...The Management of Hypertension Allison A. Torbert, Pharm.D. Roberta M. Skoronski, Pharm.D. Clinical Instructors UW School of Pharmacy Objectives • Explain the classification and goals of therapy in the treatment of hypertension based on JNC VI recommendations • Describe nonpharmacologic and pharmacologic treatment approaches • Recognize patients with hypertension and comorbid conditions in order to optimize therapy • Develop an approach to manage hypertensive patients Prevalence • Approximately 50-60 million Americans have HTN defined as: systolic BP (SBP) 140 mm Hg or > diastolic BP (DBP) 90 mm Hg or > • • • • Incidence increases with age Blacks > whites Men > women Greater in less educated, lower socioeconomic groups hard disk\course\728-721\htn.ppt 1 Classification of Blood Pressure for Adults Age 18 & Older* Category Optimal+ Normal High-normal Hypertension++ Stage 1 Stage 2 Stage 3 Systolic (mm Hg) < 120 < 130 130-139 140-159 160-179 > 180 & & & & & & Diastolic (mm Hg) < 80 < 85 85-89 90-99 100-109 > 110 *Not taking antiHTN drugs & not acutely ill. When SBP & DBP fall into different categories, highest classification should be used. Isolated systolic HTN defined as SBP > 140 and DBP < 90 and staged appropriately. In addition to classifying accordingly, clinicians should specify presence or absence of target organ disease & additional risk factors + Optimal BP with respect to CV risk is < 120/80; unusually low BP’s should be evaluated...
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...Clinical management and patient’s response and evidence based comparisons Upon admission, following subsequent blood works, the doctor on duty ordered for Miss N.M. to be administered IV Lasix 40mg, Nifedipine 10mg po stat, cocktail stat (100cc 50% Dextrose, 20 cc of calcium gluconate and 20 units of soluble insulin) slow push to be infused 3 unit of Packed Red Blood Cells, and IVF 2.5L/24 hrs: normal saline. Four days later Miss N.M. was diagnosed with Hypokalemia, obstructive Uropathy, Anaemia and Likely Cervical Cancer. A biopsy confirmed Cervical Cancer Stage III B and bilateral Nephrostomy tubes were ordered and inserted to aid the client in eliminating wastes from here body. With the administration of the IV Lasix 40 mg and Nifedipine 10 mg po there was a significant improvement in the client’s blood pressure readings 149/96 122/82. However, there was still no urinary output of significance. There should have been increased urinary output due to the therapeutic action of this loop diuretic. The administering of the loop diuretic, cocktail (100cc 50% Dextrose, 20 cc of calcium gluconate and 20 units of soluble insulin) and the insertion of the nephrostomy tubes improved the clients potassium reading from a 7.6 to a 5.8mEq/l. Normal potassium level range between 3.5-5.0. The potassium level in the blood was still elevated thus Kayexalate 15g po tds was added to the regime. This antihyperkalemic drug releases sodium ions in exchange primarily for potassium ions and ultimately...
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...crystals that have accumulated (Ignatavicius & Workman, 2013, p. 1507). 70-80% of kidney stones are composed primarily of calcium, while more infrequently stones can be composed of uric acid, cystine, struvite, or a combination of crystals (Barnela et al., 2012). These natural components that are a part of urine become more concentrated in certain conditions, which causes calcification, or what are generally known as stones. This is most commonly caused by super-saturation of crystals in the urine due to a decrease in urine output (ex: dehydration), injury to the lining of the urinary tract, or a decrease in substances that inhibits the urine from becoming too concentrated (Ignatavicius & Workman, 2013, p.1507). However, the majority of renal stone formation is linked to some sort of metabolic problem, which in turn causes the imbalance in the urine composition (Barnela et al., 2012). While the direct cause of kidney stones is not completely understood, there are many risk factors that increase the chance of stone formation. Many of these deal with either the impaired excretion or increased absorption of the crystals that end up in the urine (Fink et al., 2013). The most common is hypercalcemia (an increase in calcium), which can be caused by hyperparathyroidism, kidney tubular acidosis, and immobilization, to name a few. This causes an increase in calcium in the urine, which leads to super-saturation and eventually the formation of stones (Fink et al., 2013). This is also the...
