NURS 6521 Week 3: Cardiovascular System

NURS 6521 Week 3: Cardiovascular System

Sample Answer for NURS 6521 Week 3: Cardiovascular System Included After Question

Discussion: Pharmacotherapy for Cardiovascular Disorders 

As the leading cause of death in the United States for both men and women, cardiovascular disorders account for 7 million hospitalizations per year (NCSL, 2012). This is the result of the extensive treatment and care that is often required for patients with these disorders. While the incidences of hospitalizations and death are still high, the mortality rate of cardiovascular disorders has been declining since the 1960s (CDC, 2011). Improved treatment options have contributed to this decline, as well as more knowledge on patient risk factors. As an advanced practice nurse, it is your responsibility to recommend appropriate treatment options for patients with cardiovascular disorders. To ensure the safety and effectiveness of drug therapy, advanced practice nurses must consider aspects that might influence pharmacokinetic and pharmacodynamic processes such as medical history, other drugs currently prescribed, and individual patient factors. 

Consider the following case studies: 

Case Study 1: 

Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following: 

• Atenolol 12.5 mg daily 
• Doxazosin 8 mg daily 
• Hydralazine 10 mg qid 
• Sertraline 25 mg daily 
• Simvastatin 80 mg daily 

Case Study 2: 

Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following: 

• Warfarin 5 mg daily MWF and 2.5 mg daily T, TH, Sat, Sun 
• Aspirin 81 mg daily 
• Metformin 1000 mg po bid 
• Glyburide 10 mg bid 
• Atenolol 100 mg po daily 
• Motrin 200 mg 1–3 tablets every 6 hours as needed for pain 

Case Study 3: 

Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following:  

• Glipizide 10 mg po daily 
• HCTZ 25 mg daily 
• Atenolol 25 mg po daily 
• Hydralazine 25 mg qid 

• Simvastatin 80 mg daily 
• Verapamil 180 mg CD daily 

To prepare: 

• Review this week’s media presentation on hypertension and hyperlipidemia, as well as Chapters 19 and 20 of the Arcangelo and Peterson text. 
• Select one of the three case studies, as well as one the following factors: genetics, gender, ethnicity, age, or behavior factors. 
• Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes. 
• Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy. 
• Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient. 

With these thoughts in mind: 

By Day 3 

Post an explanation of how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you selected. Then, describe how changes in the processes might impact the patient’s recommended drug therapy. Finally, explain how you might improve the patient’s drug therapy plan. 

By Day 6 

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different case study than you did, in one or more of the following ways: 

• Provide alternative recommendations for drug treatments. 
• Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library. 
• Validate an idea with your own experience and additional research. 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! 

Submission and Grading Information 

Grading Criteria  

Alterations of the cardiovascular system can cause serious adverse events and may lead to death when not treated in a timely and safe manner. Unfortunately, many patients with cardiovascular disorders are unaware until complications appear. Consider hypertension. An estimated 68 million people in the United States have this disorder (CDC, 2012). However, about 30 percent of these patients are not treated at all, and of those who are treated, less than 50 percent have properly controlled blood pressure levels (University of Maryland Medical Center, 2009). In clinical settings, patients often present with symptoms of hypertension and other cardiovascular disorders making it essential for you, as the advanced practice nurse, to be able to recognize these symptoms and recommend appropriate drug treatment options. 

This week you examine the impact of changes in pharmacokinetic and pharmacodynamic processes on patient drug therapy for cardiovascular disorders. You also explore ways to improve drug therapy plans for these disorders. 

Learning Objectives 

By the end of this week, students will: 

• Evaluate the influence of patient factors on pharmacokinetic and pharmacodynamics processes 
• Analyze the impact of changes in pharmacokinetic and pharmacodynamic processes on patient drug therapy 
• Evaluate drug therapy plans for cardiovascular disorders 
• Understand and apply key terms, concepts, and principles related to prescribing drugs to treat cardiovascular disorders 

Photo Credit: GIPhotoStock/Cultura/Getty Images 

Learning Resources 

This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below. 

A Sample Answer For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Case Study 2 

 Patient HM has an extensive cardiovascular history.  There is a history of atrial fibrillation, ischemic attack (TIA), type 2 diabetes, hypertension, hyperlipidemia, and ischemic heart disease.  The patient is prescribed a list of medications that include: 

 

• Warfarin 5 mg daily po MWF and 2.5 mg daily T, TH, Sat, Sun  
• Aspirin 81mg daily po  
• Metformin 1000 mg PO  
• Glyburide 10 mg PO BID  
• Atenolol 100 mg PO daily  
• Motrin 200 mg 1-3 tablets every 6 hours as needed for pain  

 

Cardiovascular disease affects many people worldwide annually.  Kendir et al. 2018 state that cardiovascular diseases are the most common cause of death from non-communicable diseases (p.46).  Cardiovascular disease can refer to many diseases that affect the heart, and it’s vessels.  Our patient HM had many diagnosed cardiovascular disorders.  Atrial fibrillation which is an arrhythmia the heart due to loss of coordination of electrical and mechanical activity in the atria (Arcangelo, Petterson, Wilbur, & Reinhold, 2017, p.864).  Clots or thrombi can develop from atrial fibrillation causing strokes or ischemic attacks.  Unfortunately, HM had a history of ischemic attacks (TIA).  According to Arcangelo et al. 2017, an ischemic stroke is described as a sudden or progressive onset of focal neurologic sign due to the inadequate blood supply to the brain (p.868).  Having hyperlipidemia which is a high blood level of cholesterol further makes heart disease worse because the cholesterol builds up in vessels affecting blood flow.  Hypertension heightens the potential of developing cardiovascular disease and chronic kidney disease.  Hypertension can go for a long period of time going undetected because it can be asymptomatic.  Finally, HM was diagnosed with type II diabetes, which is caused when adipose and muscle cells become less sensitive to the actions of insulin or the pancreas produces less insulin than the body needs (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.785).  

 

Patient Factor 

  The disorders that HM has been diagnosed with can happen at any age, however, in elderly patients, they may have a poorer prognosis because medications are not always processed by the body as well or as intended.  The development and worsening of cardiovascular disease are associated with many factors such as genetics, lifestyle choices/behaviors, ethnicity, and age.  With so many other factors as a person ages, it is worsening the disease because that is a factor that cannot be changed.  With the patient HM’s medical history as a provider, you have to be cautious when prescribing because medications are absorption may be affected because of age.  

 

Drug Therapy Plan 

 The patient’s medical history puts him at higher risk of having a heart attack or stroke from complications of cardiovascular disease.  With this patient, we want to control his diabetes, hypertension, hyperlipidemia, and atrial fibrillation keeping levels within normal limits without over prescribing to this patient.  The first thing that was noticed when looking at the patient’s medication list is that he is talking two medications with anticoagulant effects.  Warfin which is a strong anticoagulant and aspirin.  When taking Warfin routine lab work is needed to check the PT, INR, and aPTT levels in the blood to determine if the medication dose needs to be adjusted.  Added aspirin in could cause increased bleeding, the elderly population with underlying malignancy and those taking interacting drugs that increase warfarins effect are at high risk for bleeding and should receive lower initial doses (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.874). 

 HM has type two diabetes and is taking Atenolol 100mg daily which is a beta-blocker.  Arcangelo et al. 2017 stated, in diabetic patients, beta-blockers can mask all symptom of hypoglycemia except sweating (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.266).  Being on this medication, the patient would have to consistent with monitoring his glucose levels and educated well on signs and symptoms of hypoglycemia.  This patient may benefit better from an Angiotensin II Receptor Blocker such as losartan.  For diabetics, losartan is a better choice because it is more effective than atenolol in lower cardiovascular morbidity and mortality in diabetic patients with hypertension and left ventricular hypertrophy (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.267).  Being that HM is elderly, his initial dose should be losartan 50 mg Po daily.  Starting at 50 mg daily leaves enough room to adjust up if needed depending on the patient’s blood pressure (Kizior,2018). 

 

Reference: 

 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). 

 Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins 

 Kendir, C., van den Akker, M., Vos, R., & Metsemakers, J. (2018). Cardiovascular disease 

 patients have increased risk for comorbidity: A cross-sectional study in the Netherlands. The European Journal Of General Practice, 24(1), 45–50. https://doi-org.ezp.waldenulibrary.org/10.1080/13814788.2017.1398318 

 Kizior, R. (2018). Saunders Nursing Drug Handbook 2019. Elsevier – Health Sciences Division. 

