1. Diuretics
    1. furosemide
      1. Class:
        1. Parenteral & enteral loop diuretic class medication
      2. MOA:
        1. Acts in the thick segment of ascending limb of Henle’s loop to block reabsorption of Na+ and Cl- to prevent passive reabsorption of water
      3. Indications:
        1. Pulmonary edema from heart failure
        2. Edema non-responsive to other agents
        3. HTN not controlled by other agents
        4. Renal disease
      4. Adverse Effects:
        1. ↓ Na+, Cl-, K+, & BP
        2. Transient ototoxicity/Tinnitus; increased risk with other ototoxic meds
        3. Dehydration, with increased risk for thrombosis & emboli
        4. Ventricular dysrhythmias with concurrent digoxin use
      5. Nursing Considerations:
        1. Monitor
          1. I/O
          2. VS & LOC
          3. Weight
          4. Hearing
          5. Electrolytes
          6. Kidney labs
        2. Slow IVP - can give 10-20 mg/min
        3. Administration Time
          1. Morning to early afternoon
        4. Education on potassium-rich sources in diet
        5. Use carefully with other ototoxic drugs, digoxin, and other antihypertensives
        6. Fall precautions
    2. hydrochlorothiazide
      1. Class:
        1. Enteral Thiazide
      2. MOA:
        1. Acts in the early segment of the distal convoluted tubule to block reabsorption of Na+ and Cl- to prevent passive reabsorption of water and modest diuresis
      3. Indications:
        1. Essential Hypertension
        2. Edema Secondary to heart failure, hepatic or renal disease
        3. Diabetes insipidus
        4. Postmenopausal osteoporosis
      4. Adverse Effects:
        1. Similar to loop diuretic, except no ototoxicity
      5. Nursing Considerations:
        1. Contraindicated with patients with low GFR
        2. Monitor
          1. I/O
          2. VS
          3. Weight
          4. Electrolytes
          5. Kidney labs
        3. Administration Time
          1. Morning to early afternoon
        4. Fall precautions
        5. Use carefully with digoxin and other antihypertensives
    3. spironolactone
      1. Class:
        1. Enteral potassium-sparing/aldosterone antagonist
      2. MOA:
        1. Blocks the actions of aldosterone in the distal nephron to produce diuresis Little UOP as monotherapy, often combined with others Acts as a hormone and can interact with the receptor sites of other hormones
      3. Indications:
        1. Essential hypertension when co-administered with potassium-wasting diuretics
        2. Edema
        3. Heart Failure
        4. Hyperaldosteronism
      4. Adverse Effects:
        1. Hyperkalemia
        2. ↓BP
        3. Endocrine effects
          1. Menstrual irregularities
          2. Impotence
          3. Deep voice
          4. Hirsutism
        4. Arrhythmias
      5. Nursing Considerations:
        1. Monitor
          1. I/O
          2. VS
          3. Weight
          4. Electrolytes
          5. ECG
          6. Kidney labs
        2. Educate patient on monitoring intake of potassium-rich sources in diet
        3. Use cautiously with ACE inhibitors or ARBs (may worsen hyperkalemeia)
    4. triamterene
      1. Similar to spiralactone
        1. NOT a hormone
        2. Urine turns bluish color
    5. mannitol
      1. Class:
        1. Parenteral osmotic diuretic
      2. MOA:
        1. Large molecular osmotic (sugar alcohol) Once filtered in nephron, creates osmotic force that inhibits passive reabsorption of water Increases serum osmolality to draw fluid back into vascular and extravascular space 
