I.  Overview
    Key Drugs:   Diuretics - hydrochlorathiazide (Hydrodiuril)
                            Beta Blockers - Propranolol (Inderal)
                            Centrally Acting Adrenergic Inhibitors - clonidine hydrochloride (Catapres)
                            Alpha Adrenergic Blocking Agents - prazosin hydrochloride (Minipress)
                            Angiotensin Converting Enzyme Inhibitors - captopril (Capoten)
                            Calcium Channel Blockers nifedipine (Procardia)
                           Vasodilators
                                    hydralazine hydrochloride (Apresoline)
                                    sodium nitroprusside (Nipride)

II. Antihypertensives

A. Introduction - Physiological control of blood pressure

B. Antihypertensive therapy

1. Stepped-care Regimen - see pg. 527: Figure 27-4

2. Special Considerations

a. Pregnancy - Do not use ACE inhibitors - can cause renal failure/deaths in neonates

b. Sexual dysfunction - loss of libido, impotence

c. Surgical clients - resume antihypertensive medications as soon as possible after surgery

d. Children - goal - to reduce blood pressure without adverse effects that limit compliance or growth and development.

e. Elderly -  monitor closely

f. Chronic illness - Careful selection and monitoring of antihypertensive agents necessary.
        eg. beta blockers may increase lipid levels
 

C. 5 major categories - discuss a prototype for each one including drug action, indications, usual dose side/adverse effects, and nursing management
1. Diuretics
a. Chlorothiazide (Diuril) or hydrochlorithiazaide (hydrodiuril, Esidrix)
1. Drug Action -
Increases excretion of sodium and water.
                                        Promotes excretion of K, Mag., and Bicarb
Increases levels of Ca++, Glucose, and uric acid
2. Indications - mild/moderate HTN

3. Nursing Management

a. Assessment:
1. Review client's current medications to check for interactions.

2. Diabetes mellitus - may need to alter dosage of hypoglycemic agent

3. Monitor I/O, daily wt., assess for edema

4. Check for K+ level

5. Check for allergy to sulfonamides
 

b. Nursing Diagnoses - Side/Adverse Effect
Oxy: hypotension

Nut: N/V, anorexia,

Hyperuricemia

Fluid/Elec: Hypokalemia

Neuro: Drowsiness, lethargy, dizziness

Endo: hyperglycemia-

c. Implementation
1. Check blood pressure before giving

2. Administer in am to promote night sleep

3. May give with food or milk

4. Monitor for fluid/electrolyte imbalance.

d. Education
1.Instruct to take med at same time qd

2. Lose weight, exercise, stress management

3. Change position slowly

4. Diet high in potassium

5. Report muscle weakness, cramps, nausea, and dizziness to doctor.

6. Use sunscreen - photosensitivity

e. Evaluation -
1. Increased urine output

2. Decreased edema

3. Decreased B/P

4.  Weight loss
 

2. Adrenergic Inhibiting Agents
a. Beta Blocking Agents - propranolol (Inderal) - see chapter 22

b. Centrally Acting Adrenergic Inhibitors

clonidine hydrochloride (Catapres)
1. Nursing Management
a. Assessment
1. Use with caution in CAD, CVA, CRF, Raynaud's disease or history of depression

2. Watch for orthostatic hypotension especially in elderly.

3. Transdermal dosage form - assess skin

b. Implementation
1. Monitoring
a. Monitor B/P closely

b. Weight daily 3-4 days as Na++/H2O retention may be a problem.

2. Intervention
a. Patch - reapply q 7 days - do not trim, remains in place when bathing or showering

b. Do not stop abruptly - rebound hypertension

c. Education
1. Stress importance of follow-up visits

2. Discuss abrupt withdrawal including sequential doses - HTN crisis can occur in 8-24 hours

3. Instruct client to take last dose before bedtime to ensure continuous blood pressure control during night and reduce daytime drowsiness if taking oral form of drug.

