Question

Mr. Cohen goes in for an employee sponsored free BP screening at his work. Mr. Cohen’s BP reading was 160/90 mmHg when measured with the large BP cuff. The nurse working the screening notices that the patient is overweight. The nurse assesses the patient for risk factors for HTN, and learns that Mr. Cohen sits at a desk all day answering calls from customers with questions about the use of the company’s computer software. He does not exercise regularly and admits that he does not follow a special diet stating, “My wife is a great cook. I’ll eat anything she puts in front of me. At night I like to have a snack while I watch television.” The patient denies tobacco and recreational drug use, but does report drinking “socially”. He states, “I have four or five beers on the weekend while I watch football.” Mr. Cohen does not take any prescription medications or herbal supplements, but does report taking “Tylenol on occasion when I have a headache, about a few times a week.” The nurse records Mr. Cohen’s BP and gives the patient instructions on making an appointment with his primary care provider ASAP for follow-up treatment.

Mr. Cohen calls his PCP to schedule an appointment, as recommended by the nurse. Prior to the appointment, Mr. Cohen goes to a local lab and has a series of blood tests drawn as prescribed by his PCP. At his appointment with the PCP, the nurse weighs Mr. Cohen. He is 5’9” and weighs 225 lbs. His BP is 166/92 mmHg with a large BP cuff in the right arm and 168/96 mmHg in the left arm. His HR is 84 bpm with a regular rhythm, RR is 18, and he is afebrile. His total cholesterol level is 260 mg/dL. During the health history and assessment, the PCP learns that Mr. Cohen drinks at least 4-6 cups of regular coffee per day. His father has CAD and HTN. Mr. Cohen denies feeling stressed due to his job, relationship with his wife and family, or any other factors. The PCP prescribes hydrochlorothiazide daily for the patient and asks the nurse to provide both Mr. & Mrs. Cohen with instructions regarding the medication and lifestyle modifications for HTN. A follow-up appointment is scheduled for one month.

1. Based on Mr. Cohen’s clinical manifestations and history, how would you classify his HTN (pre-HTN, stage 1, stage 2 HTN), and does he have primary of secondary HTN?

2. Identify Mr. Cohen’s risk factors for HTN. Indicate which of his risk factors are considered ‘modifiable’ and ‘non-modifiable’.

3. Discuss the mechanism of action, indications, and common side effects associated with hydrochlorothiazide.

4. The nurse is providing Mr. & Mrs. Cohen with instructions regarding lifestyle modifications to help in controlling HTN. Identify at least 4 teaching points the nurse should include in the patient’s teaching plan.

Answer 1

As per The BP recorded, Mr. Cohen is having stage 2 HTN. Because More severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

Mr. Cohen is sufferering from primary HTN. Primary hypertension can result from multiple factors, including: blood plasma volume. hormone activity in people who manage blood volume and pressure using medication. environmental factors, such as stress and lack of exercise

Modifiable risk factors:

Modifiable risk factors of hypertension are attributes, characteristics, exposures or life style patterns that can be adjusted or changed to prevent the development of the disease. These modifiable risk factors include overweight, lack of diet control, inactivity or lack of exercise, sedentary lifestyle, high fat diet, caffine consumption, alcohol consumption.

Non Modifiable risk factors:

The non-modifiable risk factors are attributes or characteristics in the individual that cannot be changed or adjusted, hence they are out of our control and little or nothing can be done to control them; such factors include age, sex, race, family history for Mr Cohen's father suffering from CAD and HTN, genetic composition.

Hydrochlorothiazide:

Action: It is a thiazide diuretic.It interferes with renal tubular mechanism of electrolyte reabsorption. It increases absorption of sodiumand chloride in approximately equivalent amounts. Natriuresiscauses secondary loss of potassium and bicarbonate.

Indications:

Hydrochlorothiazide is used to treat high blood pressure (hypertension).

Hydrochlorothiazide is also used to treat fluid retention (edema) in people with congestive heart failure, cirrhosis of the liver, or kidney disorders, or edema caused by taking steroids or estrogen, nephrogenic diabetes insipidus,, renal calculi.

Side effects:

signs of an allergic reaction to hydrochlorothiazide: hives; difficulty breathing; swelling of face, lips, tongue, or throat.

Call the doctor at once if one has:

• a light-headed feeling, like one might pass out;

• eye pain, vision problems;

• jaundice (yellowing of the skin or eyes);

• pale skin, easy bruising, unusual bleeding (nose, mouth, vagina, or rectum);

• shortness of breath, wheezing, cough with foamy mucus, chest pain;

• signs of electrolyte imbalance--dry mouth, thirst, drowsiness, lack of energy, restlessness, muscle pain or weakness, fast heart rate, nausea and vomiting, little or no urine; or

• severe skin reaction--fever, sore throat, swelling in the face or tongue, burning in the eyes, skin pain followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling.

Common hydrochlorothiazide side effects may include:

• nausea, vomiting, loss of appetite;

• diarrhea, constipation;

• muscle spasm; or

• dizziness, headache.

Lifestyle modification teaching:

• Teaching regarding Salt restriction: The target of salt restriction is <6 g day⁻¹, but an even lower salt intake is better. Salt intake can be safely restricted to 3.8 g day⁻¹
• Nutrients other than salt: The intake of fruit and vegetables should be increased, and that of cholesterol and saturated fatty acids should be reduced. Fish (fish oil) intake should also be increased.
• Maintaining an appropriate body weight: The target body mass index (BMI: body weight [kg]÷{height [m]}²) is <25 kgm⁻², but a significant decrease in blood pressure can be achieved by reducing body weight by 4–5 kg. Waist circumference should also be maintained at an appropriate level.
• Exercise: Exercise, primarily periodic (30 min or longer daily if possible) aerobic exercise, at a moderate intensity, should be practiced. This applies to hypertensive patients with no cardiovascular disorders.
• Restriction of alcohol intake: Alcohol intake should be restricted to ⩽20–30 ml ethanol day⁻¹ in men
• Lifestyle modifications can lead to a mild decrease in blood pressure and so allow a reduction in the dose of antihypertensive drugs.