Lisinopril Nursing Considerations

Lisinopril is a prescription drug used to treat high blood pressure in adults and children at least 6 years of age.

By lowering blood pressure, it prevents stroke, heart attack, and kidney disease.

It is also given to treat heart failure and help to improve recovery among patients who had a heart attack. Lisinopril is under a drug classification called ACE or angiotensin-converting enzyme inhibitor, it lowers chemicals that narrow blood vessels, resulting in smoother blood flow.

Indications of Lisinopril

• Hypertension. Lisinopril is given to both adults and children 6 years of age and older as a treatment for high blood pressure. In controlled clinical trials, hypertensive patients with mild to moderate conditions were given lisinopril daily. And it shows a higher reduction of both systolic and diastolic pressure. Among patients with essential hypertension, blood pressure reduces with the reduction of peripheral arterial resistance with less or without change in cardiac output and cardiac rate. In cases of renovascular hypertension, it has been demonstrated to be effective and well-tolerated in lowering blood pressure. In a clinical study among pediatric patients, lisinopril is given to hypertensive patients ages 6 to 16 years. Patients weighing less than 50kg received 20mg of lisinopril, once a day. For patients weighing more than 50kg, 40mg of lisinopril once a day is prescribed. The antihypertensive effect of lisinopril was consistent and generally well-tolerated by pediatric patients.

●  Heart Failure. ACE inhibitors such as lisinopril are prescribed in patients with heart failure as they demonstrate effectiveness in relieving symptoms such as fluid build-up and swelling, shortening the duration of hospital stay, and improving survival. Lisinopril combined with other drug therapy has been proven effective in reducing signs and symptoms of heart failure. Which includes edema, rales, paroxysmal nocturnal dyspnea, and jugular venous distention. It also has been shown that in patients with systolic heart failure, single doses of lisinopril promote a decrease in pulmonary capillary wedge pressure, systemic vascular resistance, and blood pressure, with an increase in cardiac output and without changes in heart rate.

• Acute Myocardial Infarction. Lisinopril is administered to hemodynamically stable patients within 24 hours to patients with acute myocardial infarction to improve their chance of survival.

Mechanism of Action of Lisinopril

Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that prevents the conversion of angiotensin I to angiotensin II, resulting in to decrease in the level of angiotensin II in the body. Angiotensin II is a vasoconstrictor hormone that causes an increase in blood pressure. It promotes dilation of arteries and veins, resulting to improve blood flow, making it easier for the heart to pump blood and regulate blood pressure.

Pharmacokinetics of Lisinopril

• Peak. In adult patients, after oral administration of lisinopril the peak serum concentration happens within 6 to 8 hours. However, in cases of acute myocardial infarction, there was a trend of little delay in time to reach the peak.
• Absorption. Absorption remains unchanged even with the presence of food in the gastrointestinal tract.
• Metabolism. Lisinopril does not come out to be confined to other serum proteins, it also does not go through metabolism, and excretion occurs completely through urine. Bioavailability is 25% and the initial onset is 1 hour, while the peak time takes up to 6 hours. The duration period is 24 hours. On multiple dosages, lisinopril displays an effective half-life of accumulation of 12 hours.

Side Effects of Lisinopril

The most common side effects that can happen with lisinopril are the following:

• headache
• dizziness
• persistent cough
• decreased blood pressure
• chest pain
• fatigue
• metallic or salty taste
• elevated uric acid, BUN, and creatinine levels

These side effects are mild and are expected to go away on their own within a couple of days or weeks. However, if these symptoms persist, the healthcare team may discuss alternatives to lisinopril.

