CASE PRESENTATION OF A PATIENT WITH A DIAGNOSIS OF

HYPERTENSION

SUBMITTED BY: ARQUIZA, EDELINA I.BSN 3-C GROUP 1SUBMITTED TO: MR. JAVIER

HYPERTENSION

Hypertension (HTN) or high blood pressure is a chronic medical condition in which the blood pressure in the arteries is elevated. It is classified as either primary (essential) or secondary. Primary hypertension which refers to high blood pressure for which no medical cause can be found. The Secondary hypertension are caused by another conditions that affect the kidneys, arteries, heart, or endocrine system.

Tiredness Irregular Heartbeat Blurred Vision ConfusionHeadacheHigh blood pressure

SIGN AND SYMPTOM:

RISK FACTORS:•Diabetes Mellitus• Family History•Advance age•Obesity• Sedentary Lifestyle• Stress• Smoking•High intake of Na, saturated fats •Alcohol

NORMAL VALUE

RESULTS

WBC 5-10∗10 g/L 15.8

RBC 4.2-5.4 x 106µL

5.51

Hgb 12.0-16.0 g/dl 15.8

Hct 37%-47% 48.6%

Lymphocyte 20-40% 14%

Monocyte 2%-8% 5%

LABORATORY RESULTS

ANATOMY AND

PHYSIOLOGY

The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest.

The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood).

All the veins drain into the superior and inferior vena cava which then drain into the right atrium. The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out.

The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries.

PATHOPHYSIOLOGY

Diabetes MellitusFamily HistoryAdvance ageObesitySedentary LifestyleStressSmokingHigh intake of Na, saturated fats and alcohol

Kidney release RENIN into the bloodstream

RENIN helps convert angiotensin I in liver

Angiotensin I is converted to angiotensin II (a potent vasoconstrictor) in lungs

Angiotensin II

Aldosterone: Causes Na and water retention

Retained Na and Water Increased Blood Volume

Arteriolar constriction Increased Peripheral vascular resistance

Increased Blood pressure and vascular resistance to hypertension

NURSING CARE PLAN

NCP 1

SUJECTIVE:“Bakit kaya madalas ako mahilo?” as verbalized by the patient.

OBJECTIVE:Request for informationConfuseInaccurate follow through of instructions V/S: T: 37.2 P: 84R: 18 BP: 180/110

NURSING DIAGNOSIS ( A ): Deficit knowledge related to lack of understanding

and information about the disease.

PLANNING:After rendering nursing care interventions, the patient will verbalize understanding of the disease process and treatment regimen.

INTERVENTION:• Monitored vital sign especially blood pressure.• Explained hypertension and its effect on the heart, blood

vessels, kidney, and brain. • Reinforced the importance of adhering to treatment regimen

and keeping follow up appointments.• Encouraged patient to decrease or eliminate caffeine like in

tea, coffee, cola and chocolates.• Provided basis for understanding elevations of BP, and

clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well.

• Suggested frequent position changes, leg exercises when lying down.

RATIONALE:• Provides basis for understanding elevations of

BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. • Lack of cooperation is common reason for

failure of antihypertensive therapy. • Decreases peripheral venous pooling that may

be potentiated by vasodilators and prolonged sitting or standing. • Caffeine is a cardiac stimulant and may

adversely affect cardiac function. • Community resources like health centers

programs and check ups are helpful in controlling hypertension.

EVALUATION:

After rendering nursing care interventions, the patient was able to verbalize understanding of the disease process and treatment regimen.

NCP 2

SUBJECTIVE:“Nanghihina ako at madaling mapagod kya maghapon lang akong nakahiga” as verbalized by the patient.

OBJECTIVE:• Body weakness• Fatigue• V/S:BP=160/100PR=55 bpm

NURSING DIAGNOSIS ( A ): Activity Intolerance

related to body weakness.

PLANNING:

After rendering nursing care interventions, the patient will be able to report measurable increase in energy and will participate in necessary desired activities.

INTERVENTION:

• Assessed response to activity including pre/post v/s.• Provided patient with positive atmosphere.• Encouraged patient’s participation in planning of

activities.• Assisted patient in carrying out self-care activities.• Encouraged patient to carry out ADLs.• Placed patient on a position of comfort.

RATIONALE:

• To identify causative factors.• To assist pt. to deal with manage factors that

contribute to fatigue.• To provide pt. with a sense of control. • To improve mobility. • To enhance motivation. • To maintain body alignment.

EVALUATION:

After rendering nursing care interventions, the patient was able to report measurable increase in energy and was able to participate in necessary desired activities.

