Exam 1 Chapter 39 AntiHypertensives Flashcards
Purpose of DIURETICS
Decrease BP
Decrease edema
Beta blockers 1 and 2
Heart kidneys lungs Beta 1
Lungs Liver Beta 2
Metoprolol is a Beta Blocker
Non-selective or Selective
Selective - one receptor effect
Antagonist on Beta 1
Decrease in HR
Decrease in heart contractility
Decrease in BP
Decrease the workload of the heart, dec. oxygen need
Regulators of BP
- Kidneys - secrete - Renin
- Baroreceptor stimulation - coronary arteries/Adrenal glands
if brady, will stim. neuor/catecholamines/norepinephrine
Stimulate/agonize: beta 1,2 receptors alpha 1,
will inc HR, BP - Antidiuretic hormone - (ADH) Pituitary gland. Inc ADH (less pee, bp up less ADH, pee more, bp goes down, less volume.
- BNP Brain Natriuretic Peptide - released from the heart
BNP - Brain natriuretic Peptide
Muscles cells of the heart releases it.
when the heart senses it needs to contract more
with fluid overload it releases more.
RAAS System
Renin angiotensin aldosterone system
- Kidney releases renin
- Liver releases angiotensinogen
- Angiotensin I - weak vasoconstrictor
- ACE - angiotensin converting enzyme
- Angiotensin II - potent vasoconstrictor
Two Functions - - Peripheral vasoconstriction, inc BP
ARBS (angiotensin receptor blocker) can stop this - Aldosterone (Adrenal Glands) - sodium/water retention (inc. BP) - restores fluid
RAAS - review diagram
Lifestyle modifications for hypertension
COME FIRST and part of
ANY TREATMENT PLAN
Smoking cessation
Diet (Eat more colors, the rainbow) limit sodium
Control blood glucose and (Cholesterol) lipids (diabetes –heart disease)
Physical Activity (150 minutes/week)
Two main classes of drugs to control hypertension
(Also known as Anti-hypertension drugs)
ACE inhibitors (no converting to Angiotensin II)
ARBS (allows the conversion, but then blocks the receptors)
8 types of antihypertensive drug
- Diuretics (pee, decrease Na/water and ECFV)
- Angiotensin II receptor blockers ARBS
- Alpha Beta blockers
4.Calcium Channel Blockers - ACE inhibitors (no conversion to Angiotension II)
- Beta adrenergic blockers - Beta 1 or Beta 1/2
- Centrally acting Alpha 2 agonist
- Direct acting vasodilators -
Why do we give diuretics?
FIrst line for - Hypertension
Heart Failure
Fluid overload
pulmonary edema
peripheral edema
Diuretics - mechanism of action
Prevent kidneys from reabsorbing sodium/water
Vasodilation
Diuretic - Universal Assessment for all
I and O’s
Vital signs /BP. can cause hypotension
Kidney function
Daily weights - gain of more than 3 lbs/day or 5 lbs in a week notify HCP
Electrolytes. - esp. potassium
Safety - walking to bathroom, distance, already incontinent
*Teaching:
If 1x day med - take in the morning, so sleep not interrupted
No sudden position changes - elderly
most photosensitivity
What are the diuretic classes?
- Thiazides
- Loops
- Potassium Sparing
- Osmotic Diuretics
If you give a person a diuretic (foley) outcome would be
increased urine output
Kidney
Fluid enters at:
Nephron
Glomerulus/Bowman’s Capsule
Proximal Tubules 50-55% closest
Loop of Henle 35-40% loop diuretics
Distal Tubule 5-10%
Collecting Tubule < 3%
How much of sodium reabsorbed?
99%
Thiazide Diuretics - Pharmokinetics
Promotes sodium/water loss in distal tubule
Vasodilatory effect
Acute heart failure
would you use a thiazide diuretic?
No - maintenance hypertension heart failure
not for acute emergencies
List 3 Thiazide diuretics
Hydrochlorothiazide (HCT) MOST COMMON
Metolazone
Chlorthalidone
Thiazides are effective for immediate diuresis?
True or false
Thiazides are NOT effective for Immediate diuresis.
Maintenance therapy in heart failure
Potassium
3.5-5. mq/l
hypo excreted from distal renal tubule
Magnesium
1.2-2.5 mq/l
hypo occurs when K+ and Na+ are lost
Calcium
8.6-10.2 mg/dl hyper happens w thiazides as block excretion
Chloride
96-106 mEq/l hypo when Na+ and K+ are lost
BiCarbonate
24-28 mEq/L minimal from proximal tubule
Uric Acid
2.8-8.0 mg/dl hyperuricemia thiazides block release
Blood Glucose
70-99 mg/dl hyperglycemia thiazides inc blood sugar
Who should NOT use THIAZIDES?
