ACE Inhibitors

Description
 Angiotensin-converting enzymes inhibitors (ACE Inhibitors) are antihypertensive agents that
act in the lungs to prevent the conversion of angiotensin I into angiotensin II, which is a
potent vasoconstrictor.
Therapeutic Action
 By preventing the production of angiotensin II which is a potent vasoconstrictor and a
stimulator of aldosterone release, blood pressure is decreased with resultant loss of
serum sodium and fluid but with a slight increase in serum potassium.
Indications
 Primarily indicated for hypertension and can be used alone or in combination with other
drugs.
 Aside from its indication in treating hypertension, it is also combined
with diuretics and digoxin in the treatment of heart failure and left ventricular dysfunction.
The resultant effect is decreased in peripheral resistance and blood volume leading to
decreased cardiac workload.
 It is also approved for treatment of diabetic nephropathy, in which the renal artery is being
damaged by diabetes. It is thought that decreased in stimulation of angiotensin receptors
in the kidney will slow down the damage in the renal artery.
 Children: safety and efficacy of ACE inhibitors has not been established in this age group.
 Adults: ACE inhibitors are not allowed during pregnancy.
 Older adults: are more susceptible to drug toxicity because of underlying conditions that
would interfere with metabolism and excretion of drug. Renal and hepatic function should
always be monitored.

Contraindications and Cautions

 Allergy to ACE inhibitors. Prevent severe hypersensitivity reactions.
 Renal impairment. Decreased renal blood flow effect of these drugs can exacerbate renal
impairment.
 Heart failure. Changes in hemodynamics caused by these drugs can exacerbate heart
failure.
 Hyponatremia and hypovolemia. Can be exacerbated by the therapeutic effects of the drug.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus and can decrease
milk production. Pregnant women are advised to use barrier type of contraceptives while
taking this drug.


Adverse Effects
 GI: irritations, ulcer, constipation, liver injury
 GU: renal insufficiency, renal failure, proteinuria
 CV: reflex tachycardia, chest pain, heart failure, cardiac arrhythmias
 EENT: rash, alopecia, dermatitis, photosensitivity
 Captopril is associated with sometimes-fatal pancytopenia, cough, and GI distress.
Interactions
 Allopurinol: increased risk for hypersensitivity
 NSAIDs: increased risk for decreased antihypertensive effects
Nursing Considerations
Here are important nursing considerations when administering this drug:

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history
taking, and examination:

 Assess for the mentioned contraindications to this drug (e.g. renal

impairment, hyponatremia, hypovolemia, etc.) to prevent potential adverse effects.
 Obtain baseline status for weight, vital signs, overall skin condition, and laboratory tests
like renal and hepatic function tests, serum electrolyte, and complete blood count (CBC)
with differential to assess patient’s response to therapy.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:

 Decreased cardiac output related to effect of drug in increasing fluid volume excretion

 Impaired skin integrity related to dermatological effects of the drug
 Increased risk for infection related to potential decreasing effect of drug to circulating
blood cells
Implementation with Rationale
These are vital nursing interventions done in patients who are taking ACE inhibitors:

 Educate patient on importance of healthy lifestyle choices which include regular exercise,
weight loss, smoking cessation, and low-sodium diet to maximize the effect of
antihypertensive therapy.
 Administer drug on empty stomach one hour before or two hours after meal to ensure
optimum drug absorption.
 Monitor renal and hepatic function tests to alert doctor for possible development of renal
and/or hepatic failure as well as to signal need for reduced drug dose.
 Monitor for presence of manifestations that signal decreased in fluid volume
(e.g. diarrhea, vomiting, dehydration) to prevent exacerbation of hypotensive effect of
drug.
 Educate patient and family members about drug’s effect to the body and manifestations
that would need reporting to enhance patient knowledge on drug therapy and promote
adherence.
Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

 Monitor patient response to therapy through blood pressure monitoring.

 Monitor for adverse effects (e.g. hypotension, arrhythmias, renal failure, cough, and
pancytopenia).
 Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.

