Assignment: NR 508 Week 3 Discussion: Case of Mr Russell

NR 508 Week 3 Discussion: Case of Mr. Russell – 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.

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Vital Signs: B/P 180/95, 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.

Assignment: NR 508 Week 3 Discussion: Case of Mr. Russell

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?

NR 508 Week 3 Discussion: Case of Mr Russell Sample Treatment Plan

NR 508 Week 3 Discussion: Case of Mr Russell

The treatment goals for Mr. Russel:

Based on the information provided Mr. Russel is experiencing elevated blood pressure, irregular heartbeat, palpitation, and intermittent lightheadedness. After careful evaluation of the current presentation, the patient will receive for the following conditions.

Goal one. Rule out heart abnormality (failure) and other secondary causes: I will obtain a 12-lead electrocardiogram (ECG) to analyze his cardiac rhythm. I would also check his other recent laboratory results including serum potassium, magnesium, creatinine with corresponding GFR, urinalysis, cardiac enzymes and liver functions tests. I would also perform a thorough physical exam including height, BMI, dietary and activity status.

Goal two. Manage elevated blood pressure: The current antihypertensive medication (the HTCZ) does not seem to control the blood pressure to the acceptable level to the patient’s age. Mr. Russel needs either modification or additional antihypertensive regimen.

Goal three. Treat Arrhythmia: Depending on the result of the 12 lead ECG, place the patient on an antiarrhythmic agent.

Goal four: Treat dyslipidemia. Based on his lipoprotein profile, combined with his history of hypertension, irregular heartbeat, and advanced age, Mr. Russell is at increased risk of stroke, coronary artery diseases, and heart failure.

Assignment: NR 508 Week 3 Discussion: Case of Mr Russell

Pharmacological plan.

Manage high blood pressure: After ruling out other precipitating factors for lightheadedness and edema, Mr. Russell will be prescribed additional antihypertensive medications. According to Whelton et al. (2018), the seventh report of the Joint National Committee (JNC7) on Prevention, Detection, and Treatment of High Blood Pressure classification of blood pressure for adults, Mr. Russell has stage 1 hypertension. The JNC7 recommendation is to treat all patients with stage 1 and stage2 hypertension (HTN) to prevent further risk of stroke, heart attack, heart failure and kidney diseases (Whelton et al., 2018). Mr. Russell was taking HCTZ, which is the recommended choice of drug for stage 1 HTN. The JNC7 2017 does not encourage increasing the dose of HCTZ as it does not add any hypertensive benefits instead increased dose is associated with more hypokalemia and other adverse effects (Whelton et al., 2018). Once the initial thiazide monotherapy fails to control stage 1 HTN, the JNC7(2017), recommends considering ACEI, ARB, BB, CCB, or combination of these classes of antihypertensives. Any of the above classes (combinations) of antihypertensive medication could be added; however, if Mr. Russell is an African American, the preferred medication would from the CCB class (Whelton et al., 2018). I would start Mr. Russell with Amlodipine (Norvasc) 2.5 mg by mouth once a day. Depending on how he responds to this medication, the dose may be adjusted up to 10 mg within seven to fourteen days.
Manage Arrhythmia: If Mr. Russell’s 12 leak ECG resulted in any arrhythmia another CCB agent diltiazem (Cardizem) 120 mg by mouth daily may be a preferred choice to treat both hypertension and arrhythmia (Rodríguez et al., 2016).
Manage hyperlipidemia: Atorvastatin 80 mg by mouth daily. According to the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA, 2013), recommends initiating high-intensity statin therapy for the prevention of atherosclerotic cardiovascular disease (ASCVD). The ACC/AHA (2013) classified the statin therapy with low intensity, moderate intensity and high intensity based on age and risk of ASCVD. Based on the given risk factor Mr. Russell fits into the high-intensity groups.
Manage heartburn: Zantac (Ranitidine Hydrochloride) 150 mg by mouth daily. Zantac (an H2 receptor antagonist) has no drug interaction with the statin as well as with CCBs. According to Mungan and Pınarbaşı (2017), CCBs cause or exacerbate gastroesophageal disease (GERD) by relaxing the lower esophageal sphincter muscle. If adding (H2 receptor antagonist) does not help with the symptom of GERD, I would place Mr. Russel in a different antihypertensive medication.

Key patient educations.

