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7/27/2019 Care of Clients With Cardiovascular Disorders
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LEARNING OBJECTIVES:
1. Discuss the different assessment parameters for cardiacfunctioning.
2. Describe Nursing care of clients undergoing diagnostic tests toassess cardiac functioning.
3. Describe treatment modalities for clients with cardiacdisorders.
4. Explain the basic pathophysiology, clinical manifestations andcollaborative management of cardiac disorders.
5. Design a nursing care plan for clients with cardiac disorders.
6. Discuss about the prevention, management and rehabilitation
factors that optimize health.
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OUTLINE
I. ANATOMY AND PHYSIOLOGY OF THE HEART
II. DIAGNOSTIC TEST: ELECTROCARDIOGRAM
III. CORONARY HEART DISEASESIV. ANGINA PECTORIS
V. MYOCARDIAL INFARCTION
VI. CONGESTIVE HEART FAILUREVII. CARDIAC TAMPONADE
VIII.HYPERTENSION
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ANATOMY AND PHYSIOLOGY OF THE HEART
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ELECTROCARDIOGRAM
A non-invasive procedurethat evaluates theelectrical activity of theheart
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Deflection Waves of ECG
1. P wave - initial wave, demonstrates the depolarization from SA
Node through both ATRIA; the ATRIA contract about 0.1 s after
start of P Wave.
2. QRS complex - next series of deflections, demonstrates the
depolarization of AV node through both ventricles; the ventriclescontract throughout the period of the QRS complex, with a short
delay after the end of atrial contraction; repolarization of atria also
obscured
3. T Wave - repolarization of the ventricles (0.16 s)
4. PR (PQ) Interval - time period from beginning of atrialcontraction to beginning of ventricular contraction (0.16 s)
5. QT Interval - the time of ventricular contraction (about 0.36 s);
from beginning of ventricular depolarization to end of
repolarization.
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CORONARY HEART DISEASES
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A. PRESDISPOSINGFACTORS
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. Hyperlipidemia6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet: increased saturatedfats
10. Type A personality
B. SIGNS AND SYMPTOMS
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
C. TREATMENT Percutaneous
Transluminal CoronaryAngioplasty and
Intravascular Stenting
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Percutaneous
Transluminal Coronary
Angioplasty
Mechanical dilation of
the coronary vessel
wall by compresing the
atheromatous plaque. It is recommended for
clients with single-
vessel coronary artery
disease.
Prosthetic
intravascular cylindricstent maintain good
luminal geometry after
ballon deflation and
withdrawal. Intravascular stenting
is done to prevent
restenosis after PTCA.
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CORONARY ARTERIAL BYPASS GRAFT
SURGERY
Greater and lesser
saphenous veins are
commonly used forbypass graftprocedures
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Objectives of CABG
1. Revascularize
myocardium2. To prevent angina
3. Increase survival rate
4. Done to single occludedvessels
5. If there is 2 or more
occluded blood vessels
CABG is done
Nursing Management:
Nitroglycerine is the
drug of choice for reliefof pain from acute
ischemic attacks
Instruct to avoid over
fatigue
Plan regular activity
program
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For Saphenous Vein Site:
Wear support stocking
4-6 week postop Apply pressure
dressing or sand bag
on the site
Keep leg elevated
when sitting
3 Complications of CABG
1. Pneumonia: encourage
to perform deepbreathing,
coughing exercise and use
of incentive spirometer
2. Shock
3. Thrombophlebitis
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ANGINA PECTORIS
DEFINITION:
Transient paroxysmal chest painproduced by insufficient bloodflow to the myocardiumresulting to myocardial
ischemia. Clinical syndrome characterized
by paroxysmal chest pain that isusually relieved by rest ornitroglycerine due to temporarymyocardial ischemia
Types of Angina Pectoris
Stable Angina: pain less than 15minutes, recurrence is lessfrequent.
Unstable Angina : pain is morethan 15 mins.,but not less than30 minutes, recurrence is morefrequent and the intensity ofpain increases.
Variant Angina ( PrinzmetalsAngina ): Chest pain is on longer
duration and may occur at rest.Result from coronaryvasospasm.
