NUR 602 Milestone one for MR X Pharmacology

NUR 602 Milestone one for MR X Pharmacology
NUR 602 Final Project Unfolding Scenario Part One
Mr. X is a 63-year-old, married, African American male who presents to the primary care office where you are working as a master’s-prepared nurse.
He is relatively new to your practice. Until recently, he had not received primary healthcare for some time due to lack of health insurance. He lives with his wife and three children. He works for the U.S. Postal Service as a mail clerk. He does not smoke and he consumes alcohol only on rare social occasions. He walks daily for his job and claims to eat healthily, though he admits to eating a lot of red meat, canned foods, and soda. When asked, Mr. X admits he is under a fair amount of stress at home and work.
Previous blood pressure readings taken over the past two weeks were: 176/108 mm Hg in the right and left arms, while seated and supine, during his first office visit; and 172/110 mm Hg in both arms, while seated and standing, during his second encounter.
Today, he reports that he has occasional episodes of exertional chest pain and has been taking sublingual nitroglycerin prn for relief. He states, “I seem to be getting these episodes more frequently over the past month or so.” He also describes a remote history of migraine headaches but in recent months only suffers with one about two to three times per month.
Medications: naproxen 440mg daily prn, Tylenol 625mg daily prn, multivitamin
Drug Allergies: NKDA
Past Medical History (PMH): migraines, basal cell carcinoma
Past Surgical History (PSH): laparoscopic cholecystectomy (2006); basal cell carcinoma excision on back (2011)
NUR 602 Milestone one for MR X Pharmacology
Family History (FH):
Mother: alive at 84, hypertension (HTN)
Father: deceased at 78 from myocardial infarction (MI), HTN, type 2 diabetes (T2DM), hyperlipidemia
4 siblings: one brother and one sister with HTN, others healthy as far as he knows
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NUR 602 Final Project Unfolding Scenario Part Two
BP 170/100 mm Hg in both arms, seated and standing; BP 186/106 mm Hg both legs, supine. Pulse: 86/min, regular. Respirations: 18/min, unlabored. Temperature: 98°F PO. His height is 74” and he weighs 212 lbs (96.4 kg).
Eye examination reveals visual acuity of 20/25 OU, uncorrected. Pupils are equal, round, regular, and react to light and accommodation. Fundoscopic examination reveals AV nicking and narrowing of arterioles, but no exudates, hemorrhages, or papilledema. Thyroid is smooth, non-tender, without thyromegaly. No JVD or carotid bruit is noted. Cardiac examination reveals a regular rate and rhythm at 86 BPM. S1 and S2 are of equal intensity; an S4 is audible. No murmur, rub, or thrill is appreciated. Chest is clear to auscultation and percussion. Abdomen is soft, non-tender, non-distended, with normoactive bowel sounds in all quadrants. No aortic, renal, iliac, or femoral bruits are noted. No hepatosplenomegaly or masses. The lower extremities are pink, warm, and dry without asymmetry, clubbing, or cyanosis. 1+ pedal edema is present bilaterally. Neurological exam is non-focal.
Today, his EKG shows no evidence of ischemia; there are no Q-waves, but it does show mild LVH. Laboratory testing reveals a serum creatinine of 1.6 mg/dl. (elevated); a serum potassium of 3.8; a sodium of 130, and FBS of 100 mg/dl, LDL is 172, HDL 40, triglycerides 184. CBC, U/A and LFTs are within normal limits.
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Example 1
Milestone One: Introductory Analysis of Subject Mr. X
Overview
A fairly new patient, Mr. X has presented to the office for follow-up visit. Mr. X is a 63 year old African American male. He is married with three children. Works for the United States Post Office, a non-smoker, occasional alcohol drinker. His exercise regimen is the walking he does at his job. Mr. X’s diet consists of red meat, processed and canned foods and soda. He admits to stress in his job and home life, and has not had regular visits to a physician due to lack of healthcare (NUR 602 Final project unfolding scenario part one, 2020). Mr. X’s medical history includes: No known drug allergies
Medications: naproxen 440mg daily prn(reason for prescription not given),Tylenol 625mg daily prn,( reason for use not given) Multivitamin( type, dose and frequency not stated) and sublingual nitroglycerin prn for chest pain (no dose or frequency stated)
Past Medical History (PMH): migraines, basal cell carcinoma
Past Surgical History (PSH): 2006- laparoscopic cholecystectomy
2011- Basal cell carcinoma excision on back
Family Medical History (FMH): Mother: alive, Hypertension (HTN)
Father: deceased at age 78 from myocardial infarction (MI), HTN, type 2 Diabetes, hyperlipidemia
Siblings: four one male & one female have HTN, others healthy
Previous office visits include elevated blood pressures. Visit from two weeks ago was 176/108 mm/HG, one week ago 172/110 mm/Hg in bilateral arms sitting and standing. Complaint of chest pain with exertion, which is relieved with sublingual nitroglycerin, multiple times of the past month. Increased migraine frequency of two-three a month.
Subjective Data
Subjective data is ”information from the patients point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews” (Daniels, n.d., Chapter 11). Mr. X informs us:
His diet is healthy, even though his diet consists of processed and canned food, carbonated beverages and large amounts of red meat.
Increased episodes of chest pain on exertion, that is relieved with sublingual nitroglycerin (patient does tell us where he got this drug from).
Migraines are occurring more frequently to two-three times a month.
Has stress at home and work (no explanation of what the stress is).
Objective Data
Objective data is ”observable and measurable (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing” (Daniels, n.d., Chapter 11).
Elevated blood pressure: over last two visits and today’s visit:
176/108 mm/Hg in bilateral arms in sitting and supine positions from first visit.
172/110 mm/Hg in bilateral arms in sitting and supine positions from second visit.
170/100 mm/Hg in bilateral arms in sitting and supine position and 186/106 mm/Hg
bilateral legs in supine position.
Pulse: 86/min, regular.
Respirations: 18/min, unlabored.
Temperature: 98 degree Fahrenheit, oral
Height 74 inches, weight 212 lbs.
Eye exam: visual acuity: 10/25 OU, uncorrected
pupils: equal, round, regular, reactive to light and accommodation
Fundoscopic: AV nicking and narrowing of arterioles, no exudate, no
papilledema.
Thyroid: smooth, non-tender, no thyromegaly
Cardiac: regular rate & rhythm, S1 & S2 equal intensity, S4 is audible, no murmur,
rub, or thrill. Clear with auscultation and percussion
Abdomen: soft, non-tender, non-distended, positive bowel sounds in all four
quadrants. no aortic, renal, iliac or femoral bruits noted.
Neurological: non-focal
Lower extremities: pink, warm, dry, no asymmetry, clubbing, no cyanosis, 1+ pedal
edema present bilaterally
EKG: no evidence of ischemia, no Q-waves, mild LVH present
Blood Labs: creatinine 1.6 mg/dl (elevated)
potassium 3.8
sodium 130
fasting blood sugar (FBS) 100mg/dl
LDL 172 HDL 40 Triglycerides 184
CBC, UA, LFT’s all WNL (NUR 602 Final project unfolding scenario part one, 2020, p. 1),(NUR 602 final project unfolding scenario part two, 2020, p. 1) .
Analysis
Mr. X’s cultural, demographic and socioeconomic status should also be considered when analyzing his subjective and objective data. Mr. X is African American(AA), older, he works as a postman, didn’t have health insurance for awhile (exact amount of time not given). In the U.S. heart disease is the no.1 killer, and stoke is also a leading cause of death. The “risks of getting those diseases are even higher for African-Americans”(American Heart Association, 2019, para. 1). “The prevalence of hypertension in African-Americans is the highest in the world. It also increases the risk of heart disease and stroke”(American Heart Association, 2019, para. 5). Researchers believe that there is a “genetic difference that predisposes blacks to high blood pressure. They suspect that people who lived in the equatorial Africa developed a genetic predisposition to being salt-sensitive, which means their bodies retain more sodium”(Harvard Health Publishing Harvard Medical School, 2015, para. 4). Those of African American ethnicity have a higher prevalence of traditional risk factors of hypertension (HTN), diabetes , obesity and atherosclerotic cardiovascular risk(Carnethon et al., 2017).
Culturally, AA diets traditionally contain food that is considered ‘soul food’, or a southern style diet(Carnethon et al., 2017). Foods in these type of diets tend to be high in fat (red meat), processed foods, and lead to unhealthy lifestyles. Known risk factors for cardiovascular diseases include: hypercholesterolemia, diabetes, hypertension, obesity and smoking (Wilson, 2017). In looking at all the data, their seems to be a lack of knowledge or education regarding risk factors and how he falls into a high-risk category is as important as starting Mr. X on medications and setting up appointments for follow up visits here and with specialists. “The same lifestyle habits that can help treat coronary artery disease can also help prevent it from developing in the first place”(Mayo Foundation for Medical Education and Research (MFMER), 2019, para. 9).
Personalized medicine strives for “treatments targeted to the needs of individual patients on the basis of genetic, biomarker, phenotypic, or psychosocial characteristics that distinguish a given patient from other patients with similar clinical presentations” (Williams, Ravenell, Seyedell, Nayef, & Ogedegbe, 2017, p. 283). The biological profile associated with HTN in blacks is called the low renin physiology. This physiology is linked with a salt-sensitive phenotype with excess effective circulating volume being the mechanism of HTN. These beliefs lead to the current practice of using specific anti-HTN drugs that address volume issues ( dihydropyridine calcium channel blockers and diuretics)(Williams et al., 2017). AA are also at a high risk for chronic kidney disease (CKD). In a study by African American Study of Kidney and Hypertension (AASK), AA patients were placed in a randomized drug therapy of either ramipril or amlodipine for HTN. Amlodipine had a more impressive result of lowest blood pressures, the drug ramipril was more effective in reducing chance of worsening CKD, along with lowering blood pressures(Williams et al., 2017).
References
American Heart Association. (2019). African Americans and heart disease, stroke [fact sheet]. Retrieved from https://www.heart.org>health-topics/African-Americans-and-heart-disease-stoke
Brewer, L. C., & Cooper, L. A. (2014, June). State of the art and science, race discrimination and cardiovascular disease. Virtual Mentor, 16, 455-460. http://dx.doi.org/10.1001/virtualmentor.2014.16.6stcs2-1406
Carnethon, M. R., Pu, J., Howard, G., Albert, M. A., Anderson , C. A., Bertoni, A. G., … Yancy, C. W. (2017, November 21). Cardiovascular health in African Americans: A scientific statement from the American Heart Association. Circulation, 136(21), e393-e423. http://dx.doi.org/10.1161/CIR0000000000000534
Choudhury, T., West, N. E., & El-Omar, M. (2016). ST elevation myocardial infarction. Clinical Medicine, 16(3), 277-282. Retrieved from https://doi.org.ezproxy.snhu.edu/10.7861/clinmedicine16-3-277-282
Daniels, R. (n.d.). Chapter 11: Assessment. In (Ed.), Online companion: Nursing fundamentals: Caring & clinical decision making. Retrieved from https://www.delmarlearning.com/companions/content/0766838366/students/ch11/faq.asp
Division for heart disease and stroke. (2019). Heart disease [fact sheet]. Retrieved from National Center for Chronic Disease Prevention and Health Promotion: https://www.cdc.gov>hus>spotlight>heartdiseasespotlight_2014-0404
Harvard Health Publishing Harvard Medical School. (2015). Race and ethnicity: Clues to your heart disease risk? [educational]. Retrieved from Harvard University: https://www.health/harvard.edu>heart-health>race-and-ehtnicity-clues-to-your-heart-disease-risk?
Know the facts about heart disease [fact sheet]. (2019). Retrieved from National Center for Chronic Disease Prevention and Health Promotion Website: https://www.cdc.gov>hus>spotlight>heartdisesaespotlight_2014_0404
Lippi, G., Sanchis-Gomar, F., & Cervellin, G. (2016, April 13). Chest pain, dyspnea and other symptoms in patients with type 1 and 2 myocardial infarction. A literature review. International journal of Cardiology, 215(), 20-22. http://dx.doi.org/10.1016/j.icard.2016.04.045
Mayo Foundation for Medical Education and Research (MFMER). (2019). Coronary artery disease [educational]. Retrieved from https://www.mayoclinic.org>symptoms-causes>syc-20350613
Muncan, B. (2018, October 18). Cardiovascular disease in racial/ethnic minority populations: illness burden and overview of community-based interventions. Public Health Reviews, 39(32), 1-11. http://dx.doi.org/10.1186/s40985-018-0109-4
NUR 602 Final project unfolding scenario part one [Case Study]. (2020). Retrieved from https://learn.snhu.edu/content/enforced/183470-NUR-602-X4103-OL-TRAD-GR.20TW4/csfiles/home_dir/NUR-602%20Student%20Documents/nur602_part_one_unfolding_scenario.pdf?_&d21SessionVal=D13S49L4GaSoMlqGbvoAdOJtS&ou=183470
NUR 602 final project unfolding scenario part two [case study]. (2020). Retrieved from https://learn.snhu.edu/content/enforced/183470-NUR-602-X4103-OL-TRAD-GR.20TW4/csfiles/home_dir/NUR602%20Student%20Documents/nur602_part_two_unfolding_scenario.pdf?_&d21SessionVal=D13S49L4GaSoMlqGbvoAdOJtS&ou=183470
RNpedia. (2017). Congestive heart failure (CHF) nursing care plan & management [educational]. Retrieved from RNpedia complete nursing notes and community: https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/congestive-heart-failure-chf/nursing-care-plan-management
Saab, K. R., Kendrick, J., Yracheta, J. M., Lanaspa, M. A., Pollard, M., & Johnson, R. J. (2015). New insights on the risk for cardiovascular disease in African Americans: The role of added sugars. Journal of the American Society of Nephrology, 26, 247-257. http://dx.doi.org/10.1681/ASN.2014040393
Williams, S. K., Ravenell, J., Seyedell, S., Nayef, S., & Ogedegbe, G. (2017, November 1). Hypertension treatment in blacks: Discussion of the U.S. clinical practice guidelines. Progress in Cardiovascular Diseases, 59(3), 282-288. http://dx.doi.org/10.1016/j.pcad.201609.004
Wilson, P. W. (2017). Overview of established risk factors for cardiovascular disease. In H.
Libman & B. C. Downey (Ed.), UpToDate. Waltham, Mass. UpToDate. Retrieved from
https://www.uptodate.com
Example 2
NUR 602 – Milestone 1
Mr. X is a 63-year old African American male, who is married with three children. He has not had primary health care for a significant period of time related to lack of insurance. Mr. X has a past medical history notable for migraines, basal cell carcinoma (post excision in 2011), and a laparoscopic cholecystectomy in 2006. He has no known drug allergies, and takes a daily multivitamin, as well as 440mg naproxen, and 625mg Tylenol as needed. Family history is notable for hypertension (mother, father, two siblings), as well as a father with type 2 diabetes and hyperlipidemia, who is deceased related to a myocardial infarction (MI).
Mr. X presented as a new patient with blood pressure readings consistent with stage 2 hypertension – 176/108 at his first office visit, and 172/110 at his second visit two weeks later. Stage 2 hypertension is when an individual’s blood pressure is consistently greater than 140/90 (American Heart Association, 2017).
Mr. X reports occasional episodes of exertional chest pain, which has been responsive to sublingual nitroglycerin tabs. He states that these occurrences have increased in frequency over the last month. Mr. X also reports experiencing migraine headaches two to three times per month. Mr. X states that his work for the US Postal Service affords him the opportunity to walk daily. He states that he is a non-smoker, and that he rarely consumes alcohol. He claims to eat healthy foods, though does state that he eats a lot of red meat, canned foods, and soda pop. Mr. X also reports being under a fair amount of stress at both home and work.
Based on this subjective data, Mr. X should be educated on how culture, ethnicity, and diet, and how they relate to hypertension. African Americans are more prone to have hypertension than Caucasians, with the onset of hypertension occurring earlier in life. This is due to a combination of factors, including lower than average incomes for African Americans, and strong cultural influences regarding food preferences and preparations (Chan, Stamler, & Elliott, 2015).
African American men traditionally eat what is known as a ‘Southern’ diet – fried, processed foods, organ meats, processed meats, foods high in sodium and fats, as well as sugary beverages such as soda. Mr. X endorses a diet which contains many of those staples of the ‘Southern’ diet. Instead, he should be educated on the DASH (dietary approaches to stop hypertension) diet, which includes lean proteins, fruits, vegetables, and whole grains (Howard, et al, 2018). When followed properly, DASH diets are associated with a reduction in blood pressure (Chan, Stamler, & Elliott, 2015).
Mr. X’s blood pressure is currently elevated at 170/100 in his bilateral arms, and 186/106 in his bilateral legs. His remaining vital signs are within normal limits. His BMI calculates to 27.2, which is considered overweight. Ocular exam reveals AV nicking, with narrowing of arterioles. Cardiac auscultation reveals audible S4 heart sounds. Bilateral 1+ pedal edema is noted. EKG shows mild left ventricle hypertrophy. Laboratory testing shows that Mr. X’s creatinine is high at 1.6, sodium is low at 130, LDL cholesterol is high at 172, HDL cholesterol is borderline low at 40, and triglycerides are borderline high at 184. All other parts of his physical exam, laboratory tests, and EKG testing are within normal limits.
The finding of AV nicking with narrowing of arterioles is concerning for hypertensive retinopathy. This rarely causes significant visual loss but can be used as a predictor for a patient being at risk for hypertensive crisis (Modi, 2020). Likewise, Mr. X’s audible S4 heart sound is concerning for a thickening of the left ventricular wall caused by hypertension (Williams, 1990). These findings are consistent with his presentation with consistent stage 2 hypertension.
All in all, Mr. X appears to be an overweight patient with essential hypertension, and hyperlipidemia. As stated, there are numerous socioeconomical, and cultural factors at play here, such as Mr. X being prone to hypertension due to his ethnicity (African American), and culture (‘Southern’ style diet). Mr. X needs extensive education on the health disparities that exist among African Americans, so that he may make lifestyle changes which can help reverse some of the damage which has been done to his body.
His care team should likewise use this information to determine safe, effective, and appropriate pharmacotherapeutics for Mr. X. A recent report from JNC 8 states that there is strong evidence which supports treatment for hypertension for patients 60-years old and over, with a goal blood pressure of less than 150/90. They further report that in the African American hypertensive population, calcium-channel blockers, or a thiazide-type diuretic are recommended as front-line therapies (James, et al, 2014).
It is notable that Mr. X did not receive care for some time due to his lack of insurance. It is therefore reasonable to assume that he may need to be prescribed medications which are available in a low-cost, generic form.
References
American Heart Association. (2017, November 30). Understanding Blood Pressure Readings. Retrieved from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
Chan, Q., Stamler, J., & Elliott, P. (2015). Dietary Factors and Higher Blood Pressure in African-Americans. Current Hypertension Reports, 17(2). doi: 10.1007/s11906-014-0517-x
Howard G, Cushman M, Moy CS, et al. (2018). Association of Clinical and Social Factors With Excess Hypertension Risk in Black Compared With White US Adults. JAMA. 320(13):1338–1348. doi:10.1001/jama.2018.13467
James, P. A., Oparil, S., Carter, B., Cushman, W., Dennison-Himmelfarb, C., Handler, J., & Lackland, D. (2014, February 5). 2014 Guideline for Management of High Blood Pressure. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/1791497
Modi, P. (2020, January 8). Hypertensive Retinopathy. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK525980/
Williams, E. S. (1990, January 1). The Fourth Heart Sound. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK344/