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Afterload definition
Resistance to blood outflow from heart
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Increase in afterload =
- Increased resistance
- Vasoconstriction
- Increased BP
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Decrease in afterload =
- Decrease in resistance
- Vasodialation
- Heart doesnt have to work as hard
- AKA "unload"
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Hypertension definition
Generally refers to a persistent elevation of BP greater than 140/90 mmHg
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Essential HTN (cause)
Unknown direct cause
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Secondary HTN (cause)
- Linked to another problem
- Ex: Renal disease
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Risk factors for HTN
- Smoking
- Obesity
- Diabetes mellitus
- Dyslipidemia
- Physical inactivity
- Diet
- Age (over 60)
- Genetic predisposition, male gender
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Lifestyle modifications
- Diet
- Alcohol moderation
- Exercise/weight reduction
- Stop smoking
- Stress management
- Control of diabetes
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Pharmacological classes of HTN drugs
- ACE-I
- ARBs
- Beta blockers
- Calcium channel blockers
- Diuretics
- Extras
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ACE-I generic drugs end in what?
-prils
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ACE-I mechanism of action
Blocks the angiotensin converting enzyme (ACE)
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What does the angiotensin converting enzyme do?
The ACE converts angiotensin I to angiotensin II (ATII), a potent vasoconstrictor
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Therapeutic effects of ACE-I
- Decrease in BP, constriction, resistance, & afterload
- Renal protective vascular effects
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Indications of ACE-I
- HTN
- CHF & MI
- Renal protection in diabetic patients
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Precautions of ACE-I
- Other antihypertensives and diuretics may increase hypotensive effects
- Impaired renal function
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Contraindicaitons of ACE-I
- Baseline hyperkalemia (drug will increase K)
- Children, pregnant, lactating women
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Normal potassium range
3.5-5
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Side/adverse effects of ACE-I
- "ACE cough"
- Fatigue
- Dizziness
- Hyperkalemia
- Angioedema (swelling of face)
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Nursing actions of ACE-I
- Assessment: BP, I/O, daily weight, side effects
- Physical assessment focus: Cardiac, pulmonary
- Lab work: Potassium levels, renal function
- Patient education: Side effects, BP monitoring, drug interactions, hypotension symptoms, renal function
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Prototype drugs for ACE-I
- Vasotec (enalapril)
- Zestril (lisinopril)
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ARB generic drugs end in what?
-sartans
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ARB mechanism of action
Block binding of ATII to its receptors
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Therapeutic effects of ARBs
- Decrease BP, constriction, resistance, & afterload
- Renal protective vascular effects
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Indications of ARBs
- HTN (often used for those who are intolerant of ACE-I)
- CHF & MI
- Renal protection in diabetic patients
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Precautions of ARBs
- Other hypertensives and diuretics may increase hypotensive effects
- Impaired renal funciton
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Contraindications of ARBs
- Baseline hyperkalemia (drug will increase K)
- Children, pregnant & lactating women
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Side/adverse effects
- Headache
- Upper respiratory infection
- Sinusitis
- Muscle weakness/cramps
- Angioedema
- Fatigue
- Dizziness
- Hyperkalemia
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Nursing actions of ARBs
- Assessment: BP, I/O, daily weight, side effects
- Physical assessment focus: Cardiac & pulmonary
- Lab work: Potassium levels, renal function
- Patient education: Side effects, BP monitoring, drug interactions, hypotension symptoms, renal function
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Prototype drugs for ARBs
- Benicar (olmesartan)
- Cozaar (losartan)
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Beta blocker generic drugs end in what?
-olol
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Mechanism of action of beta blockers
- Cardioselective: Bind to, and block B1 receptors (May still block some B2)
- Nonselective: Bind to, and block any B receptor
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B1 receptors are located in what part of the body?
Heart
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B2 receptors are located in what part of the body?