Angina Decubitus: paroxysmalchest pain that occur when theclient sits or stand.
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A. PRESDISPOSING FACTORS
1. Sex: male
2. Race: black
3. Smoking
4. Obesity5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypertension
9. CAD: Atherosclerosis
10. Thromboangiitis Obliterans
11. Severe Anemia
12. Aortic Insufficiency: heart valvethat fails to open &
close efficiently
13. Hypothyroidism
14. Diet: increased saturated fats
15. Type A personality
B. PRESIPITATING FACTORS
4 Es of Angina Pectoris
1. Excessive physical exertion: heavyexercises, sexual activity
2. Exposure to cold environment:vasoconstriction
3. Extreme emotional response: fear,anxiety, excitement, strongemotions
4. Excessive intake of foods or heavy
meal.
C. SIGNS AND SYMPTOMS
1. Levines Sign: initial sign thatshows the hand clutching the chest
2. Chest pain: characterized by sharpstabbing pain located at sub sternalusually radiates from neck, back,arms, shoulder and jaw musclesusually relieved by rest or takingnitroglycerine(NTG)
3. Dyspnea
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4.Tachycardia
5. Palpitations
6. Diaphoresis
D. DIAGNOSTICPROCEDURE
1. History taking and physicalexam
2. ECG: may reveals ST
segment depression & T waveinversion during chest pain
3. Stress test / treadmill test:reveal abnormal ECG duringexercise
4. Increase serum lipid levels
5. Serum cholesterol & uricacid is increased
E. MEDICAL MANAGEMENT
1. Drug Therapy: ifcholesterol is elevated
Nitrates: Nitroglycerine(NTG)
Beta-adrenergic blockingagent: Propanolol
Calcium-blocking agent:
nefedipine Ace Inhibitor: Enapril
2. Modification of diet & otherrisk factors
3. Surgery: Coronary arterybypass surgery
4. Percutaneuos TransluminalCoronary Angioplasty (PTCA)
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F. NURSINGINTERVENTIONS
1. Enforce complete bed
rest2. Give prompt painrelievers with nitrates ornarcotic
analgesic as ordered3. Administer medicationsas ordered:
A. Nitroglycerine(NTG):when given in small doseswill act as venodilator, but
in large doses will act asvasodilator
Give 1st dose of NTG:sublingual 3-5 minutes
Give 2nd dose of NTG: ifpain persist after giving1st dose with interval of3-5 minutes
Give 3rd& last dose ofNTG: if pain still persistat 3-5 minutes interval
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NTG Tablets(sublingual)
Keep the drug in a dry place,avoid moisture and exposure to
sunlight as it may inactivate thedrug
Change stock every 6 months
Offer sips of water before givingsublingual nitrates, dryness ofmouth may inhibit drug
absoprtion Relax for 15 minutes after taking
a tablet: to prevent dizziness
Monitor side effects: orthostatichypotension, flushed face.Transient headache & dizziness:
frequent side effect Instruct the client to rise slowly
from sitting position
Assist or supervise inambulation
NTG Nitrol or Transdermal patch
Nitropatch is applied once a day,usually in the morning.