A Sample Answer 2 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Patient CB has a history of strokes and has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed are              Glipizide 10 mg po daily, HCTZ 25 mg daily, Atenolol 25 mg po daily, Hydralazine 25 mg qid, Simvastatin 80 mg daily, Verapamil 180 mg CD daily 

Pharmacological Evaluation 

Glipizide 10 mg PO daily 

               Glipizide is classified as a sulfonylurea (Connective Rx, 2018) which is being utilized to treat the patient’s diabetes. This medication should be administered 30 minutes before meals (Connective Rx, 2018). Dosing starts at 5mg by mouth daily with a max of 40mg per day, and maintenance is usually 10mg-15mg once a day (Connective Rx, 2018). The mechanism of action for glipizide is to lower the blood sugar by stimulation of the pancreatic islet cells, which in turn causes an increase in insulin secretion (Connective Rx, 2018). There is a decrease in efficacy of the medication if there is a decrease in the number of functioning beta cells or a low number of viable cells. This medication is highly protein bound, metabolized by the liver, excreted in the urine, has a half-life of 2-4 hours, and duration of action of 12-24 hours (Connective Rx, 2018). Special considerations include hepatic impairment in which the initial dose should be decreased to 2.5mg by mouth daily (Connective Rx, 2018). Patients with renal impairment have an increased predisposal to hypoglycemic reactions requiring close monitoring of blood glucose levels (Connective Rx, 2018). Within the current drug regime currently prescribed for the patient, drug to drug interactions are present with atenolol and hydrochlorothiazide (HCTZ). Atenolol can hide the symptoms of hypoglycemia which causes the need to monitor blood glucose levels more frequently.  HCTZ can decrease insulin sensitivity and glucose tolerance. 

Hydrochlorothiazide (HCTZ) 25 mg daily 

               Hydrochlorothiazide (HCTZ) is classified as a thiazide diuretic (Connective Rx, 2018) that is being used to treat the patient’s hypertension (HTN). Initial dosage is  12.5mg – 25mg PO once daily with a maximum dosage of 50 mg daily prescribed in one or two doses (Connective Rx, 2018). The mechanism of action for HCTZ is to decrease the excretion of sodium, chloride, and water by inhibiting sodium ion transport across the renal tubule epithelium (Connective Rx, 2018). The main mechanism of action occurs with the inhibition of the chloride reabsorption to the distal portion of the ascending limb or previous parts of the distal tubule (Connective Rx, 2018). Dosage adjustments must be made with renal patients based on the creatinine clearance (Connective Rx, 2018). HCTZ is excreted unchanged in the urine. 61% of it excreted within 24 hours and it has a half-life of 5.6 – 14.8 hours (Connective Rx, 2018). Caution must be considered in individuals with diabetes due to the impaired glucose tolerance that occur with this medication. The administration of glipizide and HCTZ can cause decreased insulin sensitivity (Connective Rx, 2018). 

Atenolol 25mg daily 

               Atenolol is a selective beta-blocker that is also being utilized for blood pressure management. Initial dosing is 25-50mg by mouth daily with a maximum dosage of 100 mg per day (Connective Rx, 2018). The mechanism of action includes a beta-adrenergic antagonist countering the effects of the sympathetic neurotransmitters by fighting for the receptor sites (Connective Rx, 2018). Atenolol is minimally bound to plasma proteins, has little to no metabolism in the liver, 30% of it is excreted in the urine after 24 hours, and has a half-life of 6-7 hours (Connective Rx, 2018). Food reduces the bioavailability by 20% without impacting the overall bioavailability and it has a peak of 2-4 hours after administration. Renal adjustment dosing is done based on creatinine clearance values and 25mg to 50mg can be administered with each standard dialysis session (Connective Rx, 2018). Atenolol can enhance hypoglycemia by interfering with glycogenolysis (Connective Rx, 2018). Atenolol, taken in conjunction with Verapamil, can improve exercise tolerance; however, it can lead to a significant AV nodal blockade, which would manifest as bradycardia, heart conduction abnormalities, or a heart block (Connective Rx, 2018). 

Hydralazine25mg QID 

               Hydralazine is classified as an Arteriole Smooth Muscle Drug being utilized to treat the hypertension. Initial dosing is 10 mg by mouth four times a day, which can be increased to 25 mg by mouth four times a day for the remainder of the week, and can be increased to a dosage of 80 mg by mouth four times a day the second and subsequent weeks (Connective RX, 2018). The max dosage is 300 mg per day (Connective RX, 2018). Hydralazine is a peripheral vasodilator which causes relaxation of arteriolar smooth muscle via a direct effect (Connective RX, 2018). The percentage that binds with plasma proteins is 87%, it is hepatically metabolized (plasma levels depend on the acetylation), it is excreted via the feces and urine (Connective RX, 2018).  The half-life is 3-7 hours, it peaks at 1-2 hours, and lasts 2-4 hours (Connective RX, 2018). Renal dosing is based on creatinine clearance. Dosing can be in intervals of 12-24 hours for patients with intermittent hemodialysis or peritoneal dialysis (Connective RX, 2018). Patient education should include caution with driving when starting the medication to determine the effect of the medication on the patient. It can cause confusion and disorientation (Connective RX, 2018). 

Simvastatin 80mg daily 

               Simvastatin is classified as a statin and being utilized to treat hyperlipidemia. Initial dosing is 10-20 mg daily in the evening with dose adjustments made to achieve lipid level targets (Connective RX, 2018). The maximum daily dose is 40 mg per day for initial therapy and 80 mg per day in individuals with chronic myopathy (Connective RX, 2018). Simvastatin impacts hyperlipidemia by impacting the De novo synthesis of cholesterol, enhancing clearance of LDL, decreasing the total cholesterol, LDL, triglycerides, and apolipoprotein B, while increasing HDL (Connective RX, 2018). It is contraindicated for hepatic impairment and initial dosing is decreased to 5 mg per day with renal impairment (Connective RX, 2018). It is activated in the liver, is 95% plasma protein bound, lipophilic, excreted in the feces (60%) and urine (13%) (Connective RX, 2018). It has a half-life of 1.9 hours, with a peak plasma level of 1.3-2.4 hours (Connective RX, 2018). Bioavailability can be impacted by the consumption of high fat meals (Connective RX, 2018). Caution must be taken with individuals with diabetes mellitus due to simvastatin usually worsening glycemic control during therapy and increasing the hemoglobin A1C (Connective RX, 2018). Simvastatin has a major interaction with verapamil in which the risk of myopathy is increased, including rhabdomyolysis (Connective RX, 2018). The dose should not exceed 10 mg per day in patients taking verapamil or clinicians should consider switching to another statin because verapamil increases the exposure of simvastatin two fold (Connective RX, 2018). 

Verapamil 180 mg CD daily           

               Verapamil is classified as a Phenyaklamine Calcium Channel Blocker that is being used to treat the hypertension. Initial dosing is 80 mg by mouth three times a day, with dosage increases occurring at weekly intervals (Connective Rx, 2018). The maximum dosage is 480 mg per day; however, not much benefit has been observed greater than 360 mg per day (Connective Rx, 2018).Verapamil inhibits the influx of extracellular calcium ions across the vascular smooth muscle and the myocardial muscle cell membrane which deforms the channels (Connective Rx, 2018). Verapamil is impacted by the “first-pass” effect, binds to the plasma protein (90%), excreted by the kidneys (70%), and excreted fecally (16%). The onset is in 1-2 hours with duration of 8-10 hours (Connective Rx, 2018). A 33% decrease in the initial dose must be prescribed for individuals with hepatic impairment. Dosing adjustment has to be made with patients with renal impairments (Connective Rx, 2018). Grapefruit juice must be avoided because it increases the bioavailability of verapamil (Connective Rx, 2018). Drug to drug interactions have been mentioned above. 

  Changes to the Drug Regime 

               After reviewing the medication list, the one change that would be made is selection of a different statin. This change would be made because of the interaction of the statin with the verapamil. Data indicates the need to change the statin, if verapamil is being prescribed in individuals with high doses of simvastatin (Connective RX, 2018). The drug of choice would be Rosuvastatin Calcium. 

Pharmacological Evaluation of the New Drug 

               Rosuvastatin calcium is a statin that is also utilized to treat hyperlipidemia (Connective Rx, 2018). Initial dosing is 10 mg daily with a maximum dose of 40 mg by mouth per day (Connective Rx, 2018). Rosuvastatin calcium  decreases LDL cholesterol, triglycerides, total cholesterol , and apolipoprotein B, while increasing HDL (Connective Rx, 2018). 80 % of Rosuvastatin calcium is bound to the plasma protein, 90% is excreted un-metabolized in the fecal matter, and 10 % by the renal system (Connective Rx, 2018). Just like Simvastatin, caution must be taken with individuals with diabetes mellitus due to simvastatin usually worsening glycemic control during therapy and increasing the hemoglobin A1C (Connective Rx, 2018). The presence of food decreases the bioavailability by 20%; however, it does not impact the overall bioavailability. The medication peaks in 3-5 hours (Connective Rx, 2018). A decreased initial dose should be prescribed to Asians (Connective Rx, 2018). Unlike Simvastatin, Rosuvastatin calcium does not have a serious interaction with Verapamil, which is why this medication was chosen. 

