1. Medications Affecting the Cardiovascular System I ATI PN PHARMACOLOGY FOR NURSING 7.0 EDITION UNIT 4 – CHAPTERS 18-19, PAGES 143-162 PHARMACOLOGY MADE INSANELY EASY, PP. 84-93 & 44-69

2. Concept: DIURETIC, PMIE, pp. 84-85 ▪ Diet ▪ Intake/Output; Daily weights ▪ Undesirable effects: F/E imbalances ▪ Review HR, BP, and electrolytes ▪ Elderly – CAREFUL ▪ Take with or after meals and in AM ▪ Increased risk of orthostatic hypotension – move slowly ▪ Cancel alcohol (NO ALCOHOL)

3. Chapter 18 Medications Affecting Urinary Output ▪ CLASSIFICATIONS of Drugs in this category ▪ LOOP DIURETICS ▪ Furosemide (Lasix) ▪ Ethyacrynic acid (Edecrin), Bumetanide (Bumex), Torsemide (Demadex) ▪ THIAZIDE DIURETICS ▪ Hydrochlorothiazide (Microzide, HCTZ) ▪ Chlorothiazide (Diuril), Methylclothiazide (Enduron) ▪ Thiazide-like such as Metalozone (Zaroxolyn) ▪ POTASSIUM-SPARING DIURETICS ▪ Spironolactone (Aldactone) ▪ Triamterene (Dyrenium), Amiloride (Midamor) ▪ OSMOTIC DIURETICS ▪ Mannitol (Osmitrol)

4. Chapter 18 Medications Affecting Urinary Output

5. ▪ LOOP DIURETICS – Furosemide (Lasix) ▪ Work in the ascending limb of Loop of Henle to prevent the reabsorption of sodium/potassium/chloride – Remember water follows sodium. This is how the loop diuretics increase urine output to help the body get rid of excess fluid (water). If the body can get rid of excess fluid, then edema decreases and BP decreases. ▪ Mostly used for HTN and fluid volume excess (edema) ▪ Highly effective diuretic even in severe renal dysfunction ▪ Administered as PO, IM, IV ▪ Works fast and is given IVP for acute onset pulmonary edema (emergency)

6. Chapter 18 Medications Affecting Urinary Output ▪ LOOP DIURETICS Complications ▪ Dehydration, hyponatremia, hypochloremia - monitor electrolytes, daily weights, monitor for s/s dehydration, urine output <30 mL/hr, ▪ Hypotension – monitor BP, postural hypotension ▪ Ototoxicity – transient w/ furosemide and permanent w/ ethacrynic acid, give diluted and very slowly if IVP, report tinnitus, avoid using w/ other ototoxic drugs such as gentamicin ▪ Hypokalemia – monitor electrolytes, instruct dietary modifications ▪ Other AE include ↑GLU, ↑Uric Acid, ↓Calcium, ↓Magnesium – monitor these and report if abnormal ▪ For clients with DM and gout, monitor labs and report abnormal to MD

7. Chapter 18 Medications Affecting Urinary Output ▪ LOOP DIURETICS Interactions ▪ If ↓potassium, digoxin can become ↑ and cause ventricular arrhythmias – monitor potassium and digoxin levels, potassium-sparing diuretics may be used, potassium supplements are usually prescribed ▪ Additive effect when taken with other HTN medications – monitor BP ▪ If ↓sodium, lithium carbonate (Lithobid) can become ↑ (toxic) – monitor sodium and lithium levels ▪ Early s/s of hypokalemia, hyponatremia, digoxin toxicity and lithium toxicity? What s/s are going to alert the nurse to possible electrolyte imbalances or medication toxicity? ▪ NSAIDs reduce blood flow to kidneys which leads to decreased diuretic effectiveness. Watch for decreased urine output if taking NSAIDs.

8. Chapter 18 Medications Affecting Urinary Output ▪ LOOP DIURETICS Nursing Responsibilities ▪ Obtain baseline data – VS, urine output, weight, location and character of edema ▪ Daily weights ▪ Instruct client to weigh every morning upon awakening after 1 st urination and before anything else (eating, drinking, dressing) and to keep a record of daily weights to show to MD at each visit. Instruct client to call MD if weight gain or loss is ≥3 lbs/day or ≥5 lbs/week. ▪ If client hospitalized and using a bed scale, weigh at the same time with only sheets (no blankets) on the bed. ▪ Monitor BP and I/O ▪ If home health client, instruct client to check BP daily 1-2 hours after taking BP meds and write BP down on a logbook or small notebook to show to MD at each visit.

