Mr. Russell is a 73-year-old male who presents to your clinic with complaints heart palpitations
and light headedness on and off for the past 3 months. He has a history of hypertension and is
currently prescribed HCTZ. He also is complaining of heartburn and belching after a large meal.
Vital Si...
mr russell is a 73 year old male who presents to your clinic with complaints heart palpitations and light headedness on and off for the past 3
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Chamberlain College Of Nursing
NR 508 Advanced Pharmacology
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Mr. Russell is a 73-year-old male who presents to your clinic with complaints heart palpitations
and light headedness on and off for the past 3 months. He has a history of hypertension and is
currently prescribed HCTZ. He also is complaining of heartburn and belching after a large meal.
Lower extremities with moderate 3+edema noted in left leg, 2 + edema in right leg, ABD + BS,
Neuro AOX3,
Labs: NA 143mEq/L (135-145), CL 99 mmol/L (96-106) BUN 18mg/dL (7-20), Hbg 15 (13-17),
Total cholesterol -TC 234 mg/dL (less than 200), LDL 137 mg/dL (less than 100), HDL 35 mg/dL
(40-50), triglycerides 241mg/dL (less than 150).
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What are your treatment goals for Mr. Russell today?
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Address concerning vital signs of HTN, irregular HR, palpitations, edema, lab values,
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heartburn/belching, preventative measures and education.
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Electrocardiogram (EKG) initially to rule life-threatening arrhythmias that may alter course of
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treatment or that need to be addressed immediately and/or need cardiology consult. Wilken
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(2016) supports EKG’s to helpfully evaluate palpitations and considers potentially essential for
diagnosis in a primary care setting. It is also the first test used for therapeutic decision making
for progression and/or stabilization of HTN impact (Woo & Robinson, 2016)
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aC s
Address HTN using the JNC 8 guidelines for HTN, and addressing potentially complications of
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undiagnosed HF including peripheral edema. The JNC 8 guidelines recommend in patients
greater than 60 years of age (Mr. Russell is 73), without diabetes or chronic kidney disease to
have blood pressure reading less than 150/90 (Elam, 2017). Mr. Russell currently fits into
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Hypertension stage I due systolic BP 140-159 and diastolic BP 90-99 per the JNC 7 guidelines
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that were unchanged in the JNC 8 guidelines (Woo & Robinson, 2016). . Echocardiogram and
doppler flow studies are needed for diagnostic purposes for suspicious HF and/or cardiac
dysfunction will need to be scheduled as soon as possible in an outpatient setting (Woo &
Robinson, 2016).
is
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The recommended guidelines from the American College of Cardiology and American Heart
Association (ACCF/AHA) include laboratory values needed for HF that include renal function,
complete blood count, urinalysis, serum electrolytes including magnesium and calcium,
hemoglobin A1c, liver function tests, fasting lipid levels, BNP, troponin T, and thyroid stimulating
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hormones (Woo & Robinson, 2016). These values are for screening and diagnosis of HF and
organ function. These tests should be completed day of office visit prior to medication
administration.
Identify lifestyle modifications and preventative measures that Mr. Russell can work towards that
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, include smoking cessation (if applicable), diet modification, obesity, exercise, alcohol
consumption, and illicit drug use as this is the first step of treatment for HF, cardiovascular
disease, and hyperlipidemia (Woo & Robinson, 2016). Has Mr. Russell had his yearly influenza
vaccination or pneumococcal vaccination in the last five years, if not, address. Lifestyle
modifications such, diet, alcohol, exercise, can all impact his symptoms of heartburn and
belching.
Address new pharmacological approaches, see below.
Overall, treatment goals are to optimize physiologic status, decrease risk of complications,
prevent further progression of disease, promote patient well-being, education, and compliance
(Kellicker & Cabrera, 2018).
What is your pharmacologic plan; please state your rationale for your plan?
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Start ACEI, they are used for angina and reduced blood pressure and improve function for those
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with heart failure (HF) and are the first line therapy (Woo & Robinson). ACEI are drug of choice
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due to decreased morbidity and increase life span for all populations, and should be started
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immediately (Woo & Robinson, 2016). ACEI of choice would be captopril. A short-acting ACE
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inhibitor was chosen over a long-acting ACEI in case patient has adverse drug reactions (ADR)
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such as prolonged hypotension, angioedema, or renal impairment (Woo & Robinson, 2016).
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May consider long-acting ACE once patient tolerance determined. If Mr. Russell does not
tolerate ACEI due to ADRs, the next drug of choice per the JNC-8 recommendation is
angiotensin II receptor blockers (ARBs) (Elam, 2017).
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aC s
According to Woo & Robinson (2016), lowering LDL cholesterol levels are top priority, and first
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line treatment for high-risk cardiovascular disease patients, such as Mr. Russel, include lifestyle
changes and medications concurrently. Reductase inhibitors should be used first, such as
Atorvastatin, due cost and effectiveness (Woo & Robinson, 2016).
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Thiazide diuretics, such as, HCTZ, has been seen to cause hyperlipidemia with increase in
cholesterol, LDL, and triglycerides (Woo & Robinson, 2016), so I would discontinue the HCTZ,
and start a loop diuretic for it’s large natriuresis and decrease hyperlipidemia risk. Drug of
choice is furosemide (Woo & Robinson, 2016). Furosemide is used help reduce edema and fluid
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retention in HF.
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ACEI are combined with diuretics if volume overload develops, such as the bilateral lower
extremity edema present (Woo & Robinson, 2016). Diuresis alone may lower Mr. Russell's
blood pressure enough to meet JNC 8 guidelines, to avoid hypotension, I would start both ACEI
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and loop diuretics at low doses and assess drug response.
With this combination, electrolytes and renal function, and blood pressure need to be monitored
closely. ACEI alter aldosterone function and may lead to hyperkalemia, while loop diuretics may
decrease potassium.
This study source was downloaded by 100000823518935 from CourseHero.com on 07-17-2021 03:23:23 GMT -05:00
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