Case Study Hypertension

OVERVIEW OF THE DISEASE

INTRODUCTION

A hypertensive emergency is severe hypertension (high blood pressure ) with acute impairment of organ system 9 especially the central nervous system , cardiovascular system and/or renal system ) and the possibility of irreversible organ damage. In case of hypertensive emergency, the blood pressure should be lowered aggressively over minutes to hours with a hypertensive agent. Several classes of hypertensive agents are recommended and the choice of hypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated blood pressure and the patient’s usual blood pressure before the hypertensive crisis. In most cases, the administration of an intravenous Sodium Nitroprusside injection which has an almost immediate anti hypertensive effect is suitable but in many cases, oral agents are given like Captopril, Clonidine, Labetalol, Prazosin, which all have a delayed onset of action by several minutes compared to Sodium Nitroprusside, can also be used.

DEFINITION

Generally, the terminology describing hypertensive emergencies can be confusing. Terms such as hypertensive crisis, malignant hypertension, hypertensive urgency, accelerated hypertension and severe hypertensions are all used to=in the literature and often overlap.

As a specific term hypertensive emergency is primarily used as a crisis with a diastolic pressure of 120 mm hg and above plus end organ damage (Brain, Cardiovascular, renal) as described above in contrast to hypertensive urgency where as yet no end organ damage has developed. The former requires immediate lowering of blood pressure as with Sodium Nitroprusside infusions.

SIGNS AND SYMPTOMS Headache High blood pressure usually 140/100 and above Shortness of breath Convulsion Changes in vision Nausea Vomiting

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Heart palpitations

DIAGNOSTIC EXAM Blood pressure monitoring using sphygmomanometer Electrocardiogram (ECG) Complete Blood Count(CBC) Physical Examination LDL-HDL Ratio

TREATMENT

The usual treatment is to reduce blood pressure using anti –hypertensive drugs, it includes:

ACE inhibitors;

ARBs;

Diuretics;

Beta-blockers;

Calcium- blockers

Diuretics are usually recommended as the first line of therapy for most people who have high blood pressure. If one drug doesn’t work or is disagreeable, other types of diuretics are available.

NURSING INTERVENTION

The primary responsibility of the nurse is to assess the condition of the patient during the treatment. It includes the following but are not limited to;

Vital signs monitoring specifically blood pressure, Assessment for possible and sudden drop of blood pressure, Monitoring of adverse reactions to drugs, Tabulation of Input and Output when ordered and carrying out doctor’s order.

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A. Client’s profile:Name: Mr. AMAddress: Abbay Maddela QuirinoAge: 26 years oldSex : MaleCivil status : MarriedNationality : FilipinoReligion : Born AgainBirthDate : November 5,1983Occupation : BaKerDate of admission: May 4, 2010Time of admission: 2:45PMChief Complaint: body weakness and pale lookingDiet : DATDiagnosis: Anemia to consider Blood DyscrasiaPhysician: Dr.X

MEDICAL HISTORY:• Present health history of illness:

- Two weeks prior to admission the patient suffered body weakness associated with pale looking. According to the patient he also felt dizziness and severe headache; he take paracetamol to relieve the pain but then he was not relieve that’s why they decided to have his check up at QPH and his Physician advised him for confinement with a diagnosis of Anemia. Admitted last May 4, 2010 @ 2:45pm

• Past medical history:- He is not fully immunized that’s why he occasionally experienced Childhood

diseases like; cough,colds and fever. His last confinement was on October 2009 at Dundayong Hospital at part of Maddela Quirino. Also Last December 28, 2009 at QPH with an admitting diagnosis of Idiopathic thrombocytopenia Purpura . Last April 16-22, 2010 he was confined at SIGH and was diagnosed with Anemia.

• Family health history:

Father Possible hereditary Mother+ HPN +- Asthma -- Cancer -- DM -

II GORDONS HEALTH FUNCTIONAL PATTERN

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1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

BEFORE HOSPITALIZATION: the Pt. verbalized that he is healthy. He can actually maintain his body healthy without any problems.

DURING HOSPITALIZATION: when he was admitted at QPH he still thinks that he is okay because he feel good still but easily feel tiredness.

2. NUTRITIONAL-METABOLIC PATTERN

BEFORE HOSPITALIZATION: Pt.AM prefers vegetables than meat. He rarely eats meat because he thinks those are the reason that’s why he is suffering anemia.

DURING HOSPITALIZATION: the doctor ordered DAT diet. And the hospital usually serves meat as their vian.

