Ch 43: Medications affecting blood pressure

Classification of Blood Pressure

Hypertension ("Silent Killer") can also be defined by its cause
When a person's blood pressure is above normal limits for a sustained period, a
diagnosis of hypertension is made. The underlying cause of blood pressure fall
into two categories: Primary and Secondary
Unknown cause (Primary)-90% of the people with hypertension have what is
called Primary essential hypertension, idiopathic(a condition that arises
spontaneously for which the cause is unknown) or hypertension with no known
cause. People with essential hypertension usually have elevated total peripheral
resistance (which is the resistance of the arteries to blood flow. As the arteries
constrict, the resistance increases and as they dilate, resistance decreases.
-Sympathetic activity(fight or flight) constrict peripheral arteries
Vasoconstriction drugs increase resistance, while vasodilator drugs decrease it.
Primary hypertension usually show no symptoms
Known cause (Secondary Hypertension) Only about 10% of the people develop
secondary hypertension resulting from a known cause. A clearly identifiable
cause of the blood pressure is determined.

Categories:
Normal blood pressure: systolic <120 mmHg and diastolic < 80 mmHg
Hypertension: systolic 140 or higher, OR diastolic 90 or higher
Prehypertension systolic 120-139 mmHg OR 80-89 mmHg
(These readings lie between the normal and hypertension ranges of stage 1 & 2)
Stage 1-systolic no higher than140- 159 mmHg and diastolic no higher than 99 mmHg
Stage 2- systolic greater than 160 mmHg, OR diastolic greater than 100 mmHg
Note: Most people with hypertension have elevations in both systolic and diastolic, but a
persistent elevation in either one constitutes the diagnosis of hypertension.
**NURSING GOAL THERAPY IS TO RESTORE BLOOD PRESSURE TO NORMAL
Elements Determining Blood Pressure- the pressure in the cardiovascular system is
is determined by:
Heart Rate(pulse) the # of times a person's heart beats per minute. Blood pressure and
heart rate are interrelated components of the cardiovascular system. One can affect the
other. Heart rhythm problem such as cardiac arrhythmia or irregular heart beat.
Stroke Volume- Amount of blood pumped out of the ventricle with each heartbeat
(cardiac output)
Total Peripheral Resistance- Resistance of the muscular arteries to the blood being

pumped through.
The ReninAngiotensin System- is a signaling pathway responsible for regulating the
body's blood pressure. The vasomotor center in the medulla responds to stimuli from
aortic and carotid baroreceptors to cause sympathetic (fight or flight) stimulation. The
kidneys release renin (an enzyme secreted by the kidney) to activate the system,
causing vasoconstriction and increased blood flow.

**controlled hypertension=reduced risk of cardiovascular death and disease**

Steps To Treat Hypertension
Step 1: Lifestyle modifications are instituted
weight reduction
smoking cessation
moderation of alcohol intake
reduction of salt in diet
increase in physical activity

Step 2: Inadequate Response: Continue lifestyle modifications. If the measures in step 1

are not sufficient to lower BP to an acceptable level, then drug therapy is added:
Diuretic(decrease serum sodium levels and blood volume)
Beta-Blocker(leads to a I in heart rate and strength of contraction and vasodilation
Angiotensin-converting-enzyme inhibitor (blocks the conversion of angiotensin I
to angiotensin II
Calcium Channel Blockers (relax muscle contraction or other autonomic blockers

Angiotensin II-receptor blocker(blocks the effects of angiotensin on the blood

vessel)
Step 3: Inadequate response: If the patients response is inadequate, consider change
in drug dose or class, or addition of another drug for combined effect.
NOTE: Fixed-combination drugs are available for treating hypertension. This
allows for fewer tablets or capsules each day, making it easier for the patient
to comply with drug therapy. Fixed- combination drugs should only be used when
the patient has been stabilized on each drug separately.

Step 4: Inadequate Response: All of the above measures are continued with the
addition of a second or third agent or diuretic( more antihypertensive agents) if not
already prescribed until blood pressure is controlled.

Beta Blockers:

Alpha Blockers:

Ace Inhibitors:

Reduce BP by reducing heart rate

Used to treat hypertension

Action: Block ACE from

through beta1 blockade.

Cause reduced secretion of renin
long-term use causes reduced

Usually after other drugs

converting angiotensin I to

have failed due to adverse

angiotensin II, leading to a

peripheral vascular resistance

End in "OLOL"
Examples: nebivolol, propranolol,

effects

decrease in blood pressure,

Clonidine is useful in the

aldosterone, and a small increase in

management of withdrawal

serum potassium levels along with

symptoms in opiod-

sodium and fluid loss

dependent persons

Indications: treatment of

atenolol, metoprolol
High incidence of orthostatic
hypotension
MOST COMMON AFFECT:
o bradycardia w/reflex
tachycardia

o
o
o
o
o

dry mouth
drowsiness, sedation
constipation
edema
sexual dysfunction

hypertension, CHF, diabetic

nephropathy, left ventricle
dysfunction.
Pharmacokinetics: Well absorbed,
widely distributed, metabolized in
the liver, excreted in urine & feces.
Adverse Effects: Related to the
effects of vasodilation and
alterations in blood flow