Lungs
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Therapeutic effects of beta blockers
- Decrease BP, constriction, resistance & afterload
- Negative chronotrope
- Negative inotrope
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Inotrope =
Contractility (force of contractions)
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Indications of beta blockers
- HTN
- Angina (chest pain)
- Cardiac dysrhythmias
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Precautions of beta blockers
- Other antihypertensives and diuretics may increase hypotensive effects
- Pulmonary disease or illness
- Heart failure; bradycardia
- Can mask evidence of hypoglycemia
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Contraindications of beta blockers
- Some pulmonary diseases
- Some cardiac dysrhythmias
- (patient specific)
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Side/adverse effects of beta blockers
- CHF
- Some dysrhythmias
- Bronchospasm/bronchoconstriction (dyspnea, wheezing)
- Fatigue
- Depression
- Impotence
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Nursing actions for beta blockers
- Assessment: BP, HR, pulmonary status, I/O, daily weight, side effects
- Physical assessment: Cardiac & pulmonary
- Patient education: Side effects, HR/BP monitoring, drug interactions, hypotension symptoms, renal function, effects with stress testing
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Prototype drugs for beta blockers
- Inderal (propranolol)
- Lopressor (metoprolol)
- Tenormin (atenolol)
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Mechanism of action of calcium channel blockers (CCBs)
- Inhibits the transport of calcium into myocardial and smooth muscle cells
- Decrease cardiac output
- Decrease HR and force of myocardial contraction
- (Not as strong as beta blockers)
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Therapeutic effects of calcium channel blockers
- Decrease BP, constriction, resistance, & afterload
- Negative chronotrope
- Negative inotrope
- Decrease coronary artery spasms
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Indications of calcium channel blockers
- HTN
- Cardiac dysrhythmias
- Angina
- Migraine headaches
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Precautions of calcium channel blockers
- Other hypertensives and diuretics may increase hypotensive effects
- Bradycardia
- Heart failure
- Fluid overload
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Contraindications of calcium channel blockers
- Acute MI
- Some cardiac dysrhythmias
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Side/adverse effects of calcium channel blockers
- Bradycardia/tachycardia
- Fluid overload, peripheral edema
- Constipation
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Nursing actions of calcium channel blockers
- Assessment: BP, HR, I/O, peripheral edema, daily weight, side effects
- Physical assessment: Cardiac & pulmonary
- Patient education: Side effects, HR/BP monitoring, drug interactions, hypotension symptoms, renal function
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Prototype drugs for calcium channel blockers
- Calan (verapamil)
- Cardizem (diltiazem)
- Norvasc (amlodipine)
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Classes of diuretics
- Loop
- Potassium-sparing
- Thiazide and thiazide-like
- Osmotic
- Carbonic anhydrase inhibitors (CAI)
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Mechanism of action of loop diuretics
- Inhibits Na+ and Cl- reabsorption in the loop of henle, and, therefore, H2O
- Dilates blood vessels
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Therapeutic effects of loop diuretics
Potent diuresis resulting in substantial fluid loss
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Indications of loop diuretics
- HTN
- Fluid overload/edema associated with CHF, hepatic or renal disease
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Precautions of loop diuretics
- Impaired renal function
- Pre-existing intravascular dehydration
- Pre-existing electrolyte disturbances (hypokalemia)
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Contraindications of loop diuretics
- Chronic renal failure
- Untreated dehydration/electrolyte disturbances
- Sulfa allergy
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Side/adverse effects of loop diuretics
- Electrolyte disturbances = hypokalemia
- Dehydration
- Hypotension
- Dizziness
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Nursing actions for loop diuretics
Assessment: BP, I/O, K+, Mg++
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Prototype drugs for loop diuretics
Lasix (furosemide)
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Mechanism of action of potassium-sparing diuretics
- Acts of distal tubule
- Block sodium/potassium exchange
- Block aldosterone receptors
- Increase Na+ and H2O excretion while retaining K+ and H+
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Therapeutic effect of potassium-sparing diuretics
- Diuresis
- Less K+ excretion
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Indications of potassium-sparing diuretics
- HTN
- Fluid overload/edema
- Hyperaldosteronism
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Precautions of potassium-sparing diuretics
- Impaired renal function
- Pre-existing dehydration
- Pre-existing electrolyte disturbance (hyperkalemia)
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Contraindications of potassium-sparing diuretics
- Untreated dehydration/electrolyte disturbances
- Renal failure