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...NUR 427 WEEK 1 ASSIGNMENT CONDITION TABLE Condition andDefinition | Signs andSymptoms | Conventional orComplementary Therapy | Community Resourceand EducationalNeed | Multiple Sclerosis: A disease that causes demyelination of the nerves of the Central Nervous System. | Signs and symptoms include: muscle weakness, lack of coordination, parasthesia, speech difficulty, loss of bladder function, and visual disturbances. Symptoms vary according to where the demyelination is located. | Conventional: Medications: Treatment and prevention of relapses:Interferon, beta 1b & 1a, oral methylprednisolone, Imuran, methotrexate, and corticosteroids. Antidepressants are used to treat depression associated with MS and baclofen and benzodiazepines are used to treat spasticity. Other Treatments: Plasmapheresis and psychosocial support.CAM: Medications:Vitamins B12, D3, fish oil, octocosonal, L-carnitine CoQ10, panthethine, and Vitamin C.Other Treatments: * Stress reducing techniques to avoid exacerbation of MS (prayer, massage, yoga, and relaxation techniques). * Manual manipulation (acupuncture and acupressure). * Low fat and low carbohydrate diet. | Educational Needs:Patients will need to be taught about what to expect with their disease process such as how to manage symptoms, how to take preventative measures, and coping techniques for the mind and emotions. They will also need have education about the medications that they will be taking...
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...treatment is restarted after an interruption. Let your doctor know if you develop these symptoms and they do not go away after a few days or they become troublesome. Avoid driving or operating hazardous machinery until you know how the medications affect you, and use caution when getting up from a sitting or lying position. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. MONITOR: The hypotensive effects of levodopa and antihypertensive agents may be additive. Postural hypotension may occur. MANAGEMENT: Hemodynamic responses should be monitored during coadministration, especially during the first few weeks of therapy. Dose adjustments of the antihypertensive agent may be required. Patients should be advised to notify their physician if they experience dizziness or syncope. LEVODOPA + ACETAZOLAMIDE Levodopa and Acetazolamide have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. These side effects are most likely to be seen at the beginning of treatment, following a dose increase, or when treatment is restarted after an interruption. Let your doctor know if...
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...occurring in an estimated 10% to 20% of all adults with cancer. It also occurs in children with cancer, but with much less frequency (approximately 0.5%–1%).[1-3] Solid tumors (such as lung or breast cancer tumors) as well as certain hematologic malignancies (particularly multiple myeloma) are most frequently associated with hypercalcemia.[4] Although early diagnosis followed by hydration and treatment with agents that decrease serum calcium concentrations (hypocalcemic drugs) can produce symptomatic improvements within a few days, diagnosis may be complicated because symptoms may be insidious at onset and can be confused with those of many malignant and nonmalignant diseases. However, diagnosis and timely interventions not only are lifesaving in the short term but also may enhance the patient’s compliance with primary and supportive treatments and may improve quality of life.[5] When a patient has a refractory, widely disseminated malignancy for which specific therapy is no longer being pursued, the patient may want to consider withholding therapy for hypercalcemia. For patients or families who have expressed their wishes regarding end-of-life issues, this may represent a preferred timing and/or mode of death (as compared with a more prolonged death from advancing metastatic disease). This option is best considered long before the onset of severe hypercalcemia or other metabolic abnormalities that impair cognition, so that the patient may be involved in the decision making. In...
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...Multiple Myeloma Pamela Haverly B.S.N., R.N. Multiple Myeloma Multiple Myeloma is a cancer formed by malignant plasma cells. Normal plasma cells are found in the bone marrow and are an important part of the immune system. Plasma cells become cancerous and grow out of control they can produce a tumor called a plasmacytoma. Theses tumors can develop in a bone but are also rarely found in other tissues. If there is only a single plasma cell tumor, it is called an isolated or solitary plasmacytoma. When there is more than one plasma cell tumor, it is called multiple myeloma. In the United States , the risk of getting multiple myeloma is 1 in 149% (0.67%). The American Cancer Society estimates in 2013: About 22,350 new cases will be diagnosed (12,440 men and 9,910 women). About 10,710 deaths will occur (6,070 men and 4,640 women). (https://www.cancer.org/cancer/multiplemyeloma/detailsguide/multiple-myeloma-key-statistics.) Most people who develop multiple myeloma have no clear risk factors: However some risk factors have been identified. Risk factors concerning multiple myeloma included: age, gender, race, obesity, employment in the petroleum industry and exposure to radiation. Most first diagnosis is usually seen in patient’s in the early to mid 60’s, men are diagnosed much more frequently than women, African American’s are diagnosed twice as often as white Americans, a study by the American Cancer Society shows that obesity increases the risk of multiple myeloma, exposure...
