Drugs For Hypertension ( HTN )

1. Drugs For Hypertension (HTN) Chapter 23

2. Hypertension & Demographics In the United States: • 74.5 Million adults Dx with HTN • 56,561 deaths in 2006, contributing factor in 300,000 additional deaths/year • Incidence is 1:3 adults, 77% unaware until diagnosed • 1996-2006: death rate increased 19.5% • Am. Heart Assn. 2010

3. 2006 Death Rates in U.S./100,000 15.6% White males 51.1% Black males 14.3% White females 37.7% Black females Am. Heart Assn. 2010

4. Hypertension (HTN) Classification • Normal: SBP <120 and DBP <80 • PreHTN: SBP 120-139 or DBP 80-89 • Stage 1 HTN: SBP 140-159 or DBP 90-99 • Stage 2 HTN:SBP>159 or DBP>99 • Joint Nat’l Committee 7, 2003

5. Life Span and HTN • Blood Pressure naturally changes over one’s lifetime, gradually and constantly increasing from infancy through later years. HTN is common among the elder population, occurring in: • 64% of all Males older than 65 • 75% of all Females older than 75 Pharmacology for Nurses, A Pathophysiological Approach 3rd Ed. 2011 • Widespread under-treatment for this age group.

6. Target Organs affected by HTN • Heart • Brain • Kidneys • Retina • Compelling Reason For Instituting Pharmacotherapy: MI, HF, CAD, DM, CRF, CVA. • Pharmacology and the Nursing Process, • Mosby/Elsevier 2008 DVD-ROM • Adams, M., Leland, N., Urban, C.

7. Disease Progression • Heart failure • Transient Ischemic Attack (TIA) and/or Cerebral Vascular Accident (CVA) • Renal failure (RF) • Visual impairment and blindness Pharmacology and the Nursing Process, Mosby/Elsevier 2008 DVD-ROM

8. Case Study • Mr. F. is a 39 y.o. Black male who was admitted to the ICU from the County Clinic, diagnosed with Hypertensive Crisis. His history includes childhood Appendectomy, Obesity, newly diagnosed Hypercholesterolemia, Essential Hypertension and Alcoholism. Mr. F. had sustained BP’s of 200-210/115-120 mm/Hg while in the Emergency Department (ED) until treated with IV Nitroprusside (Nitropress). His pressure was stabilized at 140-160/80-88. Transfer orders to Telemetry Care Unit (TCU) were written.

9. Neuman System Model • How deeply is the Hypertensive Stressor penetrating Mr. F.’s Lines of Resistance? • Is the Basic Structure threatened? • At what Level of Prevention is the administration of IV Nitroprusside?

10. nitroprusside sodium (Nipride or Nitropress) • Drug Class: Direct-acting vasodilator • Actions and Uses: to lower blood pressure quickly in a hypertensive crisis, relaxation of arterial and venous smooth muscle. Adverse Effects: Increased intracranial pressure, bradycardia; cyanide toxicity with long term use Dosage: initially 0.25-0.35mcg/kg/min IV then gradually titrate for effect every few minutes for max dose of 10mcg/kg/min. Half-life: 2 minutes

11. Report from ICU Nurse, & Chart Review • Unemployed auto mechanic • Completed 2 years High School • Weight 188 lbs, Height 5’5’’ • Noncompliant with medications • Previously diagnosed Essential HTN • Cholesterol 244mg/dl (<200mg/dl desirable) • NKDA • 6 beers daily for 20 years

12. Transfer to TCU • Mr. F.’s first set of VSS on the Unit are 97.9, 148/92, 76, 16, O2 SAT 98%. Pain 2/10 headache. • MD has Ordered: Hydrochlorothiazide 25 mg PO BID Lisinopril 40 mg PO BID, hold for SBP < 100 VSS q2H and prn, IV Lock, NAS Cardiac Diet, Intake & Output (I&O), up ad lib, daily labs include Serum Electrolytes and CBC.

