565_HTN_Lipid_Protocol_Student_Form_MAR23_v2
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Chamberlain College of Nursing *
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565
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Apr 3, 2024
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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
Bendroflumethiazide
Chlorthalidone
Hydrochlorothiazide
Indapamide
Angiotensin receptor blockers
Losartan
Valsartan
Eprosartan
Candesartan
Calcium Channel
Blockers
Amlodipine
Nifedipine
Verapamil
Dilitiazem
ACE inhibitor
Captopril
Enalapril
Lisinopril
Quinapril
Citation (Provide (Author, year) and not full reference): (Paul, J.A. et al. 2014), (Burchum & Rosenthal, 2021). 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: Enalapril
ii)
Dose: 5mg
iii) Route: By mouth
iv)
Frequency: Once daily
v)
Instructions to provide patient: Take 1 tablet by mouth daily with or without meals. If you miss a dose, take it as soon as you remember. If it is almost time for your next
NR565 HTN Lipid Protocol 3
dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses. vi)
Caution/Precautions: Enalapril is not safe during pregnancy, contact your doctor immediately if you become pregnant. Contact your doctor if you experience any of the following adverse effects including angioedema, cholestatic jaundice, cough, hematologic effects, hyperkalemia, hypersensitivity reactions, hypotension/syncope, and renal function deterioration. vii)Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? A 30-day supply is between $9.26-$18.80. viii)
What patient education is needed for this drug? Limit salt substitutions, which are high in potassium, or a potassium-rich diet as these can lead to hyperkalemia. Hyperkalemia can cause an abnormal heartbeat, confusion, dizziness, fainting, weakness, shortness of breath, numbness, and tingling. Be aware of your blood pressure prior to treatment and monitor it often after beginning treatment. Periodic labs may need to be drawn to monitor your kidney function. Do not abruptly discontinue medication without consulting your doctor first.
Citation (Provide (Author, year) and not full reference): (Access Medicine, 2023),
(GoodRx, 2023), (Mayo Clinic, 2023). c)
1
st
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: Amlodipine
ii)
Dose: 5mg
iii) Route: By mouth. iv)
Frequency: Once daily. v)
Instructions to provide patient: Take 1 tablet by mouth daily with or without meals. If
you miss a dose, take it as soon as you remember. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses. vi)
Caution/Precautions: Dizziness, lightheadedness, or fainting may occur with hot weather, exercise, or getting up from a sitting to a standing position too quickly. Do not abruptly discontinue medication without consulting your doctor first. Consult your doctor if you have signs of liver problems including pain or tenderness in the upper stomach, pale stools, dark urine, loss of appetite, nausea, vomiting, or yellow eyes or skin. vii)Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? A 30-day supply is between $6.29-$17.67
viii)
What patient education is needed for this drug? Frequent side effects include fatigue, loss of strength or energy, flushing, nausea, and abdominal pain. Contact your doctor if these side effects do not improve or become severe. Be aware of your blood pressure prior to treatment and monitor it often after beginning treatment. Periodic labs may need to be drawn to monitor your liver function.
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NR565 HTN Lipid Protocol 4
Citation (Provide (Author, year) and not full reference): (Access Medicine, 2023),
(GoodRx, 2023), (Mayo Clinic, 2023).
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)
African Americans who have type 1 diabetes with proteinuria
ii)
African Americans with hypertensive nephrosclerosis
iii) And when BP cannot be controlled with a single drug. Combining an ACEI and thiazide diuretic can prove to be effective. Citation (Provide (Author, year) and not full reference): (Burchum & Rosenthal, 2021).
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 Greater than or equal to 50%
Daily dose lowers LDL-C on average by 30% to less than 50%
Daily dose lowers LDL-C on average by
Less than 30% Drug/Dose 1: Atorvastatin 40-80 mg
Drug/Dose 2: Rosuvastatin 20 mg
Drug/Dose 1: Atorvastatin 10 mg
Drug/Dose 2:Rosuvastatin 10 mg Drug/Dose 3:Simvastatin 20-40 mg
Drug/Dose 4:Pravastatin 40
mg
Drug/Dose 5:Lovastatin 40 mg
Drug/Dose 1: Simvastatin 10 mg
Drug/Dose 2:Pravastatin 10-20 mg
Drug/Dose 3:Lovastatin 20 g
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.