CKF GFR > 30
Diabetics
Gout patients
Problems with Thiazides
LOW
HYPOkalemia. - low K+. ie K+=3. Low
HIGH
HYPERcalcemia - high Ca+
HYPERglycemia - high blood sugar
HYPERURICEMIA - gout - high uric acid
Loop Diuretics
promote loss of sodium and water
works in 5 minutes on IV
potent natriuretic effect
If patient is hypokalemia on thiazides
what can they do?
Foods with potassium
fruits and veg. potatoes
or supplements
If allergic to sulfa, can you take a thiazide?
No you will have an allergic reaction.
What to know about patient who is taking
a THIAZIDE -
Know electrolyte level
know K+ level
GFR<30
Allergies to sulfa
First line for hypertension
Loop Diuretics - potassium _______-
Potassium Wasting
at risk for hypokalemia
Name two diuretics are K+ wasting
Thiazides
Loop Diuretics
When are Loop diuretics used?
FV Fluid volume overload
Acute pulmonary edema
Heart failure
OTo get fluid out fast
promote the loss of sodium and water
aggressive drug IV onset 5 minutes
Name Loops
Furosemide (lasix)
Bumetanide (critical care) Bumex
Torsemide (heart failure) Demadex
IDE - LOOPS
S/S of fluid overload
edema
djv
inc rr
bounding pulse
inc pulse
crackles
sob
dec. pulse ox
Black Box Warning for Loops
severe diaphoresis (urination)
Loops can cause what -
electrolyte imbalances
everything doe
hypo K Mg Ca
orthostatic hypotension
HIGH
Hyperglycemia and
Hyperuricemia
Similarities Thiazides and Loop
Hypo K. may need extra K+
Hyperglycemia
Hyperuricemia
Contraindication for Sulfa Allergies
Differences thiazides and loops
thiazides ca up.
Loops ca down
Loops ototoxicity - if aminoglycicides combined worse
Potassium Sparing diuretics works by
altering aldosterone action (less)
sodium/water excreted
so K+ increases, spared
Name most common K+ sparing drug
Spironolactone
Eplerenone
K+ Sparing diuretic used for
heart failure most common
blocking aldosterone action
sodium water are released (anti)ADH
K+ concerns with K+ sparing diuretics
If 5.6 K+ what do you do
3.4-5.0
hyperkalemia
call provider
Male patients with K+ sparing side effects
gynecomastia, will reverse
S/S Hyperkalemia
lethargic
weak
paresthesia
N/V
arrhythmias
numbness, tingling
Why dont take K+ sparing with ARBS or ACE
as they interfere with RAAS ARBS ACE
so can increase more K+ with these.
Can have hyperkalemia
Osmotic diuretics work by
shifting fluid of greater concentration to less concentration
increase renal blood flow and renal vasodilation
cause large amounts of diuresis
Why Osmotic diuretics?
High Pressure in 2 places not necessarily both
1. Cerebral Edema -head inc. intracranial pressure (tumor, trauma)
2. Glaucoma - IOP increased intraocular pressure
Fluid shift to lungs
Osmotic diuretics look for …
Fluid shift to lungs
-crackles in lungs
-dec in pulse ox
-inc HR
Beta Blockers - how do they work
decrease contractility beta 1
negative inotrope = dec cardiac contractility
decrease heart rate beta 1
Dec. Renin secretion beta 1
dec blood pressure beta 1
Beta Blockers - selective and non-selective
Selective beta 1. one heart two kidneys
Non selective Beta 1 and 2 2 lungs one liver
Name beta 1 (selective) blockers
Atenolol. PO
Metoprolol PO and IV
asthma/COPD can only have beta 1
Name beta 1/2 non-selective beta blockers
Propanolol
Labetalol
Sotalol
Why beta blockers
Heart failure
MI
angina
dysrhythmia
CHF
Post MI
To help heart not work as hard
by dec. bpr and contractivity
dec. oxygen demand
Side effects of beta blockers
Fatigue
impotence
dry mouth
bradycardia
hypotension - ck hr and bp.
hold less than 90 systolic
hr less than 60 hold
masking of hypoglycemia NS or S
bronchospasm specific NS
Hold beta blocker when
systolic less than 90
hr less than 60
Beta blockers patient education
nonselective - copd asthma do NOT GIVE
DO not abruptly stop cause heart attack
Antidote for beta blocker
GLUCAGON
HYPERMAGNESEMIA S/S
antidote -calcium gluconate
dec reflexes bowel vital signs
Patient Teaching for beta blockers
Teach how to take their pulse
masking of sugar
non-selective beta 2 less blood sugar release, need less insulin
pregnancy d - not use it
ALPHA/Beta Blockers - how do they work
same as beta blockers - decrease contractility and hr
vasodilation
Name Alpha/beta blockers
CARVEDILOL - think carvel - A+B
For HF
combine non selective beta and alpha
Beta 1 dec hr, dec contractility
Beta 2 bronchoconstriction, dec. glycogenolysis lower blood sugar,
Alpha 1 vasodilation
labetalol po and iv
What are alpha/beta blockers used for?