9. Chapter 18 Medications Affecting Urinary Output ▪ LOOP DIURETICS Nursing Responsibilities ▪ Administer early in the day to avoid nocturia – usually given at 0800 and 1400. ▪ Furosemide can be given PO, IM, IV. If given continuous IV, rate should not be faster than 20 mg/min to prevent hypotension and hypovolemia. ▪ Monitor potassium level. If <3.5, report to MD. Administer potassium supplement as ordered. ▪ Postural hypotension – avoid by standing slowly, changing position slowly. If dizziness occurs, instruct client to sit or lie down. ▪ Teach s/s hypokalemia and hypovolemia – weight loss ≥3 lbs/day or ≥5 lbs/week, dizziness, GI distress, generalized weakness – to call the MD

10. Chapter 18 Medications Affecting Urinary Output ▪ LOOP DIURETICS Nursing Responsibilities ▪ Teach clients to eat high potassium foods – potatoes (any kind), sundried tomatoes, kidney beans, dried fruits, bananas, avocado, fish, red meat, chicken, turkey, squash, diary products, dark leafy greens ▪ Diabetic clients should monitor blood glucose and keep a log ▪ Monitor for hypomagnesemia or teach s/s – weakness, muscle twitching and tremors – and report to MD if occurs. ▪ Nursing Evaluation ▪ ↓Edema and BP ▪ Weight loss ▪ ↑Urine output ▪ ↓Brain natriuretic peptide (BNP - a hormone that is increased in heart failure)

11. Chapter 18 Medications Affecting Urinary Output THIAZIDE DIURETICS ▪ Hydrochlorothiazide (HCTZ) THIAZIDE-LIKE DIURETIC ▪ Metolazone (Zaroxolyn) Early distal convoluted tubule Works when kidney function is not impaired Used for mild-moderate HF (heart failure), liver/kidney disease Often found in combination with other HTN meds, i. e. Benicar HCT. AE are same as loop diuretics – hypokalemia, hyperglycemia, dehydration Nursing Responsibilities same as loop diuretics Decreases blood flow to the placenta Crosses into breastmilk and is harmful to baby Medication and food interactions same as loop diuretics Thiazide-type diuretics are usually given on alternate day dosing or weekly dosing since this is a very strong diuretic.

12. Chapter 18 Medications Affecting Urinary Output ▪ POTASSIUM-SPARING DIURETICS ▪ Spironolactone (Aldactone) ▪ Blocks action of aldosterone which leads to the retention of potassium and excretion of sodium and water ▪ May be combined with loop diuretics to help retain potassium ▪ Are administered to treat fluid build-up in HF, liver scarring, kidney disease, and HTN ▪ Are administered in primary hyperaldosteronism ▪ Can take 12-48 hours to take effect ▪ Only available as a PO med ▪ AE include hyperkalemia, impotence in males, irregularities in menstrual cycle in females ▪ Contraindicated in client w/ hyperkalemia, severe kidney failure and anuria (ESRD)

13. Chapter 18 Medications Affecting Urinary Output ▪ POTASSIUM-SPARING DIURETICS ▪ Spironolactone (Aldactone) ▪ Nursing Responsibilities ▪ Obtain baseline data. ▪ Monitor potassium and report potassium ≥5.0 mEq/L to MD ▪ Teach early s/s hyperkalemia - muscle weakness, tiredness, tingling sensations, or nausea ▪ Teach no salt substitutes or potassium supplements ▪ Teach client self-monitoring of BP and weight and to keep a log ▪ Teach triamterene can turn urine a bluish color

14. Chapter 18 Medications Affecting Urinary Output ▪ OSMOTIC DIURETICS ▪ Mannitol (Osmitrol) ▪ Given in the ICU setting with client on cardiac monitor ▪ When given, it increases the concentration of the blood (vascular space) which will pull fluid into the vascular space to dilute the blood back to its original concentration. ▪ Given to reduce intracranial pressure (ICP) which draws fluid from around the brain into the vascular space. ▪ Given to reduce intraocular pressure (IOP) which draws fluid from inside the eye into the vascular space. ▪ Can prevent kidney failure by preserving urine flow – given in the oliguric phase (4 - 16 mL/hr urine output) of acute kidney injury (AKI) ▪ Helps to retain sodium and get rid of water for clients with hyponatremia and fluid volume excess

