Primary Care of Adults Journal Entry week two

As a nurse practitioner student about to start my clinical experience, I have asked myself am I making the right choice. How is it going to be since this in a new environment and a new learning experience? I had to ask myself a lot of questions, but I realized the only way I would obtain the answers is to face the fact that I am about to begin a new chapter in my nursing career. This office is located in Douglasville, GA, and provides care to pediatric, adult and geriatric patients. It has one nurse practitioner and one physician that comes in by appointment only, the nurse practitioner actually runs the office. For a fairly new office, she sees a lot of patients.

Practicum Week two Day one

On December 6, 2013, I went for my second day at the clinic. It was very uneasy for me, I was scared not knowing how it was going to be. Everybody received me with open arms, and was willing to help me with the computer system that office uses. I was quickly taught how to use the system and then we called in the first patient. It was a challenge for me because in the hospital, I am used to getting report on my patients then going to the chart so I know their history. I was uncomfortable with the idea of not having any history on the patient, but I quickly realized that it was a different setting and I have to get accustomed to it. In my mind, I was thinking about how I was going to approach the situation by first obtaining history of the present illness, past medical history, social and family history. perform an assessment, formulate differential diagnosis, generate a plan of care, implement that plan of care, and educate the patient on the plan that has been generated, and the most important piece is to make sure that the patient understands. Thinking about what I had to do in a short period of time was terrifying, but I understand that as time passes I will be more comfortable in my new role.

Assessment

The first patient was J.O. a 42-year-old African American female who came to the office for uncontrolled hypertension. She has history of hypertension, asthma, insomnia, hyperlipidemia, and obesity. Her medications included Lisinopril/Hydrochlorothiazide 20/25mg daily, Zocor 40mg every night daily, Zolpidem 10mg every night, and her rescue inhaler. Her vital signs were as follow: B/P 168/92, HR 82, Temp 98.3, RR 20, Weight 305 pounds and height 64 inches. Patient denied any pain and appeared in no acute distress.

Her blood pressure was previously assessed and her systolic ranged from 150s to 170s and diastolic in the 90s and some occasional 100s. My preceptor told me that it looks like the treatment regimen is not working because the blood pressure is not being properly controlled, therefore, Lisinopril was increase to 40mg to reach the target goal of less than 130/80. According to Arcangelo and Peterson, the blood pressure goal for patients with comorbidities, such as this patient, should be less than 130/80 mm Hg (2013). The other medications remained the same. We did not draw any labs during this visit because the patient previously had labs drawn less than three months ago, and she was scheduled to come back in three months or as needed. The patient verbalized interest in losing weight, and asked the nurse practitioner if it is possible to prescribe her some weight loss pills. The National Heart, Lung, and Blood Institute (NHLBI) guidelines for weight loss recommend that a combination of increased physical activity and dietary modification should be attempted for at least 6 months before consideration of the addition of Food and Drug Administration (FDA)-approved antiobesity pharmacotherapy for individuals with obesity associated with other risks for CVD, including hypertension (Medscape, 2013).

Reflection

Since J.O. is an African American, I think lifestyle modifications should be strongly recommended. Lifestyle modifications are effective in lowering blood pressure and can reduce other cardiovascular risk factors. Nonpharmacologic interventions, including weight reduction, a low-fat diet, and increased physical activity, have a primary role in the treatment of hypertension. Weight reduction should be addressed with every overweight or obese hypertensive patient (Medscape, 2013). I think the patient needs more education concerning the risks associated with increasing weight and uncontrolled blood pressure and treatment strategies should be discussed more in-depth with the patient. I think a copy of the DASH diet information should have been giving to her, and stress more on exercise since patient showed interest in weight loss. I think the drug therapy is appropriate for an African-American, maybe she should consider adding a calcium channel blocker to her regimen.

My goal of fully assessing a hypertensive patient and complete a comprehensive history and physical has not been met yet, I feel that there was not enough education done and I was not comfortable giving my opinion in the plan of care of J.O.. Hopefully next time I will be able to have an input in the decision of care and that would complete my goal. My plan is to become very efficient with assessing, diagnosing, and generating treatment strategy for patients with hypertension.

References

Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for advanced practiced: A

practical approach (3^rd ed.). Ambler, PA: Lippincott Williams & Wilkins.

Medscape (2013). Therapeutic considerations in the treatment of obesity hypertension. Retrieved

from http://www.medscape.com/viewarticle/438087_5