(Non selective Betas and Alpha 1)
HTN
CHF
Pulmonary Edema
Side effects of Alpha/beta blockers are…
same as beta blockers by
greater risk of HYPOTENSION beta 1 and alpha 1
Teaching AB blockers
no copd, asthma, diabetes concern
parkinsonian
ANGIOTENSION Converting Enzyme Inhibitor
ACE works -
Inhibits the conversion of angiotensin 1 to 2
Vasodilation
Inhibits aldosterone
Name ACES
common ending
Lisinopril
Captopril
Fosinopril
Ramipril
Enalapril
PRIL - coming ending
Think APRIL. A for ACES + PRIL
Who gets ACEs
Hypertension
CHF
Post MI
ACE side effects/
irritating cough - dry hacking
first dose effect - drop BP after first dose
ADVERSE RX:
angioedema - indication of allergic rx swelling of tongue, lips, airway - can develop years later
hyperkalemia
hypotension
ACE nursing concerns
monitor K+
Monitor BP
renal and kidney function
Pregnancy D drugs
ACE and ARBS are similar because the both effect
the __________ system, but at different parts.
RAAS
How does ARBS work
Blocks angiotensin 2 from AT1 receptors
Vasodilation
Inhibits aldosterone
NAME 3 ARBS
common ending
Irbesartan
losartan
valsartan
THINK SARTAN - ARBS
Indications for ARBS
Same as ACE
HTN
CHF
Most MI
ARBS S/E AR
Same as as ACE but no coughfirst dose effect - drop BP after first dose
ADVERSE RX:
angioedema - indication of allergic rx swelling of tongue, lips, airway - can develop years later
hyperkalemia
hypotension
ACES and ARBS nursing concerns similar
monitor renal hepatic function k+
hyperkalemia
pregnancy d
Calcium channel blockers how do they work. - 2 types
inhibits the transport of calcium into vascular smooth muscle
promotes vasodilation
slows cardiac electrical conduction reduce tachy
help to dec angina
dec high bp and irregularities
and relax spasming of coronary arteries
Ca channel blockers what are the 2 types
non-dihypyridens - nothing to do with BP, just HR
Verapamil
Dilitazem (cardazem)
dihyropyridene-
Amlodipine -
Ca Channel Blockers side effects
Hypo tension
bradycardia
edema peripheral. ankles amlodipine
Ca Channel blockers teaching
photosensitive
pulse check
no grapefruit
Stable angina on ca channel blocker
how do you know its working
drug relaxes smooth cardiac muscle
are they still having angina ? less chest pain
Direct Acting Vasodilators
EMERGENCY CARE
AGGRESSIVE DRUGS
what are they used for
relax smooth muscles
potent vasodilators
Direct Acting Vasodilator drugs
Hydralazine - work well on african americans
Minoxidil
Direct Acting Vasodilators side effects
Edema - retains Na/H20
Hypotension
Reflex tachycardia caused by change in blood pressure dropping quickly
Centrally Acting alpha agonists work by. __
stimulating alpha 2 receptors (agonists)
vasodilation
Centrally acting alpha agonist names
**Methyldopa - pregnancy safe
Clonidine
What are CAAA used for?
HTN
PIH methydopa
sode effects edem,a drowsiness, bradycardia
ACE ARBS THiazide, Ca Channel blockers most commonly for what ________
Hypertension
Hypertension and pg drug
Methydopa
short duration beta blocker
Compelling complications what drug used
For a Diabetic - use ACE and ARBS, to protect kidneys
Cultural backgrounds -different responses
***African american - not ACE or ARBS or beta blockers
most effective drugs are ca channel blockers and thiazides
**Asian/American - decrease dose, more sensitive
*Herbs inc. metabolism ephedra moo lang wt. lose supplements, they inc. blood pressure -reconciliation
Asses before and after
Diuretics electrolytes must be managed.
black box warning beta blockers and loop diuretics
Safety - elderly - safe on their feet, orthostatic move slowly.
Case study for diuretic
52 year old black male, 158/92 bmi 30, smoking 1 pack 10 years, rx hct
What are risk factors? Similarities? Differences?
Should he eat K+ rich foods?
Pre assessment
risk: african american, elevated bmi, smoking
HCT (loop) vs Thiazide - both are K+ wasting, risk for hyperkalemia, monitor electrolytes. may require K+ supplementation. if sulfa allergy do not sue, will inc. uric acid and glucose.
Differences: Thiazides hyperkalemia, HCT - hypercalcemia
Loops have a black box warning for ototoxicity and more aggressive.
Yes eat k+ foods.
Preassessment - electrolytes uric acid, blood sugar vitals
Case study 1 month later muscle weakness and fatigue
Na 135, K+ 3.2, Uric acid 4 mg glucose 120
- hypokalemia and elevated glucose
- Symptoms of hypokalemia
- increase K+ food intake and K+ supplementation.
COMMON ENDINGS
ACE AND ARBS
PRIL AND SARTAN