15. Chapter 18 Medications Affecting Urinary Output ▪ OSMOTIC DIURETICS ▪ Mannitol (Osmitrol) ▪ AE ▪ HF & Pulmonary edema- stop med if these s/s occur ▪ Kidney failure – urine output <30 mL/hr, ↑creatinine, ↑BUN – stop the med ▪ F&E imbalances – daily labs are done – stop the med if abnormal ▪ Contraindications ▪ HF and pulmonary edema ▪ Interactions ▪ Lithium may be lowered – monitor lithium levels

16. Chapter 18 Medications Affecting Urinary Output ▪ OSMOTIC DIURETICS ▪ Mannitol (Osmitrol) ▪ Nursing Responsibilities ▪ Administer by continuous IV ▪ Use filter needle when drawing up from vail if nurse prepares IV solution to administer – hospital pharmacy will prepare this IV solution in most facilities but in some cases, the nurse will be responsible for preparing the IV solution. Exercise extreme caution when preparing IV medications. ▪ Monitor daily weight, I/O (this may be monitored hourly in the ICU setting and the client will have a foley catheter) and electrolytes. Urine output should always be at least 30 mL/hr or GREATER. If it drops below 30 mL/hr, notify the MD immediately. ▪ Monitor for s/s of dehydration, AKI, and edema ▪ BE SURE TO DO THE QUESTIONS AT THE END OF EACH CHAPTER!

17. Chapter 19 Medications Affecting Blood Pressure ▪ 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) ▪ This report made 9 recommendations on how physicians should treat hypertension based on evidence from studies. A flowchart describes the various pathways to be used to control blood pressure. ▪ 10 medication classifications used to treat HTN Thiazide diuretics Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Aldosterone antagonists Direct renin inhibitors Calcium channel blockers Alpha adrenergic blockers Centrally acting alpha ₂ agonists Beta adrenergic blockers Vasodilators

18. Concept: PRESSURE, PMIE, pp. 44-45 ▪ Pressure (BP) monitor ▪ Rise slowly to reduce orthostatic hypotension ▪ Eating must be considered (Low salt/No added salt diet) ▪ Stay on meds: skipping or stopping is a no-no ▪ Safety precautions to prevent falls ▪ Undesirable responses ▪ Remind to exercise/No alcohol/lose weight (lifestyle changes) ▪ Eliminate smoking; educate smoking cessation

19. Chapter 19 Medications Affecting Blood Pressure ▪ ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ▪ Generic name ending “pril” ▪ Examples: enalapril (Vasotec), Fosinopril (Monopril), Lisinopril (Prinivil), Ramipril (Altace), captopril (Capoten) ▪ Works by blocking the enzyme that converts angiotensin I to angiotensin II which lead to: ▪ Vasodilation ▪ Excretion of sodium and water, retention of potassium in the kidneys ▪ Reduces the damage caused by angiotension II and aldosterone to the heart and blood vessels ▪ Used for: HTN, HF, myocardial infarction (MI or heart attack), diabetic and nondiabetic neuropathy ▪ Ramipril may be used to help prevent MI, stroke, or death in high risk clients

20. Chapter 19 Medications Affecting Blood Pressure ▪ ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ▪ AE ▪ First dose orthostatic hypotension – will start with a low dose, monitor BP for 2hr post initiation of medication, teach client to sit or lie down if dizziness occurs and to change positions slowly ▪ Cough (dry, nonproductive) – teach client to call the MD if this occurs, AE goes away when stop med ▪ Hyperkalemia – Obtain baseline, monitor potassium per MD orders, teach client to avoid salt substitutes that contain potassium ▪ Rash and dysgeusia – occurs mostly with captopril, teach client to call the MD if this occurs, AE goes away when stop med ▪ ANGIOEDEMA – severe allergic rxn – Epinephrine SQ injection, call 911 ▪ Neutropenia – rare, compare baseline WBC to subsequent WBC, when detected early is reversible, teach early s/s if infection and to call MD if occurs

