NR 565 Week 3 Hypertension ^0 Lipid Treatment Protocol

Sample Answer for NR 565 Week 3 Hypertension ^0 Lipid Treatment Protocol

HYPERTENSION PROTOCOL: INITIAL VISIT

1. RATIONALE for NR 565 Week 3 Hypertension ^0 Lipid Treatment Protocol
   1. This protocol will assist in the differentiation between essential hypertension and renal artery stenosis to aid in the identification of patients in need of referral to nephrology to prevent further renal damage from an unidentified renal artery stenosis. The design of the protocol for UTI encompasses these principles.

• SYMPTOMS
  • HYPERTENSION
    • Blood pressure >140/90 mmHg
    • Other possible subjective symptoms
      • Headache
      • Visual changes
      • Dyspnea
      • Chest pain
      • Sensory or motor deficit
  • RENAL ARTERY STENOSIS
    • Onset of hypertension age >55 years or <30 years
    • History of accelerated, malignant, or resistant hypertension
    • History of unexplained kidney dysfunction
    • History of multivessel coronary artery disease
    • History of other peripheral vascular diseases
    • Abdominal bruit
    • Sudden or unexplained recurrent pulmonary edema
    • Other possible factors
      • Absence of family history of hypertension
      • Other bruits
      • History of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist (ARB)

• HISTORY for NR 565 Week 3 Hypertension ^0 Lipid Treatment Protocol
  • Continue with the treatment of hypertension but consult supervising physician if the patient has:
    • History of accelerated, malignant, or resistant hypertension
    • History of unexplained kidney dysfunction
    • History of multivessel coronary artery disease
    • History of other peripheral vascular diseases
    • Abdominal bruit
    • Sudden or unexplained recurrent pulmonary edema

• PHYSICAL EXAM
  • Perform the following examinations:
    • Vital Signs (blood pressure, pulse)
    • Auscultation for bruits (carotid, abdominal, and femoral)
    • Palpation of thyroid
    • Cardiac
    • Respiratory
    • Lower extremities for edema and pulses
    • Neurological
  • Consult supervising physician if findings of:
    • Abdominal bruit
    • Another bruit

• LAB TESTS
  • Metabolic panel
    • Cholesterol
    • Blood sugar
    • Uric acid level
  • Glomerular filtration rate
  • Consult supervising physician if:
    • GFR indicates chronic kidney disease (CKD) or renal failure

• PHARMACOLOGICAL TREATMENT
  • List the hypertension drug classifications and examples you would prescribe in order of treatment according to clinical practice guidelines without consideration of race or ethnicity: (Provide generic names for examples. Doses are not needed or required.)

Citation: (“JNC 8 Hypertension Guideline Algorithm,” 2014)

• 1^st line pharmacological treatment if warranted in a non-African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)
  • Drug: LisinoprilDose: 10-40 mgRoute: OralFrequency: Once a dayInstructions to patients: Take the medication simultaneously every day, with or without food, as directed by the doctor. Do not stop taking the medication without consulting with the healthcare provider.Caution/Precautions: Lisinopril may cause side effects such as headache, hypotension, renal insufficiency, hyperkalemia, dizziness, dry cough, and angioedema. Patients with cardiomyopathy should be monitored closely while using the medication. Besides, lisinopril may interact with other medications, such as antidiabetics, non-steroidal anti-inflammatory agents, renin-angiotensin system (RAS) blockers, lithium, and mTOR inhibitors. Therefore, it is essential to inform the healthcare provider of any other medications being taken. Additionally, lisinopril should be avoided during pregnancy and breastfeeding.
  • Using a source such as GoodRX, what is the estimated cost of this drug for a 30-day supply?

The estimated cost of 30 tablets of amlodipine 5-10mg on GoodRX is $10.17-$10.91.

• What patient education is needed for this NR 565 Week 3 Hypertension ^0 Lipid Treatment Protocol drug?

      Patient education for lisinopril includes the information about the unchanged nature of the medication absorption after eating food and its potential side effects. Care recipients should also be advised to seek immediate medical attention if they experience symptoms of side effects or an allergic reaction, such as rash, itching, swelling, severe dizziness, or difficulty breathing.