The following are more severe side effects which require immediate medical intervention:

• allergic reaction – symptoms include swelling of face, lips, tongue, or throat, difficulty breathing, difficulty swallowing, and hives.
• abdominal pain
• nausea
• vomiting
• renal problems, which may include symptoms such as fatigue, swelling of hands, feet, or ankles, dark-colored urine, and urine output of less than 30ml per hour.
• shortness of breath
• weight gain
• loss of consciousness
• symptoms of elevated potassium level in blood: muscle weakness, tingling sensation, chest pain, nausea, slow or irregular heartbeat.
• signs of infection, including fever, chills, sore throat, and others
• liver failure, with symptoms such as yellow-colored skin and sclera (whites of eyes), increased level of liver enzymes, abdominal pain, nausea, loss of appetite, vomiting, and clay-colored stool.
• hyperkalemia or increased potassium levels – lisinopril can cause an excessive increase in potassium levels. elevated potassium levels may lead to irregular heartbeats or arrythmia. there is a higher risk among patients with renal disease, diabetes, or those who are taking other drugs that increase potassium levels.

Adverse Reactions of Lisinopril

Lisinopril was tested in controlled clinical trials and found to be well tolerated by most hypertensive and post-heart failure patients. Mostly, the adverse reactions are experienced mild and temporary:

• General body: Allergic reactions, syncope, fever, chills, body pain, pelvic pain, chest pain, orthostatic pain, viral infection.
• Cardiovascular: Hypotension, arrhythmia, pulmonary embolism, palpitation, premature ventricular contraction, transient ischemic attacks, orthostatic hypotension, decreased blood pressure, vasculitis, peripheral edema, and cardiac arrest.
• Digestive disease: Diarrhea, abdominal pain, nausea, vomiting, dyspepsia, gastrointestinal cramps, gastritis, pancreatitis, hepatitis, heartburn, constipation, flatulence, dry mouth.
• Musculoskeletal: Muscle cramps, arthritis, joint pain, hip pain, lower back pain, knee pain, shoulder pain, lumbago.
• Nervous and psychiatric disorders: headache, dizziness, burning and prickling sensation in arms, legs, fingers; decreased libido, vertigo, ataxia, memory impairment, tremor, peripheral neuropathy, confusion, insomnia. Somnolence, hypersomnia, irritability, nervousness, and mood swings with depressive symptoms.
• Respiratory disorder: Cough, upper respiratory infection, common colds, nasal congestion, flu, hemoptysis, bronchitis, lung infiltrates, pleural effusion, asthma, bronchospasm malignant lung neoplasm, wheezing, epistaxis, laryngitis, sinusitis, throat pain, throat inflammation, rhinitis, rhinorrhea, orthopnea, painful respiration
• Integumentary disease: rash, urticaria, alopecia, herpes zoster, light sensitivity, skin infections, erythema, diaphoresis, flushing, steven-johnson syndrome, and toxic epidermal necrolysis
• Urogenital disease: Impotence, decreased urine output, blood in urine, uremia, acute renal failure, difficulty urination, urinary tract infection and breast pain, elevated creatinine level
• Special senses: Loss of vision, double vision, blurred vision, tinnitus, photophobia, altered taste.
• Metabolic: Hyperkalemia, weight loss, dehydration, fluid overload, gout, weight gain, hypoglycemia
• Endocrine: Diabetes mellitus
• Miscellaneous: positive ANA in blood, eosinophilia, leukocytosis, elevated erythrocyte sedimentation rate

Drug Interactions of Lisinopril

• Diuretics. Starting lisinopril in patients taking diuretics may lead to overmuch lowering of blood pressure. The risk of hypotension effect with lisinopril can be avoided by either lowering or discontinuing of diuretic or starting with a lower dose of lisinopril. Lisinopril decreases potassium loss caused by thiazide-type diuretics. Using potassium-sparing diuretics can expand the possibility of hyperkalemia. That being the case, continuous usage of both drugs will require frequent monitoring of the serum potassium level of the patient.

• Hypoglycemic agents. Concomitant use of lisinopril and hypoglycemic agents including insulin and oral diabetic medications may increase the effect of glucose-lowering medications, resulting in a higher risk of hypoglycemia.