3. ELIMINATION PATTERN

BEFORE HOSPITALIIZATION: PTA, the pt. urinates 7-8x a day with colorless - light yellow urine with no foul odor.

DURING HOSPITALIZATION: when he was admitted, he urinates 6-7x a day. And perspires at all times bec.of warm environment in the hospital.

4. ACTIVITY-EXERCISE PATTERN

BEFORE HOSPITALIZATION: The pt. is fun of playing basketball and this serve as his exercise.

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DURING HOSPITALIZATION: He can’t play basketball because of his condition .

5. SLEEP-REST PATTERN

BEFORE HOSPITALIZATION: Sometimes his number of sleep ranges from 6-7 hours a day. But mostly he has hard time on getting his sleep with unknown cause.

DURING OSPITALIZATION: he mentioned that, since his confinement here in QPH, he felt as though he was refreshed than that as compared with before because he had enough time to sleep without any interruptions. he had no more worries about his routine activities.

6. COGNITIVE PERCEPTUAL PATTERN

Pt. AM is only a high school undergraduate but he can read and write. He can easily understood and respond to our questions directly.

7. SELF PERCEPTION/ SELF CONCEPT PATTERN

BEFORE HOSPITALIZATION: He sees himself as a very busy person and responsible father on his two child.

DURING HOSPITALIZATION: Because of her stay at QPH, his anxiety about his daily routines/activities at home is temporarily relieved.

8. ROLE RELATIONSHIP PATTERN

BEFORE HOSPITALIZATION: He is a responsible father and husband. He is a baker on a small bakery at Zamora.

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DURING HOSPITALIZATION: he can’t work anymore because of his condition.

9. SEXUALITY-REPRODUCTIVE PATTERN

He was 7 years old when he was circumcised by what they call “de pok-pok”before.

10. COPING STRESS MANAGEMENT

BEFORE HOSPITALIZATION: Due to his routine Activities, he was not aware that he was under stress. he had been encountering it every day which may trigger the disease.

DURING HOSPITALIZATION: he now understand that having enough rest when he is tired and stressed is very indispensable to overcome his condition. He also recognizes though our health teachings are the essence of taking of multivitamins rich in iron to strengthen his immune system.

11. VALUE BELIFE PATTERN

BEFORE HOSPITALIZATION: He was a devoted Born again. He sometimes attends mass together with his wife and children at their nearby church.

DURING HOSPITALIZATION: Now that he is confined, he can’t attend mass anymore but still prays all the time.

PHYSICAL ASSESSMENT

Date: May 06,2010@10:00am

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General Appearance: conscious

BODY PARTS TECHNIQUE FINDINGS

INTERPRETATION

HEAD Hair Inspection Black in

colorNo lice

Normal

Scalp InspectionPalpation

No presence of dandr

uffNo masse

sNo tenderness

NormalNormal

Ears Inspection With norma

l hearin

g

Normal

Earlobes Inspection Bean-shape

d

Normal

Ear Canacl Inspection No abnormal

discharges

Normal

Eyes(Conjunctiva)

Inspection PERRLAWith pale

conjunctiva

NormalDue to lack of red

blood cell

Lips Inspection Pale in color

(white)

Due to lack of red blood cell

Teeth Inspection With presence of dental carrie

s

Due to poor hygiene

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Gums Inspection Pinkish in color

Normal

Tongue Inspection Moist NormalFACE Inspection

PalpationPale in

colorNo masse

s


Normal

NECK Inspection Symmetrical and pale in

color

Normal

Due to present condition

UPPER EXTREMITIES

InspectionPalpation

No lesion and pale in

colorSymmetri

cal, no

bones dislocated


Normal

Fingernails Inspection

Palpation

Clean and prope

rly cut

Slightly poor capillary

refill

Normal


Shoulder Inspection symmetrical and pale in

color.

Normal


Heart Auscultation 115 bpm Normal

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Thorax and lungs

Palpation

Auscultation

No tenderness

No wheez

ing sound

Normal

Normal

Abdomen Inspection

Auscultation

Palpation

Percussion

Flat, Sym

metrical

slightly pale

in color

Normoactive

soundNo tenderness

Resonant


Normal

Normal

Normal

LOWER EXTREMITIES

Inspection

Palpation

Symmetrical

Pale in color

Normal


Legs Inspection Hairy and slightl

y pale. And with

complain of pain

on the left leg.


Due to basketball accident.