Avoid placing near hairy areas asit may decrease drug absorption
Avoid rotating transdermalpatches as it may decrease drugabsorption
Avoid placing near microwaveovens or during defibrillation asit may lead to burns (mostimportant thing to remember)
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B. Beta-blockers:decreases myocardialoxygen demand by
decreasing heart rate,cardiac output and BP
Propanolol
Metropolol
Pindolol
Atenolol
Assess PR, withhold if
dec.PR Administer with food (
prevent GI upset )
Propanolol: not givento COPD cases: itcauses bronchospasmand
DM cases: it causehypoglycemia
Side Effects: Nauseaand vomiting, mentaldepression and fatigue
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C. Calcium ChannelBlockers: relaxessmooth cardiac
muscle, reducescoronary vasospasm
Amlodipine ( norvasc )
Nifedipine ( calcibloc )
Diltiazem ( cardizem )
Assess HR and BP
Administer 1 hour
before meal and 2hours after meal (foods delay absorption)
4. Administer oxygeninhalation
5. Place client on semi-tohigh fowlers position
6. Monitor strictly V/S,I&O, status of
cardiopulmonary fuction& ECG tracing
7. Provide decreasesaturated fats sodium and
caffeine
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8. Provide client healthteachings and dischargeplanning
Avoidance of 4 Es Prevent complication
(myocardial infarction)
Instruct client to takemedication beforeindulging into physicalexertion to achieve themaximum therapeuticeffect of drug
Reduce stress & anxiety:relaxation techniques &guided imagery
Avoid overexertion &smoking
Avoid extremes oftemperature
Dress warmly in cold
weather Participate in regular
exercise program
Space exercise periods &allow for rest periods
The importance of followup care
9. Instruct the client to notifythe physician immediately if
pain occurs & persists despiterest & medicationadministration
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MYOCARDIAL INFARCTION
Death of myocardial cells from
inadequate oxygenation, oftencaused by sudden completeblockage of a coronary artery
Characterized by localizedformation of necrosis (tissuedestruction) with subsequent
healing by scar formation &fibrosis
Heart attack
Terminal stage of coronaryartery disease characterized bymalocclusion, necrosis &
scarring.
Types of M.I
Transmural MyocardialInfarction: most dangerous typecharacterized by occlusion ofboth right and left coronaryartery
Subendocardial Myocardial
Infarction: characterized byocclusion of either right or leftcoronary artery
The Most Critical Period FollowingDiagnosis of
Myocardial Infarction 6-8 hoursbecause majority of deathoccurs due to arrhythmia leadingto premature ventricularcontractions (PVC)
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A. PREDISPOSING FACTORS
1. Sex: male
2. Race: black
3. Smoking4. Obesity
5. CAD: Atherosclerotic
6. Thrombus Formation
7. Genetic Predisposition8. Hyperlipidemia
9. Sedentary lifestyle
10. Diabetes Mellitus
11. Hypothyroidism
12. Diet: increased saturatedfats
13. Type A personality
B. SIGNS ANDSYMPTOMS
1. Chest pain
Excruciating visceral,viselike pain with suddenonset located atsubsternal& rarely inprecordial
Usually radiates from neck,back, shoulder, arms, jaw &abdominal muscles(abdominal ischemia):severe crushing
Not usually relieved by restor by nitroglycerine
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2. N/V
3. Dyspnea
4. Increase in bloodpressure & pulse, with
gradual drop in blood
pressure (initial sign)
5. Hyperthermia: elevatedtemp
6. Skin: cool, clammy,
ashen7. Mild restlessness &apprehension
8. Occasional findings:
Pericardial friction rub
Split S1& S2
Rales or Crackles upon
auscultation
S4 or atrial gallop
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DIAGNOSTIC PROCEDURES
1. Cardiac Enzymes
CPK-MB: elevated Creatininephosphokinase(CPK):elevated
Heart only, 12 24 hours Lactic acid
dehydrogenase(LDH): isincreased
Serum glutamic pyruvatetransaminase(SGPT): isincreased
Serum glutamic oxal-acetic
transaminase(SGOT): isincreased
2. Troponin Test: is increased
3. ECG tracing reveals
ST segment elevation
T wave inversion
Widening of QRS complexes:indicates that there isarrhythmia in MI
4. Serum Cholesterol & uric acid:are both increased
5. CBC: increased WBC