Angiotensin II-Receptor Blockers

Description
 ARBs are antihypertensive agents that exert their action by blocking vasoconstriction and
release of aldosterone through selective blocking of angiotensin II receptors in vascular
smooth muscles and adrenal cortex.
Therapeutic Action
 The main action is to block the blood pressure raising effect of the renin-angiotensin-
aldosterone system (RAAS).
Indications
 Like ACE inhibitors, they can also be used alone for treatment of hypertension or in
combination with other antihypertensive agents.
 Utilized in treatment of heart failure for patients who do not respond to ACE inhibitors.
 By blocking the effects of angiotensin receptors in vascular endothelium, these drugs are
able to slow down the progress of renal disease in patients with type 2 diabetes and
hypertension.
 Children: safety and efficacy of ARBs has not been established in this age group.
 Adults: ARBs are not allowed during pregnancy.
 Older adults: are more susceptible to drug toxicity because of underlying conditions that
would interfere with metabolism and excretion of drug. Renal and hepatic function should
always be monitored.
Contraindications and Cautions
 Allergy to ARBs. Prevent severe hypersensitivity reactions.
 Renal and hepatic impairment. Can alter metabolism and excretion of drugs which can
increase the risk for toxicity.
 Hypovolemia. Can be exacerbated by the drug’s action on blocking important life-saving
compensatory mechanisms.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus and potential
termination of pregnancy between second and third trimester. It is still not known whether
ARBs can enter breast milk but it is generally not allowed in lactating women because of
potential adverse effects to the neonate.
Adverse Effects
 CNS: headache, dizziness, syncope, weakness
 Respiratory: symptoms of upper respiratory tract infections (URTI), cough
 GI: diarrhea, abdominal pain, nausea, dry mouth, tooth pain
 EENT: rash, alopecia, dry skin

Nursing Considerations
Here are important nursing considerations when administering ARBs:

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history
taking, and examination:

 Assess for the mentioned contraindications to this drug (e.g. drug allergy, hypovolemia,
renal impairment, etc.) to prevent potential adverse effects.
 Obtain baseline status for weight, vital signs, overall skin condition, and laboratory tests
like renal and hepatic function tests, and serum electrolyte to assess patient’s response to
therapy.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:

 Ineffective tissue perfusion related to fluid excretory effect of the drug

 Impaired skin integrity related to dermatological effects of the drug
 Risk for injury related to CNS side effects of the drug
Implementation with Rationale
These are vital nursing interventions done in patients who are taking ARBs:

 Educate patient on importance of healthy lifestyle choices which include regular exercise,
weight loss, smoking cessation, and low-sodium diet to maximize the effect of
antihypertensive therapy.
 Administer drug with food to prevent GI distress associated with drug intake.
 Monitor renal and hepatic function tests to alert doctor for possible development of renal
and/or hepatic failure as well as to signal need for reduced drug dose.
 Provide comfort measures (e.g. quiet environment, relaxation techniques, etc.) to help
patient tolerate drug effects.
 Educate patient and family members about drug’s effect to the body and manifestations
that would need reporting to enhance patient knowledge on drug therapy and promote
adherence.

Calcium-Channel Blockers
Description
 Calcium-channel blockers as antihypertensive agents decrease blood pressure, cardiac
workload, and myocardial consumption of oxygen.
 Since these drugs can significantly decrease cardiac workload, they are effective in
treatment of angina.
Therapeutic Action
 These drugs inhibit the movement of calcium ions across myocardial and
arterial musclecell membranes. As a result, action potential of these cells are altered and
cell contractions are blocked.
 Resultant effects include: depressed myocardial contractility, slow cardiac impulse in
conductive tissues, and arterial dilation and relaxation.
Indications
 Like ACE inhibitors and ARBs, they can also be used alone for treatment of hypertension
or in combination with other antihypertensive agents.
 Extended-release preparations are usually indicated for hypertensions in adults.
 Children: calcium-channel blockers is the drug group that is first considered in cases of
hypertension in this age group that needs drug therapy.
 Adults: these drugs are not allowed during pregnancy.
 Older adults: are more susceptible to drug toxicity because of underlying conditions that
would interfere with metabolism and excretion of drug. Renal and hepatic function should
always be monitored.
Contraindications and Cautions
 Allergy to calcium-channel blockers. Prevent severe hypersensitivity reactions.
 Heart block (sick sinus syndrome). Can be exacerbated by conduction-slowing effect of the
drug.
 Renal and hepatic impairment. Can alter metabolism and excretion of drugs which can
increase the risk for toxicity.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus and should not be
used unless the benefit to the mother clearly outweighs the risk to the fetus. It is not clear
whether this drug can enter breast milk so another method of feeding is implemented for
lactating mothers who are taking this drug.
Adverse Effects
 CNS: headache, dizziness, light-headedness, fatigue
 CV: hypotension, bradycardia, peripheral edema, heart block
 GI: nausea, hepatic injury
 EENT: rash, skin flushing
Interactions
 Increased serum level and toxicity of cyclosporine if taken with diltiazem.
 Grapefruit juice can increase serum level and toxicity of calcium-channel blockers.
Nursing Considerations
Here are important nursing considerations when administering calcium-channel blockers:

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history
taking, and examination:

