NR-508 Week 7 Grand Round presentation// HYPERTENSION// GRADED A

HYPERTENSION Chamberlain College of Nursing NR 508 Case Study • David a 54 yo Caucasian male went to his primary care providers office for his yearly physical. The nurse came in and took Davi ...

HYPERTENSION Chamberlain College of Nursing NR 508 Case Study • David a 54 yo Caucasian male went to his primary care providers office for his yearly physical. The nurse came in and took Davids vitals. His blood pressure was 150/92, HR 75, RR 16, 98 kg. His blood pressure was repeated 2 times five minutes apart and the systolic pressure remained <150 and diastolic <90. While discussing the elevated blood pressure, David mentioned to the practitioner that he has been having dizzy spells and headaches off and on for the past 5 months. David works three jobs to support his family. He is a non smoker but admits to having other bad habits like eating fast food on a daily basis and avoiding the gym. Upon assessment the provider notices bilateral lower extremity +1 pitting edema. Davids routine lab work (CBC, CMP, urinalysis) shows all values are within normal limits. There is no past medical history and Davids surgical history includes a tonsillectomy at the age of 4. Hypertension JNC 8 Clinical Guidelines • In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (James et al., 2014) James PA, Oparil S, Carter BL, et al. (2014) Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520. doi:10.1001/jama.2013.284427 Hypertension Most commonly prescribed drugs • Thiazides Inhibit reabsorption of Na and Cl ions in distal convoluted tubules in the kidneys • ACE Inhibitors Inhibits the conversion of angiotensin I to angiotensin II • ARBS Prevents angiotensin II from binding to angiotensin II receptors • Beta Blockers Inhibits epinephrine and norepinephrine from binding too beta-adrenoceptors • Calcium Channel Blockers Inhibit Ca+ entry into excitable cells Hypertension Most commonly prescribed drugs • Thiazides- SE include orthostatic hypotension, severe electrolyte imbalances, and dizziness. Remain well hydrated while taking a thiazide diuretic to avoid possible dehydration. • Hydrochlorothiazide (HCTZ)- 12.5-25 mg PO q day, max dose of 50mg/day. • ACE Inhibitors- SE include angioedema, agranulocytosis, leukopenia, hyperkalemia, and a dry cough. ACE inhibitors are not recommended for African Americans. Avoid salt substitute products and medications containing potassium while on ACE inhibitors. Monitor kidney levels (BUN, Cr, urinalysis etc..) • Lisinopril (Zestril)-initial dose 5 mg PO q day if not treated with a diuretic or 10 mg PO q day if treated with a diuretic, may be increased every 2 weeks, max dose 80 mg/day. • Captopril (Capoten)- initial dose is 12.5-25 mg PO bid, may be increased every 1-2 weeks, max dose of 450 mg/day. Must be taken 1 hour before meals. Hypertension Most commonly prescribed drugs cont’d. •ARBS- SE are similar to those of ACE Inhibitors including hyperkalemia, agranulocytosis, and leukopenia. ARBS are generally recommended for those who cannot tolerate ACE Inhibitors. •Losartan (Cozaar)- initial dose 25-50 mg PO q day, may increase every 2-4 weeks, max dose is 100mg/day. Losartan is a good antihypertensive to use in diabetics because it can treat hypertension as well as diabetic neuropathy. •Beta Blockers- SE include dizziness, headaches, tachycardia. Not first line agents – reserve for post-MI/CHF (James et al., 2014) Beta-blockers are not recommended for people with asthma or COPD. It is also recommended to avoid beta-blockers for those with diabetes because it may mask the signs of hypoglycemia. Beta-blockers would predictably be least effective in patients with low-renin, volume-dependent forms of essential hypertension, which are more commonly seen among African-Americans, older patients, and low renin patients, in whom diuretics and CCBs have been consistently shown to be more effective (Mann, 2017) •Carvedilol (Coreg)-initial dose 6.25 mg PO bid, may increase every 1-2wk to 12.5 mg PO bid, then 25 mg PO bid, Max dose 50 mg/day. It is recommended to give carvedilol with food. Hypertension Most