1
Running head: HYPERTENSION
Elizabeth Anderson
NURS 504
Hypertension
2
ASTHMA
CC:
“My daughter is a CNA and says I need to see a doctor for a check-up.”
HPI:
GKC is a 61 YO Caucasian male who presents to his new family practice physician for
evaluation of his medical problems. He has no particular complaints today. He states he
occasionally has problems with sinus allergies and “picked up some Sudafed at Wal-Mart.”
PMH:
Hypertension for approximately 8 yrs.
No history of CAD or DM.
FH:
Father died of acute MI at age 73; mother died of lung cancer at age 69; brother (age 68)
has HTN and hyperlipidemia; and younger sister (age 55) has no known medical
problems.
SH:
He has been married for 39 years and has one son and daughter (in their 20s) who are
healthy. He quit smoking a pipe about 6 years ago. He states his alcohol intake is 6–8
drinks/week. He is retired and enjoys walking around the neighborhood with his wife 1–2
times per week. He does not pay attention to what he eats. He enjoys a “good ole
Southern diet” and adds salt to his food. He denies ever being placed on any diet due to
his medical conditions.
Meds:
Hydrochlorothiazide/triamterene 25/37.5 mg QD x 8 years
Sudafed 60 mg Q6 hours prn sinus drainage
Aleve 1 to 2 tablets QD PRN joint pain
All:
NKDA
PE:
Gen–A&O, obese Caucasian man in NAD
VS–Average BP 155/86, HR 55, RR 16, T 98.6, Ht. 6’0,” Wt. 255 lbs.
HEENT–TM’s clear throughout and no drainage, EOMI; funduscopy shows
arteriolar
narrowing
Lungs–few basilar crackles; no
wheezing
Heart–RRR (slow), normal S1
and S2
Abd–Soft and ND; mildly tender in suprapubic area, no masses, bruits
Rectal/GU–Prostate 1+ (enlarged); prostate benign. Heme (-) stool
Ext–No clubbing, cyanosis, or edema.
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ASTHMA
Labs (Fasting):
Na–136 mEq/ml K–3.8 mEq/ml
Cl–98 mEq/ml HCO3–29 mEq/ml
BUN–22 mg/dl Glucose–181 mg/dl
HbA1c–8.5% TCHOL–262 mg/dl
LDL–180 mg/dl TGs–275 mg/dl
HDL–35 mg/dl AST–32 U/I
ALT–30 U/I Alk Phos–38 U/I
SCr – 1.0 mg/dl
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ASTHMA
Hypertension
I. AP Note
A. Present the problem:
GKC presented today stating, “my daughter is a CNA and says I need to see a
doctor for a check-up.” GKC is a 61 yo Caucasian male with no current
complaints. He occasionally has allergies affecting his sinuses and decided to
“pick up some Sudafed at Wal-Mart.” He currently has an overall sedatary
lifestyle and only walks with his wife 1 to 2 times a week and is retired. He is
6’0” and weighs 255 lbs (BMI of 34.58; Class I obesity). He has a “good ole
southern diet” and adds salt to his food but denies ever being placed on a diet.
GKC has a history of HTN for approximately 8 years with no history of CAD or
DM. GKC is in no apparent distress.
B. Risk Factors
Male
Age of 61 yo
Overweight: BMI 34.58
Hypertension x 8 years
Minimal exercise
Family Hx of HTN
Smoked a pipe up until 6 years ago
Elevated HbA1C, HDL, LDL, BUN, HCO3, glucose, TCHOL, and TGs
Salt intake
C. Assessment:
1. Evaluation:
GKC is a 61 yo Caucasian male who presents for evaluation of
medical problems with no current complaints except for allergies. GKC
quit smoking a pipe 6 years ago, drinks 6-8 times a week, has a hx of HTN
for 8 years, and currently has an increased BP of 155/86 which is
classified as stage I hypertension as per the Journal of the American
Medical Association (2015). His BMI is 34.58 which is classified as Class
1 obesity per U.S. National Library of Medicine (2015). He has an
elevated glucose of 181 mg/dl and a HbA1C of 8.5% shows GKC has
developed Type II diabetes. Combined with an elevated LDL of 180mg/dl
and a decreased HDL of 35 mg/dl can lead to diabetic dyslipidemia and
places him at risk for coronary heart disease and stroke (American Heart
Association, 2015). This risk is greater with a HCO3 of 29 mEq/ml,
TCHOL of 262 mg/dl, TGs of 275 mg/dl and his HDL low at 35mg/dl. Cr
CL is normal at 127.2 mL/min. GKC also has mild bradycardia with RR of
55 and basilar crackles in his lungs which need further testing.