21. Chapter 19 Medications Affecting Blood Pressure ▪ ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ▪ Contraindications – pregnancy risk category D, allergy to med, clients with renal impairment AND collagen vascular disease more at risk for neutropenia ▪ Interactions ▪ Diuretics – additive effect for dehydration and first dose hypotension ▪ Other antihypertensive medications – additive effect for hypotension ▪ ACE inhibitors increase lithium levels – monitor lithium levels ▪ NSAIDs decrease ACE inhibitor effectiveness by decreasing blood flow to the kidneys – avoid NSAIDs

22. Chapter 19 Medications Affecting Blood Pressure ▪ ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ▪ Nursing Responsibilities ▪ ACE inhibitors available as PO meds EXCEPT for enalaprilat (Vasotec IV) which is the only ACE inhibitor for IV use. ▪ May be combined with HCTZ ▪ Teach clients about first dose hypotension ▪ Teach client captopril and moexipril must be taken on empty stomach; all other prils can be taken with or without food. ▪ Teach clients to report AE to MD when they occur

23. Chapter 19 Medications Affecting Blood Pressure ▪ ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) ▪ Generic name ends with “sartan” ▪ Examples: ▪ Valsartan (Diovan) ▪ Irbesartan (Avapro) ▪ Candesartan (Atacand) ▪ Olmesartan (Benicar) ▪ Works by blocking the action of angiotensin II in the body which leads to: ▪ Vasodilation ▪ Excretion of sodium and water with retention of potassium in the kidney ▪ Used to treat: ▪ HTN ▪ HF and prevention of mortality (death) after MI ▪ Stroke prevention ▪ Slow down progression of diabetic nephropathy

24. Chapter 19 Medications Affecting Blood Pressure ▪ ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) ▪ AE ▪ Angioedema – allergic rxn – epinephrine SQ and call 911 ▪ Contraindications ▪ Pregnancy risk category D ▪ Clients with renal stenosis ▪ Interactions ▪ Other antihypertensives – additive effect – teach client s/s hypotension and to sit or lie down and to call MD if occurs. ▪ Nursing Responsibilities ▪ Available only as PO form ▪ Teach med may be prescribed as a combo drug ▪ Teach med can be taken with or without food

25. Chapter 19 Medications Affecting Blood Pressure ▪ ALDOSTERONE ANTAGONISTS (POTASSIUM-SPARING DIURETICS) ▪ Examples: Eplerenine (Inspra), Spironolactone (Aldactone) ▪ Works by blocking aldosterone’s action in the kidneys which reduces blood volume by getting rid of excess fluid ▪ Used for: ▪ HTN ▪ HF ▪ AE ▪ Hyperkalemia, hyponatremia – monitor electrolytes, teach client to avoid salt substitutes which contain potassium, potassium supplements, and other potassium-sparing diuretics, avoid high potassium foods. ▪ Flulike symptoms – fatigue, HA, mild GI manifestations – teach to report this to MD if occurs ▪ Dizziness – Teach client no hazardous activities until know how this med will affect them.

26. Chapter 19 Medications Affecting Blood Pressure ▪ ALDOSTERONE ANTAGONISTS (POTASSIUM-SPARING DIURETICS) ▪ Contraindications ▪ Clients with hyperkalemia, kidney impairment and DM type 2 with albuminuria ▪ Interactions ▪ Verapamill, ACE inhibitors, ARBs, erythromycin and ketoconazole ↑risk of hyperkalemia – monitor potassium, teach s/s of hyperkalemia ▪ Lithium toxicity if taken with potassium-sparing diuretics – Teach client taking lithobid, s/s of lithium toxicity ▪ Nursing Responsibilities ▪ Administer PO with or without food ▪ Do not give with potassium supplements or other potassium-sparing diuretics

27. Chapter 19 Medications Affecting Blood Pressure ▪ Direct Renin Inhibitors ▪ Aliskiren (Tekturna) ▪ Works by binding renin to prevent production of angiotensin I ▪ Used for: HTN ▪ AE ▪ Angioedema – epinephrine SQ, call 911 ▪ Hyperkalemia – monitor K+, no salt substitutes w/K+, no K+ supplements ▪ Diarrhea – dose related, teach to call MD if diarrhea severe, monitor for dehydration (geriatrics) ▪ Contraindications ▪ Allergy ▪ Pregnancy Risk Cat C (1 st trimester), D (2 nd and 3 rd trimester)

