CHAPTER 39

Antihypertensives

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HYPERTENSION

 Selectedregulators of
blood pressure
 Kidneys via renin–
angiotensin system

Renin-Angiotensin System
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REGULATORS OF BLOOD PRESSURE

 Baroreceptorsin 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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PHYSIOLOGIC RISK FACTORS

 Physiologic risk factors

 Excess saturated fat and simple carbohydrates
 Alcohol increases renin secretions.
 Obesity increases cardiac output, stroke
volume, and left ventricular filling.
 Cultural responses to antihypertensive
agents
 African Americans
 Asian Americans

 Hypertension in older adults

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NONPHARMACOLOGIC
CONTROL OF HYPERTENSION

 Nonpharmacologic control
 Stress-reduction techniques
 Exercise

 Salt restriction
 Decrease alcohol ingestion
 Smoking cessation

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GUIDELINES FOR DETERMINING
HYPERTENSION
Category Systolic pressure Diastolic pressure

Normal Less than 120 mm Less than 80 mm

Hg Hg

Prehypertension 120 to 139 mm Hg 80 to 89 mm Hg

Stage 1 140 to 159 mm Hg 90 to 99 mm Hg

hypertension

Stage 2 Greater than 160 Greater than 100

hypertension mm Hg mm Hg

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ANTIHYPERTENSIVE DRUGS

 Diuretics
 Thiazides
 Hydrochlorothiazide
 Loop diuretics
 Furosemide
 Combination of thiazide with potassium-sparing
diuretics
 Combination of thiazide with other antihypertensive
drugs
 ACE inhibitors, beta blockers, ARBs

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SYMPATHOLYTICS

Sympatholytics

Beta-adrenergic blockers
Centrally acting alpha2 agonists
Alpha-adrenergic blockers
Adrenergic neuron blockers
Alpha1- and beta1-adrenergic
blockers

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SYMPATHOLYTICS (CONT.)
 Beta-adrenergic blockers
 Nonselective beta blockers
 Inhibit beta1 and beta2 receptors
 Propranolol and carvedilol
 Cardioselective beta blockers
 Block beta1 receptors
 Acebutolol, atenolol, betaxolol, bisoprolol, and
metoprolol
 Side effects
 Hypotension, dizziness, fatigue
 Insomnia, nightmares
 Depression, sexual dysfunction
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NURSING PROCESS: BETA-
ADRENERGIC BLOCKERS
 Assessment
 Obtain a medication and herbal history from the
patient.
 Obtain vital signs.
 Nursing diagnoses
 Cardiac output, decreased related to variations in
blood pressure readings
 Sexual dysfunction related to a side effect of beta
blockers
 Planning
 The patient’s blood pressure will be decreased.

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NURSING PROCESS: BETA-
ADRENERGIC BLOCKERS (CONT.)
 Nursing interventions
 Monitor vital signs.
 Monitor laboratory results, especially BUN, serum
creatinine, AST, and LDH.
 Do not abruptly stop taking beta blockers as
rebound hypertension may result.
 Advise patients to avoid over-the-counter drugs
without first checking with a health care provider.
 Evaluation

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SYMPATHOLYTICS

 Centrally acting alpha2 agonists

 Methyldopa,clonidine, guanabenz,
and guanfacine
 Action

 Stimulate alpha2 receptors

 Decrease cardiac output
 Decrease epinephrine,
norepinephrine, and renin release
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SYMPATHOLYTICS (CONT.)

 Centrally acting alpha2 agonists

 Contraindications

 Impaired liver function

 Side effects
 Sodium and water retention
 Dry mouth, bradycardia
 Avoid abruptly stopping drug
 Rebound hypertension may result.
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SYMPATHOLYTICS (CONT.)
 Alpha-adrenergic blockers
 Doxazosin, prazosin, terazosin
 Action
 Block the alpha-adrenergic receptors
 Result in vasodilation of arteries and veins and decreased blood
pressure
 Side effects
 Orthostatic hypotension
 Headache, drowsiness
 Nausea, nasal congestion
 Edema, weight gain or
 Syncope, sexual dysfunction
 Increased drowsiness, orthostatic hypotension, HR
 Need to be recumbent for 3 – 4 hours after initial dose
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SYMPATHOLYTICS (CONT.)

 Adrenergic neuron blockers

 Reserpine
 Action
 Block norepinephrine release from the sympathetic
nerve endings, decrease in norepinephrine
release, result lower BP
 Side effects
 Orthostatic hypotension, tachycardia
 Dizziness, drowsiness, headache
 Nasal congestion, edema, weight gain

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SYMPATHOLYTICS (CONT.)

 Alpha1- and beta1-adrenergic blockers

 ‘lol’ team: Labetalol, carteolol, propranolol (Inderal)
 Action
 Blocks alpha1 receptors; binds to beta 1 (cardiac)
and beta 2 (lungs) adrenergic receptor sites that
prevents the release of catecholamine. ↓
contractility, ↓ renin release, ↓ in the sympathetic
output.
 Side effects
 Hypotension
 Bradycardia
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NURSING PROCESS: ALPHA-
ADRENERGIC BLOCKERS
 Assessment
 Obtain a medication history including current
drugs.
 Obtain baseline vital signs and weight for
future comparisons.
 Nursing diagnoses
 Activity intolerance, risk for
 Planning
 The patient’s blood pressure will decrease.

