Regis University NU 664B Week 6 Discussion 1: Patient with Hypertension-Step-By-Step Guide

This guide will demonstrate how to complete the Regis University NU 664B Week 6 Discussion 1: Patient with Hypertension  assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NU 664B Week 6 Discussion 1: Patient with Hypertension                                                                      

Whether one passes or fails an academic assignment such as the Regis University NU 664B Week 6 Discussion 1: Patient with Hypertension  depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NU 664B Week 6 Discussion 1: Patient with Hypertension                                                                    

The introduction for the Regis University NU 664B Week 6 Discussion 1: Patient with Hypertension    is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NU 664B Week 6 Discussion 1: Patient with Hypertension                                                                    

After the introduction, move into the main part of the NU 664B Week 6 Discussion 1: Patient with Hypertension  assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NU 664B Week 6 Discussion 1: Patient with Hypertension                                                                    

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NU 664B Week 6 Discussion 1: Patient with Hypertension                                                                      

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NU 664B Week 6 Discussion 1: Patient with Hypertension

Differential Diagnosis

Essential hypertension- This is the most likely diagnosis for this patient. The reason that this is chosen as the most likely diagnosis is due to the high prevalence of hypertension which is found in 34% of the U.S. population and occurs in one out of three Americans (Dunphy et al. , 2019). The patient has two readings of systolic blood pressure on two separate dates of greater than 140 placing her in the category of stage 2 hypertension. There is no single identifiable cause of elevated blood pressure in 95% of people with this condition which is then diagnosed as essential or primary hypertension (Dunphy et al.,2019). Less than 5 % of people with elevated blood pressure are found to have a specific cause such as medication induced, renal, or endocrine problems ( Dunphy et al.,2019). Therefore, it is most likely that this patient has elevated blood pressure due to essential hypertension. This diagnosis was solidified by asking follow up questions inquiring about any medications that could be contributing to high blood pressure which the patient reported a negative response to. The patient has proteinuria, signs of hypertensive retinopathy on fundoscopic exam, and renal insufficiency which are common manifestations of hypertension (Dunphy et al.,2019). The fact that she reports lack of exercise and excess sodium in her diet put her at risk for essential hypertension (Dunphy et al.,2019).

White Coat Hypertension- White coat hypertension is found in 13% of patients. Patients will experience higher readings in the primary care office setting than at home readings. According to one review 30%-40% of patients who were diagnosed with hypertension in the office setting were normotensive by ambulatory blood pressure readings (Dunphy et al.,2019). In order to rule in or out this I asked the patient about home readings. The patient reports at home her readings have been 130’s/ 80s which although lower than found in the office is still classified as hypertension. I would want to rule out white coat hypertension further by ordering a 24-hour ambulatory blood pressure monitor. Depending on the resources in my office I could refer the patient to a remote patient monitoring blood pressure program to assess further home readings. At the very least I would like to at least have a log of the patient monitoring her blood pressure at home in the morning and in the evening for at least two weeks.

Chronic venous disease– The patient has lower extremity edema which is a common manifestation of chronic venous disease. This condition may result from hypertension and is present in up to 50% of people. Standing for long periods of time can contribute to development of the condition and the patient is a teacher so she may be standing for long periods of time during the day in her classroom. This condition is more prevalent in women which fits the picture of our patient. Confirming the diagnosis would involve asking about typical symptoms such as leg pain or heaviness. Definitive diagnosis would be made by Venous duplex ultrasound however, I would first discuss with the patient eliminating salt in the diet and elevating the legs to see if this helps alleviate the problem first (Kabnick & Scovell, 2023).

Glomerular disease- This patient has renal insufficiency demonstrated by a creatinine of 2.0 mg/dl. The patient also has both proteinuria and edema which may be seen due to renal sodium retention caused by glomerular disease. Providers should be suspicious for glomerular disease when there is acute onset of hypertension in a previously normotensive patient or worsening of hypertension in someone who previously had controlled hypertension. The first thing to do would be to rule out chronic kidney disease and proteinuria as a result of diabetes by ordering a fasting glucose. A urinalysis could be ordered to evaluate for the presence of hematuria which can be present in some forms of kidney disease ( Radhakrishnan, 2023).

Heart failure– This diagnosis occurs when cardiac output does not meet the metabolic demands of the body. Heart failure can be caused by long standing hypertension and one of the first presenting symptoms can be lower extremity edema. Evidence against this would be that on exam lungs were clear bilaterally with good aeration. The diagnosis could be ruled out by ordering a BNP, ECG, ECHO, and chest xray (Dunphy et al.,2019).