NCP 3

SUBJECTIVE:“Nahihilo at nanghihina ako” as verbalized by the patient.

OBJECTIVE:• Restlessness.• Body malaise.• Body weakness.• V/S:PR=55 bpm

NURSING DIAGNOSIS ( A ):

Decreased cardiac output r/t altered stroke volume.

PLANNING:

INTERVENTION:

After rendering nursing care interventions, the patient’s cardiac output will become adequate.

• Monitored and recorded v/s.• Assessed radial pulse every hour and reported any deviations from the baseline.• Reduced stressful elements, such as excessive noise in the patient’s environment.• Encouraged the patient to increase fluid intake and dietary fiber .• Provided dietary • Changed patient’s position frequently.restrictions.• Due medication such as metoprolol given.

RATIONALE:

• To establish baseline data.• To monitor for arrhythmias; impending cardiac arrest.• To help decrease arrhythmias.• To avoid valsalvas maneuver during defecation, which can increase heart rate and blood pressure, and decrease cardiac output.• To promote comfort and avoid tachycardia.• To reduce risk of cardiac disease.• It is a drug indicated for hypertension.

EVALUATION:

After rendering nursing care interventions, the patient’s cardiac output was become adequate.

MEDICAL AND SURGICAL MANAGEMENT

Life style

Lose weight. Exercise regularly.

Eat a diet rich in fruits, vegetables, and low-fat dairy products while reducing total and saturated fat intake.

Avoid smoking. Do not consume more than 1 or 2 alcoholic drinks per day.

Keep your blood sugar under control.

Try to manage your stress.Follow your health care provider's recommendations.

DRUG STUDY

GENERIC NAME:Captopril

CLASSIFICATION:CV agent; ACE inhibitor; antiHPN

CONTRAINDICATION : History of angioedema related to previous ACE inhibitor use, pregnancy (Cat. D), lactation

ADVERSE REACTION: NSG. CONSIDERATION: •Give an hour before meal.•Advise client to report to the physician without delay the onset of unexplained fever, unusual fatigue, sore throat & mouth, easy bruising & bleeding.•Advise physician promptly if vomiting & diarrhea occur.•Monitor VS , potassium, hematologic, renal.•Lost of taste may be experience.BRAND

NAME:Capoten

MECHANISM OF ACTION : Inhibits angiotensin-converting enzyme resulting in decreased plasma angiotensin II, which leads to decreased vasopressor activity and decreased aldosterone secretion.

SPECIAL PRECAUTION:Use with caution in case of impaired renal function and during lactation. May cause a profound drop in BP following the first dose or if used with diuretics.

SIDE EFFECT:Rash, dysgeusia, gastric irritation, aphthous ulcer/peptic ulcer, headache, dizziness, fatigue, drowsiness, malaise, N&V, diarrhea, dry mouth,

DRUG INTERACTION:Indomethacin/↓24-hr antihypertensive effects of captopril Iron salt/↓Captopril blood levels; separate administration by atleast 2 hrProbenecid/↑Captopril blood levelsR/T↓renal excretion.

CHEMICAL CONTENT:Tablet- stock 25 mg/tab

INDICATION:HPN; in conjunction with digitalis & diuretics in CHF, diabetic nephropathy, rheumatoid arthritis, Raynaud’s syndrome, idiopathic edema, Bartter’s syndrome.

GENERIC NAME:Nifedipine

CLASSIFICATION:CV agent; Ca channel antagonist; antiarrhythmic (Class IV); nonnitrate vasodilator.

CONTRAINDICATION:Hypersensitivity and lactation. A.cute MI

ADVERSE REACTION:

NSG. CONSIDERATION:•Monitor BP & sugar level. Nifedipine has diabetogenic properties.•Avoid smoking.•Inspect gums everyday & seek prompt treatment for symptoms of gingival hyperplasia (easy bleeding of the gingiva, & gradual enlarging of the gingival mass).•Protect capsules from light and moisture.•Can be taken without regard to meals.•Maintain fluid intake of 2-3L/day to avoid constipation.•Brush teeth and floss regularly to reduce swelling and tenderness of the gums.•Do not crushed or chewed or divided the sustained release tablets. Grapefruit may cause increased serum drug level.

BRAND NAME:Calcibloc

MECHANISM OF ACTION: Inhibits the influx of calcium through the cell membrane, resulting in a depression of automaticity and conduction velocity leading to a depression of contraction.

