aCase summary:
James Frank is a 64 year old African American presenting with a history of occasional mild headaches and dizziness when taking medications. He is on treatment for a cold. He has a history of hypertension, type 2 diabetes, chronic obstructive pulmonary disease, benign prostatic hyperplasia, chronic kidney disease and gout. He is on medication for these conditions. Similarly, he has a family history for myocardial infarction, lung cancer, hypertension, dyslipidemia and also diabetes. He has a BMI of 27.5kg/m2. His vital signs are BP 162/90 mm Hg (sitting; repeat 164/92 mm Hg), HR 76 bpm (regular), RR 16/min and T 37°C.
Case Summary Table
• Symptoms: List 2 pertinent signs and/or symptoms
1. Mild headaches
2. Dizziness
• Recommended Drugs: List minimum of 3 recommended drugs as indicated
for this diagnosis
¬ Enalapril/hydrochlorothiazide 10 mg/12.5 mg
¬ Losartan 50 mg
¬ Benazepril 10 mg
• Drug Categories and Subcategories: Identify these for each recommended drug
Medication
Category
Subcategory
Enalapril/hydrochlorothiazide
Antihypertensive
Angiotensin converting enzyme inhibitor/diuretic
Losartan
Antihypertensive
Angiotensin II receptor blocker
Benazepril
Antihypertensive
Angiotensin converting enzyme inhibitor
• Drug of Choice: List drug(s) of choice
⎫ Enalapril/hydrochlorothiazide
• Rationale: Provide rationale, clinical guidelines, and/or evidence to support you drug of choice
⎫ The combination of the two drugs produces an essential effect in the treatment of hypertension. Enalapril plays an essential role that helps in preservation of the kidneys and also preventing progression of diabetes. This is because of the regulatory effect on the hormone angiotensin in increasing blood sugars and also elevating blood pressure (Blumenthal, 2016). Hydrochlorothiazide enhances inhibition of sodium reabsorption within the distal tubules.
• Other medications
⎫ Benazepril: Is an ACE inhibitor is that can be used as the first choice in treating patients with hypertension and kidney failure. Similarly, it is beneficial to patients with diabetes. It is tolerable just like enalapril and at same time it enhances the reduction of high lipids in blood.
⎫ Losartan: It is essential in that it can be used to treat hypertension, diabetic nephropathy, left ventricular hypertrophy and marfan’s syndrome. As an ARB, it plays a critical role in preserving the heart, kidneys and regulates blood sugars through blockage of the effects of angiotensin hormone.
• Contraindications and/or Risks for the medication selected:
⎫ Should not be co-administered with Aliskiren in patients having diabetes mellitus
⎫ Avoid in patients having hypersensitivity to ACEs and thiazides
⎫ Avoid in patients with renal stenosis, anuria, and hepatic impairment
• What Patient Must Understand: Identify at least 3 appropriate teaching points
for the patient and/or family
¬ The medication may cause dizziness and therefore should be avoided in driving or participating in other activities that require alertness
¬ The patient should avoid smoking because nicotine in cigarettes causes vasoconstriction of blood vessels
¬ To keep taking his current medications to avoid worsening of the conditions
¬ To report any severe side effects e.g. hypotension to patients’ health care provider
Linda Varghese, MSN, RN, FNP
701 S Nedderman Dr., Arlington, TX 76019
Cell: 817- 992- 0001
Fax: 817- 992- 0002
DEA # AB428569477
NPI # 0123456789
License # 654321
Name ___James Frank________________________ Date_____09/13/2017_________
Address ______560 Lafferty Lane Arlington, TX 76019 _ DOB ______10/04/1953 __ M/F
Allergies ____No Known Drug Allergies__________ Weight ______95 kg____________
Rx
Enalapril/hydrochlorothiazide 10 mg/12.5 mg tablets PO
Take 1 tablet by mouth every 12 hours for 30 days for the treatment of chronic hypertension.
Dispense: 60 tablets
Refills: None
Void after: __10/13/2017________
Substitution permitted: Yes Dispense as written: _ No
Signature: _____Linda Varghese_______________________ MSN, RN, FNP
(leave this page blank)
For the Disease: Uncontrolled Chronic Hypertension
• Population
⎫ It affects individuals older than 20 years old, however it is very common above individuals older than 50 years old.