Type II diabetes- Is an endocrine disorder caused by impaired metabolism of carbohydrates, fat, and protein leading to hyperglycemia which results in organ damage including that of the kidneys and eyes if left uncontrolled. In setting of renal insufficiency and proteinuria type II diabetes should be ruled out with fasting glucose. Also, the fact that she has cotton wool spots on fundoscopic exam is another reason to rule out diabetes because diabetes can cause retinopathy.  In the early stage of diabetes patients may not have symptoms. Our patient has a first degree relative with history of diabetes so this puts her at greater risk. Her age and history of hypertension put her at risk for developing diabetes. Also if she is Latino this would put her at risk for diabetes as well ( Dunphy et al.,2019).

Plan:

Primary Differential Diagnosis: Primary Essential Hypertension

Pharmacology:

Reduce atenolol to 25 mg daily at night because patient reports feeling dizzy on higher dosage of atenolol leading to non- compliance.

Add Lisinopril 5 mg daily in the morning. There are several reasons for addition of this agent. As mentioned above the patient cannot tolerate increase in dosage of atenolol as above due to side effect of dizziness which is also leading to non compliance with the medication. Another reason is that she is bradycardic on the current dosage of atenolol which is a common side effect due to its mechanism of action. Another reason is that beta blockers are no longer recommended for first line treatment of hypertension. Recommend drug classes for first line treatment of hypertension include ACE-I, ARB, CCB, or thiazide diuretic. Lisinopril is chosen in this case because of the compelling indication of proteinuria and renal insufficiency these drugs are beneficial in preserving or even enhancing renal function. A low dose is started on this medication to help reduce potential side effects and also due to the fact that she does have renal insufficiency which will need to be closely monitored (Dunphy et al.,2019).

Non- pharmacology

The patient has stated that she does not exercise. This is a modifiable risk factor she should be encouraged to increase physical activity for example brisk walking for thirty minutes most days of the week.

She reports that she uses a lot of salt and should be counseled to follow a low sodium diet. She should reduce sodium intake to no more than 2.4 G of sodium daily.

She should follow the DASH diet which is high in fruits and vegetables and low in saturated fats.

She should be counseled on ways to reduce stress such as yoga or meditation.

She already has a healthy BMI, is drinking alcohol only in moderation, and does not smoke.

(Dunphy et al.,2019).

Diagnostics:

Due to the fact that she is starting on lisinopril I would want to check a BMP in two weeks to check on renal function and potassium. I will instruct the patient to fast for the BMP so that we can check her fasting glucose and rule out diabetes. Since she is already going for lab work a BNP could be added to evaluate for increased myocardial demand and rule out heart failure as cause of lower extremity edema. EKG could be done in the office today to assess for LVH and if abnormal would order ECHO (Dunphy et al.,2019). Urinalysis can be completed to assess for any microscopic hematuria to rule out other causes of renal insufficiency ( Radhakrishnan, 2023). Renal ultrasound can also be ordered for further evaluation of renal disorders (Radhakrishnan, 2023). I would order lipid panel to evaluate for other cardiovascular disease risk factors (Dunphy et al.,2019).

Consults/Referrals

Would refer patient for ambulatory 24 hour blood pressure monitoring or remote patient monitoring blood pressure program to rule out isolated white coat hypertension as the patient does state she has lower readings at home.

Patient education:

1. The patient would be advised that it is extremely important to remain adherent to the treatment regimen and be sure to take antihypertensive medications every day at the same time each day.
2. I would discuss with the patient common side effects of lisinopril. I would discuss rare but serious incidence of angioedema and need to seek emergency medical attention immediately with lip swelling. Would advise that dry cough can develop usually resolves after taking medication for several weeks but can remain constant for some which may lead to discontinuing this drug and trying alternative.
3. Would recommend low salt diet to help blood pressure and also reduce lower extremity edema.
4. Would counsel patient to elevate legs to prevent development of dependent edema in lower extremities.
5. Would counsel the patient against taking over the counter NSAIDs or decongestants which can elevated blood pressure.
6. Recommend DASH diet
7. Recommend moderate aerobic exercise for 30 minutes most days of the week
8. Recommended stress reduction techniques such as yoga or meditation.
9. Only drink alcohol in moderation.
10. If referring for remote patient monitoring of blood pressure instruct patient on proper technique for checking blood pressure and to check twice a day morning and evening and bring readings to next visit.
11. Advise patient to avoid abrupt positional changes due to risk of orthostatic hypotension and to stay adequately hydrated to prevent this.
12. Discuss with patient the risks involved with uncontrolled hypertension such as cardiovascular disease and organ damage. Discuss that although the patient may feel well symptoms of uncontrolled hypertension are often not evident until target end organ damage occurs.
13. Discuss signs that warrant ER visit such as sustained headaches, vision changes, shortness of breath or chest pain.
14. Discuss need for annual eye exam as funduscopic exam already showing evidence of damage to eyes from hypertension.