28. Chapter 19 Medications Affecting Blood Pressure ▪ Direct Renin Inhibitors ▪ Interactions ▪ ↓es Lasix blood levels – MD may ↑ Lasix dose ▪ Additive effect with other antihypertensives – monitor for hypotension ▪ Atorvastation and ketoconazole ↑ Tekturna levels – monitor for hypotension ▪ Nursing Responsibilities ▪ Avoid high-fat meals which interfere with absorption ▪ Available alone or in combo

29. Chapter 19 Medications Affecting Blood Pressure Calcium Channel Blockers

30. Chapter 19 Medications Affecting Blood Pressure ▪ Calcium channel blockers (CCBs) ▪ Generic name ends with “dipine” with exceptions verapamil and diltiazem ▪ Examples: ▪ Nifedipine (Procardia) ▪ Amlodipine (Norvasc) ▪ Felodipine (Plendil) ▪ Nicardipine (Cardene) ▪ Verapamil (Calan) ▪ Diltiazem (Cardizem)

31. Chapter 19 Medications Affecting Blood Pressure ▪ Calcium channel blockers (CCBs) ▪ Works by blocking the entry of calcium into the muscle cells of the heart and arteries, thus slowing the electrical conduction within the heart, decreasing the force of contraction (work) of the muscle cells, and dilating arteries. The veins are not affected. ▪ “Dipine” used for angina pectoris and HTN ▪ Verapamil and diltiazem used for angina pectoris, HTN, and A fib / A flutter / SVT ▪ AE ▪ “Dipine” – reflex tachycardia, peripheral edema, acute toxicity – monitor HR, BP, Edema; report abnormal VS to MD; administer meds per MD orders, teach client about AE and to report to MD if occur ▪ Verapamil/Diltiazem – orthostatic hypotension, peripheral edema, constipation, bradycardia, HF, wide QRS complex, prolonged QT interval, AV block, ventricular tachycardias – monitor VS and ECG (cardiac monitor), edema, daily weight and have crash cart available for hospitalized client – teach home health client about monitoring BP/HR/weight and to report to MD if abnormal.

32. Chapter 19 Medications Affecting Blood Pressure ▪ Calcium channel blockers (CCBs) ▪ Contraindications ▪ Pregnancy Risk Category C ▪ “Dipine” – Acute MI, unstable angina, aortic stenosis, shock, intestinal obstruction ▪ Verapamil – heart block, digoxin toxicity, severe HF, lactation ▪ Interactions ▪ NO GRAPEFRUIT ▪ “Dipine” – metoprolol may be used to counteract reflex tachycardia – monitor HR when given together, HR<60 call MD with SBAR ▪ Verapamil ▪ Digoxin– can increase digoxin to toxicity – monitor Digoxin level and VS when given together, call MD if abnormal occurs ▪ Beta blockers – can lead to HF, AV block, and bradycardia – monitor VS and administer IV verapamil and beta blockers several hours apart (do not administer together)

33. Chapter 19 Medications Affecting Blood Pressure ▪ Calcium channel blockers (CCBs) ▪ Nursing Responsibilities ▪ DO NOT CRUSH and teach client not to crush this medication ▪ Verapamil IVP 2.5 – 5 mg over 2-3 minutes followed with 10 mL NS flush (this is the adult code blue initial dose if given) ▪ Teach client to keep a log of angina with pain frequency, intensity, duration, and location and to call the MD if attacks increase in frequency, intensity, and/or duration. ▪ Teach client to keep BP (instruct to take BP 1-2 hours after taking med) and PULSE log (instruct to take pulse before taking med).