Treatment Optimization and Conclusion  

               The medication regime above would require optimization based on laboratory values, vitals sign readings, blood glucose readings, and the known interaction of verapamil and simvastatin. A lipid panel would be required to determine if the current dosage of simvastatin was effective and the equivalent dose of Rosuvastatin calcium would be prescribed (due to the drug-drug interaction).  If is not effective, re-evaluation would be required due to the change from simvastatin to Rosuvastatin calcium.  Blood glucose readings in conjunction with the vital sign reading would have to be reviewed for optimization of the glipizide, HCTZ, atenolol, verapamil, and Hydralazine. Both Rosuvastatin calcium and HCTZ decreases the body’s sensitivity to insulin, impacting the effects of glipizide; however, atenolol helps counteract those effects because is enhances the sensitivity of the cells to insulin. In order to create a balance between the diabetic management and blood pressure, the first adjustments would more than likely be made to the glipizide and atenolol since they are not maxed out, and they both benefit the diabetic management. An assessment of the patient compliance would be obtained. Identifying compliance would assist with the development of the education plan for the patient and family. A significant amount of patient education would be provided to ensure the patient is aware of the possible side effects, how to handle them, and the impact of not following the medication regime (Arcangelo, Peterson, & Reinhold, 2017). Education about the value of the required tests would also be provided to the patient and/or family. 

  References 

Arcangelo, V. P., Peterson, A. M., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Ambler, PA: Lippincott Williams & Wilkins. 

Connective Rx. (2018). Atenolol. Retrieved from PDR.net: https://www.pdr.net/drug-summary/Tenormin-atenolol-1128.3571 

Connective Rx. (2018). Atenolol. Retrieved from PDR: https://www.pdr.net/drug-summary/Tenormin-atenolol-1128.3571 

Connective Rx. (2018). Glipizide-Drug Summary. Retrieved from PDR: https://www.pdr.net/drug-summary/Glucotrol-glipizide-1635 

Connective RX. (2018). Hydralazine. Retrieved from PDR: https://www.pdr.net/drug-summary/Hydralazine-Hydrochloride-Tablets-hydralazine-hydrochloride-738.119 

Connective Rx. (2018). Hydrochlorothiazide. Retrieved from PDR: https://www.pdr.net/drug-summary/Hydrochlorothiazide-Tablets-hydrochlorothiazide-1973 

Connective Rx. (2018). Rosuvastatin Calcium – Drug Summary. Retrieved from PDR: https://www.pdr.net/drug-summary/Crestor-rosuvastatin-calcium-2318 

Connective RX. (2018). Simvastatin. Retrieved from PDR: https://www.pdr.net/drug-summary/Zocor-simvastatin-402.3285 

Connective Rx. (2018). Verapmil. Retrieved from PDR: https://www.pdr.net/drug-summary/Calan-verapamil-hydrochloride-1693 

A Sample Answer 3 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Case study 1 

Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following: 

• Atenolol 12.5 mg daily  
• Doxazosin 8 mg daily  
• Hydralazine 10 mg qid  
• Sertraline 25 mg daily  

• Simvastatin 80 mg daily  

  

Hypertension is a chronic condition caused by obesity, sedentary lifestyle, and an increase of salt intake (Nickson, 2015). Hypertension is called the silent killer because the condition can be asymptomatic, no signs or symptoms. (Nickson, 2015). It is a condition that can be treated and maintained if compliant with medications.  

  

Hyperlipidemia is an increase in cholesterol levels. It is caused by genetic, and environmental factors and It does not cause any symptoms. Hyperlipidemia is a treatable condition if compliant with medication.  

  

Pharmacokinetic 

  Obesity is a disorder involving excessive body fat which leads to dangerous health problems.   93.3 billions of adults live with obesity in the US. (CDC). Drug administration in obese patients is difficult because the recommended dose of medication is based on pharmacokinetic data from standard weight data (Nickson, 2015). Organs involved in drug elimination can be affected by pharmacokinetics more difficult due to obesity (Nickson, 2015). Obesity affects drug distribution and elimination.  Using total body weight will help. 

  

Pharmacodynamic 

  Atenolol 12.5 mg daily, beta-adrenoreceptor blocking activity by reducing heart rate and cardiac output, decreasing blood pressure, and isoproterenol-induced tachycardia (Drug.com, 2017).The beta-blocking effects of atenolol measures by reduction of exercise tachycardia are within one hour after administration of a single dose(Drug.com, 2017).  

 Doxazosin 8 mg daily,  reduces in systemic vascular resistance. Max reduction between 2-6 hours following a dose, a greater effect on blood pressure and heart rate in the standing position (Drug.com, 2017). 

Hydralazine lowers blood pressure by peripheral vasodilating effects decreasing the arterial blood pressure(Drug.com, 2017). Hydralazine is rapidly absorbed orally and peaks plasma level 1-2 hours(Drug.com, 2017).   

Sertraline 25 mg daily, blocks the uptake of serotonin into the human platelets. It is a potent and selective inhibitor of neuronal serotonin reuptake and has a weak effect on norepinephrine and dopamine neuronal reuptake (Drug.com, 2017). 

  Obesity is associated with comorbidities like uncontrolled hypertension.  Drug therapy is needed to achieve blood pressure control. Obese hypertensive patients often have metabolic abnormalities. (Scholze & Sharma, 2001). 

  Bases of metabolic profile ace inhibitors, angiotensin receptor blockers, calcium channel clockers, moxonidine, and alpha-blockers can lower  the blood pressure without worsening the metabolic abnormalities 

(Scholze & Sharma, 2001). 

  Reference 

Scholze, J, Sharma, AM. (2001). Treatment of hypertension in obesity. Retrieved from 

https://www.ncbi.nlm.nih.gov/pubmed/11413801 

  Nickson, C. (2015). Obesity and pharmacokinetics. Retrieved from https://lifeinthefastlane.com/ccc/obesity-and-pharmacokinetics/ 

  Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).Pharmacotherapeutics for advanced practice: A practical approach(4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

  Centers for Disease Control and Prevention.(2018). Retrieved from https://www.cdc.gov/obesity/data/adult.html 

Drug.com (2017). Retrieve from https://www.drugs.com 

A Sample Answer 4 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Case Study 1: 

Patient AO is a 35-year-old, white male and has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Patient states he doesn’t understand why his legs are swelling and has shortness of breath.  Drugs currently prescribed include the following: 

• Atenolol 12.5 mg daily  
• Doxazosin 8 mg daily  
• Hydralazine 10 mg qid  
• Sertraline 25 mg daily  
• Simvastatin 80 mg daily  

Pharmacological Evaluation 

            Patient AO is currently taking Atenolol which has been prescribed to treat his hypertension.  Atenolol is a beta-blocker, has a bioavailability of 46%-60%, metabolized in the liver, and excreted in feces and urine.  Atenolol was prescribed in conjunction to Hydralazine to treat the hypertension, Hydralazine is a vasodilator.  The bioavailability of Hydralazine is 30%-50%, metabolized in the liver, and eliminated through the urine.  Doxazosin is an Alpha blocker that is treating AO’s hypertension.  Doxazosin has a bioavailability of 65%, metabolized extensively in the liver, and eliminated through feces and urine.  Sertraline is an antidepressant, which is a serotonin reuptake inhibitor.  Sertraline’s bioavailability is increased with the intake of food, metabolized by hepatic cytochrome P450 enzymes, and excreted through the urine and feces.  Simvastatin is a statin, a lipid lowering agent which was prescribed to treat his hyperlipidemia.  Simvastatin’s bioavailability is less than 5% and takes 4-6 weeks to have maximum effect.  Metabolized in the liver and eliminated through feces and urine.  (Drugs, 2017).   

  

Changes to Drug Regimen 

This patient is currently suffering from shortness of breath and lower leg swelling and needs to be treated with a diuretic. The patient will need to be treated with a loop or high-ceiling diuretic such as Furosemide.  Furosemide is administered orally or parenterally.  The half life is rather short which allows patients to know when the effectiveness will occur allowing them to know when they will have diuresis.  Furosemide will help the patient expel the fluid that has built up in his stomach.  By doing this it will also help with his shortness of breath (Whalen, Finkel, & Panavelil, 2015).   

Furosemide has a bioavailability of 47-64%, with onset of 30-60 minutes, and duration of 6-8 hours.  Furosemide is metabolized in the liver and eliminated through the urine.   

Treatment Optimization 

            By giving AO Furosemide the patient needs to be aware that it may react with Sertraline and possible hyponatremia.  Lab work should be ordered on this patient routinely to monitor for hyponatremia.  Atenolol increases serum potassium and furosemide decreases serum potassium; again, the patient will need to have lab work done to monitor his potassium levels.  By the patient taking Furosemide it will help decrease the 9lbs of fluid he has gained and help prevent further weight gain.  The patient needs to be instructed to weight daily and to call his primary care provider if there is a 3lb weight gain/loss.   

  

References 

Araoye MA, Chang MY, Khatri IM, Freis ED. Furosemide Compared With HydrochlorothiazideLong-term Treatment of Hypertension. JAMA. 1978;240(17):1863–1866. doi:10.1001/jama.1978.03290170045023 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Drugs. (2017, January 20). Retrieved from Drugs: https://www.drugs.com/ 

Laureate Education, Inc.  (Executive Producer).  (2012). Hypertension and hyperlipidemia. Baltimore, MD: Author.   

Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Pharmacology (Vol. 6th). Philadelphia, PA: Lippincott Williams & Wilkins. 

Woollard M, Greaves I. 4 Shortness of breath.  Emergency Medicine Journal 2004;21:341-350.  

A Sample Answer 5 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

     Patient CB is a 59-year-old black male with a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following: Glipizide 10 mg PO daily, HCTZ 25 mg daily, Atenolol 25 mg PO daily, Hydralazine 25 mg QID, Simvastatin 80 mg PO daily, and Verapamil 180 mg PO CD daily.  

 A brief discussion of this patient’s current drug regimen follows to include recommended changes in prescriptions with parameters for expected outcomes and the effect of ethnicity on pharmacogenomics and treatment choices. 

  

1. Glipizide is an oral antidiabetic agent that is metabolized in the liver and the kidneys with a maximum daily dose of 40 mg per day (Hamilton, 2018).    

  

1. HCTZ (hydrochlorothiazide) is a combination thiazide diuretic/potassium-sparing diuretic; maximum doses are is contraindicated in patients with hyperlipidemia and diabetes (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The combination allows reduces the incidence of hypokalemia: thiazide diuretics inhibit reabsorption of sodium and chloride (and potassium) in the loop of Henle, and distal tubule and potassium-sparing diuretics interfere with sodium absorption in the distal tubule decreasing potassium excretion tubule reabsorption (Arcangelo et al., 2017). Normal range of dosing is 12.5 to 25 mg per day with a maximum dose of 50 mg and is metabolized in the liver (Hamilton, 2018).  

 

1. Atenolol is an antihypertensive cardioselective beta blocker (binds to beta-1 receptors located in the heart and kidneys) which is metabolized in the kidneys; it has a long half-life which allows for once per day administration (Hamilton, 2018), but also necessitates a gradual tapering of dosage when discontinuing therapy (Arcangelo et al., 2017). The dose is 25 to 50 mg per day with a maximum dose of 100 mg per day (Hamilton, 2018). Atenolol is also considered less effective for treating hypertension (HTN) and reducing cardiovascular events than other beta-blockers (Hamilton, 2018 & Arcangelo et al., 2017) and conceal signs and symptoms of low blood sugar in diabetic patients (Arcangelo et al., 2017).  

  

1. Hydralazine causes smooth muscle relaxation and vasodilation which is results in a reduction of blood pressure (Arcangelo et al., 2017). It is metabolized in the liver and kidneys and has a maximum daily dose of 300 mg (Hamilton, 2018). Because fluid retention and tachycardia can occur, it is often given with a beta blocker or other cardiac drug such as verapamil to slow the heart rate (Arcangelo et al., 2017).  

  

1. Verapamil is a calcium channel blocker (CCB) which work by inhibiting the movement of calcium across the cell membrane causing decreased heart rate and conduction (Arcangelo et al., 2017). This drug is considered first-line treatment for HTN in black Americans and is also used in ischemic heart disease (Arcangelo et al., 2017). CD, or controlled delivery, refers to a controlled dose meaning that the amount of drug delivered to the body is equal to the amount excreted with a goal of maintaining consistent amounts of drug available (Ummadi, Shravani, Raghavendra Rao, Reddy, & Nayak, 2013)and 180 mg is consistent with this use with the maximum dose  of 400 mg per day for HTN and 480 mg per day for angina; it is metabolized in the liver (Hamilton, 2018).  

  

1. Simvastatin is a lipid-lowering agent that inhibits HMG-CoA reductase in the liver which curbs cholesterol synthesis in the liver (Olsen, 2011) where it is also metabolized (Hamilton, 2018). The 80 mg dose per day this patient is taking is contraindicated in patients who are also taking verapamil (Hamilton, 2018).    

  The plan for this patient is to have a blood pressure of 130/80 or lower and to adjust medications in a way that optimizes outcome considering concomitant diagnoses of ischemic heart failure, diabetes, and hyperlipidemia (Laureate Education Inc., 2012). This patient takes four medications for HTN, and the first consideration is to evaluate ways to manage blood pressure more efficiently. Both thiazide-type diuretics and CCB are effective monotherapy for African American patients while reducing the risk of stroke (Abel et al., 2015, Arcangelo et al., 2017 & Laureate Education Inc., 2012). Neither one of these medications has been prescribed at the maximum dose before adding a third and fourth antihypertensive, for this patient being atenolol and hydralazine. Archangelo et al. (2017) and Hamilton (2018) assert that atenolol is not the most effective beta blocker for managing hypertension or reducing stroke. For this reason, I would recommend a trial 14-day titration off of atenolol because this drug also can disguise symptoms of hypoglycemia in diabetic patients (Arcangelo et al., 2017).  

  The next change to consider is the drug therapy for hyperlipidemia. A dose of greater than 10 mg of simvastatin per day is contraindicated in patients who also take verapamil, a CCB which is considered first-line therapy for African- Americans with hypertension and risk of stroke (Abel et al., 2015 & Arcangelo et al., 2017). The first step is to evaluate the patient’s risk for a future atherosclerotic cardiovascular disease (ASCVD) event; one of the risk factors is a thrombotic stroke (Arcangelo et al., 2017). Along with diet and activity modifications, which are also non-pharmacological interventions for HTN and diabetes, a bile acid resin such as cholestyramine at a starting dose of 4 grams daily (Hamilton, 2018); This drug should be used with caution in patients whose triglycerides are approaching 250 mg/dL as triglyceride levels can increase up to 15% while taking this drug (Arcangelo et al., 2017).  

There are many unknown variables to consider when prescribing a drug regimen for this patient. While HTN, diabetes, and hyperlipidemia all contribute to increased morbidity and mortality, HTN is the is the primary focus of treatment (Arcangelo et al., 2017). This discussion created a learning experience and opens discussion for alternative treatment options as well as information unknown or not considered. 

   

References 

Abel, N., Contino, K., Jain, N., Grewal, N., Grand, E., Hagans, I., … Roy, S. (2015). Eighth joint national  

     committee (JNC-8) guidelines and the outpatient management of hypertension in the African-American  

     population. North American Journal of Medical Sciences, 2015(7), 438-445. https://doi.org/10.4103/1947- 

     2714.168669 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinh(Arcangelo et al., 2017)old, J. A. (Eds.). (2017).  

     Pharmacotherapeutics for advanced practice a practical approach (4th ed.). Philadelphia, PA: Wolters Kluwer. 

Hamilton, R. J. (Ed.). (2018). Tarascon Pocket Pharmacopoeia (32nd ed.). Burlington, MA: Jones & Bartlett  

     Learning. 

Laureate Education Inc. (2012). Hypertension and hyperlipidemia [Video file]. Retrieved from 

     https://class.waldenu.edu/bbcswebdav/institution/USW1/201930_27/MS_NURS/NURS_6521/adobePresenter 

     /Week03/media2/index.htm 

Olsen, J. (2011). Clinical pharmacology made ridiculously simple (4th ed.). Miami, Fl: MedMaser Inc. 

Ummadi, S., Shravani, B., Raghavendra Rao, N. G., Reddy, M. S., & Nayak, B. S. (2013). Overview on controlled 

     release dosage form. International Journal of Pharma Sciences, 3(4), 258-269. Retrieved from  

     http://ijps.aizeonpublishers.net/content/2013/4/ijps258-269.pdf 

A Sample Answer 6 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following: 

• Warfarin 5 mg daily M, W, F and 2.5 mg daily T, TH, Sat, Sun  
• Aspirin 81 mg daily  

• Metformin 1000 mg po bid  
• Glyburide 10 mg bid  
• Atenolol 100 mg po daily  
• Motrin 200 mg 1–3 tablets every 6 hours as needed for pain  

  Subjective and Objective Information 

Patient H.M. as described in the above case study is a 43-year old African-American female comes to your office for a new patient examination. She is new to the area and in need of a provider to help manage her medications. Other pertinent history includes chronic knee pain, a cardiac stent, and obstructive sleep apnea. Her glycosylated hemoglobin A1c (HbA1c) is 6.6; complete blood count and basic metabolic panel are unremarkable, International Normalized Ratio (INR), and a fasting blood glucose of 150. Her initial blood pressure was 148/90 and a second reading 15 minutes later was 152/94, pulse 92, and with a calculated body mass index (BMI) of 38. Fasting lipid panel reveals total cholesterol: 225, low-density lipoproteins (LDL): 165, high-density lipoprotein (HDL); 31, and triglycerides: 145.  She denies any complaints, pain or issues.   