13. Primary Drug Therapy • Hydrochlorothiazide (HydroDIURIL, Microzide) Drug Class: Thiazide Diuretic Action: increases Na+ and H2O excretion by inhibiting Na+ & Cl-reabsorption in the distal nephron, causing diuresis which lowers SBP @ 10-20mmHg. .

14. Microzide Adverse Effects: Common: minor Hypokalemia, fatigue Serious: severe hypokalemia, electrolyte depletion, hyponatremia, cardiac arrhythmias, dehydration, hypotension, hyperglycemia, coma, blood dyscrasias.

15. Drug Therapy Continued Lisinopril (Prinivil, Zestril) Drug Class: Angiotensin Converting Enzyme (ACE) Inhibitor • Action and use: ACE Inhibitors block angiotensin II, which lowers peripheral resistance and decrease blood volume by lowering aldosterone secretion. This drug action decreases blood pressure and increases cardiac output. Valued use in treating both HTN and Heart Failure (HF).

16. Lisinopril • Adverse effects: mostly well tolerated: Common: H/A, dizziness, orthostatic hypotension, cough, n/v/d, rash. Serious: severe hypotension (1st dose phenomenon), syncope, angioedema, blood dyscrasias, hyperkalemia, Chest Pain Contraindications: Hx of angioedema from ACE-I, hyperkalemia, 2nd & 3rd Trimesters of Pregnancy

17. Drug Action • ACE Inhibitors prevent vasoconstriction by blocking the formation of Angiotensin II (a potent naturally occurring vasoconstrictor) in the body. Also, ACE Inhibitors decrease the secretion of Aldosterone which decreases Na+ and H2O absorption.

18. Nursing Process • Potential / Actual Nursing Diagnosis for clients receiving diuretics & antihypertensives: • Fluid Volume , Deficient, Risk for • Falls/Injury/Activity Intolerance, Risk for, related to orthostatic hypotension • Knowledge, Deficient, related to drug therapy

19. Nursing Process Cont’ed • Risk for Imbalanced Nutrition, More than Body requirements (K+ intake) • Noncompliance, Risk for, related to adverse drug effects : sexual dysfunction, lifestyle habits, income/insurance coverage, etc. • Decreased Cardiac Output-disease process • Altered Tissue Perfusion due to drug therapy • Adams, M., Leland, N., Urban, C.

20. Planning: Client Goals & Expected Outcomes • Reduction in Systolic & Diastolic BP • Free of/minimal adverse effects • Lab values WNL • Verbalize/Demonstrate understanding of drug actions, dosing/self administration, side effects and precautions of medications • Adams, M., Leland, N., Urban, C.

21. Implementation:Intervention/Rationales Observe for hypersensitivity reactions (angioedema) Client to report any dyspnea, throat tightness, stridor, muscle cramps, hives, rash, tremors

22. Intervention/Rationales Monitor Lab Values: Neutropenia/infections ACE-Inhibitors can lower WBC’s Client to report any s/s of flu/infections • Hyperkalemia due to low aldosterone levels (esp. with CHF, Renal insufficiency & Diabetes) • Report nausea, irregular or slow heart beat, profound fatigue or weakness, avoid high K+ beverages/salt substitutes/nutritional supplements

23. Intervention/Rationales Monitor for persistent dry cough or change in cough pattern Encourage appropriate lifestyle changes ETOH, smoking, saturated fat, exercise Client to expect cough, elevate head of bed (HOB), sugar-free lozenges, antihistamines, report any change in character/frequency of cough associated with shortness of breath (SOB) or chest pain (CP).

