant women

What are consequences of hyperkalemia

Disruption of the electrical activity of the heart (stops heart) Confusion, anxiety, weakness or heaviness of legs Numbness or tingling of hands, feet, lips (can be confused with diabetics)

What are adverse effects and drug interactions of spironolactone (Aldactone)

Hyperkalemia Endocrine effects Can cause gynecomastia in men because this drug is also a mild inhibitor of testosterone ** Watch for stacking meds & BP going too low Drug interactions Thiazide and loop diuretics Agents that raise potassium levels

What are therapeutic uses of Spironolactone (Aldactone)

Hypertension Edematous states Severe heart failure Primary hyperaldosteronism Hirsutism (excessive hair)

What are therapeutic uses of ARBs

Hypertension Heart failure Diabetic nephropathy Myocardial infarction Stroke prevention Migraine headache

What are adverse effects of Hydrochlorothiazide (HydroDIURIL, HCTZ))

Hyponatremia, hypochloremia, and dehydration Hypokalemia - low potassium Use in pregnancy and lactation Enters breast milk, preg. Category B Hyperglycemia Hyperuricemia Impact on lipids, calcium, and magnesium, salts

What are adverse effects of high-ceiling (loop) diuretics

Hyponatremia, hypochloremia, and dehydration Hypotension Loss of volume with dehydration Relaxation of venous smooth muscle Hypokalemia - low potassium ** Also watch for low sodium Hyperglycemia Hyperuricemia (remember GOUT) Use in pregnancy - Category C HEARING LOSS - fairly permanent, ototoxic

What is an annoying, but benign side effect of ACE inhibitors

~The cough~

What is an example of an osmotic diuretic

Mannitol (Osmitrol)

What is a nursing consideration of Mannitol (Osmitrol)

Mannitol vial is crystallized so you have to warm it up by gently rolling vial in hands before administering

What is an example of a SELECTIVE Beta blocker

Metoprolol (Lopressor)

What are causes and consequences of hypokalemia

Most common cause is treatment with a thiazide or loop diuretic,. Also from inadequate potassium intake, vomiting, diarrhea, abuse of laxatives, excessive insulin, Adverse effects on skeletal muscle, smooth muscle, blood pressure, and the heart

What are important notes on Hydrochlorothiazide (HydroDIURIL) (HCTZ)

Most widely used, watch for Sulfa allergy to thiazide component of drug Ends with thiazide Action—distal convoluted tubule May not be as great as once thought Peaks 4-6 hours, given orally May take 3 weeks to fully work - Dirt f*cking cheap - Not very potent, not used in ER setting

What are clinical manifestations/associated problems with hypo-magnesemia

Muscle excitability - can go to tetanus if severe, preterm labor Disorientation Psychoses seizures ** Presents like tetanus (spasms and shakey)

What happens during hypermagnesia

Neuromuscular blockade - paralysis of respiratory muscles can occur Cardiac dysrhythmias Counteract with IV calcium gluconate ^That is its antidote!!!!!!!!!!!!

What is Amlodipine (Norvasc) used for

No grapefruit juice Really good for Raynaud's phenomenon - vasospasm in fingers and toes Used a lot for hypertension Really good for small kidney stones yet roller coaster actually works a bit better according to research Can cause swollen ankles quite a bit with headaches just like verapamil

Quickie notes on hypermagnesia

Opposite reaction where muscles relax and go into paralysis so lungs go into paralysis so need to go on vent Pregnant women who cannot catch breath = BAD Antidote is calcium gluconate to mag sulfate (inverse reactions, pendulum)

What are the three basic functions of the kidneys

Cleansing of extracellular fluid (ECF) and maintenance of ECF volume and composition Maintenance of acid-base balance Excretion of metabolic wastes and foreign substances

What is the normal range for magnesium

1.3-2.1 mg/dL

What potassium level does cardiac arrest occur around

8-9 mEq/L

Why can diuretics raise sugar and uric acid levels

By taking away salt and water all you're left with is sugar which is harder to pee out, SO it looks like you have high sugar and uric acid levels but really it's just hyper concentrated so make sure patient is well hydrated to get accurate levels

In reviewing the medication records of the following group of clients, the nurse determines that which client would be at greatest risk for developing hyperkalemia? A) Client receiving furosemide (Lasix) B) Client receiving bumetanide (Bumex) C) Client receiving sprionolactone (Aldactone) D) Client receiving hydrochlorothiazide (HCTZ)

C) Aldactone is K sparing. 1, 2 and 4 could result in hypokalemia

A nurse is planning to administer HCTZ to a client. The nurse understands that which of the following are concerns related to the administration of this medication? A) Hypouricemia, hyperkalemia B) Increased risk of osteoporosis C) Hypokalemia, hyperglycemia, sulfa allergy D) Hyperkalemia, hypoglycemia, penicillin allergy

C) Hypokalemia, hyperglycemia, sulfa allergy

A home health care nurse is visiting an older client at home. Lasix is prescribed for the client and the nurse teaches the client about the medication. Which of the following statements, if made by the client, indicates the need for further teaching? A) I will sit up slowly before standing each morning B) I will take my meds every morning with breakfast C) I need to always drink coffee and tea to keep healthy D) I will call my doctor if my ankles swell or my rings get tight

C) Too much caffeine, may cause hypotension ** D: probably on calcium blocker and probably needs MORE lasix

What are lifestyle modifications for HTN (first line of treatment)