4. Avoid alcohol, prolonged standing, and exercising.

5. Side effects - dry mouth, constipation, impotence, drowsiness, withdrawal phenomena

6. Periodic eye examinations to avoid possible retinal degeneration

d. Evaluation
1. Monitor for drug tolerance

2. Blod pressure will stay within normal limits.
 

c. Peripheral Adrenergic Inhibitors - reserpine (not used much anymore)

d. Alpha Adrenergic Blocking Agents - prazosin hydrochloride (Minipress)
 

3. Angiotensin Converting Enzyme (ACE) Inhibitors - captopril (Capoten)
a. Drug Action - Blocks angiotensin I converting enzyme necessary for conversion to angiotensin II

b. Nursing Management

1. Assessment
a. Assess lab studies - CBC and Urinalysis

b. Check if individual has condition aggravated by renal failure

c. Take blood pressure for baseline reading

2. Nursing Diagnoses: side effects:
taste impairment, hypotension, LEUKOPENIA, AGRANULOCYTOSIS

hyperkalemia, nausea, HA, skin rash, joint pain, proteinuria.

3. Implementation
a. Monitoring
1. Monitor K+ and Na++ levels

2. Monitor for neutropenia/agranulocytosis

b. Intervention
1. Discontinue current HTN regime before beginning new therapy.

2. Administer 1 hour before meals to enhance absorption.

3. Clients with renal disease - will increase BUN and Cr.

4. Education
a. Discuss that it takes several weeks before full benefit of drug is realized.

b. Discuss side effects and what to report to doctor.

c. Report signs of infection or bleeding stat.

d. Do not use salt substitutes as they usually are high in K+

4. Evaluation
a. Blood pressure returns to normal limits.
4. Calcium antagonists - nifedipine (Procardia)
A. Effects 3 types of tissue
1. Cardiac muscle or myocardium - Decrease force of myocardial contraction (negative inotropic effect)
2. Cardiac conduction system - Decrease automaticity in SA node (negative chronotropic effect) Slows AV nodal conduction - (negative dromotropic effect)
3. Vascular smooth muscle
a. Coronary arteries/arterioloes - Decreases force of contraction of smooth muscle = coronary artery dilation
b. Peripheral arterioles - Inhibit smooth muscle contraction
B. All decrease PVR and decrease oxygen demands of the heart = decreased B/P
C. Nursing Management
1. Assessment

2. Nursing Diagnoses

Altered mucosal membrane -  Gingivitis/gingival hyperplasia
Altered comfort - Skin rash , Flushing , Dizziness , HA
Altered elimination - Constipation
Altered cardiac output - hypotension ,
Fluid volume excess - edema ,
PC:  bradycardia,
PC: CARDIAC ARREST
PC:  ASYSTOLE

3. Implementation

a. Monitoring
1. Observe EKG for prolonged P-R interval

2. Observe for heart failure

3. Check for hepatic/renal studies

b. Intervention
1. Give on empty stomach

2. Hold if pulse below 50.

3.  Meticulous mouth care.

5. Vasodilators
a. Arteriolar Dilator Drugs - hydralazine hydrochloride (Apresoline)
1. Nursing Management
a. Assessment
1. Monitor for side effects
b. Nursing Diagnoses - side/adverse effects
Oxy: tachycardia, angina, dysrhythmias, orthostatic hypotension, edema

Nutrition: N/V

Elimination: Diarrhea

Protection: drug-induced lupus syndrome

Fluid/Elect: sodium retention

Neuro: peripheral neuritis

c. Implementation
1. Monitoring
a. Weight daily

b. Check CBC, LE cell prep and ANA lab studies

2. Intervention
a. Administer drug with meals
d. Education
1. Do not discontinue abruptly

2. Drug tolerance may develop so keep appointments with doctor

3. Orthostatic hypotension - change position slowly

4. Inform that palpitations/HA may occur during early stages of therapy.

5. Report signs of peripheral neuritis

e. Evaluation
Weigh daily

Check for edema

Observe mental status - cerebral ischemia especially if history of CVA
 

b. Arterial/Venous Dilator Drugs - sodium nitroprusside (Nipride)
Source: McKenry and Salerno, 1998, Chapter 27 and 28

                                                                                                               Designed by
                                                                                                               Carol Zeller

                                                                                                                 Revised 7/01