Pharmacological Evaluation of Current Drug Treatment 

H.M.’s medication regimen of taking warfarin and a baby aspirin daily for her history of atrial fibrillation (AF) and transient ischemic attack (TIA) is appropriate. Patient’s with AF who have a history of a stroke or TIA have the highest risk of a recurrent event. Furthermore, other risk factors H.M. has for stroke in AF are HTN and DM. The foundation for AF management is anticoagulation, rate control, and rhythm control for symptomatic patients (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The INR goal in AF is 2.0-3.0, except in patients who are at significant risk for strokes such as those with artificial valves, rheumatic heart disease, and recurrent prior strokes. These higher risk individuals INR should be between 2.5-3.5 (Rosenthal, 2018). 

While there is an array of pharmacological treatment options for type 2 diabetes, oral hypoglycemic agents such as metformin are the preferred first line of choice. A second oral agent such as a sulfonylurea, in H.M.’s case, glyburide, may be needed if the targeted HbA1c is not reached (Huether & McCance, 2017). Metformin works by decreasing hepatic glucose production and increasing sensitivity of peripheral tissues to insulin (Skidmore-Roth, 2018). Glyburide’s effect is to increase beta-cell insulin secretion from the beta cells in the pancreas (Glyburide Rx, n.d.). 

And lastly, beta-adrenergic receptor blocker agents slow the sinus rate and decrease atrioventricular nodal conduction. The use of atenolol for H.M. is two-fold, to control her blood pressure and possibly for rate control of her AF. Atenolol selectively blocks beta-1 receptors, with little or no effect on beta-2 types (Rosenthal, 2018). Beta-1 receptors are mostly located in the heart and kidneys, and beta-2 receptors are mainly located in the lungs, liver, arteriolar smooth muscle, and pancreas. Therefore, by blocking beta-1 receptors, the effects are a decreased heart rate, cardiac contractility, and renin release (Arcangelo et al., 2017). However, I would have to disagree and highly advise against the use of ibuprofen taken as needed for pain. 

The patient factor selected for this case study is obesity. The extent of simultaneous occurrence of type 2 DM and HTN depends on age, BMI and ethnicity. Moreover, many mechanisms have been suggested to explain why type 2 DM and HTN co-exist in the same individuals. Increased visceral adipose tissue and obesity are the most significant pathogenetic factors (Pavlou et al., 2018). Pathophysiologic changes in obese patients may alter the effects of drugs. Alterations in volume distribution and drug plasma concentrations may occur due to the increased ratio and distribution of fatty tissue to lean body mass. Theoretically, a decrease in the drug plasma concentration may result in failure of a given dosage of drug to achieve the desired therapeutic response (Chu, Lteif, & Young, 2017). 

Proposed Changes to Medication Regimen 

Advise against the use of ibuprofen. There is a major drug to drug interaction between ibuprofen and warfarin since ibuprofen may cause an increase in bleeding. There is also a moderate interaction between ibuprofen and glyburide as ibuprofen can increase the effects of glyburide and cause hypoglycemia. And it is also demonstrated that ibuprofen may reduce the effects of atenolol in lowering arterial blood pressure (Drugs.com, n.d.). An appropriate medication she could use to alleviate pain is acetaminophen. 

I would also like to add a 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor such as simvastatin 40 mg PO daily at bedtime to reduce this patient’s cholesterol levels. Statins block the conversion of HMG-CoA to mevalonate, an early and rate-limiting step in the production of cholesterol in the liver. Simvastatin reduces LDL and triglycerides and increases HDL (Drugs.com, 2018). Blocked production of cholesterol in the liver makes way for an increase in the amount of LDL cholesterol receptors on the liver, and as an outcome, more LDL cholesterol is taken up by the liver, thus, lowering LDL in the bloodstream. Also, a moderate increase in HDL transpires (Arcangelo et al., 2017). Simvastatin also appears to have very little to no interaction with H.M.’s medication regimen (Drugs.com, n.d.).  

Treatment Optimization and Outcome 

Paylou et al. (2018) suggest that when starting antihypertensive drugs in a diabetic patient, the choice between monotherapy or combination drug therapy depends on the severity of hypertension. In this case study, I believe lifestyle changes should be attempted first before adding a second antihypertensive medication. And as mentioned earlier, the effects of atenolol may have been decreased with the use of ibuprofen so by eliminating ibuprofen from H.M.; perhaps atenolol will be sufficient in treating her HTN and achieving a goal blood pressure < 140/90 mmHg. A BP target of <140/90 mmHg applies to most patients, even those with type 2 DM with and without renal impairment, according to most of the major medical societies such as the American Diabetes Association (ADA) and the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP (JNC 8) (Pavlou et al., 2018).  

Lifestyle changes include dietary changes (high in fruits and vegetables, whole grains and low-fat and cholesterol intake), exercise, smoking cessation, moderation of alcohol intake, and weight loss. Lifestyle changes should be initiated in conjunction with pharmacological therapies to optimize the effects of the medications in treating HTN, DM, and hyperlipidemia. In addition, I would want to repeat a basic metabolic panel in 4-6 weeks after starting simvastatin to monitor the patient’s potassium levels, and kidney function, as well as a hepatic panel as simvastatin must be used with caution in those with electrolyte imbalances, and it may also increase liver function tests such as ALT and AST. In addition, hepatotoxicity must be carefully monitored as warfarin, aspirin, glyburide, and simvastatin are all metabolized by the liver (Skidmore-Roth, 2018). 

 

References 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Chu, C., Lteif, L., & Young, N. (2017). Obesity: The drug dose debate. Hawaii Journal of Medicine and Public Health, 76(6), 162-165. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458583/ 

Drugs.com. (2018). Simvastatin. Retrieved from https://www.drugs.com/pro/simvastatin.html#s-34090-1 

Drugs.com. (n.d.). Drug interaction report. Retrieved from https://www.drugs.com/interactions-check.php?drug_list=2311-0,273-0,1573-0,1185-0,1310-780 

(Glyburide Rx). (n.d.). Glyburide (Rx). Retrieved December 12, 2018, from Medscape. 

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby. 

Pavlou, D., Paschou, S. A., Anagnostis, P., Spartalis, E., Spartalis, M., Vryonidou, A.,…Siasos, G. (2018). Hypertension in patients with type 2 diabetes mellitus: Targets and management. Maturitas, 112, 71-77. Retrieved from the Walden Library database. 

Rosenthal, L. (2018). Atrial fibrillation. Retrieved December 11, 2018, from Medscape. 

Skidmore-Roth, L. (2018). Mosby’s 2018 nursing drug reference (31st ed.). St. Louis, MO: Elsevier. 

A Sample Answer 7 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following: 

Glipizide 10 mg po daily 

HCTZ 25 mg daily 

Atenolol 25 mg po daily 

Hydralazine 25 mg qid 

Simvastatin 80 mg daily 

Verapamil 180 mg CD daily 

  

CB is a 65-year-old who walks into the office favoring his right side with a blood pressure of 102/62, respirations of 16, heart rate of 65 and states he feels ok today. 

He is on glipizide 10 mg po every day which is to help control his diabetes by causing the pancreas to make more insulin it is in the sulfonylureas drug class (MedlinePlus Drug Information, 2017). He is also on hydrochlorothiazide 25 mg daily with is a diuretic that helps decrease blood pressure by excreting un needed water and salt though the urine (MedlinePlus Drug Information, 2017). He also takes atenolol 25 mg daily which is a beta blocker also used to treat blood pressure by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure (MedlinePlus Drug Information, 2017). He also takes hydralazine 25 mg qid which is a vasodilator which works by relaxing blood vessels, so blood can flow more easily through the body (MedlinePlus Drug Information, 2017). He also takes simvastatin 80mg daily which is a statin or HMG-CoA inhibitors which slows the production of cholesterol in the body (MedlinePlus Drug Information, 2017). His last medication is verapamil 180 mg CD daily which is a calcium channel blocker which works by relaxing blood vessels, so the heart does not have to work as hard. It also increases oxygen and blood supply to the heart which controls the heart rate (MedlinePlus Drug Information, 2017). 

If I was to change anything it would be the beta blocker because he is a diabetic which the use of beta blockers is contraindicated (Laureate Education, 2012). I would state him on an ACE inhibitor because the combination of Ace inhibitor and thiazide would decrease his risk of strokes (Laureate Education, 2012). And with his history of a stroke it increases his risk of having another stroke along with the fact that he has hyperlipidemia. The other issue I would watch for is his creatinine clearance because being a diabetic can damage his kidneys and being on a thiazide is contraindicated if his creatinine clearance is less than 30 ml/min (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). 

An ACE inhibitor has an antihypertensive effect by inhibiting the ACE enzymes which turns angiotensin I into angiotensin II which is a strong vasoconstrictor. Adverse side effects include a dry cough, possible hypotension, rash, loss of taste, leukopenia, angioedema, neutropenia, and in less than 1% of patients agranulocytosis. Contraindications include pregnancy, patients with bilateral renal artery stenosis and unilateral stenosis. First line of medication is diabetic patients with protein in their urine and patients with congestive heart failure with systolic dysfunction (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). 

The factor I chose was age because it increases the risk for all of CB’s issues. As a patient gets older and has hyperlipidemia their risk of stroke increases especially since he has already had a stroke and the average age of a man being diagnosed with high blood pressure is around 60 years old (Laureate Education, 2012). 