commonly prescribed drugs cont’d. • Calcium Channel Blockers- SE include hypotension, headaches, pedal edema, and constipation. Avoid taking with grapefruit juice. Grapefruit juice is known to affect “the liver cytrochrome P450 enzyme system and interfere with drug metabolism” (Edmunds, & Mayhew, 2013) • Amlodipine (Norvasc)- initial dose is 5 mg PO q day; elderly patients should start at 2.5 mg PO q day; may adjust dose every 1-2 weeks; max dose is 10 mg/day. • Nifedapine (Nifedical XL) – initial dose is 30-60 mg ER (extended release) PO q day; may adjust dose every 7-14 days; max dose is 120 mg/day ER. This medication must be tapered gradually. ER pill must not be chewed, crushed, or cut. Hypertension Practice Barriers • Cultural barriers • Diet • Financial barriers • Access to care • Limited consultation time “may impair the ability to follow guidelines, resulting in poor BP control” (Khatib et al., 2014) • Insurance • Prescription coverage • Appropriate prescriptions • 21% of preventable admissions were attributed to other cardiovascular agents (Dreischulte, & Guthrie, 2012) • Capability barriers • Language barrier” is known to be an important risk factor for reduced access to medical care, poor health status, and adverse outcomes” (Kim, Kim, Paasche-Orlow, Rose, & Hanchate, 2017) • Lack of knowledge of blood pressure readings • Overall lack of understanding of hypertension Hypertension Optimal Outcomes • David is diagnosed with Stage II hypertention. • Non-pharmacologic interventions as well a pharmacologic interventions are recommended. David will have to start a healthier lifestyle by adhering to a low sodium diet and a weekly exercise routine. • A thiazide diuretic as well as an ACE Inhibitor will be prescribed. • Hydrochlorothiazide 12.5 mg PO q day • Lisinopril 5 mg PO q day • David will follow up in 1 month to check his blood pressure and see if any dose adjustments are needed. Blood work and a urinalysis will be obtained to monitor for any kidney damage. The optimal outcome would be if David returned in one month with a blood pressure, a lower BMI, and no episodes of dizziness or headaches. References • Dreischulte, T., & Guthrie, B. (2012). High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved? Therapeutic Advances in Drug Safety, 3(4), 175–184. http://doi.org/10.1177/2042098612444867 • Edmunds, M. W. & Mayhew, M. S. (2013). Pharmacology for the primary care provider (4th ed.). Retrieved from http://bookshelf.vitalsource.com • James PA, Oparil S, Carter BL, et al. (2014) Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520. doi:10.1001/jama.2013.284427 • Khatib, R., Schwalm, J.-D., Yusuf, S., Haynes, R. B., McKee, M., Khan, M., & Nieuwlaat, R. (2014). Patient and Healthcare Provider Barriers to Hypertension Awareness, Treatment and Follow Up: A Systematic Review and Meta-Analysis of Qualitative and Quantitative Studies. PLoS ONE, 9(1), e84238. http://doi.org/10.1371/journal.pone.0084238 • Kim, E. J., Kim, T., Paasche-Orlow, M. K., Rose, A. J., & Hanchate, A. D. (2017). Disparities in Hypertension Associated with Limited English Proficiency. Journal Of General Internal Medicine, 32(6), 632-639. doi:10.1007/s11606-017-3999-9 Test Questions • Which of the following medications has a side effect of a dry cough? 1. Metoprolol 2. Amlodipine 3. Lisinopril 4. Digoxin Test Questions •A 56 yo African American male is diagnosed with hypertension. What type of antihypertensive is recommended? 1. Beta Blocker 2. ACE Inhibitor 3. ARB 4. Calcium Channel Blocker/Thiazides Test Questions • ACE Inhibitors are cardioprotective True False Test Questions • A patient calls their PCP in a panic that they forgot to take their captopril this morning and its almost time to their next dose. What should the PCP instruct the patient to do? 1. Take two doses 2. Skip the missed dose and take the medication at the next scheduled time 3. Take the dose and reschedule the next dose in 12 hours 4. Skip the missed dose and do not take the medication until the Test Question • Propanalol may mask the signs and symptoms of: 1. Hyperglycemia 2. Hyponatremia 3. Hypoglycemia 4. Hypokalemia