Hypertension Protocol: Initial Visit

### Hypertension Protocol: Initial Visit

#### 1. Rationale

This protocol will assist in differentiating between essential hypertension and renal artery stenosis, helping to identify patients who may need referral to nephrology to prevent further renal damage from an unidentified renal artery stenosis.

#### 2. Symptoms

##### Hypertension
– **Blood pressure >140/90 mmHg**
– Other possible subjective symptoms:
– Headache
– Visual changes
– Dyspnea
– Chest pain
– Sensory or motor deficit

##### Renal Artery Stenosis
– Onset of hypertension age >55 years or <30 years
– History of accelerated, malignant, or resistant hypertension
– History of unexplained kidney dysfunction
– History of multivessel coronary artery disease
– History of other peripheral vascular disease
– Abdominal bruit
– Sudden or unexplained recurrent pulmonary edema
– Other possible factors:
– Absence of family history of hypertension
– Other bruits
– History of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist (ARB)

#### 3. History

Continue with the treatment of hypertension but consult the supervising physician if the patient has:
– History of accelerated, malignant, or resistant hypertension
– History of unexplained kidney dysfunction
– History of multivessel coronary artery disease
– History of other peripheral vascular disease
– Abdominal bruit
– Sudden or unexplained recurrent pulmonary edema

#### 4. Physical Exam

Perform the following examinations:
– Vital Signs (blood pressure, pulse)
– Auscultation for bruits (carotid, abdominal, and femoral)
– Palpation of thyroid
– Cardiac
– Respiratory
– Lower extremities for edema and pulses
– Neurological

Consult supervising physician if findings of:
– Abdominal bruit
– Another bruit

#### 5. Lab Tests

– Metabolic panel:
– Cholesterol
– Blood sugar
– Uric acid level
– Glomerular filtration rate

Consult supervising physician if:
– GFR indicates chronic kidney disease (CKD) or renal failure

#### 6. Pharmacological Treatment

##### Drug Classifications and Examples

##### Non-African American Patient

– **Drug**: Lisinopril
– **Dose**: 10 mg
– **Route**: Oral
– **Frequency**: Once daily
– **Instructions to Provide Patient**: Take at the same time each day. Do not skip doses.
– **Caution/Precautions**: Monitor for signs of angioedema, hyperkalemia, and renal function changes.
– **Cost (30-day supply)**: Approximately $4 – $10
– **Patient Education**: Educate on the importance of regular blood pressure monitoring and adhering to prescribed doses.

##### African American Patient

– **Drug**: Amlodipine
– **Dose**: 5 mg
– **Route**: Oral
– **Frequency**: Once daily
– **Instructions to Provide Patient**: Take with or without food. Do not skip doses.
– **Caution/Precautions**: Monitor for peripheral edema and hypotension.
– **Cost (30-day supply)**: Approximately $10 – $15
– **Patient Education**: Educate on the importance of lifestyle modifications along with medication adherence.

#### ACEIs in African Americans

– **When to Use**: ACE inhibitors can be used in African Americans with heart failure or chronic kidney disease.
– **Citation**: (Burchum & Rosenthal, 2020)

#### Statin Therapy

**Patient Education on Statins:**
– Educate on potential side effects such as muscle pain, liver enzyme abnormalities, and the importance of adherence to therapy.
– Advise patients to report any unexplained muscle pain or weakness, especially if accompanied by fever or malaise.

#### Treatment Monitoring

**Follow-Up Appointment:**
– Schedule follow-up in 2-4 weeks to monitor blood pressure response and medication adherence.

**Blood Pressure Medication Monitoring:**

– **Physical Assessments:** Blood pressure, heart rate, edema assessment
– **Labs/Diagnostics:** Serum electrolytes, renal function tests

**Statin Medication Monitoring:**

– **Physical Assessments:** Assess for signs of muscle pain or weakness
– **Labs/Diagnostics:** Liver function tests, lipid profile

#### Treatment Failure

– If the patient’s blood pressure remains uncontrolled after 2-3 months of therapy, reassess for adherence, lifestyle modifications, and possible secondary causes of hypertension.
– **Citation**: (James et al., 2014)

### References

– Burchum, J., & Rosenthal, L. D. (2020). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier – Evolve. https://ambassadored.vitalsource.com/books/9780323554954
– Grundy, S. M., et al. (2019). AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APHA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25). https://doi.org/10.1161/cir.0000000000000625
– James, P. A., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507. https://doi.org/10.1001/jama.2013.284427

NR565 HTN Lipid Protocol 2

HYPERTENSION PROTOCOL: INITIAL VISIT

1. RATIONALE

0. This protocol will assist in the differentiation between essential hypertension and renal artery stenosis to aid in the identification of patients in need of referral to nephrology to prevent further renal damage from an unidentified renal artery stenosis. The design of the protocol for UTI encompasses these principles.