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NURSING INTERVENTIONS
Goal: Decrease myocardial oxygendemand
1. Decrease myocardial workload(rest heart)
Establish a patent IV line
Administer narcotic analgesic asordered: Morphine Sulfate IV:
provide pain relief(given IVbecause after an infarction thereis poor peripheral perfusion &because serum enzyme wouldbe affected by IM injection asordered)
Side Effects: RespiratoryDepression
Antidote: Naloxone (Narcan)
Side Effects of NaloxoneToxicity: is tremors
2. Administer oxygen low flow 2-3 L /min: to prevent respiratory arrest or
dyspnea & prevent arrhythmias3. Enforce CBR in semi-fowlersposition without bathroomprivileges(use bedside commode): todecrease cardiac workload
4. Instruct client to avoid forms ofvalsalva maneuver5. Place client on semi fowlersposition
6. Monitor strictly V/S, I&O, ECGtracing & hemodynamic procedures
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7. Perform complete lung /cardiovascular assessment
8. Monitor urinary output & reportoutput of less than 30 ml/ hr:
indicates decrease cardiac output9. Provide a full liquid diet withgradual increase to soft diet:
low in saturated fats, Na & caffeine
10. Maintain quiet environment
11. Administer stool softeners asordered:to facilitate bowel
evacuation & prevent straining
12. Relieve anxiety associated withcoronary care unit(CCU)environment
13. Administer medication asordered:
a. Vasodilators: Nitroglycirine(NTG), Isosorbide Dinitrate, Isodil
(ISD): sublingualb. Anti Arrythmic Agents: Lidocaine(Xylocane), Brithylium
Side Effects: confusion and dizziness
c. Beta-blockers: Propanolol(Inderal)
d. ACE Inhibitors: Captopril(Enalapril)
e. Calcium Antagonist: Nefedipine
f. Thrombolytics / FibrinolyticAgents: Streptokinase, Urokinase,
Tissue Plasminogen ActivatingFactor
(TIPAF)
Side Effects: allergic reaction,urticaria, pruritus
Nursing Intervention: Monitor forbleeding time
i l 14 Provide client health
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g. Anti Coagulant
Heparin
Antidote: Protamine Sulfate
Nursing Intervention:
Check for Partial ThrombinTime (PTT)
Caumadin(Warfarin)
Antidote:Vitamin K
Nursing Intervention: Check forProthrombin Time (PT)
h. Anti Platelet: PASA (Aspirin):Anti thrombotic effect
Side Effects:Tinnitus,
Heartburn, Indigestion / Dyspepsia
Contraindication: Dengue,Peptic Ulcer Disease,
Unknown cause of headache
14. Provide client healthteaching & dischargeplanning concerning:
a. Effects of MI healing process &treatment regimen
b. Medication regimen includingtime name purpose, schedule,dosage, side effects
c. Dietary restrictions: low Na,low cholesterol, avoidance of
caffeined. Encourage client to take 20 30 cc/week of wine,
whisky and brandy:to inducevasodilation
e. Avoidance of modifiable riskfactors
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f. Prevent Complication
Arrhythmia: caused bypremature ventricular
contraction Cardiogenic shock: latesign is oliguria
Left Congestive HeartFailure
Thrombophlebitis:homans sign
Stroke / CVA
Dresslers Syndrome(PostMI Syndrome):client is
resistant topharmacological agents:administer 150,000-450,000 units ofstreptokinase as ordered
g. Importance of participationin a progressive activityprogram
h. Resumption of ADLparticularly sexualintercourse:
is 4-6 weeks post cardiacrehab, post CABG &
instruct to: Make sex as an appetizer
rather than dessert
Instruct client to assume anon weight bearing
position Client can resume sexual
intercourse: if can climbor use the staircase
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B. SIGNS AND SYMPTOMS
1. Pulmonary edema/congestion
Dyspnea, PND (awakening at nightd/t difficulty in breathing), 2-3 pilloworthopnea
Productive cough (blood tinged)
Rales/crackles
Bronchial wheezing
Frothy salivation
2. Pulsus alternans (A unique patternduring which the
amplitude of the pulse changes oralternates in size
with a stable heart rhythm.)This iscommon in
severe left ventricular dysfunction.)3. Anorexia and general body malaise
4. PMI displaced laterally, cardiomegaly
5. S3 (ventricular gallop)
C. DIAGNOSTICS
1. CXR cardiomegaly
2. PAP pulmonary arterial pressure
Measures pressure in right ventricle
Reveals cardiac status
3. PCWP pulmonary capillary wedgepressure
