The patient presents with hot flushing, night sweats, and genitourinary symptoms. She is 46 years old, weighing 230lb with a history of hypertension, ASCUS in pap smear in the last five years, and a family history of breast cancer. Her latest blood pressure check is at 150/90. With elevated blood pressure, she is taking Norvasc and HCTZ oral medications. The patient’s last menstrual period (LMP) was a month ago, has a regular menstrual cycle, and has a regular annual mammogram and gyne exam. Therefore, it can be concluded that her present symptoms indicate that she is in the menopausal transition. A change in menstrual periods is often the first sign of perimenopause, but there are different signs to look out for. The most common are hot flashes, sleep disturbances, mood changes, depression, night flush, high BP, changes in the genitourinary, vaginal dryness, and decreased sex drive (Eisenberg, 2020). Therefore, she needs to manage her perimenopausal symptoms to prevent more problems.
The most effective treatment for hot flashes and night sweats is hormone therapy, estrogen-progestin. Unless one has had a hysterectomy, one will likely need to take a progestin to reduce the risk of developing endometrial cancer. Low-dose estrogen by pill or patch, for example, doses that are less than or equal to 0.3 milligrams (mg) conjugated equine estrogen, 0.5 mg oral micronized estradiol, 25 micrograms (mcg) transdermal (patch) estradiol, or 2.5 mcg Ethinylestradiol. These pills or patches are advantageous because they regulate the menses and stop the hormonal irregularities of the perimenopausal stage (Harvard Health Publishing, 2020).
However, for women with more severe vaginal atrophy (the drying and thinning of vaginal tissues) and related pain, burning, or soreness during sex, low-dose vaginal estrogen products may be needed (The Northern American Menopause Society, n.d.). In addition, the vaginal estrogen may help minimize genitourinary symptoms such as urinary urgency and frequency, painful urination, incontinence, and recurrent urinary tract infections (Krause et al., 2009).
Moreover, other treatments available to help with perimenopause symptoms may include a low dose of antidepressants Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as Effexor, selective serotonin reuptake inhibitors (SSRIs), such as Prozac and Paxil to manage mood swings (Stubbs et al., 2017). In addition, Neurontin (gabapentin) reduces night sweats and hot flush, and clonidine, a blood pressure drug to treat high blood pressure (Harvard Health Publishing, 2020)
I will educate the patient to avoid possible triggers of hot flashes such as hot drinks and spicy foods and being exposed to warm air temperature. Dressing in layers so one can take off clothes as needed (Harvard Health Publishing, 2020). There is clear evidence that paced respiration, a deep breathing technique, helps alleviate hot flashes. Paced breathing (slow, deep, diaphragmatic breathing) reduces central sympathetic activity and facilitates relaxation (Sood et al., 2013). I would also recommend patient exercises such as aerobic and weight-bearing exercises to strengthen the bone and achieve a healthy weight. Furthermore, she is at risk for osteoporosis because of her age and perimenopausal stage. Therefore, I will advise her to take calcium, fiber, and a vitamin D-rich diet. A healthy diet avoiding saturated fats, high caloric food, limiting salt intake, and less alcohol necessary for her heart problem. Also, she needs consistent screening to prevent cervical and breast cancer that she is at high risk for because of her family history.
It is important to note that the healthcare environment always presents with patients showcasing different complex comorbidities as an advanced nurse practitioner. It is the nurse’s role to ensure that they develop the right care plan and understand how this care plan is effective to limit interactions with medication. In this case, the scenario presents a patient with different symptoms that could include a complex integration of comorbidities. She is 46 years old, weighs 230 lbs, and has a breast cancer and hypertension history. Having an in-depth look at the patient’s symptoms, it is possible to identify that she is within the perimenopause stage. This stage is determined by the period just before the menopause stage (McCarthy & Raval, 2020). This period showcases the body’s natural changes and transitioning to the menopause stage, which marks the end of the reproductive stage. From the patient’s symptoms, her healthcare needs are yearly breast cancer screening, hypertension management, yearly Pap smear for the previous ASCUS, and a modification within her lifestyle to help her manage her weight.
After understanding the patient’s healthcare needs, it is possible to develop an effective treatment regimen. For hypertension, I believe it is important to discontinue the Norvasc and replace it with Lisinopril 20 mg daily (Rosenthal & Burchum, 2021). This step is advised because the patient is experiencing menopause symptoms, including the hot flushing genitourinary symptoms and night sweats. It is also crucial that the patient keeps up the information about her blood pressure for the first two weeks of this care plan twice daily. This will allow for understanding the effectiveness of the medication. This will also help to develop a future care plan for the patient.
The following step is to look at the patient’s blood pressure and the impacts of the Lisinopril. If this medication can effectively control blood pressure, it is essential to discontinue the HCTZ. This is a necessary step in helping the patient handle her genitourinary symptoms. Considering that the patient is within the perimenopause stage, it is possible to recommend hormone replacement therapy (HRT) according to the patient’s needs. However, this will be done with caution and after additional diagnosis testing on the patient. This I will request and undertake a complete blood count, nuclear medicine bone scan, and comprehensive metabolic panel tests before recommending the HRT (Lobo, 2017). I will also recommend a yearly mammogram. This is important for the patient, especially with a family history of breast cancer, and HRT also increases the risk of developing cancer. Here it is also essential to encourage the patient on natural ways of managing the symptoms like exercising and yoga rather than HRT. Finally, a yearly gynecological exam is necessarily inclusive of the PAP smears.
All these requirements are essential for the patient to understand, and thus the need for her education. Besides, some patients might find it hard to manage themselves during this entire period. For this patient, patient education undertakes first teaching how to monitor blood pressure at home, an essential part of recognizing both hyper-and hypotension. Because the patient has been prescribed Lisinopril, it is also vital to educate her on the adverse side effects that might require immediate medical attention like a dry cough, headache, blurred vision, confusion, and cloudy or reduced urine output (Guglin et al., 2019). Finally, the patient needs to be educated on her weight management process, mainly because this could be a contributory factor to hypertension. This requires an exercising routine, and once within the healthy weight bracket, the Lisinopril dosage is reduced. Working towards a healthy weight can be achieved by educating the patient to change her diet and embrace healthy foods.
Nurse practitioners need to develop an effective care plan to ensure the patient gets quality healthcare services. This is an integral part of patients that present with complex comorbidities. The case study provided is an example of a 46 years old patient that needs medical attention and an improved care plan that covers her healthcare needs of yearly breast cancer screening, hypertension management, yearly Pap smear for the previous ASCUS, and also a modification within her lifestyle to help her manage her weight.