1. SYMPTOMS

1. HYPERTENSION

0. Blood pressure >140/90 mmHg

0. Other possible subjective symptoms

1. Headache

1. Visual changes

1. Dyspnea

1. Chest pain

1. Sensory or motor deficit

1. RENAL ARTERY STENOSIS

1. Onset of hypertension age >55 years or <30 years

1. History of accelerated, malignant, or resistant hypertension

1. History of unexplained kidney dysfunction

1. History of multivessel coronary artery disease

1. History of other peripheral vascular disease

1. Abdominal bruit

1. Sudden or unexplained recurrent pulmonary edema

1. Other possible factors

7. Absence of family history of hypertension

7. Other bruits

7. History of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist (ARB)

1. HISTORY

2. Continue with treatment of hypertension but consult supervising physician if patient has:

0. History of accelerated, malignant, or resistant hypertension

0. History of unexplained kidney dysfunction

0. History of multivessel coronary artery disease

0. History of other peripheral vascular disease

0. Abdominal bruit

0. Sudden or unexplained recurrent pulmonary edema

1. PHYSICAL EXAM

3. Perform the following examinations:

0. Vital Signs (blood pressure, pulse)

0. Auscultation for bruits (carotid, abdominal, and femoral)

0. Palpation of thyroid

0. Cardiac

0. Respiratory

0. Lower extremities for edema and pulses

0. Neurological

3. Consult supervising physician if findings of:

1. Abdominal bruit

1. Another bruit

1. LAB TESTS

4. Metabolic panel

0. Cholesterol

0. Blood sugar

0. Uric acid level

4. Glomerular filtration rate

4. Consult supervising physician if:

2. GFR indicates chronic kidney disease (CKD) or renal failure

1. PHARMACOLOGICAL TREATMENT

5. List the hypertension drug classifications and examples you would prescribe in order of treatment according to clinical practice guidelines without consideration of race or ethnicity: (Provide generic names for examples. Doses are not needed or required.)

Drug Category/ Classification
Example 1
Example 2
Example 3
Example 4

Click or tap here to enter text.
Click or tap here to enter text.
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Citation (Provide (Author, year) and not full reference): Click or tap here to enter text.

5. 1st line pharmacological treatment if warranted in a non-African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)

1. Drug: Click or tap here to enter text.

1. Dose: Click or tap here to enter text.

1. Route: Click or tap here to enter text.

1. Frequency: Click or tap here to enter text.

1. Instructions to provide patient: Click or tap here to enter text.

1. Caution/Precautions: Click or tap here to enter text.

1. Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? Click or tap here to enter text.

1. What patient education is needed for this drug?Click or tap here to enter text.

Citation (Provide (Author, year) and not full reference): Click or tap here to enter text.

5. 1st line pharmacological treatment if warranted in an African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)

2. Drug: Click or tap here to enter text.

2. Dose: Click or tap here to enter text.

2. Route: Click or tap here to enter text.

2. Frequency: Click or tap here to enter text.

2. Instructions to provide patient: Click or tap here to enter text.

2. Caution/Precautions: Click or tap here to enter text.

2. Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? Click or tap here to enter text.

2. What patient education is needed for this drug?Click or tap here to enter text.

Citation (Provide (Author, year) and not full reference): Click or tap here to enter text.

5. When should ACEIs be used in African Americans according to the course textbook? Include a citation with matching reference in the reference section.

3. Click or tap here to enter text.

Click or tap here to enter text.

Citation (Provide (Author, year) and not full reference): (Burchum, J., & Rosenthal, L. D. 2020).

5. Prescribe statin therapy according to the prescription table which follows:

Complete the following table to indicate which drug at which dose would be used for different intensity statin therapies to treat high low-density lipoprotein (LDL) as noted in the course textbook. Each drug listed in each column should be a different drug with a specific dose or dose rans as indicated in your course textbook.

High-Intensity Therapy
Moderate-Intensity Therapy
Low-Intensity Therapy

Daily dose lowers LDL-C on average by

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Daily dose lowers LDL-C on average by

Click or tap here to enter text.

Daily dose lowers LDL-C on average by

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Drug/Dose 1: Click or tap here to enter text.

Drug/Dose 2: Click or tap here to enter text.

Drug/Dose 1: Click or tap here to enter text.

Drug/Dose 2:Click or tap here to enter text.

Drug/Dose 3:Click or tap here to enter text.

Drug/Dose 4:Click or tap here to enter text.

Drug/Dose 5:Click or tap here to enter text.

Drug/Dose 1: Click or tap here to enter text.

Drug/Dose 2:Click or tap here to enter text.

Drug/Dose 3:Click or tap here to enter text.

What patient education is needed when prescribing statins? Consider any patient counseling points and adverse effects they may need to be aware of or report if experienced.

Click or tap here to enter text.

https://ambassadored.vitalsource.com/books/9780323554954

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. (2019).AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APHA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25). https://doi.org/10.1161/cir.0000000000000625

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., & Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507. https://doi.org/10.1001/jama.2013.284427

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