• Pathophysiology
⎫ Hypertension involves persistent increase in blood pressure secondary to changes in the function and structure of blood vessels. The macrovascular changes involve arterial rigidity, abnormal wave reflection, and changed central to peripheral pulse pressure amplification. Microvascular adjustments include: altered wall to lumen of the large arterioles, vasomotor tone abnormalities and network rarefaction. This leads to poor tissue perfusion and increase in ischemia within organs. Similarly, any hormonal changes, heart failure, and kidney failure may lead to hypertension (Yannnoutsos, Levy, Safar, Slama & Blacher, 2014).
• Symptoms
⎫ Incidence of headaches
⎫ Having blurred vision
⎫ Chest pain
⎫ Cases of dizziness or weakness
⎫ Difficulties in breathing
⎫ Epistaxis
• Goals of Treatment
⎫ Maintain blood pressure and pulse at normal levels.
⎫ Maintain therapeutic levels of antihypertensive in the blood.
⎫ Reduce fluid overload
⎫ Reduce symptoms of hypertension
For the Drug(s) of Choice: Enalapril/hydrochlorothiazide
• Drug Class: Antihypertensive (Angiotensin converting enzyme inhibitor/diuretic)
• Indications
⎫ Treatment of hypertension
⎫ Treatment of congestive heart failure
⎫ Treatment of edema
• Mechanism of Action:
⎫ Enalapril: Helps in the inhibition of the conversion of angiotensin I to angiotensin II; similarly, it inhibits bradykinin metabolism
⎫ Hydrochlorothiazide: Causes inhibition of the reabsorption of sodium in distal renal tubules thus increasing the excretion of water, sodium, potassium and hydrogen ions.
• Pharmacodynamics:
⎫ Enalapril: Causes inhibition thus leading to dilatation of arteries and veins
⎫ Hydrochlorothiazide: Increases excretion of water and sodium
• Pharmacokinetics:
⎫ Enalapril:
⎫ Absorption: Onset 1 hour; peak plasma time I hour (PO)
⎫ Distribution: 50-60% protein bound
⎫ Metabolism: 70% in the liver
⎫ Elimination: 61% excreted in urine and 27% excreted in feces; half-life 11-13 hours (Burchum & Rosenthal, 2016)
⎫ Hydrochlorothiazide:
⎫ Absorption: Onset 3-4 days
⎫ Distribution: 40-68% protein bound
⎫ Metabolism: minimally metabolized
⎫ Elimination: urine (Burchum & Rosenthal, 2016)
• Generic name: Enalapril/hydrochlorothiazide
• Brand name: Vaseretic
• Dose: Enalapril/hydrochlorothiazide 20 mg/25 mg per day
• Instructions:
⎫ The drug may cause drowsiness and dizziness; therefore, the patient should avoid driving or engaging in other activities that require alertness (Vallerand, Sanoski & Deglin, 2016)
⎫ Take the medications as directed from the hospital and never take an extra dose for missed doses
⎫ Avoid alcohol as this increases drug metabolism that leads to high toxicity levels
⎫ Always store the medication at room temperature, avoid heat and moisture
⎫ Always notify the health care provider in case of worsening drug side effects: angioedema and persistent headaches (Vallerand et al., 2016).
• Side Effects or Adverse Effects:
⎫ Enalapril: dizziness, hypotension, headache, chest pain
⎫ Hydrochlorothiazide: hypotension, anorexia, epigastric distress, hypokalemia
• Outcomes
⎫ Normal level of blood pressure
⎫ No signs of angioedema or difficulties in breathing
⎫ No weight gain as a result of fluid overload
⎫ No hypotension in the patient during receiving medications
⎫ No or minimal drug side effects
• Counseling:
⎫ To avoid smoking cigarettes because of a potential increase in the blood pressure
⎫ To avoid abusing drugs e.g. alcohol that increase chances of organ damage e.g. the kidneys and liver
⎫ To engage in aerobic exercises for a period of 30 minutes daily
⎫ To take maintain a low sodium diet daily