Citation: (Olvera Lopez et al., 2020)

• 1^st line pharmacological treatment if warranted in an African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)
  • Drug: AmlodipineDose: 5-10 mgRoute: OralFrequency: Once a dayInstructions to provide to patients: Take amlodipine orally and at the same time each day. Moreover, the medicine may be consumed with or without meals. It is advised to take the tablet with food if its consumption makes the patient sick. Keep taking the tablets unless the healthcare professional instructs otherwise. If the dose is missed, the patient should take it as soon as they remember, but they should never take two or more doses together. While using amlodipine, avoid self-treating coughs, colds, or discomfort without first consulting the doctor because drugs used to treat the mentioned conditions can elevate your blood pressure.
• • Caution/Precautions: Amlodipine may cause side effects such as dizziness, flushing, swelling of the ankles, and headache. Patients with liver or kidney disease should be monitored closely during the medication regime. Moreover, amlodipine may interact with other medications, so it is essential to inform the healthcare provider of any other drug being taken. It can also make the patient feel queasy or sleepy. Until the person is sure of how the drug affects them, they should avoid operating machinery, driving, or engaging in other activities that call for mental clarity. In the case of elderly patients, they should avoid standing or sitting up fast. The cautions lessen the chance of feeling lightheaded or passing out. It is also advised to avoid alcohol as it might increase the patient’s sense of fatigue and dizziness.
  • Using a source such as GoodRX, what is the estimated cost of this drug for a 30-day supply?

The estimated cost of 30 tablets of amlodipine 5-10mg on GoodRX is $10.39-$11.21

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• What patient education is needed for this drug?

The patient is advised to check in with their doctor frequently to see how they are doing. Additionally, they are recommended to check their blood pressure regularly. It is also essential for the patient to ask their healthcare practitioner about the normal range of their blood pressure. If a person expects drug interaction, experiences side effects, or develops an allergic reaction while using the drug, they should immediately discontinue the medicine and contact their care provider.

Citation: (Elsevier Drug Information: Amlodipine Besylate Oral Tablet, 2018)

• When should ACEIs be used in African Americans according to the course textbook?
  • When they are diagnosed with hypertensive nephrosclerosis;
  • When they have type 1 diabetes and proteinuria; and
  • When they are suffering from comorbidities.

Citation: (Rosenthal & Burchum, 2021)

• Prescribe statin therapy according to the prescription table for NR 565 Week 3 Hypertension ^0 Lipid Treatment Protocol which follows:

Citation: (Rosenthal & Burchum, 2021)

TREATMENT MONITORING

How long until a follow-up appointment should be done with a patient?

Patients with high blood pressure and high cholesterol should have their blood pressure and lipid levels monitored regularly. For individuals with well-controlled blood pressure and cholesterol, follow-up visits may be recommended every six months to a year. However, for patients with uncontrolled blood pressure or high cholesterol, more frequent follow-up visits may be necessary to adjust medication dosages or make lifestyle changes to improve their health.

Monitoring needs for blood pressure medication prescribed: (Include physical assessments and lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.)

1. Physical Assessments:

Physical examination involves the accurate reading of blood pressure. Orthostatic hypotension must be examined. A thigh blood pressure measurement is also recommended for persons under 30 with increased brachial blood pressure. Aortic coarctation should be suspected if the arm measurement is higher than the thigh measurement. Additionally, the assessment of target organ damage caused by hypertension should be a part of the physical examination. Physical characteristics that point to secondary hypertension should also be taken into consideration.

1. Labs/Diagnostics:

lipid profile

electrocardiogram

Fasting blood glucose

blood count

serum sodium, potassium, calcium

thyroid-stimulating hormone

uric acid

urinalysis

urinary albumin to creatinine ratio

serum creatinine with eGFR

echocardiogram

Citation: Whelton et al., 2018

• Monitoring needs for statin medication prescribed: (Include physical assessments and lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.)
  • Physical Assessments:

N/A

1. Labs/Diagnostics:

Liver function tests should be done before initiating therapy with statins because they are contraindicated in persons with active hepatic illness. Unless clinical indications of hepatic ailment occur, proper monitoring of the patient’s liver function is unnecessary. A baseline fasting lipid panel taken prior to treatment and a follow-up lipid panel taken six to twelve weeks later should be compared to assess efficacy and adherence. An LDL reduction of 30% to 50% from baseline is expected with a moderate-intensity program, but a reduction of more than 50% is expected from a high-intensity program. After that, evaluations should be done every 3 to 12 months or more frequently if clinically necessary. Apart from atorvastatin, statin medications include renal dose guidelines that call for measuring serum and creatinine levels.