Measures end-systolic and end-
diastolic pressure (elevated) Done through cardiac
catheterization (Swan- Ganz)
4. Echocardiograph reveals enlargedheart chamber
5. ABG analysis reveals elevated PCO2
and decreased PO2 (respiratory acidosis)
hypoxemia and cyanosis
Tracheostomy for severe RIGHT SIDED HEART
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Tracheostomy for severerespiratory distress andlaryngospasm performedat bedside within 10-15minutes
CVP reveals fluid status;Normal = 4-10cm H2o;right atrium
PAP cardiac status; leftatrium
ALLENS test collateralcirculation
Cardiac Tamponade:pulsus paradoxus,muffled heart sounds,HPN
RIGHT SIDED HEARTFAILURE
A. PREDISPOSING
FACTORS1. Tricuspid valve stenosis
2. COPD
3. Pulmonary embolism
(char by chest pain anddyspnea)
4. Pulmonic stenosis
5. Left sided heart failure
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B SIGNS AND SYMPTOMS C DIAGNOSTICS
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B. SIGNS AND SYMPTOMS(Venous congestion)
1. Jugular vein distention
2. Pitting edema
3. Ascites4. Weight gain
5. Hepatosplenomegaly
6. Jaundice
7. Pruritus/ urticaria8. Esophageal varices
9. Anorexia
10. Generalized body malaise
C. DIAGNOSTICS
1. CXR cardiomegaly
2. CVP measures pressure inright atrium; N = 4-
10cc H2O During CVP: trendelenburg
to prevent pulmo embolismand to promote ventricularfilling
Flat on bed post CVP, checkCVP readings
Hypovolemia fluidchallenge
Hypervolemia diuretics(loop)
3. Echocardiography revealsenlarged heart chamber
Muffled heart soundscardiomyopathy
C i h di
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Cyanotic heart diseases
TOF tet spells cyanosis with
hypoxemia
Tricuspid valve stenosis
Transposition of aorta
Acyanotic
PDA machine-like murmur
DOC: indomethacin SE: corneal
cloudiness
4. Liver enzymes
SGPT up
SGOT up
D. NURSING MANAGEMENT
Goal: increase myocardialcontraction increase CO;
Normal CO is 3-6L/min; N strokevolume is 60-70ml/h2o
1. Administer medications asordered
Cardiac glycosides
Digoxin (N=.5-1.5, tox=2)
Tox: Anorexia, N&V; A: Digibind Digitoxin given if (+) ARF;
metabolized in liver and not inkidneys
Loop diuretics
Lasix IV push, mornings
Bronchodilators
Aminophylline (theophylline)
Tachycardia, palpitations
CNS hyperactivity, agitation
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CARDIAC TAMPONADE
Also known as pericardialtamponade, is an emergencycondition in which fluidaccumulates in the pericardium.
(the sac in which the heart is
enclosed). If the fluid significantly elevates
the pressure on the heart it willprevent the heart's ventriclesfrom filling properly.
This in turn leads to a low stroke
volume. The end result is ineffective
pumping of blood, shock, andoften death.
A. PREDISPOSING FACTORS
1. Chest trauma ( blunt orpenetrating )
2. Myocardial ruptured
3. Cancer
4. Pericarditis
5. Cardiac surgery ( first 24 48hours )
6. Thrombolytic therapy
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CLASSIFICATION OF BP Stage 1 (mild) HPN
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CLASSIFICATION OF BPFOR ADULTS 18 YRSAND OLDER (PHIL.SOCIETY OF HPN)
Optimal o
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A. CLASSIFICATION
Essential / Idiophatic /Primary HPN, accounts
for 90 95% of all casesof HPN, cause isunknown
Secondary HPN, due to
known causes ( Renalfailure, Hypertension )
MalignantHypertension, is severe,
rapidly progressiveelevation in BP thatcauses rapid onset of endorgan complication
Labile HPN,intermittently elevatedBP
Resistant HPN, doesnot respond to usualtreatment
White Coat HPN,
elevation of B onlyduring clinic or hospitalvisits
C SIGNS AND SYMPTOMS
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Hypertensive Crisis,situation that requiresimmediate blood
pressure lowering240mmHg / 120 mmHg
B. RISK FACTORS
1. Family history
2. Age3. High salt intake
4. Low potassium intake
5. Obesity
6. Excess alcoholconsumption
7. Smoking
8. Stress
C. SIGNS AND SYMPTOMS
1. Headache
2. Epistaxis
3. Dizziness4. Tinnitus
5. Unsteadiness
6. Blurred vision
7. Depression8. Nocturia
9. Retinopathy
D TREATMENT Drug therapy
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D. TREATMENTSTRATEGIES
Non-pharmacologic
therapy1. Low salt diet.