Statins are typically taken once daily, preferably in the evening. Typically, statins are well tolerated by most patients, but some patients may develop some side effects including headache, rash,
indigestion, cramps, gas, constipation, and abdominal pain. Contact your doctor if these side effects persist or worsen. More severe side effects include liver damage and muscle damage. Signs and symptoms of muscle damage include muscle aches, tenderness, or weakness. If you experience signs of muscle damage, contact your doctor immediately. Due to the risk of liver
damage, labs may be drawn before starting medication and periodically afterward to monitor liver function. Tell your doctor
NR565 HTN Lipid Protocol 5
immediately if you become pregnant, or plan to become pregnant, as statin drugs are not safe during pregnancy. You should also avoid eating grapefruit or drinking grapefruit juice because it may interfere with how well statins work. Also, inform your doctor if you are taking any other lipid-lowering medications since this can increase the risks of developing serious adverse effects like liver or muscle damage. Citation (Provide (Author, year) and not full reference): (Burchum & Rosenthal, 2021). 7)
TREATMENT MONITORING a)
How long until a follow up appointment should be done with patient? A follow-up appointment should be done four to twelve weeks after initiation of statin therapy to evaluate any change in lipid levels and to adjust the patient’s dosage if needed.
After this, follow-up visits and labs can be completed every three to twelve months, as needed. Follow-up for the patient starting hypertension medication should be done within four weeks of initiation of medication to evaluate blood pressure. 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:
While a complete physical exam should be completed, special attention should be given to blood pressure, weight, BMI, and cardiovascular function. ii) Labs/Diagnostics: The following diagnostic tests should be completed: electrocardiogram, complete urinalysis, and hemoglobin and hematocrit. Blood levels of sodium, potassium, calcium, creatinine, glucose, uric acid, triglycerides, and cholesterol should also be completed. Citation (Provide (Author, year) and not full reference): (Burchum & Rosenthal, 2021)
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:
While a complete physical exam should be completed, special attention should be given to weight, BMI, cardiovascular assessment, and muscular system assessment. ii) Labs/Diagnostics: Liver function tests, glucose, triglycerides, total cholesterol, CMP, and CK. Citation (Provide (Author, year) and not full reference): (Grundy et al., 2018)
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.
NR565 HTN Lipid Protocol 6
Treatment effectiveness should be evaluated in several ways. Revisiting the patient’s treatment goals and performing repeat lab and diagnostic testing as well as physical assessments should all play a factor in determining whether treatment was a success or not. If the latter has not shown improvement, with patient adherence, this may be a strong
indication of treatment failure or the need to progress treatment by increasing dosing or adding additional medications. Citation (Provide (Author, year) and not full reference): (Burchum & Rosenthal, 2021)
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NR565 HTN Lipid Protocol 7
References (Full APA References)
Access Medicine. (n.d.). Drug Monographs: Enalapril. McGraw Hill. https://accessmedicine-mhmedical-com.chamberlainuniversity.idm.oclc.org/drugs.aspx?
gbosID=426598#monoNumber=426598§ionID=243239793&tab=tab0 Access Medicine. (n.d.). Drug Monographs: AmLODIPine. McGraw Hill. https://accessmedicine-mhmedical-com.chamberlainuniversity.idm.oclc.org/drugs.aspx?
gbosID=426457#monoNumber=426457§ionID=243191601&tab=tab0
GoodRx. (n.d.). Enalapril. https://www.goodrx.com/enalapril?
dosage=5mg&form=tablet&quantity=30&label_override=enalapril
Grundy et al. (2018). 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. American Heart Association. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625#d1e850
Mayo Clinic. (2023, November 1). Enalapril (Oral Route). https://www.mayoclinic.org/drugs-
supplements/enalapril-oral-route/proper-use/drg-20069221
Mayo Clinc. (2023, November 1). Amlodipine (Oral Route). https://www.mayoclinic.org/drugs-
supplements/amlodipine-oral-route/precautions/drg-20061784
Rosenthal, L., & Burchum, J. (2021).
Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants
(2nd ed.). Elsevier Health Sciences.