Orthostatic Hypotension
During my clinical rotation at Lone Tree Convalescent Hospital, I cared for a patient by the name of Mr. Vaccaro. He is 81 years old and has no known allergies. My patient has been diagnosed with chronic obstructive pulmonary disease (COPD), depression, hypertension (HTN), type 2 diabetes Meletus (DMT2), acute kidney infection (AKI), obstructive sleep apnea (OSA), and morbid obesity. His primary Diagnosis is orthostatic hypotension, weakness, and falling. For where Mr. Vaccaro is at in his life, he has shown promising signs of Integrity. He was content and happy with his life. Mr. Vaccaro came from Sicily and was a Chef, and He had a restaurant called Vaccaro's. He loves to cook and eat. Where this plays with his current diagnosis, he explained that he eats a lot of unhealthy carbs and fats such as pasta and lives a very sedentary lifestyle. Which plays a role in his morbid obesity as well as his type 2 diabetes. The pathophysiology for obesity is complex with environmental, medical, behavioral, physiological, and genetic. There are hundreds of genetic chromosomes that act with the hypothalamus, which regulates our homeostasis. For type 2 diabetes, it is characterized by insulin resistance, impaired regulation of glucose production, declining B- Cell function as well as Alpha-cell.
Medication List
The four medications that I have chosen from my patient are amlodipine (Norvasc), clopidogrel (Plavix), finasteride (Propecia), and fluticasone (Advair Diskus).
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The therapeutic class for Norvasc is Antihypertensives, which are calcium channel blockers. The mechanism of action inhibits calcium ions across the cardiac/smooth muscle cells, decreases blood pressure, and myocardial o2. The dosage is 2.5 mg, by mouth, every day. Based on my patient's age, the dosage is appropriate and therapeutic. The general adverse side effects are dizziness, fatigue, angina, bradycardia, and hypotension.
For Plavix, it is an antiplatelet drug, which is to prevent blood clots. The mechanism of action inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to platelet receptors. The dosage is 75 mg by mouth, and to be taken every day. This medication amount is a safe dose, and the general adverse side effects are confusion, hypotension, UTI, and myalgia.
The therapeutic class for Propecia is Benign Prostatic Hyperplasia (BPH) drugs, as well as androgen inhibitors. The mechanism of action Inhibits the enzyme 5-alpha-reductase, which is responsible for converting testosterone to its potent metabolite 5-alpha-dihydrotestosterone in prostate, liver, and skin. The dosage is 5 mg by mouth every day. This medication is a safe dosage, and the general adverse effects are dizziness, hypotension, orthostatic hypotension, erectile dysfunction, and dyspnea.
Advair Diskus is anti-inflammatory, and part of the corticosteroids class. This class is to help with chronic obstructive pulmonary disease. The mechanism of action is a potent, locally anti-inflammatory and immune modifier. The dosage is 100 mcg, by mouth, one puff twice a day. This medication is a safe dose, and the adverse effects are a headache, sleep disorder, abdominal pain, appendicitis, and discomfort.
Nursing Assessment
Based on Mr. Vaccaro's past medical history, medications, and his current diagnosis, orthostatic hypotension w/ falling makes complete sense. I would consider his diagnosis of morbid obesity, which includes eating high fat, high carb, and high salt intake. Secondly, he is living a sedentary lifestyle. I would consider his medications, as well. At least three out of the four medications I explained had hypotension, or orthostatic hypotension, or dizziness as an adverse side effect. He also is diagnosed with type 2 diabetes mellitus, and when I checked his labs, his glucose was abnormally high at 453, when the normal range is 70-90. Having a glucose level that high can be extremely dangerous and life threating. He is also diagnosed with hypertension. Which could mean that he is not following a proper diet. He also seemed unaware of how dangerous of the life he was living day to day. I would also consider his age, being a geriatric there are many things to consider with his past medical history and his ability to want to be educated.
Patient Education
Based on all the information that I have gathered; I would want to provide proper nutritional education about the meals he should be eating for his type 2 diabetes. Such as complex carbohydrates: brown rice, whole wheat, quinoa, vegetables, beans, or lentils. I would also emphasize exercise each day to help with his morbid obesity. The most accessible and cheapest form of exercise is walking. Alternatively, see if I could ask his physician about getting a referral to physical therapy. I would also consider his medications because of the risk of the adverse effects, and I could discuss with his physician my findings. I would also want to see what type of equipment the hospital provides. For patients that have orthostatic hypotension, knee-high or thigh-high compression socks can be applied to help with venous return. An abdominal binder can help with venous return, as well.
References
- Quiring, C., Sanoski, C. A., & Vallerand, A. H. (2019). Finasteride. Davis's Drug Guide. Retrieval from https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51307/all/finasteride
- Quiring, C., Sanoski, C. A., & Vallerand, A. H. (2019). AmLODIPine. Davis's Drug Guide. Retrieval from https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51043/all/Norvasc
- Quiring, C., Sanoski, C. A., & Vallerand, A. H. (2019). Clopidogrel. Davis's Drug Guide. Retrieval from https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51166/all/clopidogrel
- Quiring, C., Sanoski, C. A., & Vallerand, A. H. (2019). Fluticasone. Davis's Drug Guide. Retrieval from https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51328/all/fluticasone
- Richards, S. M., & Balderrama, D. R. (2017). Orthostatic Hypotension: Managing the Patient with. R. P. Pravikoff D (Ed.), CINAHL Nursing Guide. Ipswich, Massachusetts: EBSCO Publishing.
- Sheehan, J., & Ulchaker, M. M. (2012). Obesity and Type 2 Diabetes Mellitus (Oxford American Endocrinology Library). New York City, New York: Oxford University Press.
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