Week 7: Chapter 43 and Chapter 31 Antihypertensive Agents

Pharmacokinetics: ACE Inhibitors

-Metabolized in the liver -Excreted in the urine and feces -Generally well-absorbed -Given primarily orally

Pharmacokinetics: Angiotensin II Receptor Blockers

-Oral only -Well-absorbed -Metabolized in liver, excreted in feces and urine

Drug-drug interactions: Angiotensin II Receptor Blockers

-Phenobarbital -ACE Inhibitors

Adverse effects: Calcium Channel Blockers

-Related to effects on cardiac output -GI symptoms - CV symptoms - dizziness, H/A, hypotension

Indications: Nonselective Beta-Adrenergic Blocking Agents

-Treating cardiovascular problems, HTN, angina, and migraine headaches -Preventing reinfarction after MI

Pharmacokinetics: Calcium Channel Blockers

-Well-absorbed -Metabolized in the liver -Excreted in the urine -PO

Actions: Angiotensin II Receptor Blockers

-Work by selectively binding with Angiotensin II receptors in vascular smooth muscle and in the adrenal cortex that blocks vasoconstriction and the release of aldosterone - blocks BP from rising and influencing the renin-angiotensin system which causes BP to lower

Actions: Nonselective Beta-Adrenergic Blocking Agents

- work by competing w/ beta receptors in SNS and blocking beta receptors in the heart and some in the nephron - decreased HR and contractility, - leads to decrease in cardiac workload and O2 consumption

Antihypertensive Agents Overview

-ACE inhibitors "-pril" -Angiotensin II Receptor Blockers -Renin Inhibitors -Calcium channel blockers -Vasodilators -Diuretics -Sympathetic nervous system blockers -Beta blockers "-olol"

Drug-drug interactions: ACE Inhibitors

-Allopurinol -NSAIDs

Actions: ACE Inhibitors

-Blocking the conversion of angiotensin I to angiotensin II -Leads to decrease in BP, decrease in aldosterone production, small increase in serum potassium levels, some sodium and fluid loss -Act at the level of the lungs

Drug-drug interactions: Nonselective Beta-Adrenergic Blocking Agents

-Clonidine -NSAIDs -Insulin or anti-diabetic medications

Contraindications: Beta-Adrenergic Blocking Agents

-Diabetes -Bradycardia, heart block, shock, or CHF -COPD, asthma -Pregnancy and lactation Caution: diabetes, hepatic dysfunction

Indications: Calcium Channel Blockers

-Essential HTN -Angina

Indications: ACE Inhibitors

-Hypertension -Congestive heart failure (CHF) -Diabetic nephropathy -Left ventricular dysfunction after MI

Contraindications: ACE Inhibitors

-Impaired renal function -Pregnancy and lactation Caution: CHF, can change the hemodynamics, needs to be monitored really well

Actions: Calcium Channel Blockers

-Inhibit movement of calcium ions across the membranes of cardiac and arterial muscle cells - depresses impulse and leads to slow connection that decreases the contractility of the heart - dilates the arteries - lowers the BP - decreases myocardial O2 consumption

Renin-angiotensin-aldosterone system

-activated when the BP in the kidneys fall -the kidneys will release renin to activate the system if the BP is too low or if there isn't enough O2 -the renin travels to the liver where it is converted to Angiotensin I, which travels to the lungs where it is converted to Angiotensin II and that works to cause vasoconstriction which will raise the BP and restore blood flow to the kidneys

Adverse effets: Nonselective Beta-Adrenergic Blocking Agents

-urinary and sexual system effects such as impotence, low libido, dysuria -GI -respiratory effects -trouble regulating blood sugar -cardiac effects -CNS effects

A patient is prescribed Metoprolol. Which statement by the patient requires the nurse to re-educate the patient on how to take the medication properly? A. "After I stop taking this medication I will let my physician know." B. "I take this medication with my breakfast every morning." C. "I will change positions slowly while I'm taking this medication." D. "While I'm taking this medication I will monitor my heart rate."

A. "After I stop taking this medication I will let my physician know."

A patient is admitted with a dysrhythmia. The physician prescribes Propranolol. Which statement by the patient requires the nurse to hold the ordered dose and notify the physician for further orders? A. "I use an inhaler at home for asthma." B. "My heart feels like it is racing, and I feel very weak." C. "I had caffeine this morning with breakfast." D. "I smoke 2 packs of cigarettes per day."

