Chapter 43

Drugs Affecting Blood Pressure

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Elements Determining Blood Pressure

• Heart rate

• Stroke volume

– Amount of blood that is pumped out of the

ventricle with each heartbeat

• Total peripheral resistance

– Resistance of the muscular arteries to the

blood being pumped through them
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Control of Blood Pressure

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 Categories Rating the
Severity of Hypertension

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 Risks for Coronary Artery Disease
Related to Hypertension

• Thickening of the heart muscle

• Increased pressure generated by the muscle on

contraction

• Increased workload on the heart

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 Conditions Related to
Untreated Hypertension

• CAD and cardiac death

• Stroke

• Renal failure

• Loss of vision

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 Potential Causes of Hypotensive States

• Heart muscle is damaged and unable to pump

effectively

• Severe blood loss; blood volume drops dramatically

• Extreme stress when body’s level of norepinephrine

is depleted

– Body is unable to respond to stimuli to raise

blood pressure

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 Stepped Care Approach to
Treating Hypertension
• Step 1: lifestyle modifications are instituted
• Step 2: drug therapy is added if the measures in
step 1 are insufficient
• Step 3: drug dose or class may be changed or
another drug added if the patient’s response is
inadequate
• Step 4: includes all of the above measures with
the addition of more antihypertensive agents until
blood pressure is controlled
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 Types of Drugs Used to Control
Blood Pressure
• Diuretic: decreases serum sodium levels and blood
volume
• Beta-blocker: leads to a decrease in heart rate and
strength of contraction as well as vasodilation
• ACE inhibitor: blocks the conversion of angiotensin I
to angiotensin II; an angiotensin II receptor blocker;
blocks effects of angiotensin on blood vessels
• Calcium channel blocker: relaxes muscle contraction
or other autonomic blockers
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Sympathetic Nervous System Blockers

• Beta-blockers

• Alpha-blockers

• Alpha-adrenergic blockers

• Alpha1-blockers

• Alpha2-agonists

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 ACE Inhibitors
• Action
– Block ACE from converting angiotensin I to
angiotensin II, leading to a decrease in blood
pressure, a decrease in aldosterone production,
and a small increase in serum potassium levels
along with sodium and fluid loss
• Indications
– Treatment of hypertension, CHF, diabetic
nephropathy, and left ventricular dysfunction
following an MI

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 ACE Inhibitors (cont.)
• Pharmacokinetics
– Well absorbed, widely distributed, metabolized in
the liver, and excreted in the urine and feces
• Contraindications
– Allergies
– Impaired renal function
– Pregnancy and lactation
• Caution
– CHF
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 ACE Inhibitors (cont.)

• Adverse effects
– Related to the effects of vasodilation and
alterations in blood flow
– GI irritation
– Renal insufficiency
– Cough
• Drug-to-drug interaction
– Allopurinol
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 Angiotensin II Receptor Blockers
• Action
– Selectively bind with angiotensin II receptor sites in
vascular smooth muscle and in the adrenal gland to
block vasoconstriction and the release of aldosterone
• Indications
– Hypertension, CHF, slow progression of renal disease
in patients with hypertension, and type 2 diabetes
• Pharmacokinetics
– Well absorbed and undergo metabolism in the liver
– Excreted in the urine and feces

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Angiotensin II Receptor Blockers (cont.)
• Contraindications
– Allergy, pregnancy, and lactation
• Cautions
– Hepatic or renal dysfunction and hypovolemia
• Adverse effects
– Headache, dizziness, syncope, and weakness
– GI complaints
– Skin rash and dry skin
• Drug-to-drug interaction
– Phenobarbital
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 Calcium Channel Blocker
• Pharmacokinetics
– Well absorbed, metabolized in the liver, and
excreted in the urine
• Action
– Inhibits the movement of calcium ions across the
membranes of cardiac and arterial muscle cells,
depressing the impulse and leading to slowed
conduction, decreased myocardial contractility, and
dilation of arterioles, which lowers blood pressure
and decreases myocardial oxygen consumption
• Indication
– Treatment of essential hypertension in the extended
release form
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 Calcium Channel Blocker (cont.)
• Contraindications
– Allergy, heart block or sick sinus syndrome, renal
or hepatic dysfunction, pregnancy, and lactation
• Adverse effects
– Related to effects on cardiac output
– GI symptoms
– Cardiovascular symptoms
• Drug-to-drug interaction
– Cyclosporine

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 Vasodilators

• Diazoxide (Hyperstat): increases blood glucose

levels; used IV for hospitalized patients with
severe hypertension
• Hydralazine (Apresoline): maintains increased
renal blood flow
• Minoxidil (Loniten): used only for severe and
unresponsive hypertension
• Nitroprusside (Nitropress): maintains hypertension
during surgery; used for hypertensive crisis
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 Vasodilators (cont.)
• Action
– Act directly on vascular smooth muscle to
cause muscle relaxation, leading to vasodilation
and drop in blood pressure
• Indication
– Severe hypertension
• Pharmacokinetics
– Rapidly absorbed and widely distributed,
metabolized in the liver, and primarily excreted
in the urine
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 Vasodilators (cont.)
• Contraindications
– Allergy, pregnancy, lactation, and cerebral insufficiency
• Cautions
– Peripheral vascular disease, CAD, CHF, and tachycardia
• Adverse effects
– Related to changes in blood pressure
– GI upset
– Cyanide toxicity
• Drug-to-drug interactions
– Based on individual drugs
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 Midodrine
• Action
– Activates alpha-receptors in arteries and veins to
enhance vascular tone and increase blood
pressure
• Indication
– Symptomatic treatment of orthostatic hypotension
• Pharmacokinetics
– Absorbed from the GI tract, metabolized in the
liver, and excreted in the urine

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 Midodrine (cont.)
• Contraindications
– Supine hypertension, CAD, pheochromocytoma, and
urinary retention
• Cautions
– Pregnancy and lactation
– Visual problems
• Adverse effect
– Related to stimulation of alpha-receptors
• Drug-to-drug interactions
– Cardiac glycosides, beta blockers, alpha-adrenergic
agents, and corticosteroids
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Use of Drugs Affecting Blood Pressure
Across the Lifespan

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Prototype ACE Inhibitor

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Prototype Angiotensin II Receptor
Blockers

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Prototype Calcium Channel Blocker

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Prototype Vasodilators

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Nursing Considerations for ACE Inhibitors

• Assessment (history and physical exam)

• Nursing diagnosis

• Implementation

• Evaluation

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Nursing Considerations for Angiotensin II
Receptor Blockers

• Assessment (history and physical exam)

• Nursing diagnosis

• Implementation

• Evaluation

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Nursing Considerations for Calcium
Channel Blocker

• Assessment (history and physical exam)

• Nursing diagnosis

• Implementation

• Evaluation

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Nursing Considerations for Vasodilators

• Assessment (history and physical exam)

• Nursing diagnosis

• Implementation

• Evaluation

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Nursing Considerations for Midodrine

• Assessment (history and physical exam)

• Nursing diagnosis

• Implementation

• Evaluation

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