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ASTHMA
Home medications:
Hydrochlorothiazide/triamterene 25/37.5mg QD
Sudafed 60mg Q6 hrs PRN sinus drainage
Aleve 1 to 2 tablets QD PRN joint pain
2. Determine appropriateness of medications:
Hydrochlorothiazide/triamterene- appropriate for
treatment/management of HTN
a. Indication: This is a combination. Triamterene is a K+ sparing
diuretic and HCTZ is a thiazide diuretic/anti-hypertensive
(Lexicomp, 2015).
b. Interactions: Contraindicated with allergy to sulfonamides; fluid or
electrolyte imbalance, renal or liver disease, hyperkalemia, and
anuria. (Lexicomp, 2015).They should also be used cautiously with
gout because they may cause an increase in attacks, glucose
tolerance abnormalities, diabetes, elevated triglyceride levels, and
namic-depressive disorder (Karch, 2014).
c. Drug dose: Thiazide- Dosing in adults for HTN should be 12.5-50
mg PO. Triamterene- Start with 25mg PO once daily and titrate to
50-100 mg/day (Karch, 2014).
d. Compliance: GKC indicates QD use for 8 years.
e. Outcome: GKC’s HTN is not being well controlled; His BP is
elevated at 155/86.
Sudafed- appropriate for occasional allergies
a. Indication: Provides temporary relief of nasal congestion caused
by common cold, hay fever, and other respiratory allergies.
Promotes nasal and sinus drainage and relieves ear congestion
(Karch, 2014).
b. Interactions: Contraindicated with MAOI therapy, severe
hypertension, and CAD (Lexicomp, 2015).
c. Drug dose: 60mg Q4-6hrs, do not exceed 240 mg in 24 hours
(Karch, 2014).
d. Compliance: GKC does not indicate the last time the medication
was used or if the medication was used appropriately.
e. Outcome: GKC did not state the effectiveness of the medication
but currently has normal HEENT.
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ASTHMA
Aleve- appropriate for inflammation and pain control; however,
combining with hydrochlorothiazide/triamterene should be closely
monitored due to adverse affects.
Indication: Provides mild to moderate pain relief associated headache,
toothache, muscular aches, backache, minor pain of arthritis, and
fever reducer (Karch, 2014).
a. Interactions: Use cautiously with asthma, chronic urticarial, CV
disfuction, hypertension, GI bleeding, peptic ulcer, or hepatic or
renal fuction (Karch, 2014).
b. Drug dose: 500 mg initially followed by 500 mg Q12hrs not to
exceed 1250 mg/day (Karch, 2014).
c. Compliance: GKC did not indicate the last time the medication
was taken or how often.
d. Outcome: GKC did not state any current pain or discomfort. Aleve
is not recommended when taking thiazides.
2. Additional information:
EKG
Echocardiogram
Any JVD?
Does he take BP at home?
Does he understand the risks involved with his diet and salt intake?
Does he understand what his appropriate weight should be?
How often Sudafed is taken for sinus drainage?
How severe are his allergies? Seasonal?
How often Aleve is needed for joint pain?
Oxygen saturation level
Does GKC get light headed? If so, how often and when?
Has GKC ever self monitored blood glucose?
How affective is Sudafed and Aleve?
Has GKC ever had testing for diabetes? Cholesterol?
3. State desired therapeutic outcomes:
a. Short term goal(s)
Clinic visit:
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ASTHMA
HR>60
Provide information on BMI and healthy eating
Provide information on effects of diet on BP
Provide information on possible causes of joint pain
Start a daily food log, BP monitoring (weekly) and blood
glucose log (TID)
Demonstrate proper use of BP cuff and blood glucose
monitor
Home:
HR maintained between 60-100
Weight loss of 1-2 lbs per week; exercise at least 3 times a
week for 30 minutes a day
BP < 140/80
Clear lung sounds
Blood glucose 90-130 before meals
LDL and HDL levels trending back to normal values
Stop/minimize alcohol consumtion
b. Long term goals(s)
Drop BMI below 26
BP remains <140/80
RR remain WNL
HbA1c <7%
F/U with provider for routine examinations, lab testing, and
review of diaries
Increased life expectancy and overall improved quality of
life
Eventually no longer having a need for HTN, DM, or pain
medication
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ASTHMA
B. Plan (P):
1. Recommendations:
a. Nonpharmacologic therapy
Increased physical activity 3-5 times a week.
Rationale: Weight loss has shown to decrease the need for
diabetes medication and improves BP (Juel, Ali, Nilas, &
Ulrik, 2012).
