NSG 6005 Week 5 Discussion Paper

Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD), who presents to your clinic with substernal chest pain for the past 3 months. It is not positional; it reliably occurs with exertion, approximately one to two times daily, and is relieved with rest, or one or two sublingual nitroglycerin (NTG) tabs. It is similar in quality, but is much less severe, than the chest pain that occurred with his previous inferior myocardial infarction (MI) 3 years ago. Until the past 3 months, he has felt well.

The chest pain is accompanied by diaphoresis and nausea, but no shortness of breath (SOB) or palpitations. He does not vomit. He denies orthopnea, paroxysmal nocturnal dyspnea (PND), syncope, presyncope, dizziness, lightheadedness, and symptoms of stroke or transient ischemic attack (TIA).

An echocardiogram done after his MI demonstrated a preserved left ventricular ejection fraction (LVEF). Other medical problems include well-controlled type 2 diabetes mellitus (DM), well-controlled hypertension (HTN), and hyperlipidemia, with low-density lipoprotein (LDL) at goal. He also has stage 3 chronic kidney disease (CKD) and diabetic neuropathy. He no longer smokes and does not use alcohol or recreational drugs. His daily medications include: Atenolol 25 mg PO bid, Lisinopril 20 mg PO bid, aspirin 81 mg PO daily, Simvastatin 80 mg PO each evening, and metformin 500 mg PO bid.

Mr. EBR’s physical examination includes the following: height 68 inches, weight 185 lb, Blood pressure (BP) 126/78, heart rate (HR) 64, Respiratory rate (RR) 16, and temperature 98.6°F orally. He is alert and oriented, and in no apparent distress (NAD). His neck is without jugular venous distention (JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cardiovascular: normal S1 & S2, RRR, without rubs, murmurs or gallops. Abdomen has active bowel tones and is soft, nontender, and nondistended (NTND). Extremities are without clubbing, cyanosis, or edema. Distal pedal pulses are 2+ bilaterally

What would you add to the current treatment plan? Why?

I would consider this patient to have stable angina according to his symptoms and assessment. We would want to treat the symptoms in this case and prevent the patient form having severe cardiac issues. This patient is already taking a beta blocker, ACE inhibitor, statin, and aspirin. His vital signs are stable. I would control this patient’s pain if not controlled by what he is already taking. I would also have this patient follow-up and continue care with a cardiologist. He could also benefit from taking a medication to help with his diabetic neuropathy, like Gabapentin. The patient is stable for now, but might need medication adjustments if pain is not controlled.

Would you discontinue any of the currently prescribed medication? Why or why not?

No, I would not discontinue any of Mr. EBR’s medications. These medications are managing his diabetes, blood pressure, and hyperlipidemia. The Atenolol is treating his hypertension and angina, Lisinopril is treating hypertension, diabetes, and the heart failure, aspirin is helping reduce risk of future heart attacks in patients with prior history and can help with the pain, and metformin is treating his diabetes (Robinson & Woo, 2020 NSG 6005 Week 5 Discussion Paper). This patient has a good regimen going and more pain control could be added if needed. Since the patient has stable vitals and assessment no need to change his medications.

How does the diagnosis stage 3 chronic kidney disease affect your choices?

The diagnosis of stage three kidney disease can affect medication choices. A lot of medications are excreted renally but can’t happen properly in patients with kidney disease. Monitoring of renal function needs to be monitored in this patient. Medications that are excreted renally may need lower doses due to kidney function level.

Why is the patient prescribed more than one antihypertensive?

More than one antihypertensive is sometimes needed in order to control hypertension. Research shows that about fifty percent of the time two medications are needed for adequate control of hypertension (Mirniam, et al., 2019). The prescribing physician can choose from combinations of diuretics and beta blocker, diuretic and potassium-sparing diuretic, angiotensin-converting ACE and diuretic, angiotensin II antagonists and diuretic, or calcium channel blockers and ACE inhibitors (Mirniam, et al., 2019). The goal of multi medication therapy is to lower blood pressure quicker, obtain target, stable blood pressures, and decrease adverse effects from uncontrolled high blood pressure.

What is the benefit of the aspirin therapy in this patient?

Aspirin is a nonsteroidal anti-inflammatory medication used to treat pain, fever, headache, and inflammation (Robinson & Woo, 2020). It also helps reduce the risk of heart attack. With this patient’s history it is very beneficial for him to take a daily aspirin. Patient needs to be educated to not take this medication if they have increased bleeding risk (Dunphy, et al., 2019).

Discussion Question 2

List three classes of drugs affecting the Hematopoietic System. List the mechanism of action for each class of drug. Choose one medication from the three classes and discuss what disorder the drug is used to treat? How often the medication is given? What labs should get monitored while the patient is taking this medication? Your response should be at least 350 words.

Anticoagulants: The mechanism of action is to achieve their effect by suppressing the function of various clotting factors that are normally present in the blood (Robinson & Woo, 2020). The purpose of this antiplatelet drug class is to prevent the formation of blood clots in the veins or arteries, or if already in the circulating bloodstream, reduce the size from increasing. This drugs are often referred to as blood thinners. Apixaban (Eliquis) is an example of a drug in this drug It is used to prevent serious blood clots from forming due to certain disorders like irregular heartbeats, atrial fibrillation, or post-surgery, etc. The recommended dose of Eliquis is 5mg BID (Robinson & Woo, 2020). Bloodwork should be done on this patient routinely. aPTT, modified pro-thrombin, and Heptest labs should be monitored while taking this medication.
Thrombolytic: The mechanism of action is to dissolve blood clots that have already formed by converting plasminogen to plasmin, which destroys fibrinogen and other clotting factors (Robinson & Woo, 2020). One medication in this class is Alteplase (t-PA). We use this medication a lot in the emergency room for stoke patients. It is used to treat ischemic stroke, acute ST- elevation in MI, pulmonary embolism, and blocked central venous catheters (Robinson & Woo, 2020). The recommended dose is 0.9mg/kg not to exceed 90 mg total dose in adults. The labs to monitor for this medication are CBC, aPTT, PT/INR, and This is a great medication but can be very dangerous if not monitored and given correctly. The patient is at risk for bleeding issues.

Haematinics: These are considered nutrients/vitamins required for the formation of blood cells in the process of hematopoiesis. The mechanism of action is to stimulate the formation of red blood cells (Robinson & Woo, 2020). They are considered iron supplements used to prevent low blood levels in patients. Folic acid is an example of this type of drug. The recommended dose is 400 mcg daily for adults (Robinson & Woo, 2020 NSG 6005 Week 5 Discussion Paper). The CBC needs to be monitored in this patient, especially the RBC. It would be beneficial to get a RBC before starting the medication and monitoring the patient routinely while on the medication.