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) including Selective Cyclooxygenase e-2 Inhibitors. Coadministration of ACE Inhibitors like lisinopril and NSAIDs including selective COX-2 inhibitors may lead to impaired renal function, including the risk of developing acute renal failure among old aged patients, under diuretic therapy, and may worsen the condition of those with existing impaired renal function. These are reversible if prompt action is applied. Regular monitoring of kidney function is applied.

• Other anti-hypertensive drugs. A combination of lisinopril and other blood pressure-lowering agents such as angiotensin receptor blockers, angiotensin-converting enzymes, and renin inhibitors may increase the possibility of hyperkalemia, changes in renal function, acute renal injury, renal failure, and hypotension. Regular monitoring of blood pressure, renal function test, and electrolytes level in patients with renal injury.

• Mood stabilizing agents. Cases of lithium toxicity among patients receiving lithium and medications that cause sodium eliminations which include ACE inhibitors have been reported because lisinopril can increase the effects of lithium on the body. Close monitoring of lithium levels is advisable during the course of treatment.

• mTOR Inhibitors. Patients taking mTOR inhibitors and ACE inhibitors simultaneously may be at risk of developing angioedema. It may affect the face, extremities, lips, tongue, glottis, and larynx. They may also be likely to experience airway obstruction, thus, providing appropriate therapy and monitoring is needed. If using mTOR inhibitors, discontinue lisinopril first within 36 hours before switching.

• Antirejection medication after organ transplant. Taking lisinopril with these drugs increases the risk of developing angioedema.

• Injectable Gold. Patient receiving injectable gold and taking lisinopril is at higher risk of nitrite reaction. Symptoms include flushing (warm and red-colored face and cheeks), nausea, vomiting, and low blood pressure.