Citation: (Grundyr et al., 2018)

• TREATMENT FAILURE
  • How will you know if the treatment is not working or needs to progress?

Regardless of cholesterol levels, statin therapy is usually well tolerated and highly efficient in preventing and treating cardiovascular disease, but it can occasionally cause several negative side effects. The adverse events include diabetes Mellitus, myalgia, rhabdomyolysis, and myopathy. Individuals commonly cease statin therapy without medical guidance because of the side effects, enhancing their risk for cardiac events. In patients with statin intolerance, adjusting the dose, switching to a different statin, or trying an alternate-day regimen may be beneficial. Non-statin medications and specific dietary supplements can be considered if the patient is intolerant to all statins, even at the lowest dose.

Citation: (Toth et al., 2018)

References

Elsevier Drug Information: Amlodipine Besylate Oral Tablet. (2018). Elsevier.health. https://elsevier.health/en-US/preview/amlodipine-besylate-oral-tablet

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., & Saseen, J. J. (2018). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Circulation, 139(25). https://doi.org/10.1161/cir.0000000000000625

JNC 8 Hypertension Guideline Algorithm. (2014). In The PAFP (pp. 1–2). https://thepafp.org/website/wp-content/uploads/2017/05/2014-JNC-8-Hypertension.pdf

Olvera Lopez, E., Parmar, M., & Terrell, J. M. (2020). Lisinopril. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482230/

Rosenthal, L., & Burchum, J. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.).

Saunders.Toth, P. P., Patti, A. M., Giglio, R. V., Nikolic, D., Castellino, G., Rizzo, M., & Banach, M. (2018). Management of Statin Intolerance in 2018: Still More Questions Than Answers. American Journal of Cardiovascular Drugs, 18(3), 157–173. https://doi.org/10.1007/s40256-017-0259-7

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., & Williamson, J. D. (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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6). https://doi.org/10.1161/hyp.0000000000000065

NR 565 Week 8 Course Reflection

Drug Prescribing Reflection 

How has you understanding changed about identifying the most commonly prescribed agents in the major drug classes? 

My understanding has improved significantly after I received more education and conducted research on the matter. In the past, I knew the names of several prescribed drugs in major drug classes. However, through the increased knowledge I have gained from class, research, on-site experience, and discussions with my peers, I have gained a better understanding that enables me to identify the different drug classes and various agents and their respective dosages.       

How confident do you feel about analyzing factors pertinent to making the most effective drug selection for a patient with a specific diagnosis in the primary care setting? What resources are needed, if any, to help you feel more confident? 

My confidence level keeps increasing as my knowledge increases. I currently feel confident enough to select or prescribe drugs for patients after diagnosis in primary care setting. However, I know I still need to increase my confidence to be able to integrate evidence-based practice guidelines. Therefore, I will continue conducting research regarding the appropriate drugs for different patients, and I will subscribe to medical journals to keep me informed about the medication. Such knowledge will help me easily identify drug combinations and their side effects, which makes prescribing easier, based on the diagnosis undertaken. 

How has your understanding changed regarding analyzing client indicators of therapeutic, ineffective, adverse responses and side effects to drug therapy? 

My understanding has improved through the increased knowledge I have gained with different forms of drugs and their impact on patients. I have also gained knowledge through observations in a hospital setting where I often document the responses of patients to different medications. This has helped me to know how different patients react to certain medications, including adverse responses, side effects, and whether the medications are effective or not (Vaismoradi et al., 2020). I now understand which conditions guarantee some medications and under what circumstances should patients take medication. For instance, I know what medication to avoid prescribing in cases where patients are allergic or asthmatic.     

Reflect on your preparedness to write appropriate prescriptions according to evidence-based practice guidelines. What resources are needed, if any, to help you feel more prepared? 

I have basic knowledge of the common principles that would enable me to write appropriate prescriptions according to evidence-based practice guidelines. I understand the importance of a patient’s medication history while prescribing and dosage titration whenever the side effects are too extreme. I recognize that I have more learning to do; therefore, I ought to read pharmacology books, nursing journals, medication manuals, read case studies, and consult healthcare professionals who would guide me in this area.   

References 

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International journal of environmental research and public health, 17(6), 2028. https://doi.org/10.3390%2Fijerph17062028