article

Peer Response

Instructions:

• Review the plans posted by your peers from your advanced practice nursing role perspective (educator, leader or nurse practitioner).  From this mindset, reflect upon a discussion you would like to have with your colleagues about their plan.
• For example -
  
  • If you are a nurse educator (clinical or academic) what are your thoughts about the patient education provided in the plan, or do you want to comment on or add to the education provided?  
  • If you a nurse leader what are your thoughts about the risk profile or cost effectiveness of the plan?
  • If you are a nurse practitioner did your peer develop a plan that aligns with evidence-based practice and current clinical guidelines? Etc.

 

Kristen Kavanagh- Week 2 Initial Discussion Post 

Management of the Patient with Cardiovascular Disease 

Provide your diagnosis. 

This patient is experiencing stage 2 hypertension that is poorly controlled. The patient also has an ASCVD risk score of 20.5% making him at high risk for experiencing a cardiovascular event in the next 10 years (American College of Cardiology, n.d.).  

Discuss how you would manage the patient’s current medication regimen and provide a rationale supported by scholarly reference for your treatment plan. 

Per the American College of Cardiology (n.d.), for stage 2 hypertension, it is recommended to initiate 2 classes of antihypertensives along with non-pharmacological therapy. First-line medication treatments should include thiazide diuretics, CCBs, ACE inhibitors, and ARBs (American College of Cardiology, n.d.). The goal of treatment should be a achieve and maintain a blood pressure below 130/80 (American College of Cardiology, n.d.). Per Arcangelo et al. (2021), in African Americans, the initial recommended treatment options for hypertension are CCBs and Thiazide diuretics. For this reason, I would attempt to increase the dose of this patient's CCB and add a low dose of thiazide diuretic that could later be increased if needed. The thiazide diuretic would not only treat the patient's hypertension but also help to decrease the patient's mildly elevated fluid volume as evidenced by trace lower extremity edema found on assessment.  

The patient's ASCVD score is above 20% making him at risk for a cardiac event in the next 10 years (American College of Cardiology, n.d.). The American College of Cardiology (n.d.) recommends that patients at high risk of a cardiac event lower their LDL by 50% or greater. Per the American College of Cardiology (n.d.), this should be achieved by implementing a high-intensity statin. My recommendation would be to start this patient on an HMG-CoA reductase inhibitor such as atorvastatin.  

The patient is currently taking Famotidine 40mg daily. Famotidine is an H2-blocker and not meant for consistent long-term use (Vallerand, & Sanoski, 2023). I would speak to the patient about the frequency and duration for which he has been taking this medication. If it is only used occasionally, then I believe it would be appropriate to continue it on an as-needed basis.   

Include your specific prescription(s) for the patient. (This must include the medication name, dose, route, and frequency as well as any special instructions that apply as you would include when writing a prescription). 

Amlodipine 10mg orally once daily 

Special instructions:  

• This medication treats high blood pressure. 
• Take this medication at approximately the same time each day. 
• Contact your provider if you are experiencing side effects. 
• Monitor for symptoms of low blood pressure, such as dizziness or lightheadedness, and notify your provider immediately. Do not take this medication if you suspect that your blood pressure is low.  

(Vallerand, & Sanoski, 2023) 

Hydrochlorothiazide 12.5 orally once daily 

Special instructions: 

• This medication treats high blood pressure and elevated fluid levels. 
• Take this medication at approximately the same time each day. 
• Do not take the medication close to bedtime. 
• It is normal for this medication to increase urinary frequency, especially in the first couple of weeks.  
• Contact your provider if you are experiencing side effects. 
• Monitor for symptoms of low blood pressure, such as dizziness or lightheadedness, and notify your provider immediately. Do not take this medication if you suspect that your blood pressure is low. 

(Vallerand, & Sanoski, 2023) 

Atorvastatin 20mg orally once daily 

• This medication is to help manage your cholesterol levels. 
• Take this medication at approximately the same time each day. 
• Contact your provider if you are experiencing side effects.  

(Vallerand, & Sanoski, 2023) 

Famotidine 40mg orally once daily as needed for GERD 

Special instructions: 

• This medication treats gastroesophageal reflux disorder. 
• Only take this medication if you are experiencing symptoms. If you need to take the medication consistently for longer than 14 days, notify your healthcare provider.  
• Contact your provider if you are experiencing side effects.  

(Vallerand, & Sanoski, 2023) 

Describe the patient education you would provide in relation to your treatment plan. 

I would speak to the patient about the importance of medication adherence and take the time to thoroughly answer all questions. I would ensure that the teaching provided was patient-specific and add pamphlets or brochures specific to the patient. Furthermore, I would spend a significant amount of time reviewing non-pharmacological ways to improve the patient's hypertension, ASCVD risk, and GERD. Highlights of patient education would include: 

• Consume a diet low in sodium and cholesterol (American College of Cardiology, n.d.). 
• Engage in moderate to intense physical activity at least 150 minutes per week (American College of Cardiology, n.d.). 
• With a BMI of 31.6, weight loss is recommended (American College of Cardiology, n.d.). I would review weight loss strategies such as calorie counting, decreasing the amount of processed or fatty foods (especially saturated fats), and increasing physical activity level. I would explain to the patient that systolic blood pressure decreases an average of 5 to 20 mmHg per 22lbs of weight loss (Arcangelo et al., 2021).  
• After assessing the patients' current immunizations, I would counsel on any additional recommended immunizations and offer these immunizations to the patient. Additionally, I would speak to the patient on the importance of vaccine compliance and thoroughly answer any questions.  
• If you are experiencing symptoms of GERD, eat small, frequent meals while avoiding fried or fatty foods that can trigger symptoms (Arcangelo et al., 2021). Limiting fluids with meals can decrease symptoms, as well as eating dinner earlier to allow time for your food to digest prior to bed (Arcangelo et al., 2021). Elevating the head of your bed or sleeping in a recliner chair can also assist with symptom management (Arcangelo et al., 2021).  

