ACE

Angiotensin-converting enzyme inhibitors ACE inhibitors reduce blood pressure by interrupting the renin-angiotensin activating system (RAAS). Commonly prescribed ACE inhibitors include: benazepril captopril enalapril enalaprilat fosinopril sodium lisinopril Moexipril quinapril hydrochloride ramipril trandolapril. ACE inhibitors: Captopril Actions Thought to inhibit angiotensin-converting enzyme (ACE), preventing conversion of angiotensin I to angiotensin II (reduced formation of angiotensin II decreases peripheral arterial resistance, thus decreasing aldosterone secretion) Indications Sodium and water retention High blood pressure Impaired renal function in patients with diabetes

 Nursing considerations Monitor white blood cell and differential counts before therapy, every 2 weeks for the first 3 months of therapy, and periodically thereafter. Give the drug 1 hour before meals because food may reduce drug absorption. Withhold the dose and notify the prescriber if the patient develops fever, sore throat, leukopenia, hypotension, or tachycardia. Keep in mind that light-headedness and syncope can develop in hot weather, with inadequate fluid intake, vomiting, diarrhea, and excessive perspiration.

Pharmacodynamics
ACE inhibitors work by preventing the conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor that increases peripheral resistance and promotes the excretion of aldosterone (which promotes sodium and water retention). As angiotensin II is reduced, arterioles dilate, reducing peripheral vascular resistance. By reducing aldosterone secretion, ACE inhibitors promote the excretion of sodium and water, reducing the amount of blood the heart needs to pump and reducing blood pressure.

ACE
Pharmacotherapeutics ACE inhibitors may be used alone or in combination with other agents, such as a thiazide diuretic, to treat hypertension. They're commonly used when betaadrenergic blockers or diuretics are ineffective. Captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, and trandolapril are also indicated for use in heart failure for the following situations: left ventricular systolic failure (unless contraindicated or intolerant) left ventricular systolic dysfunction without symptoms of heart failure after acute MI (especially in patients with prior myocardial injury) to reduce mortality left ventricular dysfunction (recent or remote) to prevent or delay the development of left ventricular dilation and overt heart failure combined use with beta-adrenergic blockers to produce complementary effects combined use with diuretics if fluid retention persists.

Drug interactions ACE inhibitors can cause several different types of interactions with other cardiovascular drugs: All ACE inhibitors enhance the hypotensive effects of diuretics and other antihypertensives such as betaadrenergic blockers. They can also increase serum lithium levels, possibly resulting in lithium toxicity. When ACE inhibitors are used with potassium-sparing diuretics, potassium supplements, or potassiumcontaining salt substitutes, hyperkalemia may occur. ACE inhibitors may interact with other medications, both prescribed and over the counter. For example, patients taking ACE inhibitors should avoid taking NSAIDs. In addition to decreasing the antihypertensive effects of ACE inhibitors, NSAIDs may also alter renal function. Food decreases the absorption of ACE inhibitors.

Assessment Obtain a baseline blood pressure and pulse rate and rhythm, and recheck regularly. Monitor the patient for adverse reactions and drug interactions. Monitor the patient's weight and fluid and electrolyte status. Assess the patient's underlying condition before therapy and regularly thereafter. Monitor laboratory results, including WBC and differential, potassium level, and renal function (BUN and creatinine clearance levels and urinalysis). Monitor the patient's compliance with treatment. Observe the patient's tolerance of the drug's therapeutic effects. The dosage may need to be increased. Potential patch problems Monitor a transdermal patch for dermatitis, and ask the patient about pruritus. Keep in mind that the patch can require several days to take effect and that interim oral therapy may be needed.