Follow up: I would advise the patient to return to the office in 4 weeks for a blood pressure check. At four weeks full effect of current medication regimen can be evaluated. Can also discuss compliance. Advise to call the office sooner with any side effects. Blood work as above in two weeks.

Health Maintenance: I would counsel the patient on a healthy lifestyle by discussing a healthy diet high in fruits, vegetables, and whole grains and low in saturated fats. I would discuss doing moderate aerobic exercise for 30 minutes most days of the week. She is already at a healthy weight with BMI of 24.9.I would order lipid panel to evaluate for other cardiovascular disease risk factors (Dunphy et al.,2019).

Social Determinants of Health: It is important as a health care provider to communicate clearly by using shared decision making and teach- back methods because health information may be complex and more challenging for the patient if English is their second language. Effective communication strategies or using an interpreter if the patient is more comfortable conversing in their native language can help to improve outcomes. When discussing hypertension, it would also be important to ensure that the patient has access to nutritious foods and physical activity opportunities. The patient can be connected with community resources if these are obstacles to following the plan of care (U.S Department of Health and Human Services, 2023).

References

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th

ed.). F. A. Davis Company.

Kabnick, L.S., Scovell, S. (2023). Overview of lower extremity chronic venous disease. Uptodate.

Retrieved February 11, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/overview-of-lower-extremity-chronic-venous-disease

Radhakrishnan,J (2023). Glomerular disease: Evaluation and differential diagnosis in adults.

Uptodate.Retrieved February 11,2023, from  https://www-uptodate- com.regiscollege.idm.oclc.org/contents/glomerular-disease-evaluation-and-differential-diagnosis-in-adults

U.S Department of Health and Human Services. (2023). Social Determinants of Health. Social Determinants of Health – Healthy People 2030. Retrieved February 12, 2023, from https://health.gov/healthypeople/priority-areas/social-determinants-health

Sample Answer 2 for NU 664B Week 6 Discussion 1: Patient with Hypertension

Differential Diagnoses

1. Hypertension – also called high blood pressure- is a condition where a patient’s blood pressure tends to be higher than normal. High blood pressure is characterized by changes in vision, headaches, fatigue, chest pain, ear pain, buzzing, and confusion (WHO, 2021). The condition relates to the case because the patient complained of having a change in vision, fatigue after medication, headache, and swollen legs. The presented symptoms confirm the diagnosis.
2. 2.     Aortic valve disease – is a health condition affecting the heart valve. The valve between the aorta and the left ventricle fails to function correctly, causing the blood not to flow in the correct direction through the heart (Wenn & Zeltser, 2022). The disease is characterized by fatigue, dizziness, shortness of breath, and chest pain. The condition was ruled out by dizziness, shortness of breath, and chest pain because the patient denied these symptoms.
3. White coat hypertension. White coat hypertension occurs when blood pressure is consistently elevated in the office but remains normal in out-of-office readings (Basile & Bloch, 2022). This is one example of a patient who has normal blood pressure at home but has elevated blood pressure readings in medical settings or in front of health care providers. However, based on the patient’s response, this patient consistently has elevated blood pressure readings and similar subjective findings. Her most recent blood pressure reading at home was 142/90 mmHg. a month ago
4.  Hyperaldosteronism – is a condition where the adrenal gland releases excess aldosterone that causes high blood pressure and reduces potassium levels in the body. It is characterized by high blood pressure, fatigue, headache, numbness, reduced potassium levels in the blood, and muscle weakness (Penn Medicine, 2021). The condition was ruled out by numbness, reduced potassium levels in the blood, and muscle weakness.

 Plan of Care for Hypertension

Pharmacology

Atenolol 50 mg daily due to bradycardia and tapered down to avoid rebound hypertension (Steinman and Reve, 2021).

Lisinopril 10 mg daily.

Non-Pharmacology

Change in lifestyle – the patient should adopt a healthy lifestyle by taking a healthy diet and engaging in physical exercises (Verma et al., 2021). The patient eats unhealthy meals and is not physically active, leading to weight gain and thus causing health complications such as heart attacks.

Healthy diets – the patient has no time or finance to afford healthy foods, so she takes food rich in saturated fat that could lead to further health complications (Verma et al., 2021). She should also reduce her intake of salt and alcohol.

Physical exercises – the patient should create a few hours daily to do physical exercises (Verma et al., 2021).

Labs/Diagnostics

A complete blood count (Dunphy et al., 2019).

CMP with GFR (Dunphy et al., 2019).

EKG (Dunphy et al., 2019).

Urinalysis (Dunphy et al., 2019).

Hemoglobin A1C (Dunphy et al., 2019).

Lipid Panel (Dunphy et al., 2019).

