Nurse 678-B Case Scenario
The 51-year-old male patient in the provided case study reports a long history of hypertension and diabetes. The patient is currently on Lisinopril 20mg once daily, metformin 1g once daily, Lipitor 40 mg at bedtime, and junior aspirin 81 mg once daily for the management of his present conditions. His A1C levels, blood pressure, and total cholesterol are still elevated with increased LDL and triglyceride levels and reduced HDL. The patient’s diabetes and hypertension seem uncontrolled. This paper provides additional information necessary for a complete evaluation of the patient’s treatment plan, in addition to the desired outcomes and clinical guidelines utilized in promoting the medication choice.
Additional Information to Optimize Care Plan
To be able to determine whether the patient’s care plan is well optimized, additional information is required for both diabetes and hypertension. For diabetes care, it is necessary to assess for any signs of hyperglycemia and hypoglycemia, blood glucose levels at bedtime and before meals, HbA1c-glycosylated hemoglobin levels, and body weight, in addition to the provided information (American Diabetes Association, 2021). Monitoring the patient urine albumin: serum creatinine ratio is necessary to assess for renal failure due to diabetes. Generally, this information will help determine the effectiveness of the treatment plan in managing diabetes.
Other than blood pressure, certain laboratory data are necessary to determine whether the prescribed drug regimen is effective in managing the patient’s hypertension. Such additional information includes blood urea nitrogen and creatinine, ABG, electrolytes, complete blood cell count, cardiac enzymes, and cardiac markers (Skeete et al., 2018). It is also necessary to assess the presence and the quality of both central and peripheral pulses. Information on heart tone and sound such as the presence of S4 is necessary to evaluate the severity of the patient’s hypertension, whereas, S3 sound indicates impaired heart function and ventricular hypertrophy. The presence of wheezes and crackles shows that the patient’s hypertension is worsening, leading to pulmonary congestion from developing or chronic heart failure.
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According to the provided information, the patient’s diabetes and hypertension are both uncontrolled. For optimal diabetes care, the patient’s blood glucose levels should drop to less than 180 mg/dL, with a fasting glucose level less than 140mg/dL and Hb A1C level of less than 7%. The patient should be able to maintain the glucose level at a satisfactory range with the use of medication (Khayyat et al., 2019). Concerning his metabolic profile, the total cholesterol level should reduce to between 125 mg/dL to 200 mg/dL, LDL less than 100mg/dL, and HDL to increase to at least 40mg/dL.
For hypertension care, the patients need to attain controlled blood pressure less than 140/90 mmHg with medication and lifestyle modification. He should also demonstrate stable serum creatinine and BUN levels (Skeete et al., 2018). Additional desired outcomes with an improved treatment plan include a stable cardiac rhythm, reduce BP/cardiac workload, and managing stress to promote the patient’s cardiac health. Additional parameters to improve include blood urine nitrogen and creatinine.
Clinical Guidelines to help Manage the Patient
Given that the patient presents with a history of comorbid conditions such as hypertension and diabetes, it will be necessary to utilize two different clinical guidelines, one for each condition. For instance, the 2022 Standards of Medical Care in Diabetes provides the most recent clinical guideline to help with the management of diabetes (American Diabetes Association, 2021). This clinical practice guideline is mainly recommended due to the extensive review of the literature and clinical trials on diabetes care. It is also updated, with recent care plans for the management of diabetes among patients with comorbid hypertension.
For the management of hypertension, the American Heart Association and the American College of Cardiology have published current clinical guidelines which help to categorize the different stages of hypertension and effective care plan as per the severity of the patient’s condition (Skeete et al., 2018). Both organizations have engaged in substantial literature reviews and clinical trials to promote evidence-based treatment plans for hypertensive patients with comorbid diabetes.
To improve the patient’s symptoms, it is necessary to advise the patient to continue taking aspirin, Lisinopril, and Lipitor, for the management of hypertension and metformin for management of diabetes at the same doses and frequency. However, it is important to introduce life modifications like physical exercise and non-pharmacological interventions such as implementing dietary sodium, cholesterol, and fat restrictions as indicated. The American Diabetes Association (ADA) also recommends medical nutrition therapy (MNT) as an adjunct to medical therapy among patients with diabetes (American Diabetes Association, 2021).
The provided case study demonstrates a middle-aged male patient with comorbidities such as diabetes and hypertension which are poorly controlled. Additional information is however required to ensure that the patient receives optimal care in the management of these two conditions. As such, appropriate clinical guidelines must be utilized to make the necessary changes in the patient’s care plan to attain optimal care. Such changes include the incorporation of non-pharmacological intervention and life modifications to the current medication therapy to manage the patient’s diabetes and hypertension.
American Diabetes Association. (2021). Standards of medical care in diabetes—2021 abridged for primary care providers. Clinical Diabetes, 39(1), 14-43. https://doi.org/10.2337/cd21-as01
Khayyat, S. M., Mohamed, M. M., Khayyat, S. M. S., Alhazmi, R. S. H., Korani, M. F., Allugmani, E. B., … & Hadi, M. A. (2019). Association between medication adherence and quality of life of patients with diabetes and hypertension attending primary care clinics: a cross-sectional survey. Quality of Life Research, 28(4), 1053-1061.
Skeete, J., Connell, K., Ordunez, P., & DiPette, D. J. (2018). The American College of Cardiology/American Heart Association 2017 hypertension guideline: Implications for incorporation in Latin America, the Caribbean, and other resource‐limited settings. The Journal of Clinical Hypertension, 20(9), 1342. DOI: 10.1111/jch.13343
James is a 51-year-old male Hispanic truck driver with a long history of diabetes and hypertension. His current medication regimen is Lisinopril 20mg QD, metformin 1000mg QD, Lipitor 40mg QHS, and ASA 81mg QD. His A1C is 7, BP is 144/80, total cholesterol is 266, HDL 44, LDL 177, and Trig 199. What other information should you know about this patient to feel confident that his care is fairly well optimized? What parameters would you like to see improved? What clinical guidelines should you adhere to when managing this patient? Are there any changes to treatment you should consider? Support your decisions with evidence.