1. Chapter 44 Antihypertensives
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2. Renin-Angiotensin System
Hypertension
Selected regulators of blood pressure
Kidneys via renin-angiotensin system
Renin-Angiotensin System
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3. Regulators of Blood Pressure
Baroreceptors in the aorta and carotid sinus
Vasomotor center in the medulla
Hormones: antidiuretic hormone (ADH), atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP)
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4. Physiologic Risk Factors
Excessive intake of saturated fat and simple carbohydrates
Alcohol: increases renin secretions
Cultural responses to antihypertensive agents
African Americans
Asian Americans
Hypertension in older adults
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5. Guidelines for Determining Hypertension
Category
Systolic Pressure
Diastolic Pressure
Normal
Less than 120 mm Hg
Less than 80 mm Hg
Prehypertension
120 to 139 mm Hg
80 to 89 mm Hg
Stage 1 hypertension
140 to 159 mm Hg
90 to 99 mm Hg
Stage 2 hypertension
Greater than 160 mm Hg
Greater than 100 mm Hg
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6. Antihypertensive Drugs
Diuretics
Thiazides: hydrochlorothiazide
Loop (high-ceiling) diuretics: furosemide (Lasix)
Combinations of hydrochlorothiazide with potassium-sparing diuretics and other antihypertensive drugs (e.g., ACE inhibitors)
Side effects
Potassium loss or hypokalemia and others
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7. Sympatholytics (Sympathetic Depressants)
Beta-adrenergic blockers
Nonselective beta blockers: propranolol (Inderal) and carvedilol (Coreg)
Selective beta blockers: acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), bisoprolol (Zebeta), and metoprolol (Lopressor)
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8. Beta-Adrenergic Blockers for Hypertension
Noncardioselective beta blockers
Contraindications: chronic obstructive pulmonary disease (COPD)
Cardioselective beta blockers
Contraindications: patients with diabetes mellitus when taking beta blockers
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9. Beta-Adrenergic Blockers for Hypertension (cont.)
Side effects
Marked decrease in blood pressure, insomnia, depression, nightmares, sexual dysfunction
Nursing interventions
Do not abruptly stop taking beta blockers: rebound hypertension may result.
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10. Nursing Process: Beta-Adrenergic Blockers
Assessment
Nursing diagnoses
Planning
Nursing interventions
Patient teaching
Cultural considerations
Evaluation
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11. Sympatholytics (Sympathetic Depressants) (cont.)
Centrally acting alpha2 agonists: methyldopa, clonidine, guanabenz, and guanfacine
Contraindications
Impaired liver function
Side effects
Sodium and water retention, dry mouth, bradycardia
Diuretics are frequently prescribed to avoid fluid retention.
Avoid abruptly stopping drug.
Rebound hypertension may result.
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12. Sympatholytics (Sympathetic Depressants) (cont.)
Alpha-adrenergic blockers
Action
Block the alpha-adrenergic receptors, resulting in vasodilation and decreased blood pressure
Drugs
Doxazosin (Cardura)
Prazosin HCl (Minipress)
Terazosin HCL (Hytrin)
Side effects: orthostatic hypotension, nausea, headache, drowsiness, nasal congestion caused by vasodilation, edema, and weight gain
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13. Sympatholytics (Sympathetic Depressants) (cont.)
Adrenergic neuron blockers (peripherally acting sympatholytics)
Block norepinephrine release from the sympathetic nerve endings, decrease in norepinephrine release, result lower BP
Reserpine
Side effects: Orthostatic hypotension
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14. Sympatholytics (Sympathetic Depressants) (cont.)
Alpha1- and beta1-adrenergic blockers
Labetalol (Normodyne)
Carteolol (Cartrol)
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15. Nursing Process: Alpha- Adrenergic Blockers
Assessment
Nursing diagnoses
Planning
Nursing interventions
Patient teaching
Cultural considerations
Evaluation
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16. Direct-Acting Arteriolar Vasodilators
Relaxing the smooth muscles of the blood vessels, mainly the arteries, causing vasodilation
Hydralazine
Minoxidil
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17. Angiotensin-Converting Enzyme (ACE) Inhibitors
Action
Examples
Benazepril (Lotensin), captopril (Capoten), enalapril maleate (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), and trandolapril (Mavik), captopril (Capoten)
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18. Angiotensin-Converting Enzyme (ACE) Inhibitors (cont.)