Medication teaching: I would educate Mr. Russel about the newly prescribed medication, their benefit of lowering his blood pressure, cholesterol, and controlling palpitation. I would also teach him the common side effects of those medications, medication routine, compliance, and follow-ups. Mr. Russell will be encouraged to advise his physician for herbal or over the contender medication use since those agents may interfere with prescription medications.
Signs and symptom monitoring: I would recommend Mr. Russell to monitor his blood pressure daily, symptoms of drug adverse effects, other new, unexpected symptoms and report them to his physician. I would also emphasize that the symptoms that he presented are commonly associated with elevated blood pressure, and if blood pressure is not managed well, it leads to severe cardiovascular complications.
Lifestyle modification: I would encourage Mr. Russel to follow the recommended heart-healthy diet like the DASH diet, exercise and weight loss. “weight loss of as little as 10 lbs. (4.5 kg) reduces BP or prevents hypertension in a large proportion of overweight persons, although the ideal is to maintain normal body weight” (Whelton et al., 2018).
Russell needs to come to the office until his blood pressure reaches the established goal pressure. If the currently prescribed medication, dietary and lifestyle modification cannot bring the blood pressure, medication titration and other options will be followed (James et al., 2014)
Educate Mr. Russell to refrain from alcohol consumption (to consider moderation), tobacco smoking and ED medication. Those substances adversely affect the patient and interfere with the prescribed medications (James et al., 2014)

Assignment: NR 508 Week 3 Discussion: Case of Mr Russell

NR 508 Week 3 Discussion: Case of Mr Russell References:

American College of Cardiology/American Heart Association Task Force on Practice Guidelines (2013) Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Retrieved from https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437738.63853.7a

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., . . . Ortiz, E. (2014). Evidence-based guideline for the management of high blood pressure in adults. Jama, 311(5), 507. doi:10.1001/jama.2013.284427

Mungan, Z., & Pınarbaşı , B. (2017). Which drugs are risk factors for the development of gastroesophageal reflux disease? The Turkish Journal of Gastroenterology: The Official Journal of Turkish Society of Gastroenterology, 28(Suppl 1), S38-S43. doi:10.5152/tjg.2017.11

Rabar, S., Harker, M., O’Flynn, N., & Wierzbicki, A. S. (2014). Lipid modification and cardiovascular risk assessment for the primary and secondary prevention of cardiovascular disease: summary of updated NICE guidance. BMJ (Clinical Research Ed.), 349g4356. doi:10.1136/bmj. g4356

Rodríguez Padial, L., Barón-Esquivias, G., Hernández Madrid, A., Marzal Martín, D., Pallarés-Carratalá, V., & de la Sierra, A. (2016). Clinical experience with diltiazem in the treatment of cardiovascular diseases. Cardiology and Therapy, 5(1), 75-82. doi:10.1007/s40119-016-0059-1

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., . . . Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19). doi:10.1016/j.jacc.2017.11.006 NR 508 Week 3 Discussion: Case of Mr. Russell