24. Intervention/Rationales Monitor Liver ( drug metabolism) & Kidney (drug excretion) Function Client to report N/V/D, anorexia, rash, jaundice, abd pain/tenderness/distention/change in stool. Contact Health Care Provider immediately if jaundice develops, keep all medical and lab appointments, carry ID Medication Card Measure I&O and record daily weight. Observe for severe SOB/frothy sputum, profound fatigue

25. Intervention/Rationales • 1st dose phenomenon : Monitor for safe activity until response to drug is known. • Accompany client first time out of bed • Provide dose at bed time • Instruct client when getting up to raise slowly to sitting then standing position • Client to report faintness/dizziness/numbness/tingling

26. Intervention/Rationales Orthostatic B/P’s, hold meds if SBP<90 keep 2 side rails up, call bell in reach Avoid activities that require much mental alertness (driving) Use opportunities to instruct client during medication pass or assessments (rationales for drug, desired outcomes, common side effects, when to contact provider).

27. Intervention/Rationales Monitor Nutritional Status • For K+ wasting diuretics: Eat foods high in Potassium: bananas, apricots, beans, etc., • For K+ sparing diuretics: avoid foods high in K+ Monitor for Photosensitivity limit sun exposure, wear sun glasses Adams, M., Leland, N., Urban, C.

28. Evaluation of Outcome Criteria • BP WNL • Lab values WNL • Client verbalizes and demonstrates an understanding of drug action, dosing, side effects and precautions. • Adams, M., Leland, N., Urban, C.

29. Case Study Cont’d • Mr. F.’s BP over the next 24 hours has slowly climbed to the 170’s/100’s. His Serum K+ is 5.1, WBC’s 4.3, Bun 16 and Cr 0.8. • The MD adds Atenolol 50 mg PO at HS, hold for SBP < 100

30. Drug Therapy • Atenolol (Tenormin) • Drug Class: Beta-Adrenergic Antagonist Action: slows heart rate and reduces cardiac contractility which reduces cardiac output. Also, inhibits Renin secretion and the formation of Angiotension II. Thus, systemic BP drops.

31. Atenolol Adverse Effects: Common: fatigue, insomnia, drowsiness, impotence or decreased libido, bradycardia, confusion Serious: Agranulocytosis, laryngospasm, Stevens-Johnson Syndrome, anaphylaxis. Abrupt withdraw: palpitations, rebound HTN, arrhythmias, MI

32. Nurse & Patient Mr. F. is asking some questions regarding what happened to him and what does it mean. As the nurse, you determine that Mr. F. is receptive to education so you describe HTN, what the long term effects may involve and what can be done about it. Mr. F. is appreciative.

33. Quality & Safety Education for Nurses • Patient Centered Care • Mr F. is in control/full partner • Provide compassionate and coordinated care • Respect for preferences, values, needs • Cronenwett, L., Sherwood, G., Barnsteiner, J.

34. QSEN • Knowledge: • Information, communication, education • Understand concepts of pain and suffering • Examine barriers to active involvement and strategies to empower pt. in his own health care process

35. QSEN • Skills: • Elicit pt. values, preferences and expressed needs • Collaborate with and Communicate these needs to other health care team members • Assess level of physical and emotional comfort • Assess level of pt.’s decisional conflict and provide access to resources

36. QSEN • Attitudes • Value seeing pt.’s situation through ‘his eyes’ • Respect/encourage expression of values, preferences and needs • Respect pt. preference in degree of his active involvement in care process • Cronenwett, L., Sherwood, G., Barnsteiner, J.

37. More Nurse & Patient You review with Mr. F.: Medications: actions, adverse effects, need for compliance. Lifestyle Issues: diet, Etoh, smoking, obesity, exercise, unemployment. Mr. F. admits he lost his job due to his drinking and would like to return to work.

38. Next Morning • The MD discontinued (D’ced) Microzide and atenolol and began Verapamil 240 mg PO daily & Furosemide 40mg BID due to Mr. F.’s poor response. (His SBP had remained in the 170’s.) The nurse continues to monitor his BP carefully. The noon time VSS are: 98.8, 88, 18, 143/88, O2 Saturation (O2 SAT) is 97% on room air (R/A).