Provide your plan for follow-up and/or referral (if indicated) 

I would recommend this patient follow-up in 1 month. Per Arcangelo et al. (2021), patients with stage 2 hypertension should follow up with a provider approximately one month after medication changes are made. This follow-up is meant to ensure that the patient is responding well to all medications and that the blood pressure is within the desired range. During this follow-up, I would also order a lipid panel to check cholesterol levels and a comprehensive metabolic panel to ensure the patient's BUN, creatinine, and electrolytes are stable with the addition of the new medications. I would continue to recommend 1-month follow-up appointments with medication adjustments until the desired blood pressure range is obtained. Per Arcangelo et al. (2021), patients with elevated blood pressure should continue monthly follow-up appointments until the blood pressure is below the target level and stable.  

References 

American College of Cardiology. (n.d.). ASCVD Risk Eliminator Plus. American College of Cardiology. https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/Links to an external site. 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Kang, T. M. (2021). Pharmacotherapeutics for advanced practice: A practical approach. Wolters Kluwer. https://bookshelf.vitalsource.com/reader/books/9781975160616/epubcfi/6/6[%3Bvnd.vst.idref%3Dnav_2]!/4Links to an external site. 

Vallerand, A. H., & Sanoski, C. A. (2023). Davis’s drug guide for nurses eighteenth edition. F.A. Davis.  

Joy Worley-DavisJul 16 3:13pm| Last reply Jul 17 4:55pm

Reply from Joy Worley-Davis

Diagnosis:

• The patient is a 58-year-old African-American male with a past medical history of hypertension and gastroesophageal reflux disease (GERD). He presents with uncontrolled hypertension and elevated LDL cholesterol. His blood pressure today is 166/94 mmHg, which is categorized as Stage 2 Hypertension according to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines (Whelton et al., 2018). Additionally, his LDL cholesterol is elevated at 142 mg/dL, which exceeds the optimal target of less than 100 mg/dL for patients at increased cardiovascular risk.

Management of Current Medication Regimen:

• The patient is currently taking amlodipine 5 mg daily, a calcium channel blocker (CCB). Although this is a guideline-recommended first-line agent, his blood pressure remains significantly elevated, indicating the need for intensification of therapy. Considering his age, race, and the presence of trace lower extremity edema (a known side effect of CCBs), an appropriate approach is to add a thiazide-type diuretic, such as chlorthalidone, which has proven particularly effective in African-American patients (Wright et al., 2005).
• He is also taking famotidine 40 mg daily for GERD, which is appropriate and can be continued, assuming he has adequate symptom control.
• His lipid profile indicates borderline high total cholesterol (210 mg/dL) and high LDL (142 mg/dL), while HDL and triglycerides are within acceptable ranges; this places him at increased risk for atherosclerotic cardiovascular disease (ASCVD). According to the 2018 ACC/AHA guidelines, patients aged 40–75 with LDL levels of at least 70 mg/dL and additional risk factors (such as hypertension, male sex, and African-American race) should be considered for moderate- to high-intensity statin therapy (Grundy et al., 2019).

Updated Medication Plan and Prescriptions:

1. Amlodipine 5 mg orally daily – continue the current dose.
2. Chlorthalidone 12.5 mg orally daily in the morning.

Instructions: Take in the morning with food. Monitor for signs of dehydration, dizziness, and electrolyte imbalances.

1. Atorvastatin 20 mg orally at bedtime.

Instructions: Take at bedtime to enhance cholesterol-lowering effects. Notify the provider of any muscle pain or weakness and monitor liver function.

Patient Education:

• Hypertension Education: Explain the importance of consistent blood pressure control to prevent complications such as stroke, kidney damage, and heart disease. Emphasize the need for daily adherence to medication and monitoring for side effects like swelling or dizziness.
• Chlorthalidone Use: Educate the patient about increased urination and the importance of maintaining hydration. Advise on the timing of the medication to avoid nocturia.
• Statin Therapy: Discuss the role of atorvastatin in reducing LDL cholesterol and preventing cardiovascular events. Review potential side effects, particularly muscle aches and signs of liver issues.
• Lifestyle Modifications: Encourage adherence to the DASH diet, reduction in sodium intake, regular aerobic exercise (at least 150 minutes per week), weight loss, and moderation of alcohol consumption.
• Home Monitoring: Recommend that the patient monitor his blood pressure at home, keep a log, and bring it to follow-up visits.

Follow-up Plan:

• Recheck blood pressure and labs (BMP, lipids, and liver function tests) in 4 weeks to assess the effectiveness of the medication and monitor for adverse effects.
• If blood pressure remains elevated, consider further medication adjustments, such as adding an ACE inhibitor or ARB if needed.
• Consider a referral to a dietitian for assistance with the DASH diet and weight loss.
• Encourage annual eye and kidney screenings due to the long-term risks of hypertension.

References:

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., ... & Yeboah, J. (2019). 2018 AHA/ACC guideline on the management of blood cholesterol: Executive summary. Journal of the American College of Cardiology, 73(24), 3168–3209. https://doi.org/10.1016/j.jacc.2018.11.002Links to an external site.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey Jr, D. E., Collins, K. J., Dennison Himmelfarb, C., ... & Wright Jr, 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. Hypertension, 71(6), e13–e115. https://doi.