What are your treatment goals for Mr. Russell today?
1. My treatment goals for Mr. Russell are to lower his blood pressure to a safe rate, treat his bilateral 3+edema in his lower extremities, and to provide pharmacological interventions to prevent his blood pressure from rising so high again and to prevent any more extreme edema in his limbs.
What is your pharmacological plan; please state your rationale for your plan?
1. Research has found that “two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults…with hypertension” (Rubenfire, 2018). This means that instead of prescribing just one medication for our patient, it is better if I prescribe him two that can work together.
2. Metoprolol, a beta blocker
  1. The first medication that I will prescribe to help our patient’s hypertension is Metoprolol which is a beta blocker. It has “selective activity on beta-1 adrenoreceptors located mainly in cardiac muscles” and “competitive antagonism of catecholamines at peripheral and cardiac adrenergic receptors (resulting in decreased cardiac output)” (Metoprolol succinate, 2018). This means it effectively lowers blood pressure, as it lowers the amount of blood being pumped through the heart. I would prescribe a tablet at 75mg once daily. If this did not improve his hypertension (in conjunction with the second medication), I would raise the dosage to 100mg per day. It would need to be titrated, however, “at weekly or longer intervals to achieve optimum antihypertensive effect” (Metoprolol succinate, 2018).
3. Hydrochlorothiazide, a diuretic, or water pill
  1. The next medication that I prescribe the patient is Hydrochlorothiazide, also known as a diuretic, or a water pill. Hydrochlorothiazide “affects the electrolyte reabsorption at the distal renal tubule resulting in increased excretion of sodium and chloride in equal amounts” (Hydrochlorothiazide, 2018). This means, that with a reduction of sodium in the body, his edema will subside. This medication would be given to him in tablet form at 25mg per tablet to begin with and if that does not help his edema, we can increase the dose. This medication will not only help his edema, but in conjunction with the beta blocker, it can also help lower the patient’s blood pressure. So, when the patient’s edema has subsided, we would give him a daily dose of 15mg to be taken daily along with the Metoprolol.
What are five key patient education points based on your plan?
1. What could happen if we don’t address the hypertension
  1. First, I would explain to the patient the importance of getting his blood pressure under control. Many patients do not like to adhere to their medication regimen, so to ensure that he does, I would outline what could happen to him if he does not. This could include an increased risk of heart attack, stroke, and even death. However, we can get his symptoms under control so that he does not have to worry about these things just yet!
2. Signs and symptoms of a heart attack or stroke
  1. With that being said, however, I would outline with the patient what it feels like to have a heart attack or stroke. That way he would know to call for help if he felt some of these symptoms. These symptoms can include pain or tightness in the chest, shortness of breath, and pain or pressure in your neck or arms. I would advise him that he should immediately call 911 if he showed any of these signs.
3. Side effects of his medication
  1. I would definitely need to outline the side effects of the two medications that I prescribed him. The first medication, the metoprolol, can have such symptoms as diarrhea, dizziness, and fatigue (Metoprolol succinate, 2018). The second medication, the Hydrochlorothiazide, could have symptoms like vertigo and phototoxicity (Hydrochlorothiazide, 2018).
4. Prevention including diet
  1. A healthy alternative to medications that could help lower the patient’s blood pressure could be a change in diet. Eating healthier foods and cutting out things like trans fats, sodium, and sugar could help lower the strain on his heart.
5. Prevention including exercise
  1. Along with the change in diet is a change in lifestyle. Exercise has been proven to help lower blood pressure, increase life expectancy, and even increase happiness!
How would your plan change if your patient is African American?
1. 1. While research has found that two antihypertensive medications are most effective for the majority of adults, this is especially true in African American adults, so the plan for two working in conjunction with each other would remain the same (Rubefire, 2018). Hypertension and other heart problems affect African Americans at an alarming rate. In fact, the 40-year risk for developing hypertension is 93% for African Americans” (Rubenfire, 2018). Interestingly enough, however, they do not respond well to the same medications that white patients might. Research says that “blacks tend not respond as well to beta-blockade or ACE-I as do whites. However, combinations of beta-blockers or ACE-I with diuretics are equally effective in black and white hypertensive patients” (Williams, Ravenell, Seyedali, Nayef, & Ogedegbe, 2016). This could be due to low renin physiology in African Americans. So, my plan would change in that I would no longer prescribe the beat blocker, metaprolol. I would change it to an ACEI, or an ACE inhibitor, like Enalapril. I would keep the hydrochlorothiazide as it will help the edema and will work with the Enalapril to lower the patient’s blood pressure. I would prescribe the Enalapril in tablet form at 5mg to be adjusted as needed (Enalapril maleate, 2018).
How would your plan change if your patient complains of excessive heartburn and belching?
1. In research heartburn and belching in relation to hypertension, I found some very interesting overlaps. It turns out that the “prevalence of hypertension to be significantly lower in GERD (gastroesophageal reflux disease) patients than in non-GERD patients and [it is] suggested that GERD might protect against hypertension by inducing changes in the dietary habits of patients” or the administration of antacids (Li, Ji, Han, Wang, Yue, & Wang, 2018). It turns out that antacids can be used as a method of lowering hypertension. In fact, “Antacid therapy restored esophageal pH to normal and significantly lowered elevated BP, which suggested that treatment of GERD could be useful for normalizing BP in essential hypertension patients” (Li, Ji, Han, Wang, Yue, & Wang, 2018). So, if my patient had GERD-like symptoms, I would explore an antacid regimen to go along with the diuretic.

Assignment: NR 508 Week 3 Discussion: Case of Mr. Russell

References

Enalapril maleate: Mechanisms of action. (2018). In Micromedex (Chamberlain College of Nursing Library ed.) [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved from

Gleason-Comstock, J., Streater, A., Ager, J., Goodman, A., Brody, A., Kivell, L., … Levy, P. (2015). Patient education and follow-up as an intervention for hypertensive patients discharged from an emergency department: a randomized control trial study protocol. BMC Emergency Medicine, 15, 38.

Hydrochlorothiazide: Mechanism of action. (2018). In Micromedex (Chamberlain College of Nursing Library ed.) [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved from

Li, Z., Ji, F., Han, X., Wang, L., Yue, Y., & Wang, Z. (2018). The role of gastroesophageal reflux in provoking high blood pressure episodes in patients with hypertension. Journal of Clinical Gastroenterology. 52(8), 685-690. doi: 10.1097/MCG.0000000000000933

Metoprolol succinate: Mechanism of action. (2018). In Micromedex (Chamberlain College of Nursing Library ed.) [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved from

Rubenfire, M. (2018). 2017 guideline for high blood pressure in adults. American College of Cardiology. Retrieved from

Williams, S. K., Ravenell, J., Seyedali, S., Nayef, S., & Ogedegbe, G. (2016). Hypertension Treatment in Blacks: Discussion of the U.S. Clinical Practice Guidelines. Progress in Cardiovascular Diseases, 59(3), 282–288.