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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. 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
NR565 HTN Lipid Protocol 2
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 Hydrochlorothiazide Chlorthalidone
Indapamide
Triamterene
Ace Inhibitor
Lisinopril
Benazapril
Fosinopril
Quinapril
Angiotensin receptor blocker
Candesartan Valsartan
Losartan
Olmesartan
Calcium channel blocker
Amlodipine Nifedipine
Diltiazem
Verapamil
(James et. al., 2014)
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
NR565 HTN Lipid Protocol 3
v)
Instructions to provide patient: Take medication daily. Medication should be taken around the same time each day. Medication can be taken with food.
vi)
Caution/Precautions: Do not use in combination with ARBs or direct renin inhibitor. There is an increased risk of hyperkalemia, especially in patients with CKD or in those
on potassium supplements or potassium-sparing drugs. There is a risk of acute renal failure in patients with severe bilateral renal artery stenosis. Do not use if patient has a history of angioedema with ACE inhibitors. Lisinopril should be avoided in pregnancy.
vii)Using a source such as GoodRX, what is the estimated cost of this drug for a 30-day supply? The estimated cost was $7.90 according to GOODRX viii)
What patient education is needed for this drug?
Patients should be educated that Lisinopril can cause dizziness in the first few days, but they should adjust to it over time. Some people get a dry cough while taking lisinopril. This can happen at any time and can continue for many weeks after stopping lisinopril. If a dose is missed, it should be taken as soon as it is remembered (not if it is almost time for
the next dose). When starting Lisinopril, blood pressures should be monitored at home. If there is no improvement in pressures or pressures become too low, the provider should be notified. The patient must also monitor their salt and potassium intake as hyperkalemia is a possible side effect. Lastly, while uncommon, angioedema is a potential risk. If the patient notices any unusual swelling of the face, lips, tongue, and larynx they should seek medical attention immediately.
Citation: (Rosenthal & Burchum, 2017)
b)
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: Nifedipine ER
ii)
Dose: 30mg
iii) Route: oral
iv)
Frequency: once daily
v)
Instructions to provide patient: Take tablet once daily around the same time each day. Best to take it on an empty stomach. Swallow the extended-release tablet whole. Do not break, crush, or chew it.
vi)
Caution/Precautions: Nifedipine can cause flushing, dizziness, headache, peripheral edema, and gingival hyperplasia and may pose a risk for chronic eczematous rash in older patients. Nifedipine may also cause reflex tachycardia. This response is caused by Nifedipine increasing cardiac oxygen demand resulting in increased pain in patients
with angina.
vii)Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? According to GoodRX, the estimated cost is around $13.42
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NR565 HTN Lipid Protocol 4
What patient education is needed for this drug?
The patient should be aware that the tablet form has an outer shell that doesn't get digested, so it is normal to see the capsule in stool. Nifedipine can cause swelling (edema) in the feet, ankles, legs, or hands and arms about 2 to 3 weeks after starting it. This symptom doesn’t go away with time, the patient should prop feet up when possible. Nifedipine can also cause dizziness in the first few days due to hypotension with initial doses. When first starting this medication or switching to a higher dose, the patient should make sure to sit or stand up slowly to avoid dizziness and risk of falling. It can take 1 to 2 weeks to see the full effects of nifedipine. The patient should be educated to notify the provider if no improvement in blood pressure symptoms is seen after a week. It is also incredibly important to avoid consuming grapefruit or grapefruit juice since it can raise the
amount of nifedipine in the body and cause toxicity or more side effects.
Citation: (Rosenthal & Burchum, 2017) c)
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 controlled with a single medication,
iv.
One of several two-drug combinations should be used: an ACEI with a thiazide
diuretic or an ACEI with a CCB.
Citation: (Rosenthal & Burchum, 2017) d)
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 49-30%
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 10
mg
Drug/Dose 2: Rosuvastatin 10 mg
Drug/Dose 3: Simvastatin 20–40 mg
Drug/Dose 4: Pravastatin 40 mg Drug/Dose 1: Simvastatin 10 mg
Drug/Dose 2: Pravastatin 10–20 mg
Drug/Dose 3: Lovastatin 20 mg
NR565 HTN Lipid Protocol 5
Drug/Dose 5: Lovastatin 40 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.
