NR 565 Week 3 Hypertension Lipid Protocol – Download To Score An A+

NR 565 Week 3 Hypertension Lipid Protocol – Download To Score An A+ HYPERTENSION PROTOCOL: INITIAL VISIT 1) RATIONALE a) 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. 2) SYMPTOMS a) HYPERTENSION i) Blood pressure >140/90 mmHg ii) Other possible subjective symptoms (1) Headache (2) Visual changes (3) Dyspnea (4) Chest pain (5) Sensory or motor deficit b) RENAL ARTERY STENOSIS i) Onset of hypertension age >55 years or <30 years ii) History of accelerated, malignant, or resistant hypertension iii) History of unexplained kidney dysfunction iv) History of multivessel coronary artery disease v) History of other peripheral vascular disease vi) Abdominal bruit vii) Sudden or unexplained recurrent pulmonary edema viii) Other possible factors (1) Absence of family history of hypertension (2) Other bruits (3) History of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist (ARB) 3) HISTORY a) Continue with treatment of hypertension but consult supervising physician if patient has: i) History of accelerated, malignant, or resistant hypertension ii) History of unexplained kidney dysfunction iii) History of multivessel coronary artery disease iv) History of other peripheral vascular disease v) Abdominal bruit vi) Sudden or unexplained recurrent pulmonary edema 4) PHYSICAL EXAM a) Perform the following examinations: i) Vital Signs (blood pressure, pulse) ii) Auscultation for bruits (carotid, abdominal, and femoral) iii) Palpation of thyroid iv) Cardiac v) Respiratory vi) Lower extremities for edema and pulses vii) Neurological b) Consult supervising physician if findings of: i) Abdominal bruit ii) Another bruit 5) LAB TESTS a) Metabolic panel i) Cholesterol ii) Blood sugar iii) Uric acid level b) Glomerular filtration rate c) Consult supervising physician if: i) GFR indicates chronic kidney disease (CKD) or renal failure 6) PHARMACOLOGICAL TREATMENT a) 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.) Drug Category/ Classification Example 1 Example 2 Example 3 Example 4 Thiazide diuretic hydrochlorothiazid e triamterene chlorthalidone indapamide ACE inhibitor (ACEI) lisinopril benazapril fosinopril quinapril Angiotensin receptor blocker (ARB) candesartan valsartan losartan olmesartan Calcium channel blocker (CCB) amlodipine nifedipine diltiazem verapamil Citation: James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., &; Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507. b) 1st 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.) i) Drug: Lisinopril ii) Dose: 10 milligrams iii) Route: Oral iv) Frequency: Once daily v) Instructions to provide patient: Take this medication by mouth once daily with or without food. vi) Caution/Precautions: Women who can become pregnant need to be educated on the black box warning on the possibility of birth defects occurring if taking Lisinopril while pregnant. Angioedema is a rare yet potentially lethal side effect. Lisinopril can cause first-dose hypotension. Lisinopril can also cause severe renal insufficiency in patients with renal artery stenosis. This medication is contraindicated for patients with bilateral renal artery stenosis or patients with a single kidney that have renal artery stenosis. In patients with renal impairment and collagen vascular diseases, there is an associated risk of neutropenia. These patients should be monitored closely to avoid progression to fatal agranulocytosis. vii) Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? Using a source such as Good RX, if purchasing this medication for a 30-day supply would cost roughly $11.75 viii) What patient education is needed for this drug? Lisinopril can cause a cough which can range from a scratchy throat to a severe hacking cough. Patients should also avoid taking potassium supplements and potassium-containing salt substitutes unless they are prescribed. If the initial dose of Lisinopril will be taken at home, the patient should monitor their blood pressure periodically to look for hypotension. It is also recommended that the patient takes the medication daily at the same time. Lifestyle changes are recommended such as smoking cessation, monitoring sodium intake, and increasing physical activity. If hypotension occurs, the patient should assume a supine position and seek medical help if the symptoms do not go away. Patients with renal impairment and collagen vascular diseases need to be educated on the early signs of infection such as fever and sore throat and instructed to report them to their provider as soon as possible. Citation: Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier. c) 1st 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.) i) Drug: Diltiazem Extended-Release ii) Dose: 180 milligrams iii) Route: Oral iv) Frequency: Once Daily v) Instructions to provide patient: Take this medication by mouth once daily with or without food. Do not crush or chew this medication that way it can be slowly released inside of the body. vi) Caution/Precautions: Diltiazem can exacerbate suppression of AV conduction when taken with digoxin. Patients taking this combination need to be monitored closely for AV blocks. vii) Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? $27.17 viii) What patient education is needed for this drug? Grapefruit juice should be avoided when taking this medication. The medication can cause constipation which can be minimized by increasing dietary fiber intake and fluids. Other side effects include dizziness, facial flushing, headache, and edema of the ankles and feet. Citation: Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier. d) When should ACEIs be used in African Americans according to the course textbook? Include a citation with matching reference in the reference section. i) When the patient has type 1 diabetes with proteinuria, ACEIs should be used. ii) When the patient has hypertensive nephrosclerosis, ACEIs should be used. iii) When the blood pressure cannot be adequately controlled with a single medication, one of several two-drug combinations should be used: an ACEI with a thiazide diuretic or an ACEI with a CCB. Citation: Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier. e) Prescribe statin therapy according to the prescription table which follows: Complete the following table to indicate which drug at which dose would be used for different intensity statin therapies to treat high low-density lipoprotein (LDL) as noted in the course textbook. Each drug listed in each column should be a different drug with a specific dose or dose rans as indicated in your course textbook. High-Intensity Therapy Moderate-Intensity Therapy Low-Intensity Therapy Daily dose lowers LDL-C on average by ≥ 50% Daily dose lowers LDL-C on average by ~30% to <50% Daily dose lowers LDL-C on average by <30% Drug/Dose 1: Atorvastatin 40-80 mg Drug/Dose 2: Rosuvastatin 20mg Drug/Dose 1: Atorvastatin 10mg Drug/Dose 2:Rosuvastatin 10mg Drug/Dose 3:Simvastatin 20-40mg Drug/Dose 4:Pravastatin 40mg Drug/Dose 5:Lovastatin 40mg Drug/Dose 1: Simvastatin 10mg Drug/Dose 2:Pravastatin 10-20mg Drug/Dose 3:Lovastatin 20mg Citation: Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier. 7) TREATMENT MONITORING a) How long until a follow up appointment should be done with patient? Follow up appointments with patients on new statin treatment should be monitored 4-12 weeks after initiating statin medications or dose adjustment. After the initial follow-up, the patient should be monitored every 3-12 months and as needed. b) Monitoring needs for blood pressure medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.) i) Physical Assessments: When completing a physical assessment, the nurse practitioner must complete vital signs including blood pressure and pulse rate must be obtained. A minimum of two blood pressures should be completed at least 5 minutes apart. Auscultate the carotid, abdominal areas, and the femoral areas for bruits. The nurse practitioner should also palpate the thyroid. Assess the skin for chronic eczematous eruptions. Assess the lower extremities for edema and pulses. Assess the airway for any angioedema. ii) Labs/Diagnostics: Diagnostic tests that needs to be monitored for patients receiving blood pressure medications include, liver function test, creatinine, BUN, glomerular filtration rate, electrolytes, electrocardiogram for potential heart blocks, urinalysis for proteinuria, hemoglobin, hematocrit, glucose, uric acid, triglycerides, and cholesterol levels. Citation: Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier. c) Monitoring needs for statin medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.) i) Physical Assessments: N/A ii) Labs/Diagnostics: Diagnostic tests that need to be monitored for patients receiving statins include cholesterol levels, triglycerides, liver function tests and creatine kinase levels. Citation: James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison- Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., & Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507. 8) TREATMENT FAILURE a) How will you know if the treatment is not working or needs to progress? Include a citation with matching reference in the reference section. The main cause of treatment failure is lack of adherence to medication regimen. The nurse practitioner will know the treatment is not working if the blood pressure goal is not met and the low-density lipoproteins level is not decreasing. Providing thorough education that includes encouraging treatment adherence must be provided to the patient to ensure that the treatment goals are met. Citation: Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier. References 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., … Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APHA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25). James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., & Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507. Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.