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II. ANATOMY & PHYSIOLOGY

The heart pumps oxygenated blood to the body and deoxygenated to the lungs. In the human heart there is one atrium and one ventricle for its circulation, and with both a systemic and pulmonary circulation there are four chambers in total; left atrium, left ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in oxygen) and passed in to the right ventricle to be pumped through the pulmonary artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly oxygenated blood from the lugs as well as the pulmonary vein which is passed into the strong ventricle to be pumped through the aorta to the different organs of the body.

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III. PATHOPHYSIOLOGY

HYPERTENSIVE EMERGENCY

ETIOLOGIC FACTOR: RISK FACTORS:

Obesity Age Stress

IV. COURSE IN THE WARD

DOCTOR’S ORDER RATIONALE5/4/102:45 pm>pls. admit to male medicare Ward> Record TPR

>To treat underlying condition> for baseline data

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Stressor initiated

Reni is released by the

Angiotensin is produced

Angiotensin I is converted to Angiotensin II

Increased BP

>DAT>CBC>BT>PNSS1L- 25 gtts/min>Secure 4 units of FWB type O+ & transfused

after crossmatching> refer accordingly

5/5/1010:10 am>TF: PNSS1L at KVO> For Peripheral blood smear> for referral to Hematologist> continue for BT> refer

5/6/109:30am Continue BT

5/7/10 Still for BT Continue IVF PNSS1L x 24hrs

5/7/103:00pm For referral to Hematologist D5NM1L x 25 gtts/min Multivit. + Iron 1 capsule TID refer

> applicable diet to the patient> to check any abnormalities> to replace components of blood loss> for electrolytes and fluid balance>to check for compatibility of blood

to evaluate the condition

for electrolytes and fluid balance to check abnormalities of blood for further evaluation and management To replace components of blood loss To evaluate condition

To replace components of blood loss

To replace components of blood loss

For further evaluation and management For electrolytes and fluid balance To boost immune system For further evaluation

V. LABORATORY RESULTS

Name: Mr AM

Result Normal values

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WBC 3.5

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URINALYSIS

Date: 11- 30- 09

Chemical Examination

Color: yellow

Clarity: clear

MICROSCOPIC EXAMINATIONS:

Pus cells: 0-2/hpf

Red cells: 5-7/hpf

Epithelial cells: moderate/hpf

Amorphous urates: few/hpf

Mucus threads: +/hpf

Bacteria: +/hpf

Dr. Nathanael B. Vidad, MD, FPSP

Photologist ( 59251)

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CHEMISTRY

Date: Nov. 30, 2009

TEST REFERENCE VALUE

Fasting blood sugar: 5.97 mmol/L 3.89-5.83 mmol/L

Cholesterol: 7.33 mmol/L 3.87-6.71 mmol/L

Triglycerides: 1.35 mmol/L up to 1.7 mmol/L

Blood urea Nitrogen: 5.78 mmol/L 2.5-6.5 mmol/L

Creatinine: 87.9 mmol/L 150-357 mmol/L



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SERUM ELECTROLYTES

Date: Nov. 30, 2009

Test Reference Value

Sodium: 133.7 mmol/L 135.0-155.0 mmol/L

Potassium: 2.89 mmol/L 3.60-5.50 mmol/L



HEMATOLOGY

DATE: Nov. 29, 2009 Reference Value

WBC: 7.6 3.5-10

RBC: 5.14 3.80-5.80

HGB: 152 110-165

HCT: .470 .350-.500

PLT: 289 150-390

PCT: .198 .100-.500

WBC FLAGS: G3 Reference Value

LYM- 23-8% 17.0-48.0%

MON- 7.0-% 4.0-10.0%

GRA- 69.2% 43.0-76.0%

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XII. VITAL SIGNS

Admitted: November 29, 2009Initial vital sign bp- 220/140

November 29, 20098am-4pm

• 9:25 am bp-160/ 100 PR-90bpm• 10:30 am bp-160/100 PR-86bpm• 11:40 am bp-160/100 PR-86bpm• 12:50pm bp-130/90 PR-86bpm• 2:00pm bp-160/100 PR-88bpm• 3:45pm bp-170/100 PR-98bpm•

November 29, 20094pm-12am

• 5:00pm bp-190/110 PR-96bpm• 6:30pm bp-200/130 PR-102bpm• 8:15pm bp-200/120 PR-98bpm• 9:50pm bp-180/120 PR-100bpm• 11:00pm bp-210/130 PR-98bpm •