Key nursing diagnoses Risk for injury related to orthostatic hypotension Risk for injury related to presence of hypertension Deficient knowledge related to drug therapy Planning outcome goals Blood pressure will be maintained within acceptable limits. Risk for injury will be minimized. The patient will verbalize an understanding of drug therapy. Implementation If giving orally, administer the drug before meals as indicated. Follow the manufacturer's guidelines when mixing and administering parenteral drugs. Prevent or minimize orthostatic hypotension by helping the patient to get up slowly and by telling the patient not to make sudden movements. Maintain the patient's nonpharmacologic therapies, such as sodium restriction, calorie reduction, stress management, and exercise program. Keep in mind that drug therapy may be given to lower blood pressure rapidly in some hypertensive emergency situations. Know that the dosage is usually adjusted to the patient's blood pressure and tolerance. To improve adherence of a transdermal patch, apply an adhesive overlay. Place the patch at a different site each week.

Angiotensin II receptor blocking agents

ARBs lower blood pressure by blocking the vasoconstrictive effects of angiotensin II. Available ARBs include: losartan valsartan irbesartan candesartan cilexetil telmisartan eprosartan olmesartan. Pharmacokinetics ARBs have varying pharmacokinetic properties, and all are highly bound to plasma proteins. Pharmacodynamics ARBs act by interfering with the RAAS. They selectively block the binding of angiotensin II to the angiotensin II receptor. This prevents the vasoconstricting and aldosterone-secreting effects of angiotensin II (a potent vasoconstrictor), resulting in a blood pressure decrease.

ARBs

Angiotensin II receptor blockers: Losartan Actions

Pharmacotherapeutics

Inhibits vasoconstricting and aldosteronesecreting effects of angiotensin II by selectively blocking binding of angiotensin II to receptor sites in many tissues, including vascular smooth muscle and adrenal glands Indications High blood pressure Nursing considerations Monitor blood pressure before therapy and regularly thereafter. Regularly assess kidney function (creatinine and blood urea nitrogen levels).

ARBs may be used alone or in combination with other agents, such as a diuretic, for the treatment of hypertension. Valsartan may also be used as an alternative to ACE inhibitors or for the management of heart failure. Irbesartan and losartan are indicated for patients with type 2 diabetes because of their inherent renal protective effect.

ARBs
Drug interactions These drug interactions may occur with ARBs: Losartan taken with fluconazole may increase levels of losartan, leading to increased hypotensive effects. NSAIDs reduce the antihypertensive effects of ARBs. Rifampin may increase metabolism of losartan, leading to decreased antihypertensive effect. Potassium supplements can increase the risk of hyperkalemia when used with ARBs. Losartan taken with lithium may increase lithium levels. Adverse reactions Adverse effects of ARBs include: headache fatigue cough and tickling in the throat angioedema GI reactions increased serum potassium transient elevations of BUN and serum creatinine levels. ARBs shouldn't be used during the second and third trimester of pregnancy; this can result in injury to and death of the fetus.

Digoxin
Names: Lanoxicaps, Lanoxin, Lanoxin Elixir Pediatric, Lanoxin Injection, Lanoxin Injection Pediatric, NovoDigoxin (CAN)Class and Category Chemical class: Digitalis glycoside Therapeutic class: Antiarrhythmic, cardiotonic Pregnancy category: C Indications and DosagesTo treat heart failure, atrial flutter, atrial fibrillation, and paroxysmal atrial tachycardia with rapid digitalization , I.V.Capsules InjectionAdults.Loading: 10 to 15 mcg/kg in 3 divided doses every 6 to 8 hr, with first dose equal to 50% of total dose. Maintenance: 125 to 350 mcg daily once or twice daily.

DIGOXIN

P.O. Onset: 30 to 120 min Peak: 6 to 8 hr Duration: 3 to 4 days I.V. Onset: 5 to 30 min Peak: 1 to 5 hr Duration: 3 to 4 days

Mechanism of Action Increases the force and velocity of myocardial contraction, resulting in positive inotropic effects. Digoxin produces antiarrhythmic effects by decreasing the conduction rate and increasing the effective refractory period of the AV node.