Blood glucose monitoring
Rationale: Self-monitoring blood glucose because it assists
with achieving specific levels of glycemic control and helps
maintain a constant blood glucose level. This will help with
making adjustments in pharmacological and non-
pharmacological therapies (Benjamin, 2015).
BP monitoring
Rationale: It has been shown through research that
monitoring BP at home can be helpful in combination to
regular monitoring by a healthcare provider to decide what
treatments are working (American Heart Association,
2015).
Improved diet with decreased salt
Rationale: Excess sodium can increase BP and your risk
for heart disease and stroke. Improving diet can aid in
weight loss and help decrease BP (Center for Disease
Control and Prevention, 2015).
Stop or minimize alcohol consumtion
Rationale: In hypertensive patients lifestyle changes can
help reduce BP and increase responsiveness of medications
and should be tried for 6-12 weeks (Burchum & Rosenthal,
2016).
b. Pharmacologic therapy
Clinic: Evaluation of last dose of medications. Instruct GKC on
new medication regimen and ensure understanding.
Home:
Hydrochlorthiazide 25mg PO QD (Could increase to 50mg
QD)
Rationale: Preferred antihypertensive drugs for individuals
with DM are ACE inhibitors, ARBs, CCBs, and diuretics.
Hydrochlortiazide is a diuretic and the patient is currently
taking the medication without adverse effects(Burchum &
Rosenthal, 2016).
Efficacy Parameter Method Goal Alter THx
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ASTHMA
(E) or
Adverse
Effect
(AE)
when/if
EManagement
of HTN
Pt report Systolic BP <140 BP <110/70 with
symptoms
AE Dehydration Pt report
No s/s of
dehydration such as
dry mouth,
dizziness,
weakness, thirst, or
decreased urine o/p
Pt reports dry mouth,
dizziness, weakness,
thirst, or decreased urine
o/p (Lexicomp, 2015).
AE Hypotension Pt reports; BP
diary from
weekly BP
BP WNL BP <110/70 with
symptoms
AE Metabolic
Alkalosis
Pt report;
monitored with
lab checks
during PCP
visits
Pt will not
experience s/sx
such as drowsiness,
and restlessness
Pt reports drowsiness or
restlessness (Lexicomp,
2015).
AE Hypoglycemia Pt reports and
monitors
through TID BS
checks
BS WNL IF BS <70 becomes
trend for patient. Teach
pt to notify MD
AE GI/GU
irritation
Pt report No s/sx of polyuria,
nocturia,
impotence, nausea,
vomiting, or dry
mouth.
Pt reports nausea,
vomiting, diarrhea,
nocturia, polyuria, or
impotence (Lexicomp,
2015).
AE Hypokalemia Monitoring lab
values; pt report
of s/s of
decreased
potassium
No report of muscle
pain or weakness,
muscle cramps, or
an odd heartbeat.
Pt reports muscle pain or
weakness, muscle
cramps, or an odd
heartbeat or when
potassium levels drop
below 3.6 mEq/L
(Lexicomp, 2015).
Lisinopril 5 mg QD initially then increased to 20-40
mg/day in 1 to 2 doses
Rationale: Preferred antihypertensive drugs for individuals
with DM are ACE inhibitors, ARBs, CCBs, and
diuretics.Since the patient needs a second medication to
assist with decreasing BP an ACE inhibitor is used
(Burchum & Rosenthal, 2016). If on a diuretic the initial
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ASTHMA
dose should be 5mg and the patient should be monitored
for hypotension prior to increasing dose (Karch, 2014).
Efficacy (E)
or Adverse
Effect (AE)
Parameter Method Goal Alter THx
when/if
E Management of
HTN
Pt reports
through daily
BP monitoring
Systolic
BP <140
BP <110/70 with symptoms.
AE Orthostatic
Hypotension
Pt reports
through daily
BP monitoring
and recording
in a daily log
SBP will
remain
between
110 - 140
BP <110/70 with symptoms
Pt reports s/sx of orthostatic
hypotension such as light
headedness when sittin up or
standing up (Karch, 2014).
AE GI irritation Pt report No report
of nausea,
diarrhea
or gastric
irritation
such as
reflux.
Pt reports nausea, diarrhea, or
gastric irritation (Karch,
2014).
AE Neutropenia Pt will
monitor for
s/sx of
infection.
WBC will be
monitored
during routine
lab checks
WBC will
not < 4.0
Pt will not
experience
any s/sx of
infection
(fever,
sore
throat,
etc.)
Teach pt to contact provider
immediately if s/sx of
infection develop.