November 30, 200912am-8am

• 1:00 bp-190/120 PR-96bpm• 2:00 bp-220/110 PR-98bpm• 3:00 bp-200/110 PR-84bpm• 5:30 bp-180/120 PR88bpm• 7:30 bp-190/120 PR-80bpm •

November 30, 20098am-4pm

• 9:30am bp-190/120 PR-72bpm• 12:00pm bp-190/130 PR-84bpm• 1:00pm bp-200/120 PR-89bpm• 2:30pm bp-180/130 PR-83bpm• 3:30pm bp-190/120 PR-68bpm

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November 30, 20094pm-12am

• 6:00pm bp-150/100 PR-58bpm• 8:30pm bp-170/100 PR-64bpm• 9:40pm bp-140/100 PR-60bpm• 10:40pm bp-140/100 PR-57bpm• 11:30pm bp-160/100 PR-60bpm •

December 1, 200912am-8am

• 1:30am bp-170/110 PR-62bpm• 2:30am bp-160/110 PR-64bpm• 3:30am bp-180/120 PR-57bpm • 4:30am bp-170/100 PR-58bpm• 5:30am bp-170/110 PR-62bpm

December 1, 20098am-4pm

• 9:00am bp-160/100 PR-80bpm• 10:00am bp-180/110 PR-86bpm• 10:15am bp-170/100 PR-83bpm• 10:30am bp-160/100 PR-86bpm• 10:45am bp-160/100 PR-85bpm• 11:00am bp-170/100 PR-80bpm• 11:15am bp-160/100 PR-66bpm• 11:30am bp-160/100 PR-64bpm• 11:45am bp-170/110 PR-63bpm• 12:30pm bp-160/110 PR-60bpm• 1:00pm bp-160/110 PR-68bpm• 1:15pm bp-160/110 PR-67bpm• 2:00pm bp-160/110 PR-65bpm• 2:30pm bp-160/110 PR-64bpm• 3:30pm bp-170/110 PR-66bpm

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December 1, 20094pm-12am

• 5:00pm bp-170/110 PR-66bpm• 6:45pm bp-180/110 PR-68bpm• 9:30pm bp-180/110 PR-61bpm• 10:00pm bp-140/110 PR-64bpm• 11:00pm bp-170/110 PR-65bpm


• 1:00am bp-180/120 PR-72bpm• 2:30am bp-180/90 PR-70bpm• 5:30am bp-160/110 PR-80bpm• 7:30am bp-160/100 PR-79bpm


• 9:00am bp-160/110 PR-62bpm• 10:00am bp-150/90 PR-64bpm• 11:00am bp-160/100 PR-66bpm• 12:00pm bp-150/100 PR-62bpm• 2:00pm bp-150/100 PR-63bpm


• 6:30pm bp-170/110 PR-80bpm• 7:00pm bp-160/110 PR-94bpm• 9:00pm bp-140/90 PR-87bpm• 10:00 bp-150/110 PR-92bpm

December 3, 2009

12am-8am

• 1:30am bp-140/100 PR-98bpm• 5:30am bp-150/110 PR-84bpm• 7:00am bp-140/100 PR-84bpm

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• 9:30am bp-140/100 PR-89bpm• 10:30am bp-140/100 PR-87bpm• 11:30am bp-160/100 PR-90bpm• 12:30pm bp-140/100 PR-93bpm• 1:30pm bp-140/90 PR-86bpm• 2:00pm bp-140/90 PR-78bpm• 2:30pm bp-140/100 PR-68bpm


• 6:00pm bp-140/90 PR-66bpm• 10:00pm bp-130/90 PR-68bpm


• 12:30am bp-160/120 PR-85bpm• 1:15am bp-150/120 PR-86bpm• 1:30am bp-140/100 PR-89bpm• 1:45am bp-140/100 PR-86bpm• 2:00am bp-140/100 PR-83bpm• 2:15am bp-140/100 PR-86bpm• 6:00am bp-140/100 PR-79bpm


• 10:00am bp-140/100 PR-86bpm

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VI. NURSING CARE PLAN

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Assessment Diagnosis

Planning

Intervention

Rationale

Evaluation

SUBJECTIVE:• “Lagi

sumasakit ulo ko.” as verbalized by the pt.

OBJECTIVE:• Body

weakness• Irritable• Oily face

elevated blood pressure

After 1-4° of nursing intervention the pts headache will be relieved.