I believe by changing his treatment he will have a more optimal outcome and less contraindicated medications. 

References 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.).  (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins 

Laureate Education, Inc. (Executive Producer). 2012. Hypertension and hyperlipidemia. Baltimore, Md Author 

MedlinePlus Drug Information. (2017). Atenolol: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a684031.html 

MedlinePlus Drug Information. (2017). Glipizide: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a684060.html 

MedlinePlus Drug Information. (2017). Hydrochlorothiazide: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a682571.html 

MedlinePlus Drug Information. (2017). Simvastatin: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a692030.html 

MedlinePlus Drug Information. (2017). Verapamil: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a684030.html 

A Sample Answer 8 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

            Cardiovascular diseases (CVDs) affect the heart and blood vessels, these include the heart and blood vessels as well as coronary heart disease, cerebrovascular disease, peripheral arterial disease; and rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism (Kendir, van den Akker, Vos, & Metsemakers, 2018).  It is responsible for over 17 million deaths constitute 31% worldwide deaths. On the other hand, hypertension which is an elevated blood pressure affects more than 50 million Americans (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Treatment is vary depending on the personage in adults over 60 years old, when systolic pressure is 150 mm Hg or higher, or when the diastolic pressure is 90 mm Hg or higher. In younger patients, beneath the age of 60 years, treatment should start at 140 mm Hg or higher of systolic, or 90 mm Hg or higher of diastolic pressure. CVD is the leading cause of death in the United States. CVD is a group of disorders of the heart and blood vessels, and they include coronary heart disease, cerebrovascular disease, peripheral arterial disease; and rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism (Kendir, van den Akker, Vos, & Metsemakers, 2018). The purpose of this paper is to analyze the case study 1, the plan of care for a hypertensive patient Pharmacokinetics and pharmacodynamics. 

Case Study 1 

            Patient AO has a history of obesity and has recently gained 9 pounds. The patient was diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following: Atenolol 12.5 mg daily, Doxazosin 8 mg daily, Hydralazine 10 mg qid, Sertraline 25 mg daily, and Simvastatin 80 mg daily. 

Pharmacokinetics and pharmacodynamics 

            When taking care of a patient with hypertension and hyperlipidemia, the provider must be reviewing carefully the plan of care such as prescribing medications, diet, and lifestyle of the patient for compliance.  In case study 1, AO is obese and has gained 9 pounds. To initiate drug therapy, the nurse practitioner (NP) has to assess the pharmacokinetics and pharmacodynamics of the patient (Franconi & Campesi, 2014). To ensure the safety and effectiveness of drug therapy, the NP must consider general aspects such as medical history, a drug to drug interaction, metabolism, smoking, alcohol consumption, stress, co-morbidities, and education amongst others (Franconi & Campesi, 2014). Also, individual patient factors such as genetics, gender, ethnicity, age, and behavior are essential. For example, hypertension is seen more in blacks (41.2%) compared to non-Hispanic whites (28.0%), and 25.9% Hispanics (Ferdinand et al., 2017). Research shows that the leading cause of this disproportion is noncompliance with medication which is a complex and various health care problem where compliance is well-defined as the extent to which patients can follow the recommendations for prescribed treatment. Also, advanced cases of cardiovascular disease, stroke, and kidney disease are also seeing in more significant numbers among the black community (Franconi & Campesi, 2014). 

            In the plan of care, one of AO’s current prescribed medication is atenolol. The medical history of AO’s must be review and updated by the NP before prescribe to prevent specific contraindications based on the patient’s history. Certain beta-blockers should not be giving to patients with bradycardia or COPD. According to Arcangelo, Peterson, Wilbur, and Reinhold (2017), side effects of beta-blockers, in general, include dizziness, drowsiness, and reduced heart rate. The NP has to ensure that medication compliance is monitored since immediate stopping beta blockers are not suggested due to an adverse effect on the patient health. 

            Furthermore, Hydralazine was also given; this medication, in particular, is beneficial in black patients with heart failure. The vital question, “Is AO an African-American?” Doxazosin was also prescribed. Doxazosin is an alpha-blocker recommended for patients with benign prostatic hypertrophy. Perhaps, the most frequent side effects of this medication are depression; close monitoring is needed, consequently the prescription of Sertraline, an antidepressant that when prescribed, the healthcare provider needs to educate on the risk of bleeding, suicidal ideation, and hepatic function. Therefore, lab work should order accordingly. Besides, Sertraline is known to have adverse effects on patient sex drive, erectile dysfunction, and ejaculation disorder in men (Ferdinand et al., 2017). Finally, simvastatin was ordered to treat the patient’s hyperlipidemia. Since some people are susceptible to hyperlipidemia due to genetic factors or faulty gene. Careful consideration of other medications should be evaluated as beta blockers are considered secondary factors that increase cholesterol levels (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). AO also needs to let the healthcare provider know of any allergic reactions to prevent a barrier to patient compliance.  

Improving the drug therapy plan 

To improve AO’s treatment, plan several steps can be taken with close monitoring. To begin, beta-blockers can be the reason for elevated hyperlipidemia. Also, beta-blockers are not usually used as a first-line treatment for hypertension. Hence, Atenolol should be stopped, as well as the Hydralazine it should preferably be given with a beta-blocker and a diuretic. The Hydralazine could put AO’s at risk of tachycardia, and if taken with a beta blocker, it can cause drug-induced lupus which is a painful condition (Almandil, 2016). Since the recommended first line of treatment for hypertension is diuretics, a dose of 12.5 mg of hydrochlorothiazide (HCTZ) should be initiated daily to decrease fluid retention since AO has recently gained 9 pounds. Thiazide diuretics are considered safe in diabetics, with a reduction in mortality from heart disease and stroke (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Although the patient is not a known diabetic, he or she does possess high-risk factors for the disease such as obesity, hypertension, and hyperlipidemia. It should be considered a genuine possibility that the patient either already has or will soon develop diabetes. Along with the HCTZ, I would add an ACE inhibitor such as Lisinopril 10-40 mg/day. 

Simvastatin is an appropriate choice for hyperlipidemia, as the statin drug class is a recommended first-line treatment; the cholesterol levels dictate individual drug of choice (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). However, the patient needs education on avoiding grapefruit juice because it can increase the effect of Simvastatin, (Ferdinand et al., 2017). Nonetheless, instead of the simvastatin, I would begin AO on Atorvastatin 40 mg daily. Atorvastatin 40-80 mg or Rosuvastatin 20-40mg are also first-line treatments for hyperlipidemia. There is an FDA alert stating that Simvastatin should no longer be prescribed at 80mg/day doses due to the risk of myopathy (Domino, 2017). NPs should be informed that multiple drugs at the appropriate dose may successfully manage blood pressures with fewer side effects. Be mindful about dispense morning and nighttime doses for better 24-hour antihypertensive effect.     Prescribing medications require special attention to the patient condition and medical history.

The providers must take a detailed history to ensure the patient will receive the best medicine for their disorder (Domino, 2017). The patient is essential for compliance. For example, the patient should make aware that frequent urination is one of the side effects and should encourage to plan to stay close to the bathroom during the day and have good lighting at night to prevent fall in case needed to go to the toilet depending on the patient age. The caregiver should also include in teaching. Alternative therapy would be to encourage the patient to eat healthier and exercise at least 30 minutes per day, four to five days a week (Almandil, 2016).  The patient would have to follow up every three months until stable, then every six months. Encourage patient to monitor blood pressure daily and record the reading to bring with him to evaluate progress. Lastly, close monitoring of lab work results especially a lipid panel to control LDL levels should be part of the treatment plan (Domino, 2017). 

Conclusion 

Providing a plan of care for a patient treatment require knowledge and understanding of the Pharmacokinetics and pharmacodynamics for a more suitable result. Patient Combination drug therapy along with appropriate lifestyle changes can lead to a substantial estimated reduction in CVD and can benefit many individuals globally. Therefore, strategies should be adopted for CVD prevention worldwide. While there are currently many barriers to widespread use of combination therapy, they are manageable and should provide support by active listening of patient concern and make an adjustment for easy compliance. 

