HYPERTENSION CASE STUDY

INTRODUCTION

  Objectives of the study

  Reasons for choosing the disease

NURSING PROCESS

  Biographical Data

  Pertinent Family History

  History of Past Illness

  History of Present Illness

PHYSICAL ASSSESMENT

  Neurovital Signs Monitoring

Diagnostic Exams

ANATOMY AND PHYSIOLOGY

SYNTHESIS OF THE DISEASE

PATHOPHYSIOLOGY (you may click on the link)
  Pathophysiology of Hypertension
  Pathophysiology Electrolyte Imbalance

SIGNS AND SYMPTOMS WITH ETIOLOGY
NURSING MANAGEMENT
  NURSING CARE PLANS (NCP)
  NURSING CARE PLANS (NCP)
  SOPIE

Objectives of the study

1.       Gain knowledge about the pathophysiology of Hypertension and electrolyte imbalances, what are the risk factors and how it is treated.

2.       Gain insights about its manifestations and etiology.

3.       Be familiar with its possible complications

4.       Be well versed with its management

5.       Apply our learning to our nursing practice in the present and in the future as well

Reasons for choosing the disease

1.            To have a full understanding of this disease since it is very common in the community

2.            To determine the distinctions of this disease from other diseases similar to it in terms of manifestations.

3.            To evaluate if we became an effective health care providers to the patient who suffered from this illness.

4.            To established a comprehensive knowledge of this disease.

5.            We find it very interesting

Genogram

Narrative: As reflected in the genogram, the patient’s father and his oldest sister also suffered from hypertension which indicates that the said disease runs in their family. No other disease was seen similar to the patient except from hypertension.

Biographical Data

The name of the patient is Mr. Precious Brando, a 47 year-old, male, born at Sampaloc, Manila. He is Roman Catholic and a natural born Filipino citizen, currently residing at Sta. Mesa, Manila, with his wife and his four children.

The patient works as a tricycle driver in their town. He works the whole day and perspires a lot. According to his wife, Mr. Precious Brando is a heavy drinker and a chronic smoker for almost 25 years. He consumes almost 21 bottles of gin and 2 packs of cigarette sticks/day. According to his wife, before the patient was diagnosed to have Hypertension in 1990, he stops from eating high-salty foods. The wife also stated that the patient is not fond of consuming fruits.

History of Past Illness

According to the patient’s wife, the patient has no known serious illness, only occasional cough and colds.

History of Present Illness

The patient was diagnosed as having hypertension in the year 1990. He was able to control his high blood pressure by taking the prescribed anti-hypertensive drug for 8 months which he could not remember the name. However, the patient wasn’t able to comply with his medication regimen and didn’t have follow up consultation because of financial problem.

Few days prior to patient’s admission, the patient experienced headache, nausea and vomiting from unknown reasons, increase in his blood pressure, muscle weakness and drowsiness. He was rushed in a local hospital in Sta. Mesa and experienced seizures during his stay. They were advised for transfer to another hospital for further management.

On September 01, 2009 at 3:05 pm, the patient was admitted to the emergency department of Sampaloc District hospital with chief complaints of increased in blood pressure and decrease sensorium. The attending physician asked the patient’s relative regarding the symptoms experienced by the patient and ordered a series of diagnostic exams which include SGPT, H. pylori test, HCT, BUN, serum creatinine, serum Na, serum K, Complete blood count, FBS, Chest X-ray, cranial CT-scan, and RBS

PHYSICAL ASSSESMENT  Vital Signs:

BP:160/100         

T: 35.9  

P: 87      

R: 15     

Body Parts	Normal Findings	Abnormal Findings
Hair And Scalp	Evenly distributed thick, silky, resilient hair. No infection or infestation.
Face and Skull	Rounded, smooth skull contour, absence of nodules or masses, symmetric or slightly asymmetric facial features, symmetric facial movements
Skin	From light to deep brown Uniform in color No edema lesions noted, no pigmentation Brings back to previous state after pinching Normal temperature @ 37C
Eyes	Symmetrically aligned with equal movements	Slightly yellowish sclera
Ears	Symmetrical in shape and aligned in the outer canthus of the eye No tenderness, recoils after it is foiled No discharge
Nose	No discharge, no lesion and tenderness, no obstruction
Lips	No blister/cracks, moist
Tooth and gums	Pink gums, not swollen Smooth and white shiny enamel	Dark gums Yellowish teeth
Tongue	Centered, no lesions, smooth movement
Neck	Equal in size, head centered with muscles ( trapezius and sternocleidomastoid) equal in size No unusual mass noted upon palpation No enlargement of lymph nodes No distention of veins, No enlargement of thyroid gland
Thorax and Lungs	Spine is vertically aligned, no tenderness, pain, or unsual mass upon palpation Tactile fremitus present Clear breath sounds
Heart	Has a regular rate and rhythm
Abdomen	Unblemished skin Uniform in color, no swelling or lump noted Tympanic sound heard upon auscultation Symmetric contour Symmetric movements caused by respirations No tenderness
Extremities	No edema, deformities, tenderness noted Have symmetrical lower and upper extremities Clean fingernails and toenails Blanch test ( color return < 3 seconds )	Dirty fingernails

NEUROVITAL SIGNS MONITORING

Glasgow coma Scale:

Guidelines:	09/01/09	09/02/09
Eye opening	4	4
Motor response	6	6
Verbal response	4	5
Total	14	15