A. "I use an inhaler at home for asthma."

You're teaching a patient about how angiotensin II receptor blockers (ARBs) work. Which statement below BEST describes how these medications work on the body? A. "They prevent Angiotensin II Type I Receptors from binding with Angiotensin II." B. "These medications prevent the activation of Angiotensin II Type II Receptors from binding with Angiotensin II." C. "They inhibit angiotensin-converting-enzyme (ACE) from converting an Angiotensin I to Angiotensin II." D. "These medications prevent Angiotensin II Type I Receptors from binding with angiotensin-converting-enzyme (ACE)."

A. "They prevent Angiotensin II Type I Receptors from binding with Angiotensin II."

Which patient below would MOST benefit from an ACE Inhibitor? A. A 50-year-old female with systolic dysfunction heart failure. B. A 48-year-old male with severe renal failure. C. A 35-year-old female with chronic hepatitis. D. A 54-year-old male with hypovolemic shock.

A. A 50-year-old female with systolic dysfunction heart failure.

A patient is prescribed an ACE Inhibitor after experiencing a myocardial infarction. What effects on the body will this medication achieve? Select all that apply: A. Decreases SVR (systemic vascular resistance) and blood pressure B. Constriction of the vessels C. Kidneys will excrete water and sodium D. Kidneys will retain potassium. E. Increases SVR (systemic vascular resistance) and blood pressure

A. Decreases SVR (systemic vascular resistance) and blood pressure C. Kidneys will excrete water and sodium D. Kidneys will retain potassium.

What conditions are Angiotensin II Receptor Blockers (ARBs) used to treat? Select all that apply: A. Hypertension B. Renal stenosis C. Diabetic nephropathy in type 2 diabetics D. Atrial flutter E. Heart failure

A. Hypertension C. Diabetic nephropathy in type 2 diabetics E. Heart failure

Angiotensin-converting enzyme (ACE) performs what roles in the body? Select all that apply: A. Inactivates bradykinin by breaking it down B. Dilates vessels C. Causes the kidneys to keep sodium and water D. Converts Angiotensin I to Angiotensin II

A. Inactivates bradykinin by breaking it down D. Converts Angiotensin I to Angiotensin II

Which statements below CORRECTLY describe how ACE Inhibitors work? Select all that apply: A. This group of medications inhibits the renin-angiotensin-aldosterone system (RAAS). B. ACE Inhibitors prevent the conversion of Angiotensin I to Angiotensin II. C. ACE Inhibitors prevent Angiotensinogen from converting to Angiotensin I. D. ACE Inhibitors have a positive chronotropic and negative inotropic effect on the heart.

A. This group of medications inhibits the renin-angiotensin-aldosterone system (RAAS). B. ACE Inhibitors prevent the conversion of Angiotensin I to Angiotensin II.

Select all the pharmacodynamic effects of angiotensin II receptor blockers (ARBs): A. Vasodilation B. Vasoconstriction C. Sodium conservation D. Sodium excretion E. Water conservation F. Water excretion

A. Vasodilation D. Sodium excretion F. Water excretion

Pharmacokinetics: Nonselective Beta-Adrenergic Blocking Agents

Absorbed from GI tract, metabolized in liver

Renin Inhibitor: Aliskiren

Actions: inhibits renin, leads to decreased plasma renin activity and inhibits conversion of renin to angiotensin I Indications: HTN Pharmacokinetics: Absorbed in the GI tract slowly Contraindications: pregnancy and lactation Adverse effects: risk of hyperkalemia, can lead to swelling in face, tongue, and lips, respiratory effects Drug-drug interactions: Furosemide (can cause potassium levels to be too low, too much of a diuretic effect) and ACE Inhibitors Nursing considerations: monitor potassium levels prior to and during treatment

The mechanism of action of an ACE inhibitor is the blocking of ACE from converting angiotensin I to angiotensin II. What does this cause? A. Decrease in serum potassium levels B. Decrease in aldosterone production C. Sodium and fluid loss D. Increase in blood pressure

