Pharmacologic Profile

General Use

Used in the treatment of hypertension (amlodipine, diltiazem, felodipine, isradipine, nicardipine, nifedipine, nisoldipine, verapamil) or in the treatment and prophylaxis of angina pectoris or coronary artery spasm (amlodipine, diltiazem, felodipine, nicardipine, verapamil). Verapamil and diltiazem are also used as antiarrhythmics. Nimodipine is used to prevent neurologic damage due to certain types of cerebral vasospasm.

General Action and Information

Block calcium entry into cells of vascular smooth muscle and myocardium. Dilate coronary arteries in both normal and ischemic myocardium and inhibit coronary artery spasm. Diltiazem and verapamil also ↓ AV nodal conduction. Nimodipine has a relatively selective effect on cerebral blood vessels.

Contraindications

Hypersensitivity. Contraindicated in bradycardia, 2nd- or 3rd-degree heart block, or decompensated HF (all except for amlodipine and felodipine).

Precautions

Safety in pregnancy and lactation not established. Use cautiously in patients with liver disease or uncontrolled arrhythmias.

Interactions

May cause additive bradycardia when used with other agents having these effects (beta blockers, digoxin, clonidine, and ivabradine). Effectiveness may be ↓ by phenobarbital or phenytoin and ↑ by propranolol or cimetidine. Verapamil and diltiazem may ↑ serum digoxin levels and cause toxicity.

Nursing Implications

Assessment

• Monitor BP and pulse frequently during dosage adjustment and periodically throughout therapy.
• Monitor intake and output ratios and daily weight. Assess patient routinely for signs and symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention).
• Assess frequency and severity of episodes of chest pain periodically throughout therapy.
• ECG should be monitored continuously during IV therapy and periodically during long-term therapy with verapamil or diltiazem.
• Assess patient's neurological status (level of consciousness, movement) before and periodically during therapy with nimodipine.

Potential Nursing Diagnoses

• Ineffective tissue perfusion (Indications)
• Acute pain (Indications)
• Deficient knowledge related to disease processes and medication regimen (Patient/Family Teaching)

Implementation

• May be administered without regard to meals.
• Do not open, crush, or chew sustained-release capsules.

Patient/Family Teaching

• Instruct patient to continue taking medication, even if feeling well.
• Caution patient to make position changes slowly to minimize orthostatic hypotension. Advise patient that exercising or hot weather may enhance hypotensive effects.
• Instruct patient on the importance of maintaining good dental hygiene and seeing dentist frequently for teeth cleaning to prevent tenderness, bleeding, and gingival hyperplasia (gum enlargement).
• Advise patient to consult health care professional before taking any OTC medications or herbal/alternative therapies, especially cold remedies.
• Advise patient to advise health care professional of medication regimen prior to treatment or surgery.
• Advise patient to carry identification describing disease process and medication regimen at all times.
• Emphasize the importance of follow-up exams to monitor progress.
• Instruct patients on concurrent nitrate therapy to continue taking both medications as directed and using SL nitroglycerin as needed for anginal attacks. Advise patient to contact health care professional if chest pain worsens or does not improve after therapy, or is accompanied by diaphoresis or shortness of breath, or if severe, persistent headache occurs. Caution patient to discuss exercise precautions with health care professional prior to exertion.
• Encourage patient to comply with additional interventions for hypertension (weight reduction, low-sodium diet, regular exercise, smoking cessation, moderation of alcohol consumption, and stress management). Medication controls, but does not cure, hypertension.
• Instruct patient and family on proper technique for monitoring BP. Advise them to check BP weekly and report significant changes to health care professional.

Evaluation/Desired Outcomes

• Decrease in BP.
• Decrease in frequency and severity of anginal attacks.
• Decrease need for nitrate therapy.
• Increase in activity tolerance and sense of well-being.
• Suppression and prevention of supraventricular tachyarrhythmias.
• Improvement in neurological deficits due to vasospasm following subarachnoid hemorrhage.