34. Chapter 19 Medications Affecting Blood Pressure ▪ ALPHA-ADRENERGIC BLOCKERS (SYMPATHOLYTICS) ▪ Examples: Prazosin (Minipress), Doxazosin (Cardura), Terazosin (Hytrin) ▪ How It Works – blocks alpha 1 receptors in arterioles and veins which relaxes them (vasodilation). It also relaxes the smooth muscle of the prostatic capsule and bladder. ▪ Used for primary HTN. Doxazosin and terasozin can be used to treat BPH. ▪ AE ▪ First dose orthostatic hypotension ▪ Contraindications ▪ Pregnancy Risk category C ▪ Hypotension ▪ Use cautiously in angina pectoris, renal insufficiency, older clients ▪ Interactions ▪ Additive effect with other BP medications ▪ Nursing Responsibilities ▪ Instruct med can be taken with food, precautions for orthostatic hypotension

35. Chapter 19 Medications Affecting Blood Pressure

36. ▪ CENTRALLY ACTING ALPHA 2 AGONISTS ▪ Examples – Clonidine (Catapres), guanfacine (Tenex), methyldopa (Aldomet) ▪ How It Works – works in the brain to slow down stimulation of the alpha and beta receptors of the heart and peripheral vascular system (PVS). This slows the heart rate and relaxes the PVS producing vasodilation. ▪ Used for HTN, migraine HA, “hot flashes” menopause, ADHD and Tourette mgt, EtOH/tobacco/opioid withdrawal symptom mgt ▪ AE ▪ Drowsiness/sedation – diminishes with continued med use ▪ Dry mouth – sips of H 2 O or ice chips, will diminish with continued med use ▪ Rebound HTN with abrupt discontinuation of medication is very dangerous. This med must be weaned over 2-4 days.

37. Chapter 19 Medications Affecting Blood Pressure ▪ CENTRALLY ACTING ALPHA 2 AGONISTS – CLONIDINE ▪ Contraindications ▪ Pregnancy risk category C – avoid use during lactation also ▪ Use cautiously in stroke, recent MI, diabetes, major depressive disorder, or chronic renal disease ▪ Interactions ▪ Additive hypotensive effect when used with other BP meds ▪ Using with prazosin, MAOIs, or TCAs will counteract the antihypertensive effect of clonidine ▪ Additive CNS depression when used with other CNS depressants such as alcohol ▪ Nursing Responsibilities ▪ Monitor BP and instruct on s/s hypotension and precautions to take (sit or lie down, change positions slowly) ▪ Available as PO, epidural, transdermal patch ▪ PO usually given 2x daily with larger dose taken at night ▪ Instruct to avoid other CNS depressants (alcohol, etc) ▪ Transdermal patch changed every 7 days

38. Chapter 19 Medications Affecting Blood Pressure

41. ▪ Contraindications ▪ AV block and bradycardia ▪ Interactions ▪ Avoid verapamil and diltiazem with beta blockers ▪ Additive effect when used with other BP meds

42. Chapter 19 Medications Affecting Blood Pressure ▪ Nursing Responsibilities ▪ Monitor pulse/HR and if ≤60, hold med and notify MD ▪ Monitor for CHF exacerbation and instruct on s/s of CHF exacerbation and when to call MD – client to keep weight log. ▪ Instruct to not stop med abruptly as will cause dangerous life threatening heart rhythm – must be weaned over 1-2 weeks ▪ May mask early s/s of hypoglycemia (tachycardia) in diabetics. Instruct client to monitor blood glucose closely ▪ Beta2 blockers like propranolol should not be given to asthmatics, bronchospasm, or HF ▪ Instruct client to keep a BP and pulse log. Take pulse before taking med and take BP 1-2 hours after taking med. ▪ Instruct client no to crush or chew sustained release/extended release meds.

43. Chapter 19 Medications Affecting Blood Pressure ▪ MEDICATIONS FOR HYPERTENSIVE CRISIS ▪ Examples – Nitroprusside (nitropress), nitroglycerin (NTG, Nitrostat IV), nicardipine (Cardene), Clevidipine (Cleviprex), enalaprilat (Vasotec IV), Esmolol (Brevibloc) ▪ Used primarily in the ICU setting on an IV pump so medication can be titrated for effectiveness. ▪ Client must be on a cardiac monitor and BP should be monitored no less than every 15 minutes. Commonly nurses will monitor BP every 5 minutes until BP is normalized and then every 10-15 minutes thereafter until the client is taken off the medication. ▪ Cyanide poisoning with nitroprusside use. Give thiosulfate at the same time to prevent this. ▪ s/s of thiocyanate poisioning: delirium, psychosis ▪ Nitroprusside should be discontinued if thiocyanate level goes above 10 mg/dL. ▪ IV solution must be protected from light. Discard if any other color than clear-light brown.