Some patients develop headache, rash, or gastrointestinal disturbances such as dyspepsia, cramps, flatulence, constipation, and abdominal pain. However, these effects are usually mild and transient. Serious adverse effect such as hepatotoxicity and myopathy are relatively rare. However, patients should avoid alcohol and grapefruit juice as it can effect drug metabolism and increase the risk of toxicity. The patient must also understand that symptoms such as muscles aches, tenderness, or weakness that may be localized to certain muscle groups or diffuse could be an early sign of rhabdomyolysis and must be immediately reported to a provider. The patient should be aware that there is a risk of developing new-onset diabetes in patients who are prediabetic. should be informed about the potential for fetal harm and warned against becoming pregnant. Female patients should be informed that if pregnancy occurs and the patient plans to continue the pregnancy, statins should be discontinued. Citation: (Rosenthal & Burchum, 2017) (Grundy et al., 2019)
7)
TREATMENT MONITORING a)
How long until a follow up appointment should be done with patient? Patients who are undergoing initial lipid therapy or dose readjustment should have their levels rechecked at the 4 to 12 week mark. Then, monitoring should continue every 3 to 12 months as needed. For blood pressure medications, it is recommended to have a 1‐2 month follow‐up after initiation of therapy and a 3–6 month interval after BP is controlled.
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:
The patients' blood pressure should be taken twice 5 minutes apart. Other vitals such as heart rate and oxygen are also important to rule out any signs of heart failure. The eyes should be examined for abnormal blood vessels. The neck should be palpated for
any Swollen neck veins and for thyroid enlargement. Heart sounds should be auscultated for any extra sounds caused by enlargement of the heart. The lungs should
also be auscultated for signs of fluid. Bruits should also be investigated via stethoscope in the carotid, abdominal, and femoral arteries. Pulses in the upper and lower extremities should be palpated for any abnormalities, and the body should be checked for signs of generalized or extremity edema. All of these findings would give
evidence of whether blood pressures are being stabilized.
NR565 HTN Lipid Protocol 6
ii) Labs/Diagnostics: A liver function test, creatinine, BUN, glomerular filtration rate, electrolytes, electrocardiograms to monitor any changes in the heart, urinalysis, CBC, glucose, triglycerides, and cholesterol levels should all be monitored as need in blood pressure patients. Citation: (Rosenthal & Burchum, 2017)
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:
There are normally no physical symptoms associated with hyperlipidemia, so labs are
often the main evaluation tool. However, subjective findings in the patient such as reports of tea colored urine, muscles aches, tenderness, or weakness that may be localized to certain muscle groups or diffuse should be evaluated as signs of rhabdomyolysis. Symptoms of severe gastrointestinal discomfort should also be acknowledged for a need to change the type of medication. ii) Labs/Diagnostics: Cholesterol levels, triglycerides, liver function tests, and creatinine kinase levels should all be performed on follow up visits and as needed throughout Statin drug therapy. If serum transaminase levels rise to 3 times the ULN and remain there, statins should be discontinued.
Citation: (Grundy et al., 2019) (Rosenthal & Burchum, 2017)
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. A provider will realize that a treatment is not working based on the objective and subjective assessment findings. If the patient is experiencing severe adverse symptoms related to a new drug therapy, immediate intervention is necessary to adjust dose or medication type. If lab results do not reflect the predicted changes, such as a stabilization and reduction in blood pressure or lipid levels, intervention is also needed. Medication non-adherence is often a major cause of treatment failure. Providers must be diligent in educating their patients on the possible side effects, consequences of non-adherence, and expected timeframe of results. This will ensure accurate assessment results.
Citation: (Rosenthal & Burchum, 2017)
References
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NR565 HTN Lipid Protocol 7
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). https://doi.org/10.1161/cir.0000000000000625
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. https://doi.org/10.1001/jama.2013.284427
Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants - e-book
(2nd ed.). Saunders.