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Ikome Christiana
Presented to:
Dr. Warren-Dorsey
In partial fulfillment of the requirements of
Nursing 615 Pharmacology for advanced Nursing Practice

Coppin State University

Spring 2014




Problem identification

Mr. James Franks current list of medications may be contributing to the uncontrolled
hypertension as evidenced by high blood pressures of 162/90mmHg and 164/94mmHg, assessed
twice during his visit. One problem that might be contributing to Mr. Franks uncontrolled blood
pressure might be that his current regimen of Trimterene/hydrochlorthaixide 37.5mg/25mg daily,
and Carvedilol 12.5 mg twice a day might not be working and therefore needs to be altered.
According to the JNC 8 Hypertension Management Algorithm, all patients with diabetes and
chronic kidney diseases should have a goal systolic blood pressure of less than 140mmHg, and a
goal diastolic blood pressure of less than 90mmHg (JNC 8). In order to achieve the ideal blood
pressure as stipulated by the JNC recommendations, the current regiment has to be changed.
Another problem is that Mr. Frank is taking Carvedilol, a combination Alpha1 and
noncardioselective beta blocker, which may not be the appropriate class of medication for this
patient since patient has a history of COPD which might be worsened by bronchospasms, a side
effect caused by Carvedilol. According to Buttaro, beta blockers may lead to bronchospasms or
bronchoconstriction and therefore should be used with caution in patients with COPD (Buttaro,
T.M., et al., pg. 533). Another problem is that Mr. Frank is taking Tiotropium DPI 18mcg for
COPD however; one of the side effects of this medication is urinary retention. According to
Edward, M., Tiotropium might cause or worsen urinary retention due to its anticholinergic effect
and therefore should be used with caution in patients with Benign Prostatic Hyperplasia and
chronic kidney disease (Edmunds, M., 2009, pg. 204). Mr. Frank is also taking Mucinex D,
which is a combination of guifenesin, an expectorant and pseudoephedrine, a decongestant.
Mucinex D can cause vasoconstriction of the vascular smooth muscles and therefore raise blood
pressure. It should therefore be avoided or used with caution in patients with uncontrolled



hypertention due to its sympathomimetic side effect (Edmunds, M., 2009, pg. 171). Mr. Frank is
taking Naproxen, an NSAID for pain and head ache as needed. NSAID may increase the
patients blood pressure and worsen the risk of cardiovascular thrombotic event. NSAIDs have
also been implicated for worsening symptoms of patients with COPD, and should be used with
caution in patients with chronic kidney disease (Edmunds, M., 2009, pg. 396-397).
According to Buttaro, blood pressure is categorized as normal, pre hypertension, stage 1
hypertension and stage 2 hypertension. Normal blood pressure is systolic blood pressure less
than 120 mmHg and diastolic blood pressure less than 80mmHg. Pre hypertension blood
pressure ranges from 120-139mmHg (systolic) and 80-99mmHg (diastolic). A patient is said to
have stage 1 hypertension when systolic blood pressure ranges from 140-159mmHg and diastolic
blood pressure ranges from 90-99mmHg. Finally, blood pressure is classified as stage 2 blood
pressure when a patient has a systolic pressure above 160mmHg and a diastolic pressure above
100 (Buttaro, T.M., et al., 2007). For the purpose of this assignment, Mr. Franks blood pressure
is categorized as stage 2, although the diastolic blood pressure given in the scenario ranges from
90-92mmHg and probably does not exactly fit category two as highlight above, however, two
systolic blood pressures are more than 160mmg at both instances and therefore it is reasonable to
classify Mr. Franks blood pressure in category two.
Patients known risk factors according to the scenario are that he is diabetic, he has chronic
kidney disease, he is none compliant with low sodium diet, he is a former smoker, he does not
exercise regularly, he consumes alcohol, and although he has not been diagnosed with
hyperlipedemia, his lab work reflects high risk for cardiovascular diseases based on the low HDL
of 40mg/dL, high LDL 99 mg/dL, and high Triglyceride of 158mg/dL. Mr. Frank is also
genetically at risk for cardiovascular disease based on the family history as stated in the case



scenario. Based on Framingham risk score, Mr. Franks cardiovascular disease risk is 25%
according Buttaros text, pg 1145.
As far as evidence of target organ damage is concerned, Mr. Frank already has an established
diagnosis of chronic kidney disease so it is imperative that his blood pressure be controlled to
slow progression of chronic kidney disease to end stage renal disease. Without appropriate
management of Mr. Franks blood pressure, progression to end stage renal disease might be more
rapid, requiring him to be on hemodialysis to sustain his live. Wenzel, R., in her article entitled
Renal Protection in Hypertensive Patients, highlighted that poor control of hypertension can
foster progression of renal damage, and therefore lowering the blood pressure to 140/90mmHg in
patients without complicated hypertension and 130/80mmHg or less for patient with diabetes or
renal damage involvement is imperative (Wenzel, R., 2005).

Desired Outcome

Ultimately, treatment goal for Mr. Frank is to achieve a blood pressure of 130/80mmHg or
lower by way of altering his current pharmacological regimen, and starting him on another
regimen in order to achieve the goal blood pressure as stated above. Patient shall be encourage
to consume low sodium, low fat diet, performing routine aerobic exercises at least two to three
times a week, he shall be encouraged to reduce the consumption of alcohol, and initiate
pharmacological regimen to reduce hypertension and lower cholesterol. Wenzel, R. stated in her
article that chronic renal disease has been associated with uncontrolled hypertension, however
she emphasized that if hypertension is not controlled, or is poorly controlled, the consequence is
a progression of nephropathy to end stage renal disease (Wenzel, R., 2005). Appropriate control
of patients blood pressure can also reduce cardiovascular risk, especially because this patient is
high risk for cardiovascular disease as shown in the Framingham risk score. Patient shall be



monitored for progression of symptoms of cardiovascular disease, especially because he

complaints of shortness of breathe, and he has a genetic predisposition based on family history.
Patient shall be monitored for diabetic and renal status as well as COPD so that further
progression or worsening of above conditions can be noticed quickly and addressed accordingly.

Therapeutic Alternatives

The importance of lifestyle modification cannot be overemphasized, as subtle or minor

changes can have tremendous effects in patient outcome. Physical exercise for example, is
important as studies have shown that regular aerobic exercise increases HDL cholesterol,
decreases total and LDL cholesterol as well as decrease triglyceride levels. Regular aerobic
exercise has also shown to alter and improve control of frequent co-existing risk factors such as
obesity, hypertension and insulin resistance (Buttaro, pg. 1145). Mr. Frank would be encourage
to maintain a low sodium, low fat diet, as dietary therapy will typically achieve a reduction in
his weight by 10%, and reduce LDL cholesterol by 15 to 25mg/dl (Buttaro, pg 1143).
Reasonable pharmaceutical options available for control of Mr. Franks blood pressure
according to JNC 8 hypertension management algorithm might be to add or titrate the thiazidetype diuretic, add an ACE inhibitor or ARB as part of a multidrug therapy especially because a
consideration of patients diabetic and renal status is imperative in choosing blood pressure
regimen for this patient population.

Optimal Plan

Specific lifestyle modification for Mr. Frank would be to encourage exercise routinely at
least 2-3 times a week, maintain adequate hydration, reinforce the importance of dietary
adherence low sodium and low fat diet, consumption of fruits, vegetables and low fat dairy
products, as well as reduce alcohol consumption. Mr. Frank shall also be encourage to takes his



medications as ordered, and report any adverse drug effects. The ultimate goal again is to control
symptoms complications of disease process therefore a therapeutic treatment goal which shall be
agreed by patient and provider is important.
As far as the pharmacological regimen is concerned, an ACE inhibitor or Angiotensin
receptor antagonist in combination with either a loop or thiazide-type diuretic might work better
for this patient as ACE inhibitors and ARBs are mostly recommended for chronic renal disease
patients and for patients with diabetes (Buttaro, pg 582-585). Based on patient history of
uncontrolled hypertension, diabetes and renal impairment, the following pharmacotherapeutic
regimen might be started Irbesartan/Hydrocholorothiazide 150mg/12.5mg one tablet PO qd for
hypertension. Patient shall be started with the lowest dose of this medication as shown above
and dose shall be increased to Irbesartan/Hydrocholorothiazide 300mg/25mg one tablet PO qd
for hypertension if blood pressure control is not achieved in one - two weeks by the initial small
dose. This plan was considered for Mr. Frank because according to Wanzel, numerous clinical
trials have shown that the use of ACE inhibitors and ARBs have proven effective in lowering
blood pressure, slowing the progression of diabetic and non-diabetic renal disease, as well as
reducing proteinuria (Wenzel, 2005).

Outcome Evaluation

Based on the above regimen, patient shall be encouraged to monitor and record his daily
blood pressure to evaluate effectiveness of his new medication, as this regimen might cause
severe hypotension. Patients BUN and Creatinine shall be evaluated prior to starting this new
regimen so that a baseline BUN and Creatinine shall be obtained. Subsequent periodic
monitoring of BUN and Creatinine and electrolytes shall be performed every three months.




Patient Education

Based on above recommendations, appropriate education for this patient will emphasize
treatment compliance, as it is important that the patient takes the medication exactly as
instructed. Patient education on monitoring adverse drug effects including unusual thirst,
weakness, confusion, fast heartbeat, decreased sexual ability, change in urinary output,
worsening dizziness or fatigue, musculoskeletal pain, edema, nausea or vomiting,
lightheadedness, blurred vision, chest pain, angioedema and photosensitivity shall be
emphasized. Patient shall be instructed to take this medication with or without food at the same
time each day, drink adequate fluids, emphasis shall be made for the patient not to take any over
the counter medications without consulting the prescriber and that it may take two to four weeks
for the full effects or benefits of the medication to occur, and that it is important to continue
taking the medication even when he feels well. General dietary recommendations including the
DASH diet, lowering salt and fat intake and emphases on routine exercise and blood pressure
self monitoring shall also be emphasized because the use of mediations therapy alone may not be
enough to control Mr. Franks blood pressure.




Buttaro, T.M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2007). Primary Care: A
Collaborative Practice (3rd edition). St. Louis: Mosby, Inc.

Edmunds, Marilyn (2009). Pharmacology for the Primary Care Provider (3rd edition). Mosby,
Inc., an affiliate of Elsevier Inc

JNC 8 Hypertension Management Algorithm,

Wenzel, R., (2005). Renal Protection in Hypertensive Patients: Selection of Antihypertensive

Therapy. Drugs, 6529-39