Introduction
The aim of this paper is to present a comprehensive report on a case study conducted on an individual who is displaying symptoms of hypertension. The paper explicitly explores as a chronic disease and some of the aspects that will be touched on include its epidemiology, Pathophysiology, differential diagnosis, treatment plan, drug analysis and follow up care.
Hypertension, also commonly referred to as high blood pressure is a body condition in which blood vessels, specifically the arteries high and persistent pressure. This high pressure makes it hard for the heart to pump blood to all the other parts of the body. Hypertension inadvertently leads to the damage of body organs and also a couple of other of other body illnesses such as aunrysm, stroke, renal failure and sometimes heart failure. The causes of hypertension are varied and include common behaviors like smoking, lack of exercise or physical activity. Others include sedimentary lifestyles, obesity and diabetes.
Epidemiology/ Etiology
Statistics show that about 20% of all the adults in the world have hypertension. This statistic defines hypertension as blood pressure exceeding 140/90 mm Hg. The same statistics also show that the condition’s prevalence increases drastically in individuals aged 60 years and above. In fact, of all the people in the world who are above 60 years, 50% of them have hypertension. The approximated figure for hypertension patients across the globe is close to one billion.
Hypertension also varies according to race. When statistics are adjusted according to hypertension race prevalence, it emerges that blacks are more prone to the disease than members of the other races. The high occurrence of this condition in black people is attributed to increased risk factors that include obesity, diet rich in sodium, obesity and also a relative lack of awareness about the condition. Blacks also possess other physiological characteristics that increase their susceptibility to the disease and these include low circulatory rennin levels, endothelial dysfunction and higher intercellular calcium stores levels. In addition, blacks often display poor response to angio-tensin converting enzymes (ACE) inhibitors than their counterparts from other races. This has consequently caused mortality rates from the hypertension among blacks to be considerably very high.
It has however been noted that the prevalence of the disease is actually higher among women across all races.
Pathophysiology
Hypertension Pathophysiology is actually a very active area of research that essentially attempts to demystify the major causes of hypertension. As described earlier, hypertension is a chronic disease that is characterized by the elevation of blood pressure. The disease results from a malfunction that occurs in the control mechanisms of arterial pressure. Hypertension can be classified into two parts: essential (primary) hypertension and secondary hypertension. Essential hypertension is where the diastolic pressure is above 90 mm Hg and the systolic pressure is above 140mm Hg. This type of hypertension occurs in the absence of other hypertension causes like diabetes. The second type of hypertension primarily results from endocrine disorders, renal disease and the aorta coarctation.
It is very probable that there are a couple of interrelated factors that essentially contribute to the elevated blood pressure levels that are observed in hypertensive patients. However, the most studied factors include salt intake, sympathetic nervous system and the rennin-angio tensin system.
Role of the Nervous system
The nervous system plays an enormous role in the regulation of bold pressure. In patients with hypertension; there is increased release of norepinephrine and raised peripheral sensitivity. Additionally, these patients exhibit higher responsiveness to stimuli that are stressful.
Role of the Renal System
This system is also somehow involved in some hypertension forms, particularly renovacular hypertension and is actually suppressed when primary hyperaldosteronism is present. The rennin-angio tensin system is responsible for regulating the balance of potassium, sodium and fluids in the body. Renin produced by the kidney’s afferent arterioles converts angio tensin to angiotensin I which is further converted to a vasoconstrictor known as angiotensin II. In hypertensive patients, angiotensin II inhibits the release of renin by use of a negative feedback system. Blood pressure consequently rises when this negative feedback system fails.
In addition, hyperinsulinemia can also lead to hypertension by causing the retention of sodium and also having a stimulating effect on the sympathetic nervous system.
In our case study, the subject is MR. MR is an African American male patient. He has been referred to a hypertension clinic to be evaluated for further high blood pressure tests after his blood pressure levels were noted to be high during an initial screening. MR reported of having occasional headaches and nose bleeds and also stated that he had about 15 pounds for the last year.
