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NR 508 Week 3: Discussion

NR 508 Week 3: Discussion

NR 508 Week 3: Discussion – Mr. Russell is a 69-year-old male who presents to your clinic with complaints heart palpitations and light headedness on and off for the past month. He has a history of hypertension and is currently prescribed HCTZ.

Vital Signs: B/P 159/95, Irregular HR 78, Resp. 20, Weight 99 kilograms

Lower extremities with moderate 3+edema noted bilaterally, ABD + BS, Neuro AOX3,

Labs: NA 143mEq/L, CL 99 mmol/L BUN 18mg/dL, Hbg 15, TC 234 mg/dL, LDL 137 mg/dL, HDL 35 mg/dL, triglycerides 241mg/dL, NR 508 Week 3: Discussion

  • What are your treatment goals for Mr. Russell today?
  • What is your pharmacologic plan; please state your rationale for your plan?
  • What are five key patient education points based on your plan?
  • How would your plan change if your patient is African American?
  • How would your plan change if your patient complains of excessive heartburn and belching? NR 508 Week 3: Discussion

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Treatment Goals:

Based on the information provided, it is possible that Mr. Russell may have an underlying cardiac condition however, the current treatment goals would primarily be based on health history, patient assessment, and laboratory work. The goals for today would include the following:

  1. Optimizing blood pressure with either additional blood pressure medications, increasing the dosage of hydrochlorothiazide or both. The 2017 clinical practice guideline set forth by the American College of Cardiology and American Heart Association Task force, categorize systolic blood pressure of greater than or equal to 140 and diastolic reading of greater than or equal to 90 as stage 2 hypertension. Therefore, Mr. Russell’s blood pressure of 159/95 falls in this category and must be treated.
  2. Mr. Russell’s HR is irregular, and he complains of palpitations and light-headedness. These symptoms may be indicative of Atrial Fibrillation. A 12-Lead EKG is needed to determine his heart rhythm and guide us on further treatment.
  3. The etiology of Mr. Russell’s 3+ edema must be further explored and treated. We will need BNP levels drawn, and Chest X-ray PA/LAT to rule out CHF. Additionally, bilateral venous duplex must be done to rule out VTE. We also need a CMP to check Mr. Russell’s liver function and potassium levels. This is especially important because HCTZ is not a potassium sparing diuretic which can potentially result in low serum potassium.
  4. Mr. Russell needs medication for his high cholesterol, LDL and triglycerides.
  5. Educate Mr. Russell on the current treatment plan and answer all his questions NR 508 Week 3: Discussion.

Pharmacologic Plan:

The 2017 drug therapy guidelines for stage 2 hypertension established by the American College of Cardiology and American Heart Association Task force recommends using two first-line medications from different classes. These classes include thiazide diuretics, CCBs, ARBS and ACE inhibitors.  Mr. Russell is already on hydrochlorothiazide which is a thiazide diuretic. Hydrochlorothiazide comes in a 12.5mg, 25mg and 50mg tablets. Given the severity of his edema, I would order HCTZ 25mg two times daily. Please note that the dosage to be ordered would also depend on Mr. Russell’s current dosage.  It is possible that his current dosage is not adequate to resolve his edema. HCTZ acts by inhibiting the transport of sodium chloride in the distal convoluted tubule. This results in the excretion of more sodium and fluid in the kidneys (Herman & Bhimji, 2017) Its effect on high blood pressure when administered acutely is achieved by diuresis and a decrease in plasma volume.  However, in the long-term, it does so by decreasing peripheral resistance (Herman & Bhimji, 2017).  The most common side effects associated with HCTZ are electrolyte abnormalities such as hypokalemia, hyponatremia, hypomagnesemia, and hypochloremia. Orthostatic hypotension has also been reported in some patients. Hydrochlorothiazide has been well documented as a highly effective blood pressure medication for the elderly.

The second medication I would add is the ACE inhibitor lisinopril. Lisinopril comes in dosages ranging from 2.5mg- 40mg. The initial orders will be Lisinopril 5mg by mouth daily. I chose lisinopril because studies have shown that it’s very effective as a combination therapy with HCTZ in its management of hypertension. In fact, a study reported by Sukalo et al (2016) concluded that a reduction of an average of 32.8mm/hg in systolic blood pressure and 17.1 in diastolic blood pressure can be achieved with lisinopril/HCTZ. Furthermore, if additional testing show heart failure in Mr. Russell, lisinopril has been shown as a good adjunctive therapy with HCTZ in the setting of heart failure. Lisinopril works by inhibiting the conversion of angiotensin I to angiotensin II. The most common side effects of lisinopril are hypotension, hyperkalemia, renal impairment, dizziness, headache and photosensitivity NR 508 Week 3: Discussion.