2. Weight reduction.
3. Exercise.
4. Cessation of smoking.5. Decreased alcoholconsumption.
6. Psychological methods:Relaxation / meditation.
7. Dietary decrease insaturated fat.
Drug therapy
Stepped Care
Progressive addition of
drugs to a regimen,starting with one, usuallya diuretic, and adding, ina stepwise fashion, asympatholytic,
vasodilator, andsometimes an ACEinhibitor.
Monotherapy
Advantageous because
of its simplicity, betterpatient compliance, andrelatively low incidenceof toxicity.
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CATEGORIES OF
ANTI-HYPERTENSIVEDRUGS
Drugs that alter sodiumand water balanceDiuretics.
Loop diuretics
Thiazides Spironolactone and
Triamterene
Drugs that altersympathetic nervoussystem function
Sympatholytic drugs.
Centrally-actingsympatholytics
Clonidine
Guanabenz Guanfacine
Methyldopa
Peripherally-acting
sympatholytics Guanadrel
Guanethidine
Reserpine
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a blockers
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a-blockers
Doxazosin
Prazosin
b-blockers Acebutolol - Labetalol
Atenolol - Metoprolol
Betaxolol - Nadolol
Bisoprolol - Penbutolol Carteolol - Pindolol
Carvedilol - Propranolol
Esmolol - Timolol
Vasodilators
Direct vasodilators
Diazoxide - Hydralazine
Minoxidil - Nitroprusside
Fenoldopam
Calcium channel blockers
Amlodipine - Nifedipine
Diltiazem - Nimodipine
Felodipine - Nisoldipine
Isradipine - Nitrendipine
Manidipine - Nicardipine
Lacidipine - Verapamil
Lercanidipine -Gallopamil
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AGENTS THAT BLOCK THE DRUGS FOR HYPERTENSIVE
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AGENTS THAT BLOCK THEPRODUCTION OR
ACTION OF ANGIOTENSIN
ACE inhibitors
Benazepril - Moexipril Captopril - Quinapril
Enalapril - Perindopril
Fosinopril - Ramipril
Lisinopril - Trandolapril
AT1-receptor blockers
Irbesartan - Losartan
Telmisartan - Valsartan
Candesartan - Eprosartan
DRUGS FOR HYPERTENSIVEEMERGENCIES OR
CRISES
Trimethaphan
o 1 mg/ml IV infusion; titrate; instantaneous onset
Sodium nitroprusside
o 5-10 mg/L IV infusion; titrate;
instantaneous onset
Diazoxide o 300-600 mg Rapid IV push;
instantaneous onset
Nifedipine
o 10-20 mg Sublingual or
chewed; onset within 5-30 min.
Labetalol
o 20-80 mg IV at 10-minuteintervals (max.dose:
300mg); immediate onset
E NURSING 2. Teaching about
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E. NURSINGINTERVENTIONS
1. Patient Teaching and
Counselling Teaching about HPN and
its risk factors
Stress therapy
Low NA and lowsaturated fat
Avoid stimulants (caffeine, alcohol,smoking )
Regular pattern ofexercise
Weight reduction ifobese
gmedication
The most common sideeffects of diuretics are
potassium depletion andorthostatic hypotension.
The most common sideeffect of the differentantihypertensive drugs isorthostatic hypotension.
Take anti hypertensivemedications at regularbasis
Assume sitting or lyingposition for few minutes
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Avoid very warm bathP ti N li
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Avoid very warm bath
Avoid prolonged sittingand standing
Avoid alcoholic beverages
Avoid tyramine richfoods ( proteins ) asfollows: ( this may causehypertensive crisis )
Aged cheese Liver
Beer
Wine
Chocolate
Pickles
Sausages
Soy sauce
3. Preventing Non-compliance
Inform the client thatabsence of symptoms
does not indicate control ofBP
Advise the client againstabrupt withdrawal of
medication, rebound
hypertension may occur. Device ways to facilitate
remembering of
taking medications
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