Subjective information
Medical History
He reports having occasional headaches and nose bleeds
- He has a been a patient of diabetes mellitus for the last 5 years
- He had an appendectomy thirty years ago
- He had peptic ulcer incidence about ten years ago.
Family history
- His father also had hypertension and actually died of myocardial infarction when he was 55.
- His mother also had diabetes mellitus and died of hypertension at the age of 60.
Social History
- Alcohol: one vodka pint per week
- Coffee: 2 cups everyday
- Tobacco: 35 pack/Many years
Objective information
After a physical and a laboratory test was done on him, several things were observed.
Physical examination
- His heart a regular pulse rate of 84 beats per minute. In regards to his bold pressure, the right arm showed 164/98 mm Hg and his left arm showed 168/96 mm Hg
- A funduscopic exam showed that had, sharp disc, mild arterial narrowing, no hemorrhages or exudates
Blood urea nitrogen: 24 mg/dL
Serum creatinine: 2.0 mg/dL
Glucose: 95 mg/dL
K+: 4.0 mEq/dL
Total cholesterol 224 mg/Dl
High density lipoprotein cholesterol: 30 mg/dL
Triglycerides 125 mg/dL
Uninalysis 1 + proteinuria
Electrocardiogram and chest radiograph: mild left ventricular hypertrophy
Differential diagnosis
MR was diagnosed as suffering from stage 2 hypertension
Treatment Plan
The first line therapy or treatment for hypertension in MR case would have to be the administration of antihypertensive medication. Since he is in stage two hypertension stage, the most recommended antihypersensitive medication would have to be the thiazide type diuretics combined with an ACE inhibitor. This combination is usually very effective because it often makes the adherence to therapy by the patient very easy. The dosage should be about 12.2-100mg qd.
Drug Analysis
As mentioned above, the combination of thiazide type diuretics and the ACE inhibitor is usually very effective because it often makes the adherence to therapy by the patient very easy. If these thiazide diuretics are found not to work then other types of medication can be incorporated for example, beta blockers, calcium channel blockers and angio tensin converting enzymes. Alternative medication can also include amlodipine and chlorthalidone. These two have been found to be very effective particularly among African Americans. However, in MR case, the best option would obviously have to be thiazide diuretics due to their lowered mortality rates and also their relative morbidity towards stroke. The symptoms exhibited by MR indeed call for treatment using this kind of medication.
APN Follow up/Summary of care
The Advanced Practice Nurse (APN) definitely plays a huge role in the treatment and the follow up process of this patient. As an APN, the follow up process that I embark on should be very effective and comprehensive.
Since MR is at has stage 2 hypertension, there should be a follow up visit scheduled 2 to 4 weeks after the drug therapy initiation until the treatment goals are achieved. After, the treatment goal has been achieved; the follow up checks or visits can be extended to 3-6 months intervals. It is also vital that the patient is engaged in comprehensive discussions on his lifestyle modifications and efforts. The patient MR should also be reminded on the importance of fully adhering to the regimen of the drugs. In addition, there should be discussions about various side effects with the patients and also make adjustments in medication where necessary.
Answers to critical thinking questions
Question 1
The specific blood pressure goals for MR would normally be.
- Diastolic pressure < 130
- Systolic pressure < 85
The specific goals target range would therefore have to be around 129/84.
Question 2
The first line therapy for hypertension in MR case would have to be the administration of antihypertensive medication. Since he is in stage two hypertension stage, the most recommended antihypersensitive medication would have to be the thiazide type diuretics combined with an ACE inhibitor. This combination is usually very effective because it often makes the adherence to therapy by the patient very easy
Question 3
Lifestyle changes
- Engage in regular exercise daily, for example 25 minutes a day.
- Reduce sodium intake
- Maintain the normal body weight
- Increase the amount of potassium intake into the body
- Maintain the same amount of alcohol intake (one vodka pint per week) since more would increase chances of hypertension occurrence.