CONSIDERED FIRST LINE TREATMENT Weight loss Sodium restriction DASH eating plan - Dietary Approaches to Stop Hypertension Alcohol restriction Females cut down on glucose/salt prior to menses Aerobic exercise Smoking cessation Maintenance of potassium and calcium intake

What is Diltiazem (Cardizem)

Calcium channel blocker - less constipation than Verapamil (Calan)

Quickie notes on Beta blockers

Can improve patient status and survival Carefully control dose and go slow (low n slow) Overdose: May respond to GLUCAGON Can block signs of hypoglycemia (know this!!!) Won't be as tachy or tremor as much

How does severe trauma/burns lead to hyperkalemia

Causes cells to break open and potassium floods out and fills blood vessels ** "golden hour" to take care of this problem ^ give sugar and insulin to shove potassium back into remaining cells (or enema so you shit it all out)

What are nursing implications of beta blockers

Check the pulse, watch for rate decreasing too much Check for orthostatic hypotension Check for wheezing

What is a special consideration if giving insulin

Checking potassium levels are where they should be because you need both insulin and K to get sugar into cells (KIS)

What is the mechanism of action of ARBs

Decrease action of angiotensin II Cause dilation of arterioles and veins Reduce excretion of potassium Decrease release of aldosterone Increase renal excretion of sodium and water ** Not as much of the cough

What lung sound do you listen for when someone uses diuretics

Crackles

A client in on enalapril (Vasotec) for the treatment of hypertension. The nurse teaches the client that he should seek emergent care if he experiences which adverse effect. A) Nausea B) Insomnia C) Dry cough D) Swelling of the tongue

D) Swelling of the tongue indicates angioedema, and potential airway closure, It calls for emergent, emergency care

What is the most frequently prescribed diuretic

Furosemide (Lasix)

What is one of the easiest ways to accidentally kill a patient

Giving too much potassium (especially IV)

What are the four functionally distinct regions of the kidneys

Glomerulus Proximal convoluted tubule The loop of Henle Distal convoluted tubule ** Can use multiple drugs for multiple parts of the kidneys

What are calcium channel blockers used to treat

HTN - lowers BP by causing arteries to dilate Reduces heart rate Angina - dilation of arteries and arterioles in heart improves perfusion (blood flow) to the myocardium Cardiac dysrhythmias

What else are ACEs used for

Heart Failure Improve cardiac output Reduce pulmonary congestion by lowering blood volume Decrease production of angiotensin II in the heart which suppresses the growth of myocytes and prevents thickening of the ventricular wall (hypertrophy) Diabetic nephropathy (leading cause of kidney failure) Delay onset of kidney failure Slow progression of kidney failure

What are adverse effects of beta blockers

Heart block Heart failure Bradycardia Sinus arrest Hypotension Bronchospasm (in asthma patients) ** Monitor closely

What are consequences of HTN

Heart disease Myocardial infarction (MI) Heart failure Angina pectoris Kidney disease Stroke DEATH ** Effects over time

Should you keep medicating BP if it is normal? or stop taking your diuretic

Keep taking!!! Medicate normal to stay normal

What are side effects of Diltiazem (Cardizem)

Less constipation than Verapamil, used quite a bit Flushing, Dizziness Edema ankles and feet Grapefruit juice problem

What is a Beta blocker for pregnant women

Lobetalol (Trandate) ** has an alpha and a beta blocker **3rd gen

What is Diltiazem (Cardizem) used for

Lower blood pressure by dilating arteries Used for HTN, angina, cardiac rhythm problems Effects begin quickly, like 30 minutes

How do you prevent and treat hypo-magnesemia

Magnesium gluconate and magnesium hydroxide PO for prevention Magnesium sulfate IV ** Mag sulfate

What are the causes of hyperkalemia

Severe tissue trauma Untreated Addison's disease Misuse of potassium-sparing diuretics - Aldactone Overdose with IV potassium Acute acidosis

What are NON-selective Beta blocker effects on the heart and ECG

Slows conduction Decreases the heart rate Decreases cardiac excitability Decreases cardiac output Decreases blood pressure ** Slows everything way the F down

What is an example of a potassium sparing diuretic

Spironolactone (Aldactone)

What medication can cause gynecomastia in men (man titties)

Spironolactone (Aldosterone) - mild testosterone inhibitor

Why give a diuretic for HTN

Those with HTN oftentimes have unhealthy diet and/or retain lots of sugar and salt, that attracts water and all that fluid hangs out in the interstitial space around blood vessels, all that fluid goes into vessels and raises HTN *** SO, take diuretic to get rid of excess fluid

True or false: Beta blockers decrease vital signs but not mental status

True

True or false: It is common to take a calcium blocker with a beta blocker, ACE/ARB, and a diuretic

True

True or false: concentrated uric acid levels from diuretics without enough water can trigger gout

True

True or false: salt and water are either retained or excreted together

True

What are calcium channel blockers used for

Used in treatment of HTN, angina pectoris, cardiac dysrhythmias Used for prevention of angina By acting on the smooth muscles of the heart and blood vessels - Regulate contraction Help regulate function of the myocardium, SA and AV nodes

How does hypo-magnesemia present in pregnant women

Uterus starts twitching/contracting = preterm labor and that's bad because baby isn't done cooking (hyper-relexes)

What is Raynaud's phenomenon

Vasospasm in fingers and toes ** massive vasoconstriction ** give Amlodipine (Norvasc)

What is an example of a calcium channel blocker

Verapamil (Calan), Covera-HS, Verelan