B

Nursing considerations: Nonselective Beta-Adrenergic Blocking Agents

Assess: -History and physical exam -Bradycardia or heart blocks, shock, or heart failure -Bronchospasm, COPD, or acute asthma -Diabetes, thyrotoxicosis -VS, cardiac status, and appropriate labs (esp electrolyte levels) -should be on continuous heart monitor if taking IV -change positions slowly -use care when driving/operating machinery *Don't stop abruptly (should be on a taper over about 2 wks),

Nursing considerations: ACE Inhibitors

Assess: -History and physical exam -Impaired kidney function -Pregnancy and lactation -Salt/volume depletion and heart failure -Baseline status (BP, cardiac status, HR) before beginning therapy *Should be taken on empty stomach b/c if it's taken w/ food it decreases absorption (1 hr before or 2 hrs after meals)

Nursing considerations: Calcium Channel Blockers

Assess: -History and physical exam -Known allergy - baseline data - baseline pain data - ECG - lung status - liver and kidney function tests - heart status data - could be risk for injury r/t low BP and dizziness - ineffective tissue perfusion r/t decreased CO and hypotension - avoid stress, - small frequent meals - fall precautions

Nursing considerations: Angiotensin II Receptor Blockers

Assess: -History and physical exam -Known allergy -Monitor renal and hepatic function -Pregnancy and lactation -Hypovolemia - get a baseline - monitor fluid status - can be given w/ food if GI distress occurs - teach pts to be aware of fluid volume when exercising or ill - - provider should know that they are taking med if they are having surgery

You're providing discharge instructions to a patient that will be taking an ACE Inhibitor at home. Which statements by the patient demonstrate they understood your discharge instructions? Select all that apply: A. "If I feel unwell, it is okay that I miss a dose." B. "I will avoid using salt substitutes that contain potassium." C. "I will make sure I incorporate a high amount of potatoes, bananas, oranges, and tomatoes into my diet while taking this medication". D. "I will regularly check my blood pressure and pulse rate while taking this medication and report any significant changes to my doctor."

B. "I will avoid using salt substitutes that contain potassium." D. "I will regularly check my blood pressure and pulse rate while taking this medication and report any significant changes to my doctor."

Your patient is prescribed an Angiotensin II Receptor Blocker (ARB) for the treatment of blood pressure management. Which statement below BEST describes how this medication will manage blood pressure in a patient? A. "This medication will increase systemic vascular resistance (SVR) and decrease blood pressure, while decreasing blood volume through the excretion of sodium and water." B. "This medication will decrease systemic vascular resistance (SVR) and decrease blood pressure, while decreasing blood volume through the excretion of sodium and water." C. "ARBs will cause vasoconstriction and increase renal blood flow and volume." D. "ARBs will cause vasodilation and the kidneys to retain sodium and water."

B. "This medication will decrease systemic vascular resistance (SVR) and decrease blood pressure, while decreasing blood volume through the excretion of sodium and water.

Select all the beta blocker medications listed below that affect ONLY beta 1 receptors: A. Timolol B. Atenolol C. Metoprolol D. Esmolol

B. Atenolol C. Metoprolol D. Esmolol

A 65-year-old male patient is prescribed an ACE inhibitor for the treatment of hypertension. Which medication below is an ACE inhibitor? A. Metoprolol B. Benazepril C. Losartan D. Amlodipine

B. Benazepril

What signs and symptoms below would demonstrate a patient is experiencing an overdose of a beta blocker medication? Select all that apply: A. Blood pressure 200/110 B. Heart rate 35 beats per minute C. EKG shows atrial fibrillation with rapid ventricular rate (RVR) D. Patient is maniac and agitated E. Dyspnea F. Patient is severely drowsy G. EKG shows 3rd degree AV block

B. Heart rate 35 beats per minute E. Dyspnea F. Patient is severely drowsy G. EKG shows 3rd degree AV block

A physician writes a new medication order for a patient who has cardiovascular disease. The medication is an angiotensin II receptor blocker (ARB). What new medication on the patient's scheduled medication list is an ARB? A. Metoprolol B. Losartan C. Lisinopril D. Nicardipine

B. Losartan

Beta 2 receptors can be found in the? Select all that apply: A. Heart B. Lungs C. GI system D. Kidneys E. Vascular smooth muscle F. Skeletal muscle