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...Peptic Ulcers and Its Treatment Introduction Peptic ulcers are open sores that develop in the stomach lining. It is also develop in the lining of duodenum, or esophagus as a result of erosion that formed by acidic digestive juices which corroding the lining of the digestive system. There are three types of peptic ulcers, which are gastric ulcers, duodenal ulcers and esophageal ulcers. Gastric ulcers are ulcers that develop inside the stomach. Duodenal ulcers are ulcers that develop in the upper portion of the small intestine, called duodenum. Esophageal ulcers are ulcers that develop inside the esophagus. The etiology of peptic ulcer is not clearly known. Infection of stomach with the bacterium Helicobacter pylori or use of certain drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) is contributed to ulcer formation. In gastric ulcer, the acid secretion is normal or low. Generally acid secretion is high or normal in duodenal ulcer. The treatment of peptic ulcer is divided into 4 classes: agents that reduce gastric acid secretion, agents that neutralize gastric acid, agents that promote mucosal defense and anti-H. pylori drugs. Treatment Pharmacological measures for the management of peptic ulcers 1. Reduction of gastric acid secretion Histamine (H2) receptor antagonists Example: cimetidine, nizatidine, ranitidine, and famotidine They are highly selective H2 receptor antagonists. They work by binding to H2 receptors which are located on the basolateral...
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...Central University of Technology, Bloemfontein Early detection and prevention of Chronic Kidney Disease Contents page Definition of key terms used in the assignment Abbreviations used in the assignment Introduction Chronic Kidney Disease, a condition characterised by a gradual loss of kidney function. CKD is often misdiagnosed owing to the lack of knowledge about the disease. With early detection and prevention of the progression of the disease CKD patients can still enjoy life to the fullest while they manage their disease, however if the healthcare professionals fail to identify the disease on time the patient can suffer dire consequences. Besides the financial implications associated with the disease, there are the emotional implications together with physical and psychological. This assignment seeks to explore such implications in an effort to highlight the importance of early detection and prevention of kidney disease, with the best interest of the patient at heart Background Normal kidney anatomy http://doctorstock.photoshelter.com/image/I000096SqkYwaLhE The bean-shaped kidneys lie in retroperitoneal position in the superior lumbar region. Extending approximately from T12 to L3, the kidneys receive some form of protection from the lower part of the rib cage (E.N. Marieb, K Hoehn, 2010) The kidneys functions can be divided into two, non-excretory functions and excretory functions. Under excretory we have Glomerular filtration, Tubule...
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...osteomalcia Osteomalacia is a weakening of the bones due to problems with bone formation or the bone building process. This is totally different from osteoporosis, which is a weakening of living bone that has already been formed and is being remodeled. The most common cause of osteomalacia is a lack of vitamin D in the body. This is called osteomalacia in adults and rickets in children. (Tidy, 2012) Role of Vitamin D Vitamin D works together with calcium to protect your bones.—calcium helps build and maintain bones; while vitamin D helps your body effectively absorbs calcium. So even if there is a great intake of calcium in the diet, it could be going to waste if there is a deficient in vitamin D. It also helps maintain calcium and phosphate levels for proper bone formation. It is made within the skin from exposure to UV (ultraviolet) rays in sunlight, and it can also be absorbed from foods such as dairy products and fish. (Case-lo, 2012) When there is a low level of vitamin D in the body this mean that it cannot process calcium for use in bones to give them structural strength. This can be as a result from either a problem with diet, lack of sunlight exposure, or a problem with the intestines. In most cases if the is a surgery done to remove parts of...
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...proximal and distal ends, metaphyses i.e. region between epiphyses and diaphyses, articulate cartilage made of hyaline cartilage thin covering on epiphyses, periosteum, medullary cavity and endosteum. Microscopically bone consist of extracellular matrix (25% water, 25% collagen fibers and 50% crystallized mineral salt like calcium phosphate etc) where mineral salts deposits in framework by collagen fibre hardens tissue (calcification occur), cells like osteogenic cells, osteoblasts, osteoclast and osteocyte are present. In compact bone tissues perforating or Volkmann’s canals, haversian system (osteon), canaliculi concentric lamellae and lacunae kind of structures are present whereas in Spongy bone tissue trabeculae, canaliculi with main function of supporting and protecting red bone marrow. Bone Fracture: A fracture is a medical condition where the continuity of the bone is broken. A meaningful % of bone fractures occur because of high force impact or stress; however, a fracture may also be the result of some medical conditions which weaken the bones, like • Osteoporosis: which is increased porosity of skeleton from reduced mass of bone due to calcium loss, in other words it is weakening of living bone that has already been formed and is being remodeled; • Osteomalacia: problem in bone formation. Not as osteoporosis. This occurs due to lack of vitamin D ; • Osteoarthritis: is a degenerative joint disease also known as osteoarthrosis caused due to aging, inherited factors...