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NURSING PROCESS: ALPHA-
ADRENERGIC BLOCKERS (CONT.)
 Nursing interventions
 Monitor vital signs.
 Check daily for fluid retention in extremities
and weight gain.
 Advise patients to comply with the drug
regimen.
 Inform patients that orthostatic hypotension
may occur.
 Teach patient to monitor daily weights.
 Evaluation

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DIRECT-ACTING ARTERIOLAR
VASODILATORS
 Hydralazine, minoxidil
 Action

 Relax smooth muscles of blood vessels,

especially arteries causing vasodilation
 Side effects
 Tachycardia, palpitations, edema
 Headache, dizziness, nasal congestion
 GI bleeding, lupus-like symptoms
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 ANGIOTENSIN-CONVERTING ENZYME
(ACE) INHIBITORS

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ANGIOTENSIN-CONVERTING ENZYME
(ACE) INHIBITORS
 ‘pril sisters’: Benazepril, captopril, enalapril maleate,
fosinopril, lisinopril, moexipril, perindopril, quinapril,
ramipril, trandolapril
 Action
 Inhibits formation of angiotensin II
 Blocks release of aldosterone
 Side effects
 Nonproductive cough, fatigue, insomnia
 Nausea, vomiting, diarrhea, hyperkalemia
 Dizziness, tachycardia, hypotension, angioedema

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 ANGIOTENSIN-CONVERTING ENZYME
(ACE) INHIBITORS
 Actions: STROL
 Systemic Vascular Resistance (SVR),
Peripheral Vascular Resistance (PVR) ↓
 Tx of MI
 Release of aldosterone ↓
 Occult diabetic nephropathy
 LVD (left ventricular dilation) after MI

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 ANGIOTENSIN-CONVERTING ENZYME
(ACE) INHIBITORS
 Undesirable effects: CHF
 Cough

 Contraindicated in renal artery stenosis

 Hypotension

 Hyperkalemia

 First dose-watch for hypotension

 Food has loss of taste

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ANGIOTENSIN-CONVERTING ENZYME
(ACE) INHIBITORS (CONT.)

 African-American adults and older adults

 Do not respond with ACEI monotherapy
 Contraindications
 Pregnancy
 Potassium-sparing diuretics
 Salt substitutes that contain potassium

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ANGIOTENSIN II RECEPTOR
BLOCKERS (ARBS)
 ‘sartan’ sisters: Losartan, valsartan, irbesartan, eprosartan,
candesartan, olmesartan, telmisartan
 Action
 Prevent release of aldosterone
 Act on renin–angiotensin–aldosterone system
 Block angiotensin II from angiotensin I receptors
 Side effects
 Dizziness, hypotension, headache
 Hyperkalemia, hyperglycemia
 GI distress, diarrhea, pyrosis

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 ANGIOTENSIN II RECEPTOR
BLOCKERS (ARBS)
Administer without regard to meals

Renal function tests-review

Blocks vasoconstriction effect of

renin-angiotensin system
Salt substitution or potassium
supplements-do not use

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DIRECT RENIN INHIBITOR

 Aliskiren
 Action
 Bind with renin causing a reduction of angiotensin
I, angiotensin II, and aldosterone levels
 Side effects

 Hypotension, peripheral edema

 Hyperkalemia, diarrhea, renal failure
 Stevens-Johnson syndrome

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CALCIUM CHANNEL BLOCKERS

 Verapamil, diltiazem, amlodipine, felodipine,

nifedipine (Adalat, Procardia)
 Action
 Slow calcium channels in myocardium and
vascular smooth muscle cells promoting
vasodilation
 Side effects/adverse reactions
 Flushing, headache, dizziness
 Peripheral edema, fatigue
 GI distress, constipation
 Bradycardia, hypotension, palpitations

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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.

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PRACTICE QUESTION #2
A patient is receiving an angiotensin II receptor
blocker. Which does the nurse recognize as an
angiotensin II receptor blocker?

A. Valsartan
B. Amlodipine
C. Captopril
D. Metoprolol

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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. constipation.
B. tremors.
C. asthmatic attacks.
D. dizziness.

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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.

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PRACTICE QUESTION #5
The nurse should instruct a patient to not
suddenly stop taking antihypertensives in order
to avoid

A. rebound bradycardia.
B. rebound tachycardia.
C. rebound hypertension.
D. rebound hypotension.

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PRACTICE QUESTION #6
A patient with hypertension is ordered to receive an
angiotensin-converting enzyme inhibitor. The nurse
identifies a common benign side effect of this class
of medications as

A. hiccups.
B. flatulence.
C. abdominal distention.
D. a dry cough.

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PRACTICE QUESTION #7
Before administering the alpha-adrenergic
blocker prazosin, it is most important for the
nurse to assess the patient for a history of

A. renal disease.
B. refractory heart failure.
C. hypertension.
D. benign prostatic hypertrophy.

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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 of
antihypertensive medications.
D. understand that this cultural group does not believe
in treating hypertension.

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