Primary hypertension

 

Mark Ilescu is a 44-year-old client who has been diagnosed with primary hypertension. His medical history includes type 1 diabetes mellitus, with early signs of nephropathy. He had a myocardial infarction 2 years ago and has been treated with a beta-blocker, metoprolol, since that time. He has been taking hydrochlorothiazide in addition to the beta-blocker to treat his hypertension. His blood pressure today is 138/92 mm Hg, which is consistent with the readings on his last three visits. His physician has added captopril to his treatment regimen. (Learning Objectives 2, 4, 8, and 9)

1. Mark states that he does not understand why he needs an additional medication considering his blood pressure is below 140 mm Hg systolic. How should the nurse respond?

2. Discuss the rationale for choosing captopril in Mark’s case.

3. What should the nurse include in teaching Mark in order to minimize adverse effects of the captopril and metoprolol?

Sample Solution

Metoprolol is a beta-blocker that improves blood flow and circulation by relaxing blood vessels and slowing the heart rate. It is used to treat chest pain, heart failure, hypertension, myocardial infarction, and atrial fibrillation. Monitor your blood pressure closely because these drugs can cause hypotension. Do not take blood pressure medication if BP systolic less than 90. In order to minimize adverse effects of metoprolol always check your pulse rate before taking the drug, if pulse rate below 60 do not take the medicine. For Captopril Inform patient that light-headedness is possible, especially during first few days of therapy, and to rise slowly to minimize this effect and to report occurrence to prescriber.

NAc receive dopamine (DA) projections from the ventral tegmental area (VTA) (Björklund and Dunnett, 2007, Ikemoto, 2007, Morales and Margolis, 2017) and this pathway play a major role in motivated behaviours, reinforcement learning and reward processing (Hamid et al., 2016; Salamone and Correa, 2012; Schultz, 2016; Watabe-Uchida et al., 2017). Like any other process, there are negative feedback pathways to balance the projections and prevent overexpression of DA. This arise from various structures (Matsui et al., 2014) but recent studies show that NAc is the main source of this inhibitory input (GABAergic input) (Beier et al., 2015; Watabe-Uchida et al., 2012). There were few conflicting results on this with studies suggesting inputs from NAc to VTA to be disinhibiting (Bocklisch et al., 2013; Chuhma et al., 2011; Xia et al., 2011) and a recent study addressing that NAc synapse onto VTA GABA as well as DA neurons via GABA-A receptor (GABAAR) and GABA-B receptor (GABABR) respectively (Edward et al., 2017). This, however, also projects a different result compared to the study done by Paladini in 1999 where inhibitory responses from the striatum to DA neurons were blocked by GABA-A antagonist hinting at pathway mediated by GABA-A instead.

In this particular study by Hongbin et al. in 2017, the shell component of the NAc is further subdivided into medial shell (NAcMed) and lateral shell (NAcLat). D1-MSN in the NAcMed is found inhibiting NAcMed-projecting DA neurons via GABAAR while NAcLat-projecting DA neurons via GABABR. D1-MSNs in the NAcLat, on the other hand, projects onto VTA GABA to result in disinhibition of NAcL

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