SPECIAL PRECAUTION:Use with caution in impaired hepatic or renal function and in elderly clients. Initial increase in frequency, duration, or severity of angina.

SIDE EFFECTS:Flushing, headache, fatigue/lethargy, edema, peripheral edema, weakness, muscle cramps, dizziness, lightheaded, disturbed equilibrium.

DRUG INTERACTION:Digoxin/↑effect of Digoxin by ↓excretion by kidney.Possible/ ↑effect of theophylline.Barbiturates/↓Nifedipine effect.Mg sulfate/↑Neuromuscular blockade and hypotension.

CHEMICAL CONTENT:Stock- 5mg/cap; 10 mg/cap

INDICATION:treatment of essential HPN; coronary insufficiency with or without angina; vasospastic angina, to increase heart rate in sinus bradycardia & sick sinus syndrome.

GENERIC NAME:Nicardipine hydrochloride

CLASSIFICATION:CV agent; Ca channel blocker; antiHPN

CONTRAINDICATION:hypersensitivity; advanced aortic stenosis; lactation.

ADVERSE EFFECT: NSG. CONSIDERATION:•Give on EMPTY stomach.•Monitor BP. defer if <90/60mmHg.•Assess for CHF, if beta blockers prescribed, monitor closely.•Report any persistent/bothersome side effects such as dizziness, chest pain, SOB, weight gain, and swelling of extremities.•Maintain proper intake of fluids to prevent constipation.•Avoid alcohol and limit caffeine.•Avoid prolonged sun exposure.

BRAND NAME:Cardene

MECHANISM OF ACTION:Moderately increases CO and HR and significantly decreases peripheral vascular resistance. Slight increase in QT interval and slight to no decrease in myocardial contractility. No effect on QRS complex or PR interval.

SPECIAL PRECAUTION:Safety and efficacy in children less than 18 years of age have not been established. Use with caution in patients with CHF, impaired liver function, reduced hepatic blood flow or impaired renal function.

SIDE EFFECT:Flushing, increased angina, hypotension, palpitation, tachycardia, vasodilation, anxiety, dizziness, lightheadedness, headache, N&V, blurred vision, malaise, polyuria

DRUG INTERACTION:Cimetidine/Ranitidine/↑Bioavailability of nicardipine↑plasma levels.Rifampin/↓nicardipine effect.Cyclosporine /↑increases plasma levels of cyclosporine possibly leading to renal toxicity.

CHEMICAL CONTENT:Stock- Capsules, Extended-release: 30 mg, 45 mg,60 mg,; Capsules, Immediate-release: 20mg, 30 mg; Injection: 2.5 mg/ml.

INDICATION:chronic, stable(effort-associated) angina; HPN;

GENERIC NAME:Clonidine hydrochloride

CLASSIFICATION:CV agent; central acting hypertensive analgesic

CONTRAINDICATION:Pregnancy, lactation; scleroderma, presence of an injection site infection, patients on anticoagulant therapy, in bleeding diathesis.

ADVERSE EFFECT: NSG. CONSIDERATION:•Monitor BP closely.•Monitor I & O.•Determine wt. daily.•Instruct to not abruptly discontinue taking this meds.•Instruct to not rake OTC drugs, alcohol, or other CNS depressants without prior discussion with physician.•Examine site when transderm patch is removed.•Report if erythema, rash, irritation or hyper-pigmentation occurs.

BRAND NAME:Catapres

MECHANISM OF ACTION:Stimulates alpha-adrenergic receptors on the CNS, resulting in inhibition of the sympathetic vasomotor centers and decreased nerve impulses.

SPECIAL PRECAUTION:Use with caution during lactation and in the presence of severe coronary insufficiency, recent MI, chronic renal failure, cerebrovascular disease.

SIDE EFFECTS:Dry mouth, drowsiness, dizziness, sedation, constipation, headache, fatigue, malaise, anxiety, insomnia, respiratory depression, loss of libido, nocturia, N&V.

DRUG INTERACTION:Alcohol/↑depressant effects.Mirtazapine/ Loss of BP control→antagonism of alpha-2 adrenergic receptors.Tolazoline/ Blocks antihypertensive effect.Verapamil/ ↑Risk of AV block and severe hypotension.Narcotic analgesics/ Potentiation of clonidine hypotensive effect.

CHEMICAL CONTENT:Stock- 75 mg/tab; 150 mg/tab.

INDICATION: Hypertension, psychosis in schizophrenia, ulcerative colitis, epidurally adjunct therapy for severe pain, attention deficit hyper-activity disorder, Gilles de la Tourette’s syndrome.