Nursing Considerations for Lisinopril

• For a first-time patient that will take lisinopril, assess if allergic to lisinopril or other ACE inhibitors, any other medications, and its ingredients in tablet and solution. Verify with the pharmacist the list of ingredients.
• Gather the patient medical history, from past medical history up to existing medical conditions. Take note if the patient has or ever had elevated potassium levels, kidney and heart diseases, and liver problems.
• Ask if the patient is taking angiotensin II receptor blocker and neprilysin inhibitors, and anti-diabetic medication. Report it to the doctor immediately.
• List down all the medications of the patient, this will include prescription drugs or over-the-counter medications. Also the vitamins, nutritional supplements, and herbal products the patient is currently taking. Be sure to take note of any of the following medications: Diuretics, NSAIDs, acetylsalicylic acid, anti-diabetic agents, lithium, potassium supplements, and gold compounds. Close monitoring is needed to avoid side effects if coadministration with lisinopril will be prescribed.
• Explain the instructions carefully to the patient and encourage them to ask questions if they have any concerns or clarifications.
• Instruct the patient to continue taking lisinopril even when their condition improves. Do not discontinue lisinopril without consulting the doctor first.
• If coadministered with a diuretic, closely monitor the patient for symptoms of hypovolemia, including weakness, cold and clammy skin, decrease urine output, pallor, confusion, and others.
• Ask the patient if they have or have had angioedema. Lisinopril can cause sudden swelling of the face, legs, lips, tongue, throat, and intestines. This is a life-threatening situation. Inform your doctor immediately if you experience swelling and abdominal pain. There’s a higher risk for patients with a history of Angioedema and those black race.
• Lisinopril can cause low blood pressure, especially during the first few days from the start of medication. Tell the patient to inform their doctor if they experience lightheadedness, dizziness, or feeling they’re going to faint. Monitoring of blood pressure is required. Lowering of blood pressure may be secondary to the following: Are not drinking enough amount of fluids, sweating heavily, having diarrhea or vomiting, having heart failure, patients on dialysis and taking diuretics
• Monitor blood pressure regularly to check the patient’s response to medication.
• For pediatric patients, monitor the glomerular filtration rate. It should be not less than 30ml/min
• Instruct the patient to carefully follow the doctor’s prescription in taking lisinopril. The dosage may change occasionally depending on the patient’s progress. Lisinopril comes with some serious risks if not taken as prescribed. If the patient does not take it all, blood pressure will spike. This may put the patient at greater risk for heart attack and stroke. If stopped suddenly, the blood pressure may not be well controlled. This may result in anxiety, sweating, and an increase in heart rate. If the medication is not taken on schedule, blood pressure may be difficult to manage. There’s a greater risk of having heart attack and stroke. If taken too much, the patient may experience a drop in blood pressure and toxicity. Call the poison control center or bring the patient immediately to the nearest hospital. 
• Advise the patient not to make a self-adjustment when it comes to the dosage and frequency. Ask the doctor first before making any adjustments to the medication.
• It is recommended to increase water intake while the patient is taking lisinopril unless contraindicated.
• Instruct the patient to avoid becoming overheated or dehydrated in hot weather or during exercise. Lisinopril can lessen sweating and the patient may be more prone to heatstroke.
• Avoid taking potassium supplements otherwise prescribed by the doctor.
• Dizziness and lightheadedness are some of the side effects of lisinopril. Instruct the patient that when getting from a sitting or lying position, get up slowly and avoid getting up too fast. Make sure that they have steady themselves to prevent a fall.
• For liquid form, use a dosing syringe or a special dose spoon or medicine cup. To ensure exact measurement of the dosage required.
• If the patient is pregnant or planning to get pregnant, consult with the doctor first before starting taking lisinopril. This agent may affect the developing baby, or worst may cause fetal death.
• For breastfeeding mothers, lisinopril is present in milk during trials in the rat. Due to possible severe adverse reactions in infants, advised the mother to discontinue breastfeeding on the course of lisinopril treatment.
• Advised the patient to avoid drinking alcohol while taking lisinopril. Alcohol can stimulate the lowering of blood pressure and increases certain side effects of lisinopril.
• If the patient is having any kind of surgery, including dental procedures, let their physician know beforehand.
• If the doctor advised a low-salt or low-sodium diet, stick with the direction carefully.
• Advised the patient to consult first before using salt substitute as it may contain potassium.
• In case of a missed dose, instruct the patient to take the missed dose as soon as it was remembered. If it is almost time for the next dose, skip the missed one and continue with the regular dosage. Never take a double dose to cover up the missed one.
• To help the patient remember to take lisinopril, advise to take it around the same time every day.
• In case of overdose, contact the poison control center immediately. Symptoms of overdose include lightheadedness and fainting. If the patient loses consciousness, can’t be awakened, had a seizure, and has difficulty breathing contact the emergency hotline immediately.
• Obtain and monitor the patient’s kidney function test and electrolytes level as ordered by the physician.
• Store the medicine at room temperature. Keep away from moisture and heat.
• In addition to medication, modification of lifestyle will also help the patient to control blood pressure. Encourage them to maintain their ideal weight, follow the diet as doctors instructions, regular exercise as tolerated, smoking cessation, and stop drinking alcohol.
• If the patient is undergoing dialysis, there’s a higher risk of having serious side effects. The doctor will monitor the patient’s kidney function and adjust medication. It is important if the patient will cooperate properly to avoid adverse reactions from the drugs.
• For diabetic patients, closely monitor their blood sugar level. Lisinopril may affect the patient’s blood glucose levels.

Lisinopril Nursing Responsibilities

Possible Lisinopril Nursing Diagnoses

• Risk for Impaired Renal Perfusion related to the mechanism of action of lisinopril
• Risk for Electrolyte Imbalance (Hyperkalemia) related to the possible side effect of lisinopril
• Nausea related to the side effect of lisinopril
• Deficient Knowledge related to a new drug prescription

Nursing Assessment

Nursing Planning and Intervention

Nursing Evaluation

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon