NUR 635 Topic 5 DQ 1

Sample Answer for NUR 635 Topic 5 DQ 1 Included After Question

Lorraine is a 64-year-old African American female who has been monitoring her blood pressure at home. She brings a log of home readings with the following ranges: 150-222/102-88. Her blood pressure in the office today is 160/92. She has her BP monitor with her and the reading on the monitor is similar to today’s office reading. She states that she has swelling in both ankles at night, but the swelling usually resolves overnight. She wears compression hose at work as she is on her feet for most of her 10-hour shift. She has no comorbid conditions and no known allergies at present. Her mother and sister have hypertension and encouraged Lorraine to seek care. Use the guidelines and relevant literature in your topic Resources to discuss the following:

  • Based on the American Heart Association criteria, does Lorraine have hypertension? If so, how would you categorize it?
  • Based on the JNC8, what should be Lorraine’s target blood pressure goal?
  • Based on the mode of action, how do the following medications decrease blood pressure: hydrochlorothiazide, amlodipine, lisinopril, and losartan.
  • Based on the JNC8, what would be first-line treatment? Would you use a single agent or a combination of medications (include starting dose and frequency)? Explain your rationale regarding choice of drug(s).
  • Why is an ACE inhibitor not considered first-line treatment for Lorraine?
  • In what timeframe are you expecting to see a reduction in blood pressure? In the event the patient is not at goal, what is your next treatment strategy?
  • What lifestyle recommendations would you counsel Lorraine on?

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 1.2, 1.3, 2.2, 2.4, 2.5. 4.2, 6.4, 9.2

A Sample Answer For the Assignment: NUR 635 Topic 5 DQ 1

Title: NUR 635 Topic 5 DQ 1

Based on the American Heart Association criteria, does Lorraine have hypertension? If so, how would you categorize it?

American Heart Association (AHA) stages Lorraine at High blood pressure stage II.

Based on the JNC8, what should be Lorraine’s target blood pressure goal?

JNC 8 Recommendation 1 The same general population and AA the panel could not conclude and therefore across the board is > or = 60 y/o a SBP of < 150 mm Hg and Goal of DBP < 90 mm Hg (Strong Recommendation Grade A).

Based on the mode of action, how do the following medications decrease blood pressure: hydrochlorothiazide, amlodipine, lisinopril, and losartan?

HCTZ-  Blocks reabsorption of sodium and chloride in distal convoluted tubule at the early segment and, therefore, are different than loop diuretics where double the percentage is reabsorbed. Furthermore, the MOA also depends on GFR. If < filtrate cannot help patients with renal function impairment, and if no water has been removed, then no decrease in BP 2 volume continues to be present. 

Amlodipine (CCB) belongs to the family of 6 other CCB Dihydropyridines; they give a more significant blockade of CCB channels in vascular smooth muscle (VSM) than in the heart, and, therefore, are not used for dysrhythmias, do not cause cardiac suppression, less likely to exacerbate preexisting cardiac disorders. The primary MOA is dilation of arterioles, decrease in TPR, and Decrease in Diastolic BP.

Lisinopril- ACE inhibitor- Block AT1—ATII, resulting in a decrease in vasoconstriction and aldosterone secretion 2′ ATII cant go to the adrenal gland to stimulate receptors in Zona Glomerlosa causing inhibition of aldosterone release, block degradation of bradykinin that help with vasodilation, and therefore the cascade of events in arterioles, venular smooth muscle, < cardiac filling decrease EDV and EDP, Preload is <, SV <, CO <, decrease in systolic BP.

Losartan-ARBs block ATII receptors and prevent angiotensin-mediated vasoconstriction and aldosterone-mediated volume expansion by inhibiting the Adrenal cortex at ZG and sympathetic nerve endings.

Based on the JNC8, what would be the first-line treatment? Would you use a single agent or a combination of medications (including starting dose and frequency)? Explain your rationale regarding the choice of drug(s).

Based on JNC8, The HCTZ 25mg once a day for one week and continue with BP Log to see a trend. Furthermore, JNC8 recommends that monotherapy and titration are the best options based on adherence to the regimen.

Why is an ACE inhibitor not considered a first-line treatment for Lorraine?

In the history of Loraine, the BP is uncontrolled and wide in margins per the guidelines. The most appropriate is to control BP and have a baseline. Therefore, if ACEi are given, the dose takes weeks to work, and the flexibility must be available to add or change HTN medication.

In what timeframe are you expecting to see a reduction in blood pressure? What is your next treatment strategy if the patient is not at goal?

With HCTZ, expect a change in BP within three days if followed religiously, and if the goal is not met, then maximize monotherapy and reevaluate to add 2nd line of medication.

What lifestyle recommendations would you counsel Lorraine on?

Guidelines for areas of modification include diet weight management, Na+ restriction (does not mean any Na+ in preparing food but no Na+ added while eating at the table, K+-rich foods, relaxation techniques, and lipid management.

Reference:

American Family Physician (2014). JNC 8 Guidelines for the Management of Hypertension in Adultshttps://www.aafp.org/pubs/afp/issues/2014/1001/p503.html

American Heart Association (2023). Understanding Blood Pressure Readings. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings

Rosenthal, L., & Burchum, J. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier. 

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A Sample Answer 2 For the Assignment: NUR 635 Topic 5 DQ 1

Title: NUR 635 Topic 5 DQ 1

Hello, Marco Thank you for your input. You are true that controlling Lorraine’s blood pressure and keeping a baseline is the most suitable course of action. Since ACEi take weeks to take effect, it is necessary to have the flexibility to add or modify HTN medicine. Furthermore, the fact that Lorraine is of African American descent has implications in the context of hypertension treatment. According to Recommendation #7 of the Eighth Joint National Committee (JNC8), individuals of African descent, including those with diabetes, should be prescribed a thiazide-type diuretic or calcium channel blocker (CCB) as the first therapy for hypertension (James et al., 2014).

As stated by William et al. (2016), ACE inhibitors and ARBs exert their effects by interfering with the renin-angiotensin-aldosterone system, a hormonal cascade that plays a crucial role in the regulation of blood pressure. The attainment of optimal performance is seen when the underlying cause of high blood pressure is ascribed to an increased level of renin. Adults of African American descent with hypertension have reduced levels of renin. The prevalence of hypertension (HTN) among persons of African origin is well recognized to be associated with a dominating biological profile known as low renin physiology. The observed physiological characteristics are associated with a salt-sensitive phenotype, in which hypertension is mostly caused by an elevated effective circulatory volume.

The aforementioned finding has been utilized to substantiate the current strategy of employing specific classes of antihypertensive drugs, namely dihydropyridine calcium channel blockers (DHP-CCB) and diuretics, for managing hypertension in individuals of African ancestry. This is due to the fact that these pharmaceutical agents specifically address issues related to volume regulation. Furthermore, it is essential to recognize that the term “low renin physiology” often refers to the overall renin activity in the body, which has been seen to regularly exhibit variations compared to the renin activity in specific tissues19.

The latter, especially the activity of renin inside the kidney (intra-renal renin activity), may be of more significance in terms of its association with organ damage. Therefore, it is important to consider the tissue-protective benefits while administering “anti-renin” drugs like ACE inhibitors, ARBs, and beta-blockers to patients of African heritage, despite their possibly less significant impact on reducing blood pressure. The aforementioned factor is of utmost importance, as it not only contributes to the improvement of blood pressure control but also plays a crucial role in achieving the ultimate goal of reducing the risk of organ damage (Williams et al., 2016).

References:

James PA, Oparil S, Carter BL. (2014). Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520. doi:10.1001/jama.2013.284427

Williams, S. K., Ravenell, J., Seyedali, S., Nayef, S., & Ogedegbe, G. (2016). Hypertension Treatment in Blacks: Discussion of the U.S. Clinical Practice Guidelines. Progress in cardiovascular diseases, 59(3), 282–288. https://doi.org/10.1016/j.pcad.2016.09.004