Referrals/Interprofessional Communication

A patient with hypertension should be referred to a specialist or a cardiologist if the blood pressure is severe, they have difficulties with the prescribed medication, young age hypertension, hypertension during pregnancy, and when the doctor suspects they have secondary hypertension.

Patient Education

The diagnosis – the patient should understand her current diagnosis, which should be done through education. The doctor should explain to the patient her underlying condition, how to manage it, and how she can prevent further complications.

Blood pressure readings – the patient should understand the readings after measuring her blood pressure (Elsevier, 2022). If her blood pressure is high and seems to worsen, she should talk to the doctor.

Possible complications – the possible complications of hypertension, when not managed correctly, include heart attack, aneurysm, vascular dementia, and stroke (Elsevier, 2022).

Diet – the patient should maintain a healthy diet with less salt and fats. Consume plenty of fruits, vegetables, and water (Elsevier, 2022).

Alcohol consumption – she should also reduce or stop consuming alcohol because it could worsen her condition (Elsevier, 2022).

Physical activities – the patient should exercise regularly (Elsevier, 2022). She should create a few hours a day, in the morning or evening, after school to exercise.

Medication – the patient should adhere to the prescribed medicines and not miss taking them for improved results (Elsevier, 2022). Also, she should talk to the doctor before taking over-the-counter medicines. Patients with hypertension are only advised to use aspirin or acetaminophen as the only over-the-counter medicines.

Blood pressure monitoring – the patient should monitor their blood pressure at least once or twice daily (Elsevier, 2022). Before monitoring the pressure, they should have rested for about 30 minutes before.

When to visit the hospital – the patient is advised to visit the hospital immediately if they experience a severe headache that does not go away after taking medications and if the blood pressure does not reduce after taking the prescribed medicines (Elsevier, 2022).

Support groups and programs – the patient should identify and join the available support groups and programs in the community (Elsevier, 2022). These programs can help patients adopt a healthy lifestyle that promotes managing their health.

Hypertension is a long-term health condition, so the patient should aim to maintain normal blood pressure by taking the prescribed medicines and maintaining a healthy lifestyle.

Follow Up

Patients with hypertension should have a follow-up plan at 3-6 months, but those with higher blood pressure should have a follow-up plan at an interval of 1-2 months. Since the blood pressure for the patient has reduced after increasing the dosage, they should have a longer interval. She will be required to return to the hospital after five months for a follow-up check-up to assess the patient’s progress.

 Health Maintenance Item

Lifestyle is a health maintenance item that the patient should consider. The item is important because it will help the patient maintain hypertension. Lifestyle includes reducing or eliminating the intake of alcohol, engaging in regular physical activities, consuming healthy meals with less fat and salt, and getting enough sleep. Also, the patient should adopt a stress management strategy that would help her manage stress so that she can get enough quality sleep.

Social Determinants of Health

The social determinant of health that the patient may face is the individual socioeconomic status. The management of hypertension can be influenced by an individual’s education, income, and occupation (Nakagomi et al., 2022). In this case, the patient is a school teacher, and she said she had no time to cook because she was too occupied with her work at school. The patient’s occupation forces her to order unhealthy fast foods, given that she has a condition that requires her to eat healthily. Also, she is not physically active because she has no time to engage in physical exercise. Her income also affects how she manages her health condition. She admitted that she ordered fast food because she could not afford healthy food.

References

Basile, J., & Bloch, M. J. (2022). Overview of hypertension in adults. (In Forman, J. P. Ed.) https://www.uptodate.com/contents/overview-of-hypertension-in-adults

Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2019). Primary care: Art and science of advanced practice nursing – An interprofessional approach. (5th ed.). Philadelphia, P.A., F.A. Davis.

Elsevier. (2022). Managing your hypertension. https://elsevier.health/en-US/preview/managing-your-hypertension

Nakagomi, A., Yasufuku, Y., Ueno, T., & Kondo, K. (2022). Social determinants of hypertension in high-income countries: A narrative literature review and future directions. Hypertension Research, 45(10), 1575-1581.

Penn Medicine. (2021). Hyperaldosteronism (Conn Syndrome). https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/hyperaldosteronism

Steinman, M., Reeve, E., (2021). Deprescribing. Up to Date. www.uptodate.com

Verma, N., Rastogi, S., Chia, Y. C., Siddique, S., Turana, Y., Cheng, H. M., … & Kario, K. (2021). Non‐pharmacological management of hypertension. The Journal of Clinical Hypertension, 23(7), 1275-1283.

Wenn, P., & Zeltser, R. (2022). Aortic Valve Disease. In StatPearls [Internet]. StatPearls Publishing.

World Health Organization, WHO. (2021). Hypertension. https://www.who.int/news-room/fact-sheets/detail/hypertension#:~:text=When%20symptoms%20do%20occur%2C%20they,chest%20pain%2C%20and%20muscle%20tremors.