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Chapter 44
Antihypertensives
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Hypertension

Selected regulators
of blood pressure

Kidneys via reninangiotensin system
Renin-Angiotensin System
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Physiologic Risk Factors

Physiologic risk factors



Cultural responses to antihypertensive
agents



Excessive intake of saturated fat and simple
carbohydrates
Alcohol: increases renin secretions
African Americans
Asian Americans
Hypertension in older adults
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nursing Process: Beta-Adrenergic
Blockers
Assessment
 Nursing diagnoses
 Planning
 Nursing interventions
 Patient teaching
 Cultural considerations
Evaluation

Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Sympatholytics
(Sympathetic Depressants) (cont.)

Alpha1- and beta1-adrenergic blockers


Labetalol (Normodyne)
Carteolol (Cartrol)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nursing Process: Alpha- Adrenergic
Blockers




Assessment
Nursing diagnoses
Planning
Nursing interventions



Patient teaching
Cultural considerations
Evaluation
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Direct-Acting Arteriolar Vasodilators



Relaxing the smooth muscles of the
blood vessels, mainly the arteries,
causing vasodilation
Hydralazine
Minoxidil
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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)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Direct Renin Inhibitor


Action
Example

Aliskiren (Tekturna)
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Calcium Channel Blockers

Action


Examples


Decrease calcium levels and promote
vasodilation
Diphenylalkylamine (verapamil),
benzothiazepines (diltiazem), and
dihydropyridine (amlodipine and others)
Side effects/adverse reactions

Flush, headache, dizziness, ankle edema,
bradycardia, and AV block
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
A. within the prehypertensive range.
B. indicating stage 1 hypertension.
C. indicating stage 1 hypertension according to the
diastolic pressure.
D. indicating stage 2 hypertension according to the
new guidelines for hypertension.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Practice Question #2
A patient is receiving an angiotensin II
receptor blocker (ARB). Which does the
nurse recognize as an ARB?
A.
B.
C.
D.
Valsartan (Diovan)
Amlodipine (Norvasc)
Captopril (Capoten)
Metoprolol (Lopressor)
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Practice Question #3
A patient is receiving an angiotensin II
receptor blocker. It is most important for the
nurse to assess the patient for
A.
B.
C.
D.
constipation.
tremors.
asthmatic attacks.
dizziness.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Practice Question #5
The nurse should instruct a patient to not
suddenly stop taking antihypertensives in
order to avoid
A.
B.
C.
D.
rebound bradycardia.
rebound tachycardia.
rebound hypertension.
rebound hypotension.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
A.
B.
C.
D.
hiccups.
flatulence.
abdominal distention.
a dry cough.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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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
A.
B.
C.
D.
renal disease.
refractory heart failure.
hypertension.
benign prostatic hypertrophy.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Practice Question #8
When administering antihypertensive
medications to Asian Americans, it is most
important for the nurse to
A. increase the dose of beta blockers.
B. monitor blood pressure carefully.
C. expect to administer the usual dose
antihypertensive medications.
D. understand that this cultural group does not
believe in treating hypertension.
Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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