NR565 HTN Lipid Protocol (1)

NR565 HTN Lipid Protocol 1 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)

NR565 HTN Lipid Protocol 2 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 Indapamide Metolazone Hydrochlorothiazide Chlorothiazide ACE inhibitor Benazepril Fosinopril Quinapril Lisinopril Angiotensin Receptor Blocker Losartan Valsartan Olmesartan Candesartan Calcium Channel Blocker Felodipine Nifedipine Amlodipine Diltiazem Citation (Provide (Author, year) and not full reference): Types of blood pressure medications. (2017, November 6). b) 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.) i) Drug: Lisinopril ii) Dose: 10 mg iii) Route: Oral iv) Frequency: Once daily v) Instructions to provide patient: Take Lisinopril by mouth once daily. Lisinopril can be taken having eaten or not. You should inform your healthcare provider if you experience side effects such as vomiting, diarrhea, or sweating more than usual.

NR565 HTN Lipid Protocol 4 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 Click or tap here to enter text. Daily dose lowers LDL-C on average by Click or tap here to enter text. Daily dose lowers LDL-C on average by Click or tap here to enter text. Drug/Dose 1: atorvastatin 40 to 80 mg Drug/Dose 2: rosuvastatin 20 mg Drug/Dose 1: atorvastatin 10 mg Drug/Dose 2:rosuvastatin 10 mg Drug/Dose 3:simvastatin 20 to 40 mg Drug/Dose 4:pravastatin 40 mg Drug/Dose 5:lovastatin 40 mg Drug/Dose 1: simvastatin 10 mg Drug/Dose 2:pravastatin 10 to 20 mg Drug/Dose 3:lovastatin 20 mg What patient education is needed when prescribing statins? Consider any patient counseling points and adverse effects they may need to be aware of or report if experienced. Emphasize the importance of taking the prescribed dosage as directed. Encourage a heart-healthy lifestyle, including a balanced diet, regular exercise, and smoking. There is a need for regular checkups to monitor cholesterol levels and side effects. The patients should be informed about side effects and be advised to report any unusual symptoms. Rosuvastatin is taken once daily, either with or without food. Every day, take the medication at the same time. Rosuvastatin may require routine blood testing while being used. Even if you feel better, continue to take this medication as prescribed. Typically, high cholesterol is asymptomatic. Rosuvastatin may need to be taken for an extended period. If you have liver illness, are pregnant, nursing a baby, or are allergic to rosuvastatin, you should not take it. If you are pregnant, avoid using rosuvastatin. It might be harmful to the foetus. When taking rosuvastatin, avoid getting pregnant by using an effective birth control method. If you become pregnant, stop taking rosuvastatin and notify your doctor straight away. Citation (Provide (Author, year) and not full reference): Statins lower heart attack, stroke risk in people at average risk. (2019, October 21). 7) TREATMENT MONITORING a) How long until a follow up appointment should be done with patient?

NR565 HTN Lipid Protocol 5 Patients with active hepatic disease should not take statins; therefore, liver function testing should be done before beginning any drug. It is not necessary to regularly check the patient's liver function until there are clear indications of a hepatic ailment. A baseline fasting lipid panel taken before treatment and a second lipid panel took six to twelve weeks should be compared to assess efficacy and adherence. An LDL reduction of 30% to 50% from baseline should be achieved with a moderate-intensity program; a decrease of more than 50% from baseline should be achieved with a high-intensity regimen. Assessments should then be conducted again every three to twelve months or more frequently as needed by a clinician. Other than atorvastatin, renal dose guidelines for statin medications include serum creatinine and creatinine measurement. 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: Accurate blood pressure monitoring should be part of the physical examination process. Assessment of orthostatic hypotension is necessary. A thigh blood pressure measurement is recommended if an adult over 30 has higher brachial blood pressure. Aortic coarction should be considered a possible diagnosis if the measurement of the thigh is less than the arm pressure. The physical examination should include an evaluation of target organ damage attributable to hypertension. Any physical characteristics that point to secondary hypertension should be taken seriously. ii) Labs/Diagnostics: Urinalysis Cardiac ultrasound Fasting blood glucose Uric acid thyroid-stimulating hormone lipid profile serum solid, potassium, calcium Citation (Provide (Author, year) and not full reference): Click or tap here to enter text. 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: Patients with active hepatic sickness should have their liver function evaluated before beginning any medication, as statins are contraindicated in such cases. Regular monitoring of the patient's liver function should wait until clear indications of a hepatic ailment occur. A fasting lipid panel at the start of the treatment and a follow- up lipid panel six to twelve weeks later should be used to assess the medication's effectiveness and adherence. With moderate-intensity therapy, LDL cholesterol should drop by more than 50% from baseline after receiving high-intensity therapy. Evaluations should be conducted as clinically required every three to twelve months

NR565 HTN Lipid Protocol 7 AHA, AMA urge widespread self-measured blood pressure monitoring . (2020, July 6). www.heart.org.   https://www.heart.org/en/around-the-aha/aha-ama-urge-widespread-self- measured-blood-pressure-monitoring Cholesterol webinar series . (n.d.). www.heart.org.   https://www.heart.org/en/professional/quality- improvement/outpatient/outpatient-webinars-and-podcasts/cholesterol-webinar-series Rosenthal, L., & Burchum, J. (2020).   Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants-E-Book . Elsevier Health Sciences. Statins lower heart attack, stroke risk in people at average risk . (2019, October 21). www.heart.org.   https://www.heart.org/en/news/2019/10/21/statins-lower-heart-attack- stroke-risk-in-people-at-average-risk Triple antihypertensive therapy with Amlodipine Valsartan and Hydrochlorothiaz . (n.d.). professional.heart.org.   https://professional.heart.org/en/archive/triple-antihypertensive- therapy-with-amlodipine--valsartan--and-hydrochlorothiaz Types of blood pressure medications . (2017, November 6). www.heart.org.   https://www.heart.org/en/health-topics/high-blood-pressure/changes-you- can-make-to-manage-high-blood-pressure/types-of-blood-pressure-medications