GENERIC NAME:Hydralazine hydrochloride

CLASSIFICATION:CV agent ; nonnitrate vasodilator; antiHPN.

CONTRAINDICATION:Coronary artery disease, mitral valvular rheu-matic heart disease, MI, tachycardia, SLE. Safe use during pregnancy (category C) or lactation is established, hypersensitivity.

ADVERSE EFFECT: NSG. CONSIDERATION:•Determine antinuclear antibody titer before initiation of therapy & periodically during prolonged therapy.•Monitor BP and HR closely.•Monitor I & O when given parenterally & in those with renal dysfunction.•Monitor weight, check for edema.•Make position changes slowly and to avoid standing still, hot baths/showers, strenuous exercise and excessive alcohol intake.•Do not drive.Do not breastfeed while taking this drug.

BRAND NAME:Apresoline

MECHANISM OF ACTION:Decreases peripheral resistance but concurrently elevates cardiac output. Acts directly on smooth muscle of blood vessels.

SPECIAL PRECAUTION:Use with caution in impaired hepatic or renal function and in elderly clients. Initial increase in frequency, duration, or severity of angina.

SIDE EFFECT:Headache, tachycardia, flushing, dyspnea, peripheral edema, erythematosus-like synsrome.

DRUG INTERACTION:Digoxin/↑effect of Digoxin by ↓excretion by kidney.Possible/ ↑effect of theophylline.Barbiturates/↓Nifedipine effect.Mg sulfate/↑Neuromuscular blockade and hypotension.

CHEMICAL CONTENT:Stock- 20mg/ml

INDICATION:Moderate to severe HPN. Also in early malignant HPN & resistant HPN that persists after sympa-thectomy and PIH.

RESOURCES OF DRUG STUDY:

• 2008 Edition PDR Nurse’s Drug HandbookGeorge R. Spratto, Adrienne L. Woods.

• Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th Edition. Volume 1

• Emergency drugs. ( own ).

LEARNING FEEDBACK DIARYIt was my first time in GEAMH ER area with Mr. Javier. At first this day was an manic day for me, because we all though that our time of duty was 6-2, we are all in school at exact 4:30 am, afraid of being late. But when we arrived at GEAHM to meet Mam Lim, we thought that she was our CI for that day and she said that she is not our CI, her time is 10-6. We are all disappointed for that circumstances, because none of them inform us that our duty was 2-10. Well anyway, I don’t blame anyone. When we met sir Javier he rushed us for preparing our para-phernalia that should be use inside the ER. I have a feeling that we were so busy inside the ER, and I’m right. When I entered I already my patient, we were accidentally assigned at Pedia area. Meeting with my patient helps me a lot when providing care to them. I learned from the first day of my duty that patient is a must and important, although all of us know it. I also experienced giving TSB on my patient. I learned that you should not be affected of the condition they have. And you should put yourself on the shoes of your patient. You should act like what who they are, be humble and never ignore them when they need your help.

MOTTO:

I also got the chance to observe a procedure to a one of the patient in Pedia who is newborn. The newborn should have an orogastric tube (OGT). It was a good experience for me.

We all have dreams. But in order to make dreams into reality, it takes an awful lot of determination, dedication, self-discipline, and effort.

May 13, 2010GEAMH ER 2-10 PMMR. JAVIER

ARQUIZA, EDELINA I.BSN 3C GROUP 1

LEARNING FEEDBACK DIARYThis was the last day of our duty and we are busy again. I have so many experienced and learning inside the ER. I have a patient who fallen from a tree and I experience giving him a wound care. I also experienced giving skin test and an intramuscular injection to him for anti tetanus. I learned not in giving care but also participating in the other member of the staff in the ER station. I also got the chance to observe inserting a catheter in a male patient with the guide and supervision of our C.I..And be alert at all the times. Even in a single question you should provide an answer to them and there’s no problem if you don’t know the answer just tell them that you don’t know. Never act like you’re the best in the world.

MOTTO:Few things in the world are more powerful than a positive push. A smile. A world of optimism and hope. A you can do it when things are tough.

May 14, 2010GEAMH ER 2-10 PMMR. JAVIER

ARQUIZA, EDELINA I.BSN 3C GROUP 1

THANK YOU SIR JAVIER!!! LOVE YOU!!!God bless!! thanks for guiding us during our duty at ER. For sharing the knowledge that you have. For trusting us and for giving us a chance to experience a feeling of being registered nurse. Sana maging C.I. po namin kayo ulit. Always take care sir. mua *