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...complications. It is characterized as a disease in which the rate of bone density decay occurs more rapidly than the occurrence of new bone growth. The first suspicious indicator of one developing osteoporosis is the initial fracture. It is difficult to know if osteoporosis is present otherwise because there is no other physiological way to feel bones losing their strength. Low bone mass is the result of ongoing bone calcium loss which can be caused by a primary, or secondary illness. This disease is more prevalent in Caucasians and Asian as compared to other races...
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...COVER ARTICLE PRACTICAL THERAPEUTICS Acute Management of Atrial Fibrillation: Part I. Rate and Rhythm Control DANA E. KING, M.D., LORI M. DICKERSON, PHARM.D., and JONATHAN L. SACK, M.D. Medical University of South Carolina, Charleston, South Carolina Atrial fibrillation is the arrhythmia most commonly encountered in family practice. Serious complications can include congestive heart failure, myocardial infarction, and thromboembolism. Initial treatment is directed at controlling the ventricular rate, most often with a calcium channel blocker, a beta blocker, or digoxin. Medical or electrical cardioversion to restore sinus rhythm is the next step in patients who remain in atrial fibrillation. Heparin should be administered to hospitalized patients undergoing medical or electrical cardioversion. Anticoagulation with warfarin should be used for three weeks before elective cardioversion and continued for four weeks after cardioversion. The recommendations provided in this two-part article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality. (Am Fam Physician 2002;66:249-56. Copyright© 2002 American Academy of Family Physicians.) I Members of various family practice departments develop articles for “Practical Therapeutics.” This article is one in a series coordinated by the Department of Family Medicine at the Medical University of South Carolina. Guest editor of the series is ...
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...Introduction In the case study of Mr. J; he has been exhibiting dyspnea upon exertion and fatigue. His blood pressure was 170/95 mmHg. After reviewing his labs; his LDL level was 200 mg/dl. Upon physical examination, he was found to have peripheral edema and jugular vein distention. A chest X-ray revealed cardiomegaly and pleural effusion. An echogram has also been scheduled. Based on his signs and symptoms, the physician suspects Mr. J has new onset Stage C heart failure. Mr. J has multiple prescribed drugs for Hypertension, Hyperlipidemia, Parkinson’s, Gout and Depression. After careful reviewing Mr. J’s medications there is concerns ineffective pharmacological management. Ineffective pharmacological management refers to medication therapy prescribed that does not take into account the patient’s age, diagnoses and comorbidities; therefore leading to complications of existing health problems. Side effects, adverse reactions and drug to drug interactions have to also be considered when reviewing a patient’s medication regimen. The drug categories most commonly involved in adverse reaction are cardiovascular agents, antibiotic, diuretics, anticoagulants, hypoglycemic, steroids, opioids, anticholinergic, benzodiazepines, and non-steroidal anti-inflammatory drugs. Nurses have the unique opportunity to help identify patients at risk for ineffective pharmacological management and educate patients and families about risk reduction. In this case study I will explore potential problems...
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...most effective treatment for skin cancer? There are many different treatments for skin cancer but they depend on which types of skin cancer and the patient’s stage of cancer. Surgery and radiotherapy are the most common treatments for both NMSC and melanoma. NMSC can be treated with systemic chemotherapy, photodynamic therapy and laser surgery. Chemotherapy, immunotherapy and targeted therapy are also some effective treatments for melanoma. In 2011, two new drugs for melanoma which are approved by the US Food and Drug Administration (FDA) are ipilimumab, which can be used for many different cancers, and vemurafenib (Interview with Dr. Michael Bergel 2015; unreferenced, see “Acknowledgements”). Ipilimumab, is similar to cytokines and the Bacillus Calmette-Guerin (BCG) vaccine, which works as an immunomodulator and helps regulating the immune system. Unlike Ipilimumab which is used to treat melanoma at the early stage, vemuragenib is a B-Raf enzyme inhibitor and used for late stage of melanoma (Haque et al. 2015). For advanced melanoma, which cannot be removed by surgery, both trametinib and dabrafenib are used; this treatment is called combination therapy. Prevention is always a better option than treatment. The best thing to do is to go to the dermatologist at least once a year and apply sunscreen thirty minutes before sun exposure. More than that, according to Dr. Michael Bergel’s research, chromatin compact to protect DNA after several minutes under the effect of UV...
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