      3. Indications:
        1. Prophylaxis of renal failure with hypovolemic shock and severe hypotension
        2. Reduction of intracranial and intraocular pressure
      4. Adverse Effects:
        1. Edema (especially with existing heart failure)
        2. Fluid & electrolytes imbalances
        3. Rebound pressures
      5. Nursing Considerations:
        1. Monitor
          1. Use a filter needles and IV tubes
          2. Changes in ICP
          3. If severe declining urine output, STOP!
          4. LOC
          5. Electrolytes
          6. Weight
        2. Use with caution with digoxin
    6. The commonality between these medications?
      1. Nursing Considerations
        1. But what are the differences between each?
  2. RAAS Agents
    1. captopril
      1. Class:
        1. Angiotensin enzyme (ACE) inhibitor
      2. MOA:
        1. Reduce level of angiotensin II through inhibition of ACE and increase levels of bradykinin to: Dilate blood vessels, which reduces blood volume Prevent/reverse changes in heart and blood vessels mediated by angiotensin II and aldosterone
      3. Indications:
        1. Hypertension, heart failure, and post- MI
        2. Prevention of MI, CVA, and death in patients with high CV risk
        3. Diabetic nephropathy
      4. Adverse Effects:
        1. First-dose syncope (hypotension)
        2. Dry Cough & Angioedema
        3. Hyperkalemia
        4. Fetal Injury
      5. Nursing Considerations:
        1. Monitor
          1. BP
          2. Electrolytes
          3. Kidney labs
        2. Educate patient to change positions slowly and lie down if dizzy, light headed, or faint
        3. Daily weights
        4. Educate patient to contact provider if cough and/or angioedema occurs
        5. Educate patient on potassium intake
        6. Can be in combo with a thiazide
    2. losartan
      1. Class:
        1. Angiotensin II receptor blocker (ARB)
      2. MOA:
        1. Blocks the actions of angiotensin II by blocking access its receptors in blood vessels, adrenals, and other tissues to cause dilation of vessels, Prevent cardiac structural changes and release of aldosterone
      3. Indications:
        1. Hypertension
        2. Heart Failure
        3. Reduce stroke risk, MI, and death in patients with high CV risk
        4. Diabetic nephropathy and retinopathy
      4. Adverse Effects:
        1. Angioedema
        2. Hypotension
        3. Hyperkalemia
        4. Tachycardia
        5. Fetal Injury
      5. Nursing Considerations:
        1. ARBs used if a patient is not tolerating ACE due to cough
        2. Monitor
          1. VS, esp BP
        3. Educate patient to contact provider if angioedema occurs
        4. Do not use with renal stenosis or single remaining kidney
    3. aliskiren
      1. Class:
        1. Enteral direct renin inhibitor
      2. MOA:
        1. Binds with renin to inhibit cleavage of angiotensinogen into angiotensin I to reduce influence of entire RAAS
      3. Indications:
        1. Hypertension
        2. Well-tolerated medication and low risk of hyperkalemia, angioedema, and cough
      4. Adverse Effects:
        1. Diarrhea
        2. Hypotension
        3. Fetal Injury and death
        4. Angioedema
        5. Dry cough
        6. Hyperkalemia
      5. Nursing Considerations:
        1. Monitor
          1. VS- BP
          2. I/O
          3. Weight
          4. Electrolytes
        2. Do not give with high fat foods
    4. eplerenone
      1. review slides
    5. The commonality between the medications?
      1. Nursing Considerations
  3. CCB
    1. nifedipine
      1. Class:
        1. Dihydropyridine calcium channel blocker
      2. MOA:
        1. Blocks calcium channels on vascular smooth muscle, with minimal activity on heart
      3. Indications:
        1. HTN
        2. Angina pectoris
      4. Adverse Effects:
        1. Peripheral edema
        2. Flushing
        3. Headache
        4. Dizziness
        5. Constipation
        6. Reflex tachycardia
        7. N/V
      5. Nursing Considerations:
        1. Assess before administration
          1. BP
        2. Monitor
          1. reflex tachycardia- suppressed when combined with a beta blocker
          2. edema
          3. daily weight
        3. Education on discontinuation- gradually to prevent myocardial ischemia
    2. verapamil
      1. Class:
        1. Non-dihydropyridines calcium channel blocker
      2. MOA:
        1. Blocks calcium channels on the heart and blood vessels (mostly on heart)
      3. Indications:
        1. HTN
        2. Angina pectoris
        3. Dysrhythmias
      4. Adverse Effects:
        1. Constipation
        2. Cautious use for pts with: bradycardia, HF, or AV heart block due to cardiac suppression
      5. Nursing Considerations:
        1. Assess before administration
          1. BP
        2. Monitor
          1. edema
          2. daily weight
        3. Monitor interactions with other meds (digoxin, statins, NSAIDs, beta blockers)
        4. Avoid grapefruit juice--> toxicity
          1. If toxicity occurs
          2. Gastric Lavage
          3. Activated charcoal
          4. IVF
          5. IV calcium gluconate
          6. Trendelenburg
        5. Education on discontinuation- gradually to prevent myocardial ischemia
    3. diltiazem
  4. Direct-Acting Vasodilators
    1. hydralazine
      1. Class:
        1. Enteral and parenteral vasodilator
      2. MOA:
        1. Causes dilation of arterioles through actions on vascular smooth muscle to reduce peripheral resistance and blood pressure
      3. Indications:
        1. Essential hypertension
        2. Hypertensive crisis
        3. Heart Failure
      4. Adverse Effects:
        1. Reflex tachycardia
        2. Renin release
        3. Fluid retention
        4. SLE-like syndrome
      5. Nursing Considerations:
        1. Monitor
          1. VS- BP
        2. Reducing reflex tachycardia renin release- combine with beta blocker
        3. Reducing risk of sodium and water retention- combine with diuretic
        4. Treating heart failure- combine with isosorbide dinitrate
    2. minoxidil
      1. Class:
        1. Enteral and topical vasodilator
      2. MOA:
        1. Dilation of arterioles
          1. More potent than hydralazine
      3. Indications:
        1. Used only for hypertensive emergencies
        2. Controlled hypotension during surgery to reduce bleeding
      4. Adverse Effects:
        1. Reflex tachycardia
        2. Sodium and water retention
        3. hypertrichosis- hair
        4. Pericardial effusion
      5. Nursing Considerations:
        1. May combo with beta blocker and diuretic to help minimize effects
        2. Monitor
          1. BP
          2. electrolytes
          3. edema
    3. nitroprusside
      1. Class:
        1. Parenteral vasodilator
      2. MOA:
        1. Causes BOTH venous and arteriolar dilation to decrease blood pressure
      3. Indications:
        1. Used only for hypertensive emergencies
        2. Controlled hypotension during surgery to reduce bleeding
      4. Adverse Effects:
        1. Excessive hypotension
        2. Cyanide poisoning (especially those with liver disease)
        3. Thiocyanate toxicity
      5. Nursing Considerations:
        1. Continuous Monitor/Reassess
          1. VS- BP
          2. Electrocardiogram
        2. Initial infusion rates range from 0.3-0.5 mcg/kg/min then titrate slowly to bring down blood pressure
        3. Simultaneous coadminister with PO antihypertensives
        4. Immediate effects trigger Na+ & water retention
          1. Manage with furosemide administration
    4. What are the differences between these medications?
      1. Based on these differences, determine which is best to use in what HTN episodes.
  5. Medical Acronyms