- Quit smoking
- Adapt good sleeping habits, for example, he makes sure that he sleeps for eight houyrs daily
- Make sure that causes of stress are eliminated.
Diet changes
- Consume food that is rich in vegetables and fruits.
- Reduce the daily intake of saturated fats
- Consume whole grains instead of pasta products or low grains
- Consume relatively modest protein amounts
Question 4
Alternative medication includes calcium channel blockers (CCB’s), angio tensin-converting enzyme (ACE) beta blockers, captopril, clonidine, labetalol and minoxidil.
Regarding the over the counter drugs, there are some OTC vitamins and also some mineral supplements that have been found to have a reducing effect on hypertension. For example, the intake of two multivitamins or mineral supplements every day reduces high blood pressure. This particularly pertains to systolic pressure. Other drugs that can be used include captopril, clonidine, labetalol and minoxidil.
Question 5
Apart from the blood pressure, other things to be monitored include patient’s potassium and creatinine levels. This should be done 3 to 4 weeks after the drug therapy initiation. Other things that require constant monitoring include the activity and performance levels of the body organs. This should be done about one month after the therapy to ensure that the hypertension case did not destroy any vital body organs’.
Question 6
In prescribing the selected first line agent that was actually the diuretic type thiazine , I would not make the mistake of combining them with beta inhibitors since the combination has been found to be lethal. I would also be wary of combining the combination of ACE inhibitors and alpha blockers would not be advisable.
Question 7
Follow up plan
- Follow up visit after 2 to 4 weeks
- Evaluation of patient’s lifestyle changes and modifications
- Evaluation of patient’s adherence to drug regimens
- Discussions about any side effects
- Relevant medications or drug adjustments
PATIENT SUMMARY (Take from Case Study Information)
Drug Analysis: Family #1 (Do one page for each drug FAMILY—3/study—evaluate several specific drugs you might select to use from that family as indicated). Indicate beneath the grid which references you used for the information.
DRUG FAMILY: Alpha beta blockers
Drug Analysis: Family #2 (Do one page for each drug FAMILY—3/study—evaluate several specific drugs you might select to use from that family as indicated). Indicate beneath the grid which references you used for the information.
DRUG FAMILY Angio-tensin converting enzyme inhibitors
Drug Analysis: Family #3 (Do one page for each drug FAMILY—3/study—evaluate several specific drugs you might select to use from that family as indicated). Indicate beneath the grid which references you used for the information.
DRUG FAMILY: Diuretics
Summary of Decision Points for You in Selecting the Drug Family of Choice and the Specific Drug Being Ordered (Must be specific—do not use generalities, use guidelines, specific patient or drug variables, cost, etc.)
1. Standard of care requires Angiotensin- converting enzyme inhibitors emergently
2. Standard of care for requires alpha beta blockers emergently
3. Patient had no Cointradictions to Captopril
4. Patient had no Cointradictions to Terazosin
5. Patient is stage two hypertension and therefore requires immediate care and intervention
6. Terazosin readily available on the hospital formulatory
7. Captopril is available on hospital formulatory
8. Patient has insurance coverage to cover his prescription requirements
Write the Rx for the drug/drugs you selected from your analysis. (You will usually have only one, but if multiple meds for the same disorder are appropriate, you might want to use a combo med or 2 separate Rxs.) Use the student prescription form and the 4 line format for your Rx.
References
Hospital Satellite Network. Pennella Productions. & Milner-Fenwick, inc. (1987). Hypertension: Treatment. Los Angeles, Calif.: The Network.
Kaplan, N. M. (2003). Treatment of hypertension in general practice. London: Martin Dunitz.
Messerli, F. H. (2011). Clinician's manual: Treatment of hypertension. London: Springer Healthcare Ltd.
Nissenson, A. R. (2009). Current diagnosis & treatment. New York: McGraw-Hill Medical.
Genest, J. (1983). Hypertension, physiopathology and treatment. New York: McGraw-Hill.