AE Rash/pruitis Pt will self-
report
No rash or
itching
will occur
If sx become unbearable to
pt, teach GKC to contact his
provider
AE Angioedema Pt will self-
report/monitor
No s/s of
edema of
the
tongue,
glottis,
lips, eyes,
and
pharynx
Pt reports swelling of the
tongue, glottis, lips, eyes, or
pharynx.
AE Airway
obstruction
Pt report No cough,
swelling
in mouth
or
Pt report cough that is
unrelieved
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ASTHMA
difficulty
breathing
Sudafed 60mg Q4-6 hrs prn NTE 240mg/day
Rationale: Sudafed is compatable with hydrochlorathiazide
and Lisinopril and is an appropriate medication for
occasional relief of allergy symptoms (Lexicomp, 2015).
GKC did not specify frequency of medication use. If he has
a continual need for allergy medication then another
medication such as Flonase should be utilized.
Efficacy (E)
or Adverse
Effect (AE)
Parameter Method Goal Alter THx
when/if
E Nasal
decongestion
Pt report and
no s/s of
congestion
Pt denies
congestion
Pt has persistent congestion
that is unrelieved.
E Sinus drainage Pt report Pt denies
congestion
and
reports
ease of
breathing
through
nose
Pt reports persistent
congestion or inability to
breath(Lexicomp, 2015).
AE hypertension Pt report or
increased
blood pressure
after taking
medication
Pt denies
any s/s of
increased
BP.
If pt reports increased BP,
sweating, or palpitations
(Lexicomp, 2015).
AE Arrhythmias Pt report Pt denies
weakness,
dizziness,
light-
headednes
s,
sweating,
SOB, or
chestpain.
Pt has s/s of weakness,
dizziness, light-headedness,
sweating, SOB or chespain
(Lexicomp, 2015).
AE Fear/anxiety Pt report No report
of feeling
nervous,
powerless,
or having
feelings of
Pt reports feelings of
nervousness, powerlessness,
or having a feeling of danger.
(Lexicomp, 2015).
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ASTHMA
impeding
danger.
AE Pallor Pt report Pt denies
changes in
skin color.
Pt reports a lighter skin tone
than normal (Lexicomp,
2015).
Acetaminophen 650mg Q4-6h PRN NTE 3900mg QD
Rationale: Acetaminphen is recommended for relief of
minor arthritis pain and joint discomfort without
contraindications with other medications. However, it can
interferre with blood glucose monitoring machines used at
home and abnormal findings need to be followed up with a
PCP (Karch, 2014).
Efficacy (E)
or Adverse
Effect (AE)
Parameter Method Goal Alter THx
when/if
E Pain relief Pt report Pt denies
joint pain
Pt has unrelieved joint pain
and discomfort.
AE headache Pt report Pt denies
headache
or
throbbing
in head
If pt reports throbbing or
discomfort in head
(Lexicomp, 2015).
AE Chest pain Pt report Pt denies
pain in
chest,
sweating,
nausea,
SOB, or
weakness.
Pt reports chest pain,
sweating, nausea, SOB, or
weakness (Lexicomp, 2015).
AE Hepatic
toxicity
Pt report; liver
enlargement
No report
nausea,
vomiting,
abdominal
pain, loss
of
appetite,
diarrhea,
weakness,
or
jaundice;
signs of
liver
enlargeme
Pt reports nausea, vomiting,
abdominal pain, loss of
appetite, diarrhea, weakness,
or skin turning yellow;
enlargement of liver when
palpated (Lexicomp, 2015).
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ASTHMA
nt
AE Rash Pt report Pt denies
redness or
hives.
Pt reports redness or hives
developing on skin.
(Lexicomp, 2015).
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ASTHMA
References
American Heart Association. (2015). Home blood pressure monitoring. Retrieved from
http://www.heart.org/HEARTORG/conditions/highbloodpressure/symptomsdiagnosismon
itoringofhighbloodpressure/home-blood-pressure-
monitoring_UMC_301874_Article.jsp#maincontent
Benjamin, E. M. (2015). Self-monitoring of blood glucose: The basics. Clinical Diabetes
Journals. Retrieved from http://m.clinical.diabetesjournals.org/content/20/1/45.full
Center for Disease Control and Prevention. (2015). Most Americans should consume less
sodium. Retrieved from www.cdc.gov/salt/
Karch, A. M. (2014). 2014 Lippincott’s Nursing Drug Guide. Ambler, PA: Lippincott, Williams,
& Wilkins.
Lexicomp. (2015). Lexi-Clinical Suite [website]. Retireved from
https://online.lexi.com/lco/action/home/switch?siteid=3