References 

Almandil, N. B. (2016). Healthcare professionals’ awareness and knowledge of adverse drug reactions and pharmacovigilance. Saudi Medical Journal, 37(12), 1359–1364. https://doi-org.ezp.waldenulibrary.org/10.15537/smj.2016.12.17059 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A.  (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins 

Domino, F. J. (Ed.). (2017). The 5-Minute clinical consult (25th ed.). Philadelphia, PA: Wolters Kluwer 

Ferdinand, K., Yadav, K., Nasser, S., Clayton-Jeter, H., Lewin, J., Cryer, D. & Senatore, D. (2017). Disparities in hypertension and cardiovascular disease in blacks: The critical role of medication adherence. The Journal of Clinical Hypertension, 1-10. doi:10.1111/jch.13089 

Franconi, F. & Campesi, I. (2014). Pharmacogenomics, pharmacokinetics, and pharmacodynamics: interaction with biological differences between men and women. British Journal of Pharmacology, 171(3), 580-594. doi:10.1111/bph.12362 

Kendir, C., van den Akker, M., Vos, R., & Metsemakers, J. (2018). Cardiovascular disease patients have increased risk for comorbidity: A cross-sectional study in the Netherlands. The European Journal of General Practice, 24(1), 45–50. https://doi-org.ezp.waldenulibrary.org/10.1080/13814788.2017.1398318 

A Sample Answer 9 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Patient AO has a history of obesity with a recent 9 lb. weight gain, newly diagnosed with hypertension and hyperlipidemia. Prescriptions ordered include: 

• Atenolol 12.5 mg daily   

• Doxazosin 8 mg daily  
• Hydralazine 10 mg QID  
• Sertraline 25 mg daily  
• Simvastatin 80 mg daily  

Pharmacokinetics and Pharmacodynamics 

A healthcare provider that is initiating medication therapy to a patient diagnosed with hypertension and hyperlipidemia should consider a few factors before communicating the prescription to the pharmacy. One known fact about this case is that AO is obese and has gained 9 pounds. In order to develop the appropriate therapy, we have to evaluate the pharmacokinetics and pharmacodynamics of the patient. In general, we must consider gender (anatomical and physiological differences), metabolism, smoking and drinking status; stress, co-morbidities, and education amongst others (Franconi & Campesi, 2014). According to Ferdinand et al. (2017), hypertension is seen more in blacks (41.2%) compared to non-Hispanic whites (28.0%), and 25.9% Hispanics. According to research conducted by these authors, the main cause of this disparity is nonadherence to treatment. In return, higher cases of cardiovascular disease, stroke, and kidney disease are also seen in larger numbers among the black community (Franconi & Campesi, 2014). Age is another important factor to consider. As we age and develop other medical issues, the less ability of the liver to metabolize drugs, the kidneys are less able to eliminate the drug, which in return can increase side effects (Alomar, 2014).  

Impact the patient’s recommended drug therapy 

 AO’s drug therapy, one of the medications ordered is atenolol. AO medical history will be important information because there are certain contraindications based on the patient’s history. Not all beta-blockers can be given to a patient with bradycardia or COPD. Beta-blockers side effects, including feeling dizzy, drowsy, and reduced heart rate (Arcangelo, Peterson, Wilbur, & Reinhold, pg. 262, 2017). Medication adherence is monitored since abruptly stopping beta blockers is not recommended (Arcangelo et al., p. 265, 2017). Hydralazine , this medication, in particular, is beneficial in black patients with heart failure (is AO African-American?) Doxazosin which is an alpha-blocker recommended for patients with benign prostatic hypertrophy, which leads me to believe that AO has a history of BPH (Arcangelo et al., p. 264, 2017). One of the side effects of this medication is depression, close follow-up is also needed, hence the prescription of Sertraline, an antidepressant that when taken, the healthcare provider needs to educate on the risk of bleeding, suicidal ideation, and hepatic function. In addition, men have seen adverse effects with libido, erectile dysfunction, and ejaculation disorder (drugs.com, 2017). Finally, simvastatin was ordered to treat his hyperlipidemia (due to an increase in serum cholesterol levels either due to genetics or environmental influences) (Arcangelo et al., p. 275, 2017). Since some people are susceptible to hyperlipidemia due to genetic factors (faulty gene), careful consideration of other medication should be evaluated as beta blockers are considered secondary factors that increase cholesterol levels (Arcangelo et al., p. 275, 2017). AO needs to let the healthcare provider know of any allergic reactions to any of the medications prescribed since this will alter the treatment therapy. 

  Alternative treatment options 

In addition to pharmacological treatment, a recommendation that will be helpful for AO to control hypertension and hyperlipidemia is setting up a nutrition plan and exercise program to lose weight. Smoking and alcohol consumption should immediately be stopped (if smokes or drinks). According to Moyer (2012), a reduction in morbidity and mortality is seen in patients who indeed follow a healthy diet and exercise. The fact that AO is obese and has gained weight, and has been diagnosed with hypertension and hyperlipidemia, puts the patient at a higher to developing cardiovascular disease (Moyer, 2012).  

  References: 

Alomar, M. (2014). Factors affecting the development of adverse drug reactions (review article). Saudi Pharmaceutical Journal, 22(2), 83-94. Retrieved from https://doi.org/10.1016/j.jsps.2013.02.003 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J.A. (Eds.). (2017). Hypertension In Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J.A. (Eds.). (2017). Hyperlipidemia In Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Ferdinand, K., Yadav, K., Nasser, S., Clayton-Jeter, H., Lewin, J., Cryer, D. & Senatore, D. (2017). Disparities in hypertension and cardiovascular disease in blacks: The critical role of medication adherence. The Journal Of Clinical Hypertension, 1-10. doi:10.1111/jch.13089 

Franconi, F. & Campesi, I. (2014). Pharmacogenomics, pharmacokinetics, and pharmacodynamics: interaction with biological differences between men and women. British Journal Of Pharmacology, 171(3), 580-594. doi:10.1111/bph.12362 

Moyer, V. (2012). Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement. Annals Of Internal Medicine, 157(5), 367-371. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22733153 

A Sample Answer 11 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

In case one AO is obese and has gained 9 pounds recently. AO suffers from hypertension and hyperlipidemia and is taking Atenolol 12.5mg, Doxazosin 8 mg daily, Hydralazine 10 mg qid, Sertraline 25 mg daily, Simvastatin 80 mg daily. Behavioral factors play an important role in both patient’s diagnoses and his obesity. It is believed that obesity can affect all the aspects of pharmacokinetic such as absorption, distribution, elimination, and metabolism, (Thethi., Kamiyama, & Kobori, 2012). The pharmacokinetics of medication might also be affected in an obese person, in that the risk for adverse reactions increased seeing that the body can’t properly absorb, distribute, metabolized and eliminate the drug (Thethi et al. 2012) 

Atenolol is absorbed in the gastrointestinal system and the blood level tends to peak at between two to four hours (Drug.com, 2018). Atenolol is not metabolized much by the liver and is excreted by the liver and only a small portion in a bind to protein Drug.com, 2018). Atenolol is considered a beta blocker that is used to decrease cardiac output and inhibits the release of renin (Drug.com, 2018). Doxazosin is used to treat mild to moderate hypertension and benign prostate hyperplasia. It has 65 percent absorption rate and metabolized in the hepatic system and is eliminated from the body through feces and urinary system (Drug.com 2018). The medication also has a very high binding protein rate. Hydralazine works by relaxing blood vessels, thus increasing oxygenated rich blood to the heart. Hydralazine has a high first-pass metabolism and is metabolized in the hepatic system. The half-life is 3 to 7 hours and is mainly excreted as metabolites in urine (Drug.com, 2018).  As a vasodilator, hydralazine works by relaxing blood vessels (arterioles more than venules) and increasing the supply of blood and oxygen to the heart while reducing its workload (Drug.com, 2018). Sertraline inhibits the uptake of serotonin is used to treat disorders such as depression and obsessive-compulsive disorder. Sertraline has a high first past metabolism in the liver. Due to the high metabolism of Sertraline, only a small amount is excreted in urine. The plasma concentration of Sertraline reach is maximum concentration anywhere from 4.5 hours to 8.4 hours after being administered. Sertraline has a high protein binding rate of 98% (Food and Drug Administration, 2018). Simvastatin is rapidly absorbed and can reach its maximum plasma level is 4 hours.

The elimination half-life of Simvastatin is 14 hours. Simvastatin has a high protein binding rate and is mainly eliminated from the body through feces and a small amount through the renal system (FDA,2018). Obesity can cause renal disorders, have major impacts on organs that are involved with the distribution, metabolism, excretion and elimination of medication, therefore, impacting how the medication is prescribed. For example, an impaired renal system, urinary system, and liver system can have an influence on the pharmacodynamic and pharmacokinetics of medication. This would be the case for the patient in the case study careful considerations must be given to the current obese status because some of the medication can cause increased appetite, lower blood pressure and have psychological impacts. Obesity can certainly play a role in medication that is weight base, there can be overdosing or underdosing which has an impact on adverse reactions. Obesity can also impact the renal system, therefore, impacting the excretion of medication from the body Further obesity can cause hypertension (Thethi et al, 2012) 

Based on all the medical conditions which the AO is experiencing such as hypertension, hyperlipidemia, possible prostate issues because of the usage of Doxazosin and Sertraline which can be used for depression and obsessive-compulsive disorders. It can be inferred that AO might have some an obsession with food because obesity is one of the problems. So, it can be assumed that there are issues with eating. The main modification that the student would make to AO treatment is to lifestyle modification by encouraging change in eating habits and starting to exercise.  According to the American Society for Metabolic and Bariatric Surgery (ASMBS, 2018) hypertension is often seen in 3 out of 4 obese patients. Obesity can also lead to other such conditions as cardiac disease, impotence, liver disease, kidney disease and depression amongst others (ASMBS, 2018). Some of these disorders are seen in AO in the case study, therefore if the obesity issue is resolved then some of the medical issues that are being experienced may resolve. According to Harvard School of Public Health (2018), exercise can lower one’s risk factors for f heart disease, diabetes, stroke, high blood pressure, osteoporosis, and certain cancers, as well as reduce stress and boost mood. Inactive (sedentary) lifestyles do just the opposite.  With the change in lifestyle, careful monitoring is going to be needed with the management of AO medication to prevent any adverse reactions.  

