McKenna's Pharmacology for Nursing, 2e

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P A R T 8  Drugs acting on the cardiovascular system

CRITICAL THINKING SCENARIO Treating hyperlipidaemia

THE SITUATION M.M., a 55-year-old Caucasian businessman, was seen for a routine insurance physical examination. He was found to be obese and borderline hypertensive, with a non-fasting low- density lipoprotein (LDL) level of above 4.0 mmol/L (very high). M.M. reported smoking two packs of cigarettes a day and noted in his family history that both of his parents died of heart attacks before the age of 50. He described himself as a “workaholic” with no time to exercise and a tendency to eat most of his meals in restaurants. The primary medical regimen suggested for M.M. included ceasing or decreasing smoking, weight loss, dietary changes to eliminate saturated fats and decreased stress. On a return visit after 4 weeks, M.M. had lost 3.5 kg and reported a decrease in smoking, but his LDL levels were unchanged. The use of an antihyperlipidaemic drug was discussed. He was started on atorvastatin and advised to continue the diet and exercise program and to return in 3 months for follow-up. CRITICAL THINKING What care interventions are appropriate at this point? Consider all of the known risk factors for coronary artery disease ( CAD ) ; then rank M.M’s risk based on those factors. What lifestyle changes can help M.M. to reduce his risk of heart disease? What support services should be consulted to help M.M.? Should other tests be done before considering any drug therapy for M.M.? Think about the kind of teaching that would help M.M. to cope with the overwhelming lifestyle changes that have been suggested, yet remain compliant with his medical regimen. DISCUSSION M.M.’s description of himself as a workaholic should alert the healthcare provider to the possibility that he will have trouble adapting to any prescribed lifestyle changes. (Workaholics tend to be very organised, goal-driven and somewhat controlling individuals.) M.M. should first receive extensive teaching about CAD, his risk factors and his options. The benefits of decreasing or eliminating risk factors should be discussed. Drug therapy is intended as an adjunct to diet and exercise, and the effectiveness of drug therapy improves remarkably when diet and exercise changes are made. M.M. may be more compliant if he exercises some control over his situation, so he should be invited to suggest possible lifestyle changes or adaptations. M.M. also should be encouraged to set short-range goals that are achievable, to help him feel successful. He needs to understand that beginning drug therapy does not mean that exercise and diet are no longer important.

M.M. also needs to understand that antihyperlipidaemic drugs can cause dizziness, headaches, gastrointestinal upset and constipation. Because of his busy lifestyle, M.M. may have trouble coping with these adverse effects. M.M.’s healthcare provider may need to try a variety of different drugs or combinations of drugs to find ones that are effective but do not cause unacceptable adverse effects. The Australian National Heart Foundation has numerous booklets, diets, support groups and counsellors who can help M.M. as he tries to adapt to his medical regimen. He can contact the Foundation online at www.heartfoundation.org.au for a quick reference and referrals to other sources. M.M. will benefit from having a consistent healthcare provider who can offer him encouragement, answer any questions and allow him to vent his feelings. Often, lifestyle changes are the most difficult part of this medical regimen, so M.M. will need constant support. CARE GUIDE FOR M.M.: HMG-CoA REDUCTASE INHIBITORS Assessment: History and examination Assess M.M.’s health history for allergies to any HMG-CoA reductase inhibitor or fungal byproducts; hepatic dysfunction; or endocrine disorders. Focus the physical examination on the following areas: Cardiovascular: blood pressure, pulse, perfusion Neurological (CNS): orientation, affect, reflexes, vision Skin: colour, lesions, texture Respiratory system: rate, adventitious sounds GI: abdominal examination, bowel sounds Laboratory tests: liver and renal function tests, serum lipids Implementation Administer the drug at bedtime. Monitor serum lipids prior to therapy and periodically during therapy. Provide comfort and safety measures: Give small meals. Arrange for periodic ophthalmic examinations to screen for cataracts. Give the drug with food if GI upset occurs. Institute bowel program as needed. Provide safety measures if needed. Monitor liver function, and arrange to stop the drug if liver impairment occurs. Provide support and reassurance to deal with drug effects and the need to make lifestyle, diet and exercise changes. Provide teaching regarding drug, dosage, adverse effects, what to report and safety precautions.