 Assess for the mentioned contraindications to this drug (e.g. headache, rash, bradycardia,
etc.) to prevent potential adverse effects.
 Monitor cardiopulmonary status closely as the drug can cause severe effects on these
two body systems.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:

 Decreased cardiac output related to hypotension and vasodilating effect of the drug
 Risk for injury related to cardiovascular and CNS adverse drug effects
Implementation with Rationale
These are vital nursing interventions done in patients who are taking calcium-channel
blockers:

 Educate patient on importance of healthy lifestyle choices which include regular exercise,
weight loss, smoking cessation, and low-sodium diet to maximize the effect of
antihypertensive therapy.
 Monitor blood pressure and heart rate and rhythm to detect possible development of
adverse effects.
 Provide comfort measures for the patient to tolerate side effects (e.g. small frequent
meals for nausea, limiting noise and controlling room light and temperature to prevent
aggravation of stress which can increase demand to the heart, etc.)
 Educate patient and family members about drug’s effect to the body and manifestations
that would need reporting to enhance patient knowledge on drug therapy and promote
adherence.
 Emphasize to the client the importance of strict adherence to drug therapy to ensure
maximum therapeutic effects.

Vasodilators
Description
 Direct vasodilators are used when the previous drugs mentioned are not effective.
 These antihypertensive agents are reserved for severe hypertension and hypertensive
emergencies.
Therapeutic Action
 These antihypertensive agents exert their effect by acting directly on smooth muscles.
Consequently, there will be muscle relaxation and vasodilation. Both of these will cause
drop in blood pressure.
Indications
 As mentioned, these drugs are only used for hypertension cases that do not respond to
other drug therapies.
 Nitroprusside is used in maintaining controlled hypotension during surgery.
 Nitroprusside is administered intravenously; hydralazine is available for oral, intravenous,
and intramuscular use; and minoxidil is available for oral use only.
Contraindications and Cautions
 Allergy to direct vasodilators. Prevent severe hypersensitivity reactions.
 Cerebral insufficiency. Can be exacerbated by drug’s action to cause sudden drop in blood
pressure.
 Peripheral vascular disease, CAD, heart failure, tachycardia. These conditions can be
exacerbated by sudden drop in blood pressure.
 Pregnancy and lactation. Can cause potential adverse effects to the fetus and should not be
used unless the benefit to the mother clearly outweighs the risk to the fetus. The drug can
enter the breast milk and can cause potential adverse effects to the neonate. If needed by
lactating mothers, another method of feeding is instituted.
Adverse Effects
 CNS: headache, dizziness, anxiety
 CV: reflex tachycardia, heart failure, edema, chest pain
 GI: nausea, vomiting, GI upset
 EENT: rash, lesions (e.g. minoxidil is associated with abnormal hair growth.)
 Nitroprusside is metabolized into cyanide so it can cause cyanide toxicity characterized by
dyspnea, ataxia, loss of consciousness, distant heart sounds, and dilated pupil.
 Nitroprusside suppresses iodine uptake which leads to development of hypothyroidism.
Interactions
 Each drug in this group act differently on the body so each drug should be checked for
potential drug-to-drug and drug-to-food interactions.
Nursing Considerations
Here are important nursing considerations when administering direct vasodilators:

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history
taking, and examination:

 Assess for the mentioned contraindications to this drug (e.g. drug allergy, CAD, cerebral
insufficiency etc.) to prevent potential adverse effects.
 Obtain baseline status for weight, vital signs, overall skin condition, and laboratory tests
like renal and hepatic function tests, and serum electrolyte to assess patient’s response to
therapy.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:
 Decreased tissue perfusion related to changes in volume of blood pumped out by the
heart
 Acute pain related to GI distress, headache, and skin effects of the drug
Implementation with Rationale
These are vital nursing interventions done in patients who are taking vasodilators:

 Educate patient on importance of healthy lifestyle choices which include regular exercise,
weight loss, smoking cessation, and low-sodium diet to maximize the effect of
antihypertensive therapy.
 Monitor blood pressure and heart rate and rhythm closely to evaluate for effectiveness
and ensure quick response if blood pressure falls rapidly or too much.
 Provide comfort measures for the patient to tolerate side effects (e.g. small frequent
meals for nausea, limiting noise and controlling room light and temperature to prevent
aggravation of stress which can increase demand to the heart, etc.)
 Monitor patient for any manifestations that could decrease fluid volume inside the body
(e.g. vomiting, diarrhea, excessive sweating, etc.) to detect and treat excessive
hypotension.
 Educate patient and family members about drug’s effect to the body and manifestations
that would need reporting to enhance patient knowledge on drug therapy and promote
adherence.
 Emphasize to the client the importance of strict adherence to drug therapy to ensure
maximum therapeutic effects.