Independent:-Established

rapport

-Monitored BP and PR

-Instructed pt on proper deep breathing

-Positioned the pt on a comfortable position

Dependent:

-Due meds given

-On low fat, and low salt diet

-To gain pt trust and cooperation

-For baseline data

-To lessen anxiety and stress

-For pts comfort

-To relief headache

-To lessen fat deposit and retention of NaCl ions.

Goal met as evidence by the pts verbalization of “hindi na masakit ulo ko.”

NURSING CARE PLAN


Planning

Intervention

Rationale

Evaluation

SUBJECTIVE:-Ø

OBJECTIVE:-guarded

behavior-diaphoretic

Knowledge deficit r/t self care

After 1-2° of nursing intervention the pt will be able to demonstrate all increasing


rapport-Monitored

v/s

-Instructed pt to have adequate rest periods

-Emphasized the importance of proper hygiene, grooming and feeding


-For baseline data

-For comfort and relaxation.

-To promote cleanliness

Goal met as evidence by the pts verbalization of “ gagawin ko yung itinuro mo.”

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interest / participation of self care.

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NURSING CARE PLAN

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Planning

Intervention

Rationale

Evaluation

SUBJECTIVE: “limang araw na

akong hindi ngdudume,kaya nanghihina ako” ask verbalized by the pt.

OBJECTIVE:-facial grimace-minimal

movement

Constipation

After 1-3° of nursing intervention the pt. will be able to defecate and regain strength.


rapport

-Monitored v/s

-Palpated abdomen

-Instructed to increased fluid intake

-Encouraged pt to eat nutritious foods.

Dependent: administered

Bisacodyl as ordered.


-For baseline data

-To check for presence of distention.

-to promote hydration

-To promote moist/ soft stool.

Goal met as evidence by the pts verbalization of “”nagdumi na ako.

VII. DRUG STUDY

DRUG NAME CLASSIFICATION

INDICATION/ACTION

SIDE EFFECTS NSG. RESPONSIBILITIES

Generic name:Ketorolac

Brand name:

Stock:

Generic name: Ranitidine

Brand Name:

Stock:

Generic Name:metoclopramide

Brand name:plasil

Stock:10mg/2ml

Generic name:Furosemide

Non- steroidal anti-inflammatory

Doctor’s order:

Anti ulcer drugs

Doctor’s order:

Anti-emetics

Doctor’s order:1 amp IV now then

q8° PRN

Diuretics

Short term management of moderately severe, acute pain for single dose treatment

Gastric irritation

Nausea and vomiting

Headache Dyspepsia GI pain Constipation Flatulence

Anaphylaxis Headache Blurred vision

Bradycardia,supravetricular tachycardia

Neuroleptic malignant syndrome,seizures, suicide ideation.

Vertigo, headache, dizziness.

Correct Hypovolemia before giving. Alert: Maximum Combined duration of

parenteral and oral therapy is 5 days. When appropriate, give by deep IM

injection. Pt may feel pain at the injection site which can be relieve by applying cold bags.

Assess pt for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate.

Drug may be added to total parenteral solutions.

Monitor bowel sounds. Safety and effectiveness of drug haven’t been

established for therapy lasting longer than 12 weeks.

To prevent nocturia, give P.O. and IM

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Brand name:

Stock:

Generic name:Paracetamol

Brand name:

Stock:

Generic name:Losartan

potassium

Brand name: getzar

Generic name: Bisacodyl

Brand name:Dulcolax

Doctor’s order:1 amp IV now then

OD

Non opiod analgesic and anti pyretics

Doctor’s order:1 amp IV stat

Anti hypertensives

Diphenyl methane derivative

Hypertension

Mild pain and/or fever

For hypertension

Chronic constipation

Panceatitis, thrombocytopenia.

Neutropenia, leucopenia, pancytopenia and hypoglycemia

Headache, dizziness, fatigue, abdominal pain, nausea, back pain or leg pain, cough and respiratory infection

Dizziness, faintness, muscle weakness with

preparations in the morning. Give 2the early afternoon.

Watch for signs of hypokalemia such as muscle weakness and cramps.

Alert: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose.

Drugs can be used alone or with other antihypertensives.

Monitor patient’s BP to evaluate effectiveness of therapy and monitor patients who are also taking diuretics for symptomatic HpN.

Give drugs at times that don’t interfere with scheduled activities or sleep.

Before giving for constipation, determine whether patient has adequate fluid intake, exercise and

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excessive useAbdominal crampsElectrolyte

imbalance

diet.

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Documents

Case Study Hypertension