L6 Cardiology + Renal Pharm

Hypertension:

• Goal

• Risk factor

• Symptoms

• Alterations

• SBP <130

• Most prevalent + modifiable risk factor for CVD

• Often asymptomatic til severe

• Alterations

  • Nervous system

  • RAAS

  • Cardiovascular (vessels)

Firstline HTN Treatment

• Thiazide-type diuretics

• Calcium channel blockers

• ACE inhibitors

• ARBs

Signs of fluid overload?

• Peripheral edema

• SOB, Crackles in lungs, Diminished breath sounds

• Elevated BP

• JVD

Signs of increased ICP?

• HA, N/Projectile vomiting

• Agitation → Confusion → Drowsiness → Coma

• Vision changes

Renin Angiotensin Aldosterone System (RAAS)

Lisinopril:

• Pharm class

• Indication

• MOA

• Therapeutic effects

• Angiotensin-Converting Enzyme (ACE) Inhibitor

• HTN, HF → Decrease mortality = Cardioprotective

• Inhibits angiotensin I from converting into angiotensin II → Reduced aldosterone secretion → Less salt + water reabsorbed

• Decrease BP

Lisinopril:

• Adverse effects

• Contraindications

• Black box

• AE

  • AKI

  • Hyperkalemia

  • Dry cough + Angioedema

• CI

  • Hx Angioedema

  • Significant renal disease

  • Concurrent use with NSAIDs, some diuretics, potassium supplements

• Fetal toxicity → Contraindicated in pregnancy

Lisinopril:

• Pt. Education

• Nursing considerations

• Pt. Edu

  • Caution w/ potassium supplements + NSAIDS

  • Monitor dry cough

• NC

  • Monitor → BP + Potassium + Kidney function

Losartan:

• Pharm class

• Indication

• MOA

• Therapeutic effects

• Angiotensin II Receptor Blocker (ARB)

• HTN + CKD

• Blocks angiotensin II → Reduces aldosterone secretion → Less salt + water reabsorbed

• Decrease BP

Losartan:

• Adverse effects

• Contraindications

• Black box

• AE

  • AKI

  • Hyperkalemia

• CI

  • Concurrent use with NSAIDs

  • CKD → End stages

• Fetal toxicity → CI in pregnancy

Losartan:

• Pt. Education

• Nursing considerations

• Caution w/ Potassium supplements

• Monitor → BP + Potassium + Kidney function

A client newly prescribed lisinopril reports a persistent dry cough. Which action should the nurse anticipate?

Switch to an ARB such as losartan

Nephron structure?

Furosemide (Lasix):

• Pharm class

• Indication

• MOA

• Therapeutic effects

• Loop diuretic → Strongest

• Edema + Fluid overload + HF + Cirrhosis + Renal disease

• Inhibits reabsorption of sodium and chloride in the loop of henle + proximal + distal tubule

• Diuresis = Getting rid of fluid

Furosemide:

• Adverse effects

• Contraindications

• Black box

• AE

  • AKI

  • Fluid + electrolyte loss → HypoK/Ca/Mg

  • Cross reactive w/ sulfa antibiotics

  • Ototoxicity → Hearing changes

• CI

  • Dehydration

  • BPH → May cause urinary retention

  • Sulfa allergy

• Potent diuretic → Can lead to significant fluid and electrolyte loss

Furosemide:

• Pt. Education

• Nursing consideration

• Pt. Edu

  • Daily weight → Report 2lb change

  • Stay hydrated

  • Signs of electrolyte changes → Muscle weakness/cramps

• NC

  • Intake / Output → More urine = sign it is working

  • Daily weight

Hydrochlorothiazide (HCTZ):

• Pharm class

• Indication

• MOA

• TE

• Thiazide diuretic → Not as potent as furosemide

• Edema + Volume overload (HF) + HTN → 1st line

• Inhibits sodium reabsorption in distal tubules → Increased excretion of sodium + water + potassium

• Diuresis

Hydrochlorothiazide:

• Adverse effects

• Contraindications

• AE

  • Hypo K/Mg/Na + Hyper Ca

  • Gout → Hyperuricemia

  • Photosensitivity

• CI

  • Addison’s disease

  • Cirrhosis → Hyponatremia

  • Renal disease

Hydrochlorothiazide:

• Pt. education

• Nursing considerations

• Pt. Edu

  • Daily weight → Report 2lb change

  • May require potassium supplements

  • UV exposure

• NC

  • Monitor → BP + K + Renal function

  • Intake / Output

Metolazone:

• Pharm class

• Indication

• MOA

• TE

• Thiazide-related diuretic

• Edema + Fluid overload (HF / Renal disease)

  • Given 30-60 min before lasix for “Diuretic resistance”

• Inhibits sodium reabsorption in distal tubules → Increased sodium + water + potassium excretion

• Diuresis

Metolazone:

• Adverse effects

• Contraindications

• AE

  • Hypo K/Mg/Na + Hyper Ca

  • Orthostatic hypotension

• CI

  • Anuria

  • Severe liver/renal disease

  • Addison’s disease

  • Gout

Metolazone:

• Pt. Education

• Nursing considerations

• Pt. Edu

  • Daily weight → Report 2lb change

  • Electrolyte changes

  • May need potassium supplements

• NC

  • Monitor → BP + Electrolytes (K + Uric acid) + Renal function

  • Intake / Output

Which of the following have a known side effect of hypokalemia?

a. furosemide

b. hydrochlorothiazide

c. lisinopril

d. metolazone

e. losartan

a. furosemide

b. hydrochlorothiazide

d. metolazone

Spironolactone:

• Pharm class

• Indications

• MOA

• TE

• Mineralocorticoid Receptor Antagonist → Blocks aldosterone + Potassium sparing diuretic

• Ascites from cirrhosis + HF fluid overload + Acne

• Blocks aldosterone in distal tubule → Increases sodium + water excretion

• Diuresis

Spironolactone:

• Adverse effects

• Contraindications

• AE

  • Gynecomastia → “gyno” hormonal

  • Hyperkalemia

• CI

  • Hyperkalemia

  • Addison’s disease

  • Dehydration

  • Renal disease

Spironolactone:

• Pt. Education

• Nursing considerations

• Pt. Edu

  • Caution w/ high potassium foods + salt substitutes

  • Monitor electrolyte changes

• Monitor → BP + Weight + K + Kidney function

Mannitol:

• Pharm class

• Indications

• MOA

• Osmotic diuretic

• Reduction of ICP + Reduction of increased intraocular pressure (IOP)

• Increases osmotic pressure in blood + Increase Osmolality and tonicity of blood

  • Draws water out of blood

  • Draws water out of eye

Mannitol:

• Adverse effects

• Contraindications

• AE

  • Dehydration

  • Hypo K/Na

  • Renal injury

• CI

  • Anuria

  • Severe hypovolemia + pulmonary edema

  • Renal disease

Mannitol:

• Pt. Education

• Nursing considerations

• Pt. Edu

  • IV only

  • Requires significant monitoring

  • Accurate I/O’s

• NC

  • Kidney function

  • Serum osmolality

  • Tele + Pulse Ox monitoring

  • I/O’s

  • ICP → Neuro status

Which medication is most likely to cause ototoxicity if given rapidly IV or at high doses?

Furosemide

Which conditions/indications are appropriate for spironolactone? (Select all that apply.)

A. Ascites from cirrhosis

B. Heart failure fluid overload

C. Addison’s disease with fluid overload

D. Acne

E. Acute pulmonary edema requiring rapid diuresis

A. Ascites from cirrhosis

B. Heart failure fluid overload

D. Acne