  

References  

American Society for Metabolic and Bariatric Surgery (2018) Impact of obesity on your body and health. Retrieved from https://asmbs.org/patients/impact-of-obesity 

Drug.com (2018). Atenolol tablets. Retrieved from https://www.drugs.com/pro/atenolol- 

tablets.html#s-34090-1 

Drug.com (2018). Doxazosin. Retrieved from https://www.drugbank.ca/drugs/DB00590 

Food and Drug Administration (2018). Sertraline. Retrieved from  

https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019839s070,020990s032lbl.pdf 

Harvard School of Public Health (2018). Physical activity: exercise can help control weight.  

Retrieved from https://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/physical-activity-and-obesity/ 

Thethi, T., Kamiyama, M., & Kobori, H. (2012). The link between the renin-angiotensin- 

aldosterone system and renal injury in obesity and the metabolic syndrome. Current hypertension reports, 14(2), 160-9. doi:  10.1007/s11906-012-0245-z 

A Sample Answer 12 For the Assignment: NURS 6521 Week 3: Cardiovascular System

Title: NURS 6521 Week 3: Cardiovascular System

Case Study 2: 

Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following: 

• Warfarin 5 mg daily MWF and 2.5 mg daily T, TH, Sat, Sun
• Aspirin 81 mg daily
• Metformin 1000 mg po bid
• Glyburide 10 mg bid
• Atenolol 100 mg po daily
• Motrin 200 mg 1–3 tablets every 6 hours as needed for pain

  

Patient Situation 

Patient has history of atrial fibrillation and transient ischemic attack(TIA).  Recently diagnosed with Type 2 diabetes, hypertension, hyperlipidemia, and ischemic heart disease.  Current drug regimen is adequate but needs to haven drug regimen adjusted as well as new medications added.  Case study does not give age, gender, race or behavior facts.  We do not know patient’s allergies which will affect the medications that can or cannot be prescribed.  Objectively the patent’s current list of medications is relevant for his medical history, but patient needs to have some medications removed and needs education on what over the counter mediations to avoid and why. 

Current Pharmacological Evaluation 

Pharmacologically this patient needs to be educated on the use of Motrin for pain.  Motrin is contraindicated in patients on a blood thinner such as warfarin and aspirin, since Motrin is a non-steroidal anti-inflammatory that also can cause bleeding.  It is recommended that this patient be take Tylenol for pain.  Warfarin is an anticoagulated used to treat atrial fibrillation.  “Warfarin decreases blood clotting by blocking an enzyme called vitamin K epoxide reductase that reactivates vitamin K1.  Without sufficient active vitamin K1, clotting factors II, VII, IX, and X have decreased clotting ability.”(Reardon, G. 2013 p.167)  A patient needs to have their prothrombin time checked every 1-4 weeks to make sure they are in therapeutics levels.  Aspirin (ASA) is given as a second blood thinner, its action work by inhibiting or suppressing normal platelet function which decreases the formation of thrombi. Usually ASA is prescribed at 81mg PO daily unless contraindicated in patients with stomach ulcers or irritated bowels.  Metformin is a first line medication given to patients who are type 2 diabetics, 1000mg PO bid is a standard maintenance dose for type 2 diabetics.  Metformin works be decreasing glucose production in the liver and increasing the sensitivity of insulin in the patient’s body tissue.(Karch, 2013)  Metformin is contraindicated in patients with liver disease as well as kidney failure. 

Patient’s should stop taking Metformin for 48 hours after having intravenous iodine radiographic studies in order to give the iodine time to be flushed out of the body.  This medication along with diet should decrease this patient’s blood glucose levels.   Glyburide (Glibenclamide) is another drug used for the treatment of type 2 diabetes.  It is used in conjunction with Metformin to increase the bodies sensitivity to insulin. Closing monitoring of blood glucose levels (BGL)are important due the possibility of a sudden drop in BGL’s causing hypoglycemia.  Caution is taken is using this medication in patients with liver and kidney failure as it is absorbed in the liver and excreted in the kidneys.  Atenolol (Tenormin) is a beta-adrenergic blocker used to treat hypertension in patient’s by decreasing heart rate and the workload in the heart by inhibiting beta 1 receptors in your body. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017) It is contraindicated in patients with type 2 diabetes because it can increase symptoms of diabetes.  This drug would not be recommended in this patient due to their diagnosis of type 2 diabetes.     

Drug Regimen Changes and Pharmacological Evaluation 

            As this patient’s provider, with the little information I have I would make multiple recommendations to the medication regimen.  First, I would start with explaining to the patient that they can no longer take Motrin.  As mentioned above this medication is contraindicated in patient’s on blood thinners.  I would recommend Tylenol for pain, recommended dosage would be, 650mg PO TID as needed for pain.  Warfarin and aspirin would be continued at the current prescription with the patient getting repeat prothrombin times to monitor clotting factors.  Educating the patient on the need to watch the amount of leafy greens they eat because they contain vitamin K and can decrease the effectiveness of warfarin.  Also, education on the fact that if they get a cut or a bruise, bleeding time is increased leading to larger bruises. I would continue the patient on metformin and glyburide with special instructions to monitor their BGL’s as well as education on eating healthier and exercising.  I would take this patient off atenolol and place them on Lisinopril/ hydrochlorothiazide combination drug therapy.  I would start them off at 20/12.5mg PO daily.   Lisinopril/HCTZ is a combination drug that is recommended in patients with diabetes and HTN.  It is an Ace inhibitor that inhibits the conversion of angiotensin I into angiotensin II. (Laureate Education, 2012). 

Hydrochlorothiazide is a diuretic that works by decreasing the kidneys ability to retain water. (Sica, DA 2011) This in turn decreases blood volume, decreasing cardiac output.  As a combination drug it as an increased effect on patients with diabetes and hypertension by being effective without compromising the kidneys or liver. (Hickman, J. 2010) Since HCTZ is a diuretic it is important that the patient knows there can be a decrease in electrolytes in the body, and potassium levels should be monitored when first giving the medications.  As for the hyperlipidemia I would recommend having the patient start with lifestyle changes such as diet and exercise for six months. (Laureate Education, 2012) If this doesn’t work I would start them on a statin like Zocor (Simvastatin). Simvastatin work by inhibiting 3-hydroxy-3-methylglutaryl (HMG) coenzyme A reductase. (Arcangelo et al., 2017, p. 281) This enzyme decreases the production of cholesterol in the liver decreasing cholesterol levels in the body.  Due to the history of diabetes I would start the patient at a dose of 40mg PO daily to be taken at night.  Research shows that statins taken at night are more effective the in the morning because the body produces more cholesterol at night.  While on Simvastatin the patient needs to monitor their blood sugar for any fluctuations.  

Conclusion 

In conclusion, it is important to monitor for any unforeseen interaction in the new medications added to the patient.   With the new regimen of medication added to the patients existing list the plan is to have the patient become normotensive as well as keeping their blood sugar within an acceptable range.  Weekly then monthly monitoring of the patient’s prothrombin time as well as monitoring of their electrolyte levels and cholesterol levels.  If the patient follows this regimen there should be little negative effect on any major organs while being able to lead a healthy lifestyle. 

References 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapuetics for Advanced Practice (4 ed.). Phil., Penn.: Lippincott, Williams & Wilkins. 

Karch, A. M. (2013). Focus on Nursing Pharmacology (6 ed.). Philadelphia, PA: Lippincott Williams & Wilkins. 

Laureate Education, Inc. (Executive Producer). (2012). Hypertension and hyperlipidemia. Baltimore, MD: Author. 

Reardon G; Patel AA; Nelson WW; Philpot T; Neidecker M (2013 Feb). Usage of medications with high potential to interact with warfarin among atrial fibrillation residents in long-term care facilities. Expert Opinion on Pharmacotherapy Vol. 14 (2), pp. 165-73; Publisher: Informa Healthcare 

Sica DA; Carter B; Cushman W; Hamm L,(2011,Sept.). Thiazide and Loop Diuretics. Journal of Clinical Hypertension 13 (9), pp. 639-43; Publisher: Wiley Periodicals Inc 

Hickman J, (2010, Jan.). Does higher usage of low-cost statins correlate with a poorer achievement in cholesterol quality markers for secondary prevention?. The British Journal of General Practice: The Journal Of The Royal College Of General Practitioners Vol. 60 (570), pp. 50-52.