39. Calcium Channel Blockers (CCB’s) • Verapamil (Calan, Isoptin) • Drug Class: Nonselective CCB Actions: inhibits flow of Ca++ ions into both cardiac and vascular smooth muscle, slowing heart rate (HR) and conduction velocity which can stabilize dysrhythmias. Dilates coronary arteries as well as arterioles, thus lowering the BP and cardiac workload. Nursing Drug Book 2008 Adams, M., Leland, N. Urban, C.

40. Verapamil • Adverse Effects: Common: dizziness, H/A, facial flushing, dyspnea, hypotension, constipation Serious: new dysrhythmias or worsening of existing ones Caution: renal & hepatic impairment

41. Nursing Process-Implementation • Monitor for signs of Heart Failure (HF) • Increasing dyspnea, postural nocturnal dyspnea, rales, frothy pink sputum. (CCB’s may cause decreased myocardial contractility, which increases risk of HF) • Instruct pt. to report any above symptoms/signs as well as fatigue or edema of extremities • Monitor Constipation-(CCB’s may cause decreased peristalsis). Enc. Fluids, fiber, stool softener PRN

42. Furosemide (Lasix) Drug Class: Loop Diuretic Actions and Uses: strong inhibition of Na+ and Cl- re-absorption at the proximal and distal tubules and ascending Loop of Henle (Loop Diuretic). Beneficial when cardiac output and renal blood flow are compromised. Caution: review serum K+ levels prior to administration, if low- hold dose and notify the provider.

43. Furosemide (Lasix) Adverse Effects: Common: mild hypokalemia, postural hypotension, tinnitus, N/V/D, dizziness, fatigue, muscle spasms Serious: hypokalemia, electrolyte imbalances, blood dyscrasias, ototixicity, volume depletion, pancreatitis, (hyper- glycemia in Diabetics). Adams, M., Leland, N., Urban, C. Nursing Drug Book 2008

44. Other Primary Antihypertensive Drugs • Angiotensin II Receptor Blockers (ARB’s) losartan (Cozaar), valsartan (Diovan) block the reception of Angiotensin II in arteriole smooth muscle and Adrenal Gland, causing BP to fall. (No cough and less angioedema)

45. Alternative AntiHypertensives • Alpha 1 Adrenergic Antagonists: Doxazosin (Cardura), block sympathetic receptors in arterioles; hypotension, fatigue, nausea. Alpha 1 & Beta Blockers: nonselective blockade of α & β adrenergic receptors; carvedilol (Coreg), labetalol (Trandate)

46. Alternative Antihypertensive • Alpha 2 Adrenergic Agonists: decrease CNS stimulation to heart and arterioles; CNS side effects (sedation, etc.) Clonidine (Catapres) methyldopa (Aldomet) • Adrenergic Neuron Blockers: many significant side effects, Reserpine rarely used today

47. Mr. F. Mr. F. is tolerating the new medication regimen of Lisinopril, Verapamil and Lasix, which is maintaining his BP in the range of 120-130/80-88. He has mild dizziness when first sitting up which passes and he then tolerates mild activity. His Lab Values are WNL except his K+ of 3.2. The MD ordered IV K+ 40meq over 4 hours then 20meq PO BID. Now his K+ is 4.3. He is tolerating his diet well.

48. Implementation/Interventions The Nurse confers with fellow staff nurses and the MD, resulting in: Clinical Social Worker (CSW) consult to explore financial aid options during unemployment, help create a more supportive home environment. CSW will provide Community Information on Alcoholics Anonymous (A.A)., Employment Development Dept.(EDD), local fitness centers, smoking cessation. Nutritional Consultation to explore alternative dietary options that may reduce saturated fat/excess caloric intake.

49. Mr. F. Goes Home • Mr. F. feels encouraged by the Health Care Team and understands that lifestyle modifications are designed to be instituted gradually and one at a time. His personal preferences have remained central in the discharge plan. The goal or outcome is his improved quality of life and health. Mr. F. expresses his desire to be medication compliant and will explore A.A. and begin seeking employment.