The third medication to be ordered is a lipid lowering agent or statin. I would add atorvastatin 20mg daily. Atorvastatin is in the class of medication, HMG-CoA reductase. HMG-CoA reductase medications exert their therapeutic effect by altering the rate-limiting step of cholesterol synthesis (Siddique, 2017). Ultimately, stimulating the breakdown of LDL and causing a reduction in serum levels. When used with a low-fat diet and an exercise regimen, atorvastatin has been proven to reduce the risk of stroke and heart attack in the at-risk population (Siddique, 2017). The most common side effects of atorvastatin are musculoskeletal pain, myalgia, muscle spasms, arthritis, insomnia, elevation in serum ALT/AST and nausea.

Patient Education

Mr. Russell would be educated on the following:

  1. To take all medications as ordered and monitor daily blood pressure and weight every morning and record.
  2. Would explain the side effects of all medications ordered for example orthostatic hypotension that can occur with HCTZ and muscle pain with atorvastatin. Serious adverse effects such as angioedema that infrequently occurs with lisinopril would also be reiterated.
  3. To engage in a regular 30-minute exercise regimen. Considering Mr. Russell’s age, walking may be the most appropriate.
  4. According to the American Heart Association, a heart healthy diet forms an integral part of managing high blood pressure and cholesterol levels. For that reason, Mr. Russell would be educated to incorporate a diet rich in fruits, vegetables, whole grains, nuts, and low in saturated and trans fats, sodium, red meat and sugars. Also, other lifestyle changes like limiting the intake of alcohol and smoking cessation would be emphasized.
  5. To seek medical attention if edema doesn’t resolve or worsens and call 911 if shortness of breath develops.

Plan for African American Patient

I would replace the ACE inhibitor, lisinopril with a CCB such as amlodipine or an ARB. Dosages for amlodipine range from 2.5mg to 10ng. In this situation, amlodipine 5mg daily will replace the dose of lisinopril. The reasons are that studies have proven better efficacy of CCBs than ACE inhibitors when used in blacks.  Ogedegbe et al, (2015) reported a study that showed that blacks treated with ACE inhibitors had poorer cardiovascular outcomes than whites (Ogedegbe et al, 2015). The writers also reported that blacks treated with ACE inhibitors were more likely to develop CHF than their white counterparts. Amlodipine can be ordered as a combination therapy with atorvastatin (Caduet) for Mr. Russell. According to Pfizer Medical, Amlodipine works on vascular smooth muscles and primarily acts by inhibiting the influx of calcium ions across cell membranes. The side effects are palpitations, peripheral edema, fatigue, dizziness and flushing.

Plan for excessive heartburn or belching

I would rule out myocardial Ischemia if Mr. Russell was experiencing excessive heartburn and belching. An EKG and serial cardiac enzymes would be drawn. If a cardiac event is ruled out, Mr. Russell may be having symptoms of GERD. Antacids or proton pump inhibitors with nonpharmacologic therapy such as weight loss, eating small frequent meals and avoiding coffee may be effective in managing his symptoms (Patti, 2017)NR 508 Week 3: Discussion.

Nancy

References

Herman, L., Bhimji, S., (2017). Hydrochlorothiazide. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430766/#_NBK430766_pubdet_ (Links to an external site.)

Patti, M. (2018). Gastrointestinal Reflux Disease. Practice Essentials.  Retrieved from https://emedicine.medscape.com/article/176595-overview (Links to an external site.)

Siddique, M., (2017). Atorvastatin. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430779/#_NBK430779_pubdet_ (Links to an external site.)

Sukalo, A., Deljo, D., Krupalija, A., Zjajo, N., Kos, S., Curic, A., &…. Medjedovic, S. (2016). Treatment of Hypertension with Combination of Lisinopril/Hydrochlorothiazide. Medical Archives (Sarajevo, Bosnia And Herzegovina), 70(4), 299-302

Ogedegbe, G., Shah, N., Phillips, C., Goldfied K., Roy, J., Guo, Y., Gyamfi, J., Torgersen C., Capponi, L., Bangalore, S. (2015). Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitor-Based Treatment on Cardiovascular Outcomes in Hypertensive Blacks Versus Whites. Journal of the American College of Cardiology. Retrieved from http://www.onlinejacc.org/content/66/11/1224 (Links to an external site.)

Whelton, P., Carey, R., Aronow, W., Casey, D., Collins, K., Himmelfarb, C.D., &…Depalma, S., (2018). Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology. Retrieved from http://www.onlinejacc.org/content/71/19/e127 NR 508 Week 3: Discussion