B. Lungs C. GI system E. Vascular smooth muscle F. Skeletal muscle

Which category of beta blockers block beta 1 and beta 2 receptors? A. Selective beta blockers B. Nonselective beta blockers

B. Nonselective beta blockers

A patient states they are experiencing an annoying, persistent dry cough that started once they begin taking an ACE Inhibitor. The patient is not experiencing any other signs and symptoms. As the nurse, your response is? A. Tell the patient to immediately stop taking the medication and seek medical treatment. B. Reassure the patient this is a harmless side effect of this medication and to not abruptly stop taking the medication. C. Recommend the patient start taking the medication at night to decrease the coughing. D. Reassure the patient that the cough will disappear within 6 months of taking the medication

B. Reassure the patient this is a harmless side effect of this medication and to not abruptly stop taking the medication.

A patient is taking an ACE Inhibitor and Spironolactone. It is priority the nurse teaches the patient? A. To avoid consuming alcoholic beverages B. To limit foods high in potassium C. To limit salt intake D. To take the medications with food

B. To limit foods high in potassium

As the nurse you know to tell the patient that the best way to PREVENT rebound hypertension while taking an Angiotensin II Receptor Blocker (ARB) is to? A. assess the blood pressure daily with a self-monitoring device B. never abruptly stop taking the medication C. avoid taking the medication with milk or grapefruit juice D. avoid taking over-the-counter medications

B. never abruptly stop taking the medication

Blood Pressure Control

BP determined by - Heart Rate - Stroke Volume: Amount of blood pumped out of the ventricle with each heartbeat - Total Peripheral Resistance: Resistance of the muscular arteries to the blood being pumped through - Baroreceptors - Renin-angiotensin-aldosterone system

A patient who developed a dry, persistent cough while taking an ACE Inhibitor is switched to an angiotensin II receptor blocker (ARB). The patient reports the cough is now gone, but asks you to explain how this medication helped alleviate the cough. What is the correct response? A. "ARBs prevent ACE (angiotensin-converting-enzyme) from breaking down bradykinin so a dry, persistent cough is less likely." B. "ARBs increase ACE (angiotensin-converting-enzyme) which helps decrease bradykinin levels and helps alleviate the cough." C. "ARBs do not inhibit ACE (angiotensin-converting-enzyme), which is a substance that inactivates bradykinin by breaking it down; therefore, a cough is not likely with this medication." D. "ARBs prevent Angiotensin II Type I receptor sites from activating bradykinin in the lungs."

C. "ARBs do not inhibit ACE (angiotensin-converting-enzyme), which is a substance that inactivates bradykinin by breaking it down; therefore, a cough is not likely with this medication."

A patient with diabetes and hypertension is being discharged home. The patient will be taking Sotalol and insulin per sliding scale. Which statement by the patient demonstrates they did NOT understand your discharge instructions about the side effects of Sotalol? A. "This medication can affect my blood glucose levels." B. "I will monitor my heart rate and blood pressure everyday while taking this medication." C. "While taking this medication I will monitor for a fast heart rate because this is an early indication that my blood glucose level is low." D. "I will report to my physician if I develop shortness of breath, weight gain, or swelling in my feet."

C. "While taking this medication I will monitor for a fast heart rate because this is an early indication that my blood glucose level is low."

Your patient is taking an ACE Inhibitor to manage blood pressure. Which finding below requires immediate nursing action? A. Urinary output is 190 mL within the past 4 hours. B. Patient has a persistent, dry cough. C. EKG shows tall, peaked t-waves. D. Patient has a negative Chvostek's sign.

C. EKG shows tall, peaked t-waves. This EKG finding demonstrates hyperkalemia.

Beta 1 receptors can be found in the? Select all that apply: A. GI tract B. Uterus C. Heart D. Lungs E. Kidneys F. Vascular smooth muscle

C. Heart E. Kidneys

A patient is taking an Angiotensin II Receptor Blocker (ARB). What finding below is an adverse side effect of this medication and should be reported to the physician? A. BUN 10 B. Creatinine 1 mg/dL C. Potassium 6.8 mEq/L D. ALT 20 U/L

C. Potassium 6.8 mEq/L

Some patients who take ACE Inhibitors may develop angioedema. What signs and symptoms will you teach the patient to recognize that can present with this adverse reaction? Select all that apply: A. Hyperkalemia B. Persistent, dry cough C. Swelling in the face D. Thin and shiny skin in the lower extremities E. Difficulty breathing

C. Swelling in the face E. Difficulty breathing

At 1000 your patient is scheduled to take a dose of Atenolol. What finding below would require you to hold the scheduled dose and notify the physician? A. The patient's heart rate is 120 beats per minute. B. The patient's blood pressure is 102/76. C. The patient has swelling in lower extremities, dyspnea, and crackles in lung fields.

C. The patient has swelling in lower extremities, dyspnea, and crackles in lung fields.

A patient is prescribed a beta blocker for a cardiac condition. You know this medication blocks the beta receptors in the body so ____________ and __________ cannot bind to the receptor site and elicit a _______ ________ _________ response. A. angiotensin II and angiotensin I; sympathetic nervous system B. dopamine and norepinephrine; parasympathetic nervous system C. norepinephrine and epinephrine; sympathetic nervous system D. dopamine and acetylcholine; parasympathetic nervous system

C. norepinephrine and epinephrine; sympathetic nervous system

Fill in the blanks: Angiotensin II causes ___________ of the vessels and triggers the release of ____________. A. vasodilation; anti-diuretic hormone (ADH) B. vasodilation; aldosterone C. vasoconstriction; aldosterone D. vasoconstriction; anti-diuretic hormone (ADH)

C. vasoconstriction; aldosterone

Drug-drug interactions: Calcium Channel Blockers

Cyclosporine

You're providing discharge teaching to a patient that will be taking an Angiotensin II Receptor Blocker (ARB) at home. What statement by the patient requires you to re-educate them about this medication? A. "This medication does not cure hypertension. Therefore, I will need to also make lifestyle changes." B. "I will always stand and change positions slowly." C. "A persistent, dry cough is not common with this medication." D. "This medication can decrease potassium levels. So, I will consume a diet rich in potassium to help keep my level normal."

D. "This medication can decrease potassium levels. So, I will consume a diet rich in potassium to help keep my level normal."

True or false: The use of a loop diuretic is the first drug used in the Step Care Management program to treat hypertension.

False

Drug-food interactions: Calcium Channel Blocker

Grapefruit juice (increases concentration in the blood which can lead to toxicity)

Adverse Effects: Angiotensin II Receptor Blockers

H/A, dizziness, fainting, weakness, diarrhea, abdominal pain, nausea, dry mouth or tooth pain, skin rash, dry skin, pre-cancer or risk of cancer

Contraindications: Calcium Channel Blockers

Heart block, sick sinus syndrome

Prototype Calcium Channel Blockers: Diltiazem

Indications: HTN, angina Actions: inhibits the movement of calcium ions across the membranes which decreases the workload on the heart Adverse effects: dizziness, lightheadedness, H/A, bradycardia, flushing, rash, nausea Pharmacokinetics: oral, SR, IV *Often ER, should not be crushed or chewed

Prototype Nonselective Beta-Adrenergic Blocking Agent: Propanolol

Indications: HTN, angina, prevention of re-infarct after MI, migraine, anxiety Actions: blocks beta-adrenergic receptors Pharmacokinetics: oral and IV Adverse effects: bradycardia, HF, CV accident, impotence, bronchospasm

Prototype Angiotensin II Receptor Blocker: Losartan

Indications: HTN, diabetic nephropathy Actions: blocks angiotensin II Adverse effects: CNS, GI, muscle pain, respiratory effects

Prototype ACE Inhibitor: Captopril

Indications: HTN, heart failure, diabetic nephropathy, post MI Actions: blocks ACE Adverse effects: tachycardia, MI, rash, gastric irritation, cough, bone marrow suppression Teaching: take on empty stomach

Adverse effects: ACE Inhibitors

Related to the effects of vasodilation, alteration in blood flow, GI irritation, renal insufficiency, cough, generally well-tolerated

Stepped Care Management of Hypertension

Step 1: Lifestyle modifications are instituted (weight reduction, smoking cessation, moderating ETOH intake, moderating salt intake, increasing physical activity) Step 2: Inadequate response -Drug therapy added (typically a diuretic, ACE inhibitor, CCB, angiotensin II receptor blocker) Step 3: Inadequate response -Consider change in drug dose or add a drug Step 4: Inadequate response -Second or third agent or diuretic is added if not already prescribed

Indications: Angiotensin II Receptor Blockers

Used to lower BP or for HF, usually for pts that can't tolerate ACE inhibitors

Which instruction would the nurse give an unlicensed assistive personnel (UAP) to perform while caring for a client prescribed captopril? Select all that apply. a. Obtain blood pressure. b. Measure intake and output. c. Weigh the client every morning. d. Notify the nurse if the client has a dry cough. e. Assist the client to change positions slowly.

a, b, c, d, e ACE inhibitors such as captopril are prescribed for the management of hypertension, heart failure, and diabetic nephropathy. The nurse would ask the UAP caring for a client taking captopril to perform several tasks. The UAP would obtain the client's BP. The UAP would also measure the client's I&Os as well as obtain a daily weight in the AM. This data would help the nurse determine the client's fluid volume status and is an important component of HF management. The UAP would be aware that a dry cough is a common side effect of ACE inhibitors. Because of the blood pressure-lowering effects of this med, the nurse would instruct the UAP to assist the client to make sure the client changes positions slowly.

Which adverse effect would a nurse monitor for when caring for a client with hypertension who is prescribed metoprolol? a. Hirsutism b. Bradycardia c. Restlessness d. Angina

b. Bradycardia Beta-blockers block stimulation of beta-1 (myocardial) adrenergic receptors, which decreases the heart rate and blood pressure. The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest.

Which food would the nurse instruct a client taking diltiazem to avoid? a. Alcohol b. Grapefruit juice c. Cheddar cheese d. Summer sausage

b. Grapefruit juice Clients taking calcium-channel blockers such as diltiazem would be instructed to avoid drinking grapefruit juice or eating grapefruit because it can interfere with metabolism of the medication.

Which important nursing action would be taken after a health care provider prescribes losartan for a client? a. Assess the client for hypokalemia. b. Administer the medication with food. c. Monitor the client's blood pressure. d. Monitor serum glucose levels.

c. Monitor the client's blood pressure. Losartan is an aldosterone receptor blocking antihypertensive. A lowering of the client's blood pressure reflects a therapeutic response and should be monitored regularly.

Which antihypertensive medication class would the nurse identify as the likely cause of the cough in a client taking multiple medications for hypertension who develops a persistent, hacking cough? a. Thiazide diuretics b. Calcium channel blockers c. Direct renin inhibitors d. Angiotensin-converting enzyme (ACE) inhibitors

d. Angiotensin-converting enzyme (ACE) inhibitors The ACE breaks down kinins. When ACE is inhibited, the increase in kinins in the lung can cause bronchial irritation, leading to the common adverse effect sometimes referred to as an ACE cough.

Which client response indicates to the nurse that a vasodilator medication is effective? a. Absence of adventitious breath sounds. b. Increase in the daily amount of urine produced. c. Pulse rate decreases from 110-175 beats/minute. d. Blood pressure changes from 154/90 to 126/72 mmHg.

d. Blood pressure changes from 154/90 to 126/72 mmHg. Vasodilation will lower the blood pressure.

Which effect would the nurse anticipate after captopril is prescribed for a client? a. Increased urine output b. Decreased anxiety c. Improved sleep d. Decreased blood pressure

d. Decreased blood pressure Captopril is an angiotensin-converting enzyme (ACE) inhibitor antihypertensive. It doesn't have diuretic, sedative, or hypnotic properties.

Cautions: Angiotensin II Receptor Blockers

hepatic or renal dysfunction, hypovolemia

Not keeping HTN under control can result in

high risk for CV complications and death.

Patients may, and often do, require _____ ______ _____ blood pressure medication to treat their high blood pressure.

more than one

The underlying cause of hypertension is

often unknown.

1/3 of adults in the U.S. have

prehypertension.

Baroreceptors

pressure receptors in the aorta and they are influenced by blood as it leaves the LV; if there isn't enough blood leaving, that info is sent to the brain as well as the CV center. If the pressure is too high, vasodilation and a decrease in cardiac rate and output occur; help to keep the pressure the same in the system

Antihypertensive agents work at the _________ __________ level to __________ ____.

regulatory system, control BP