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Side/adverse effects of potassium-sparing diuretics
- Electrolyte disturbances = hyperkalemia
- Weakness
- Dizziness
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Nursing actions for potassium-sparing diuretics
Assessment: I/O, BP, K+
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Prototype drugs for potassium-sparing diureticsÂ
Aldactone (spironolactone)
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Mechanism of action for thiazide and thiazide-like diuretics
- Inhibit Na+, K+, and Cl- reabsorption in the distal tube --> water loss
- Relaxes/dilates peripheral arterioles
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Therapeutic effects of thiazide and thiazide-like diuretics
- Excretion of H2O, Na+, K+, Cl-, without altering the pH
- Peripheral arteriole relaxation = decreased resistance and afterload
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Indications of thiazide and thiazide-like diuretics
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Precautions of thiazide and thiazide-like diuretics
- Impaired renal function
- Pre-existing dehydration
- Pre-existing electrolyte disturbance (hypokalemia)
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Contraindications of thiazide and thiazide-like diuretics
- Severe renal failure
- Hepatic coma
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Side/adverse effects of thiazide and thiazide-like diuretics
- Electrolyte disturbances (hypokalemia)
- Headache
- Dizziness
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Nursing actions of thiazide and thiazide-like diuretics
Assessment: I/O, BP, K+
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Prototype drugs for thiazide and thiazide-like diuretics
- HydroDiuril or Microzide (hydrochlorothiazide, HCTZ)
- Zaroxolyn (metolazone)
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Mechanism of action of osmotic diuretics
- Increase osmotic pressure in glomerular filtrate
- Fluid pulled into renal tubules, especially proximal and descending loop of henle
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Therapeutic effects of osmotic diuretics
- Osmotic diuresis, with minimal effects on electrolytes
- Shifts fluid: decrease cerebral edema = decrease intracranial pressure (ICP)
- Early acute renal failure: rapid excretion of fluid from kidneys
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Indications of osmotic diuretics
- Considered the osmotic diuretic of choice
- Increased intracranial pressure
- Early acute renal failure
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Precautions for osmotic diuretics
- IV solution must be filtered because it crystalizes
- Should be stopped if cardiac, pulmonary, or renal impairment occurs
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Contraindications of osmotic diuretics
- Severe renal disease
- Pulmonary edema
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Side/adverse effects of osmotic diuretics
- Convulsions
- Pulmonary congestion
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Nursing actions of osmotic diuretics
- Assessment: I/O, BP, renal function, electrolytes
- Physical assessment: Neuro, pulmonary, renal
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Prototype drugs for osmotic diuretics
Osmitrol (mannitol)
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Mechanism of action of carbonic anhydrase inhibitors (CAI)
- Inhibits carbonic anhydrase activity to decrease sodium bicarbonate production
- Sodium/water excretion
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Therapeutic effects of carbonic anhydrase inhibitors (CAI)
- Decrease circulating sodium bicarbonate
- Decrease aqueous humor production which decreases intraocular pressure (IOP)
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Indications of carbonic anhydrase inhibitors (CAI)
- Altitude sickness
- Edema resistant to other treatment
- Glaucoma; increased intraocular pressure
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Precautions for carbonic anhydrase inhibitors (CAI)
Electrolyte disturbances
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Contraindications for carbonic anhydrase inhibitors (CAI)
- Severe renal or hepatic dysfunction
- Adrenal gland dysfunction
- Pre-existing electrolyte imbalance (hyponatremia, hypokalemia)
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Side/adverse effects of carbonic anhydrase inhibitors (CAI)
- Acidosis
- Drowsiness, paresthesias
- Hypokalemia
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Nursing actions for carbonic anhydrase inhibitors (CAI)
Assessment: I/O, acid base balance, serum glucose/fingerstick blood sugars
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Prototype drugs for carbonic anhydrase inhibitors
Diamox (acetazolamide)
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Mechanism of action for alpha1 antagonists
- Blocks alpha1 - adrenergic receptors
- Prevents norepinepherine from attaching which leads to smooth muscle relaxation
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Therapeutic effects of alpha1 antagonists
- Decrease BP = (relaxes/dilates peripheral arterioles and veins)
- Relaxes smooth muscle of bladder neck and urethra
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Indications of alpha1 antagonists
- HTN
- Benign prostatic hypertrophy (BPH) (overgrowth of prostatic gland)
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Precautions for alpha1 antagonists
Hepatic or renal disease
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Contraindications of alpha1 antagonists
Acute heart failure