African-American adults and older adults
Do not respond with ACEI monotherapy
Do respond when taken with diuretic
Side effects
Irritating cough, insomnia, hyperkalemia, tachycardia
Contraindications
Pregnancy
Potassium-sparing diuretics such as spironolactone (Aldactone)
Salt substitutes that contain potassium
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19. Angiotensin II Receptor Blockers (ARBs)
Action
Examples
Losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro), candesartan cilexetil (Atacand), eprosartan (Teveten), olmesartan medoxomil (Benicar), and telmisartan (Micardis) are examples of ARBs.
Less likely to cause irritating cough
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20. Direct Renin Inhibitor
Action
Example
Aliskiren (Tekturna)
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21. Calcium Channel Blockers
Action
Decrease calcium levels and promote vasodilation
Examples
Diphenylalkylamine (verapamil), benzothiazepines (diltiazem), and dihydropyridine (amlodipine and others)
Side effects/adverse reactions
Flush, headache, dizziness, ankle edema, bradycardia, and AV block
Refer to Table 44-4, Antihypertensives: Calcium Channel Blockers.
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22. Practice Question #1
A patient’s blood pressure (BP) is 142/82 mm Hg. The health care provider prescribed a diuretic to lower this BP. The nurse knows that this BP is
within the prehypertensive range.
indicating stage 1 hypertension.
indicating stage 1 hypertension according to the diastolic pressure.
indicating stage 2 hypertension according to the new guidelines for hypertension.
Answer: B
Rationale: A BP of 142/82 indicates stage 1 hypertension. The systolic range for stage 1 is 140 to 159, and the diastolic range for stage 1 is 90 to 99.
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23. Practice Question #2
A patient is receiving an angiotensin II receptor blocker (ARB). Which does the nurse recognize as an ARB?
Valsartan (Diovan)
Amlodipine (Norvasc)
Captopril (Capoten)
Metoprolol (Lopressor)
Answer: A
Rationale: ARBs have a suffix of -sartan. Valsartan (Diovan) is an ARB. Amlodipine is a calcium channel blocker; captopril is an ACE inhibitor with a common suffix of -pril. Metoprolol is a beta blocker with a common suffix of -lol.
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24. Practice Question #3
A patient is receiving an angiotensin II receptor blocker. It is most important for the nurse to assess the patient for
constipation.
tremors.
asthmatic attacks.
dizziness.
Answer: D
Rationale: Side effects/adverse effects of ARBs include dizziness, diarrhea, insomnia, occasional cough, and upper respiratory infection.
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25. Practice Question #4
An African-American patient is to be treated with initial monotherapy to control hypertension. The nurse expects the patient to receive
A. diuretics.
B. angiotensin-converting enzyme inhibitors.
C. alpha-adrenergic blockers.
D. beta blockers.
Answer: C
Rationale: African Americans do not respond well to diuretics as the initial monotherapy for controlling hypertension. This group is susceptible to low-renin hypertension; therefore, they do not respond well to beta blockers and ACE inhibitors. The antihypertensive drugs that are effective for African Americans are alpha1 blockers and calcium channel blockers.
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26. Practice Question #5
The nurse should instruct a patient to not suddenly stop taking antihypertensives in order to avoid
rebound bradycardia.
rebound tachycardia.
rebound hypertension.
rebound hypotension.
Answer: C
Rationale: Abrupt discontinuation of antihypertensive drugs may cause rebound hypertension.
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27. Practice Question #6
A patient with hypertension is ordered to receive an ACE inhibitor. The nurse identifies a common benign side effect of this class of medications as
hiccups.
flatulence.
abdominal distention.
a dry cough.
Answer: D
Rationale: The primary side effect of ACE inhibitors is a constant, irritated cough. Other side effects include nausea, vomiting, diarrhea, headache, dizziness, fatigue, insomnia, serum potassium excess, and tachycardia.
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28. Practice Question #7
Before administering the alpha-adrenergic blocker prazosin (Minipress), it is most important for the nurse to assess the patient for a history of
renal disease.
refractory heart failure.
hypertension.
benign prostatic hypertrophy.
Answer: A
Rationale: Prazosin (Minipress) is used to treat refractory heart failure, hypertension, and benign prostatic hypertrophy. Contraindication to use of the drug is renal disease.
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29. Practice Question #8
When administering antihypertensive medications to Asian Americans, it is most important for the nurse to
increase the dose of beta blockers.
monitor blood pressure carefully.
expect to administer the usual dose antihypertensive medications.
understand that this cultural group does not believe in treating hypertension.
Answer: B
Rationale: Asian Americans are twice as sensitive as whites to beta blockers and other antihypertensives. A reduction in antihypertensive dosing is frequently needed. Native Americans have a reduced or lower response to beta blockers compared with whites. Monitoring blood pressure and drug dosing should be an ongoing assessment for these cultural groups.
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