GI irritation
Renal insufficiency
***cough**
Ends in "pril"
Diuretics:
Decrease plasma and extracellular fluid volumes
Results: decreased preload
Decreased cardiac output
Decreased total peripheral resistance
Overall effect:
Decreased workload of the heart and decreased blood pressure
Thiazide diuretics are the most commonly used diuretics for hypertension

Calcium Channel Blockers

Actions: Inhibits the movement of calcium ions across the membranes of cardiac and
arterial muscle cells, depressing the impulse and leading to slowed conduction, decreased
myocardial contractility, and dilation of arterioles, which lowers blood pressure and decreases
myocardial oxygen consumption
Indications:
Treatment of essential hypertension in the extended release form
Chronic Stable Angina
Atrial Fibrillation
Pharmacokinetics
Well absorbed, metabolized in the liver, and excreted in the urine
Calcium Channel Blockers
Contraindications
Allergy, heart block or sick sinus syndrome, renal or hepatic dysfunction, pregnancy, and
lactation
Adverse Effects
Related to effects on cardiac output
GI symptoms
Cardiovascular symptoms
Drug-to-Drug Interactions

Cyclosporine
Prototype : Vasodilators
Diazoxide (Hyperstat): IV for hospitalized patients with severe hypertension;
increases blood glucose levels
Hydralazine (Apresoline): Maintains increased renal blood flow
Minoxidil (Loniten): Used only for severe and unresponsive hypertension
Nitroprusside (Nitropress): Used for hypertensive crisis; maintain hypertension
during surgery
Actions: Acts directly on vascular smooth muscle to cause muscle relaxation, leading to
vasodilatation, and drop in blood pressure
Indications: Severe hypertension
Pharmacokinetics: Rapidly absorbed and widely distributed, metabolized in the liver,
and primarily excreted in the urine
Contraindications
Allergy, pregnancy, lactation, cerebral insufficiency
Caution
Peripheral vascular disease, CAD, CHF, or tachycardia
Adverse Effects
Related to changes in the blood pressure
GI upset
Cyanide Toxicity
Drug-to-Drug Interactions
Based on individual drug

Angiotensin II Receptor Blockers

Also referred to as angiotensin II blockers or ARBs
Well tolerated
Do not cause a dry cough
End in artan
Allow angiotensin I to be converted to angiotensin II, but block the receptors that receive
angiotensin II
Block vasoconstriction and release of aldosterone
Adverse Reactions
o Upper respiratory infections
o Headache
o May cause occasional dizziness, inability to sleep, diarrhea, dyspnea, heartburn,
nasal
o congestion, back pain, fatigue
Hyperkalemia much less likely to occur
Hypotension
Heart muscle is damaged and unable to pump effectively
Severe blood loss, volume drops dramatically

Extreme stress when bodys levels of Norepinephriine are depleted

Body is unable to respond to stimuli to raise blood pressure
Hypotension Medications
Midodrine
Actions
Activates alpha-receptors in arteries and veins to produce an increase in vascular tone and
an increase in blood pressure
Indications
Symptomatic treatment of orthostatic hypotension
Pharmacokinetics
Absorbed from GI tract, metabolized in the liver, and excreted in the urine
Contraindications
Supine hypertension, CAD, pheochromocytoma, and with urinary retention
Florinef

Nursing Implications
Before beginning therapy, obtain a thorough health history and head-to-toe
physical examination
Assess for contraindications to specific antihypertensive drugs
Assess for conditions that require cautious use of these drugs
Monitor BP during therapy; instruct patients to
keep a journal of regular BP checks
Educate patients about the importance of not missing a dose and taking the
medications exactly as prescribed

Instruct patients to check with their physician for instructions on what to do if a

dose is missed; patients should never double up on doses if a dose is missed
Instruct patients that these drugs should not be stopped abruptly because this may
cause a rebound hypertensive crisis, and perhaps lead to stroke
Oral forms should be given with meals so that absorption is more gradual and
effective
Administer IV forms with extreme caution, and use an IV pump

 Remind patients that medication is only part of therapy. Encourage patients to

watch their diet, stress level, weight, and alcohol intake
Instruct patients to avoid smoking and eating foods high in sodium
Encourage supervised exercise
Teach patients to change positions slowly to avoid syncope from postural
hypotension
Instruct patients to report unusual shortness of breath; difficulty breathing;
swelling of the feet, ankles, face, or around the eyes; weight gain or loss; chest
pain; palpitations; or excessive fatigue
Male patients who take these drugs may not be aware that impotence is an
expected effect, and this may influence compliance with drug therapy
If patients are experiencing serious adverse effects, or if they believe the dose or
medication needs to be changed, they should contact their physician immediately
If a thiazide diuretic is prescribed, monitor magnesium levels, monitor potassium,
monitor sodium
Hot tubs, showers, or baths; hot weather; prolonged sitting or standing; physical
exercise; and alcohol ingestion may aggravate low blood pressure, leading to
fainting and injury; patients should sit or lie down until symptoms subside
Patients should not take any other medications, including over-the-counter drugs,
without first getting the approval of their physician
Educate patients about lifestyle changes that may be needed
Weight loss
Stress management
Supervised exercise
Monitor: Dietary measures, dizziness, fatigue, orthostatic hypotension, toxic effects