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Side/adverse effects of alpha1 antagonists
- Orthostatic hypotension
- Dizziness
- Headache
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Nursing actions for alpha1 antagonists
- Assessment: HR, BP, I/O, urinary symptoms
- Patient education: drug/side effects, BP monitoring, drug interactions, hypotension symptoms, urinary function
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Prototype drugs for alpha1 antagonists
Cardura (doxazosin)
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Mechanism of action for alpha1 (a1) and beta (B) receptor blocker
- Nonselective receptor blocker which leads to smooth muscle relaxation
- Negative inotrope
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Therapeutic effects of a1 and B receptor blockers
- Decrease progression of heart failure
- Decrease myocardial oxygen demand
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Indications of a1 and B receptor blockers
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Precautions for a1 and B receptor blockers
Some pulmonary and cardiac diseases
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Contraindications for a1 and B receptor blockers
- Decompensated class 4 heart failure
- Asthma
- Cardiac dysrhythmias
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Side/adverse effects of a1 and B receptor blockers
- Bradycardia
- Pulmonary symptoms
- Dizziness
- Fatigue
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Nursing actions for a1 and B receptor blockers
- Assessment: HR, BP
- Physical assessment: Evidence of worsening heart failure
- Patient education: Drug/side effects, HR and BP monitoring, hypotension symptoms, drug interactions
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Prototype drugs for a1 and B receptor blockers
Coreg (carvedilol)
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Mechanism of action of alpha2 (a2) adrenergic agonists
- Stimulate a2 receptors which decreases sympathetic outflow
- Decreases production of norepinepherine and renin activity
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Therapeutic effects of a2 adrenergic agonists
- Peripheral arteriole relaxation
- Decreased resistance and afterload
- Pain control
- Alcohol, opioid, and tobacco withdrawal management
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Indications of a2 adrenergic agonists
- HTN
- Migraine headaches/pain
- Withdrawal symptoms
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Precautions for a2 adrenergic agonists
- Recent MI
- Chronic renal failure
- Liver dysfunction
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Contraindications of a2 adrenergic agonists
- Acute heart failure
- Concurrent use of monoamine oxidase inhibitorsÂ
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Side/adverse effects of a2 adrenergic agonists
- Headache
- Dizziness
- Lightheadness
- Syncope
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Nursing actions for a2 adrenergic agonists
- Monitor BP and HR
- Available as oral, topical, and epidural routes
- Patient education: Drug/side effects, BP monitoring, hypotension symptoms, drug interactions
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Prototype drugs for a2 adrenergic agonists
Catapres (clonidine)
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Mechanism of action for direct vasodilators
Direct arterial smooth muscle vasodilation
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Therapeutic effects of direct vasodilators
Decrease BP, constriction, resistance, afterload
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Indications for direct vasodilators
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Precautions for direct vasodilators
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Contraindications of direct vasodilators
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Side/adverse effects of direct vasodilators
- Headache
- Dizziness
- Reflex tachycardia
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Nursing actions for direct vasodilators
- Assessment: HR/tachycardia, BP
- Patient education: Drug/side effects, BP monitoring, hypotension symptoms, drug interactions
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Prototype drugs for direct vasodilators
Apresoline (hydralazine)
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Mechanism of action for renin inhibitors
- Direct renin inhibitor
- Inhibits conversion of angiotensinogen to angiotensin 1
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Therapeutic effects of renin inhibitors
Decrease BP, constriction, resistance, afterload
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Indications of renin inhibitors
HTN
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Precautions for renin inhibitors
- Increased aliskiren level: Lipitor, Nizoral
- Decreased aliskiren level: Avapro (irbesartan)
- Decreased Lasix (furosemide) level with aliskiren
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Contraindication of renin inhibitors
Children, pregnant and lactating women
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Side/adverse effects of renin inhibitors
- Headache
- Dizziness
- Angioedema
- Cough
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Nursing actions for renin inhibitors
- Assessment: HR, BP, renal function, K+
- Patient education: Drug/side effects, BP monitoring, hypotension symptoms, drug interactions
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Prototype drugs for renin inhibitors
Tekturna (aliskiren)
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