 Contraindications: Hypersensitive carotid sinus syndrome, hypersensitivity to digoxin, presence or history of digitalis toxicity or idiosyncratic reaction to digoxin, ventricular fibrillation, ventricular tachycardia unless heart failure occurs unrelated to digoxin therapy

Adverse Reactions

CNS:Confusion, depression, drowsiness, extreme weakness, headache, syncope CV:Arrhythmias, heart block EENT:Blurred vision, colored halos around objects GI:Abdominal discomfort or pain, anorexia, diarrhea, nausea, vomiting Other:Electrolyte imbalances

Digoxin - Interactions Drugs:

adsorbent antidiarrheals, such as kaolin and pectin; bulk laxatives; cholestyramine; colestipol; oral neomycin; sulfasalazine: Inhibited digoxin absorption amiodarone, propafenone: Elevated blood digoxin level, possibly to toxic level antacids: Inhibited digoxin absorptionantiarrhythmics, pancuronium, parenteral calcium salts, rauwolfia alkaloids, sympatho-mimetics: Increased risk of arrhythmias diltiazem, verapamil: Increased blood digoxin level, possibly excessive bradycardia edrophonium: Excessive slowing of heart rate erythromycin, neomycin, tetracycline: Possibly increased blood digoxin level hypokalemia-causing drugs, potassium-wasting diuretics: Increased risk of digitalis toxicity from hypokalemia indomethacin: Decreased renal clearance and increased blood level of digoxin magnesium sulfate (parenteral): Possibly cardiac conduction changes and heart block quinidine, quinine: Increased blood digoxin levels pironolactone: Increased half-life and risk of adverse effects of digoxin succinylcholine: Increased risk of digoxin-induced arrhythmias sucralfate: Decreased digoxin absorption Foodshigh-fiber food: Inhibited digoxin absorption

 Digoxin- Nursing Considerations:

Administer parenteral digoxin undiluted, or dilute with a fourfold or greater volume of sterile water for injection, normal saline solution, or D5W for I.V. administration. Once diluted, administer immediately. Discard if solution is markedly discolored or contains precipitate.Before giving each dose, take patients apical pulse and notify prescriber if pulse is below 60 beats/minute (or other specified level).Monitor patient closely for signs of digitalis toxicity, such as altered mental status, arrhythmias, heart block, nausea, vision disturbances, and vomiting. If they appear, notify prescriber, check serum digoxin level as ordered, and expect to withhold drug until level is known. Monitor ECG tracing continuously.If patient has acute or unstable chronic atrial fibrillation, assess for drug effectiveness. Ventricular rate may not normalize even when serum drug level falls within therapeutic range; raising the dosage probably wont produce a therapeutic effect and may lead to toxicity.Frequently obtain ECG tracings as ordered in elderly patients because of their smaller body mass and reduced renal clearance. Elderly patients, especially those with coronary insufficiency, are more susceptible to arrhythmiasparticularly ventricular fibrillationif digitalis toxicity occurs.Monitor paptients serum potassium level regularly because hypokalemia predisposes to digitalis toxicity and serious arrhythmias. Also monitor potassium level frequently when giving potassium salts because hyper-kalemia in patients receiving digoxin can be fatal.

Digoxin: Patient teaching

Stress the importance of taking digoxin exactly as prescribed. Warn patient about possible toxicity from taking too much and decreased effectiveness from taking too little.Instruct patient to take digoxin at the same time each day to help increase compliance.Teach patient how to take her pulse, and instruct her to do so before each dose. Urge her to notify prescriber if pulse falls below 60 beats/minute or suddenly increases.Inform patient that small, white 0.25-mg tablets can easily be confused with other drugs. Caution against carrying digoxin in anything other than its original labeled container.Emphasize the need to use the special dropper supplied with elixir to ensure accurate dose measurement.Instruct patient to take a missed dose as soon as she remembers if within 12 hours of scheduled dose. If not, urge her to notify prescriber immediately.Urge patient to notify prescriber if she experiences adverse reactions, such as GI distress or pulse changes.Instruct patient to carry medical identification that indicates her need for digoxin.Advise patient to consult prescriber before using other drugs, including OTC products.