DIAGNOSTIC EXAMS

Laboratory procedures	Date ordered Results in	Indications/ purposes	Normal values	Results	Interpretation
BLOOD CHEMISTRY	DO: 09/01/09 @ 3pm	To determine any abnormalities in the chemical composition, structure, and properties of the blood	BUN: 2.9-9.3 mmol/L Creatinine: 4-150 umol/L S odium: 135-145 mmol/L Potassium: 3.5-5.3 mmol/L	5.03 mmol/L 114.92 umol/L 101.2 mmol/L 1.75 mmol/L	This is a normal finding This is a normal finding This indicates hyponatremia This indicates hypokalemia
HGT	DO: 09/01/09 @ 3pm		HGT in mg/dl: 60-130 mg/dL HGT in mmol/dl: 3.3-7.2 mmol/dL	165 9.07
SGPT	DO: 09/01/09		0.38 IU/L	23.2 IU/L
ASSURE TEST (Helicobacter pylori Test)	DO: 09/01/09	To determine presence H. pylori in the blood	Negative	Negative	This is a normal finding
HGT	DO: 09/01/09 @ 7:15 pm		HGT in mg/dl: 60-130 mg/dL HGT in mmol/dl: 3.3-7.2 mmol/dL	127 mg/dL 7.0 mmol/dL	This is a normal finding This is a normal finding
Hematology	DO: 09/01/09	To determine any abnormalities in blood composition such as WBS, RBC, etc.	WBC: 5-10 x 10 g/l Hct: 0.40 Hgb: 120-170 Bleeding time: 1-5 mins Clotting time: 3-7 mins Reticulocyte: 0.5-1.5% Differential Count Segmenters: 0.50-0.70 Lymphocytes: 0.20-0.40 Bands/stabs: 0-0.05 Eosinophils: 0.01-0.05 Monocytes: 0.01-0.08 Basophils: 0-0.01 Platelet Count: 150-450 x 10 g/l Erythrocyte	8.7x10 g/l 0.53 175 n/a n/a n/a 0.84 0.12 n/a 0.0-0.12 0.04 0-0.12 248x10g/l	This is a normal finding This is a normal finding This is a normal finding
BLOOD CHEMISTRY	09/02/09	To determine any abnormalities in the chemical composition, structure, and properties of the blood	FBS in mg/dl: 70-105 FBS in mmol/L: 3.9-5.8 Cholesterol: 3.1-7.3 Triglycerides: 0.45-1.81 HDL 0.78-195 LDL: 1.72-4.63 Na: 135-145 K: 3.5-5.5 Calcium: 2.1-2.8 Magnesium: 1.58-2.55	129 7.1 3.4 mmol 0.45 mmol 0.78 mmol 2.54 mmol n/a n/a 1.75 mmol 2.38 mmol	This is a normal finding This is a normal finding This is a normal finding This is a normal finding This indicates hypocalcemia

ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM – responsible for the transport of O2 and CO2, nutrients and waste products.

I. Anatomy of the Heart

Location:

1.            Apex- left at 5^th intercostals space

2.            Base-towards the shoulder at 2^nd rib

Coverings and walls

Pericardium- a double layer sac that encloses the heart

Three layers

[  Epicardium- outer layer

[  Myocardium- middle layer

[  Endocardium- inner layer

Heart Chambers

[  Atria- upper receiving chambers

[  Ventricles- lower pumping chambers

Heart Valves

AV Valves- between atria and ventricles

[  Bicuspid- left AV valve

[  Tricuspid- right AV valve

Semilunar Valves

[  Pulmonic- at the pulmonary trunk

[  Aortic- at the aorta

Cardiac Circulation

[  Coronary arteries- supplies blood to the heart

II. Physiology of the Heart

Conduction System of the Heart

Two types of controlling system

1. Autonomic Nervous System

[  Symphatetic stimulation- increases heart rate

[  Parasymphatetic stimulation– decreases heart rate

2. Nodal System

[  SA Node – atrial contraction

[  AV Node

[  AV Bundle

[  Bundle Branches

[  Purkinje Fibers

CARDIOVASCULAR SYTEM: THE BLOOD VESSELS

Arteries- carries blood away from the the heart

Veins-brings blood back to the heart

Tunics

[  Interna

[  Media

[  Externa

Physiology of Circulation

Arterial Pulse – alternating expansion and recoil of an artery that occurs with each beat of the ventricles

Blood Pressure – pressure the blood exerts against the inner walls of the blood vessels

[  Systolic Pressure- the pressure in the arteries at the peak of ventricular contraction

[  Diastolic Pressure- the pressure when the ventricles are relaxing

Peripheral Resistance- amount of friction encountered by a blood as it flows through the blood vessels

Factors affecting Blood Pressure

[  Neural factors

[  Renal factors

[  Temperature

[  Chemicals

[  Diet

Variations in Blood Pressure

Hypotension- low BP; systolic BP of below 100 mmHg

Hypertension- 140/90 or higher

FLUID AND ELECTROLYTE BALANCE

Fluid Compartments- main location of water within the body

Intracellular Fluid (ICF)- 2/3 of the body fluids, contained within the living cells

Extracellular Fluid (ECF) – 1/3 of the body fluids;all body fluids outside the cells; includes blood plasma, interstitial, CSF and serous fluids

*Very small changes in electrolyte balance, the solute concentration in various fluid compartments cause water to move from one compartment to another

Sodium- the major extracellular cation, important for water balance, conduction of nerve impulse and muscle contraction

Potassium- the major intracellular cation, necessary for the conduction of nerve impulse and muscle contraction

PATHOPHYSIOLOGY OF HYPERTENSION

  PATHOPHYSIOLOGY OF ELECTROLYTE IMBALANCE

 

SYNTHESIS OF THE DISEASE (hypertension)

Factors that predisposed the client to having hypertension includes age in which 30-50 years old are at high risks, being a male is also a risk according to statistics. Smoking which has a vasoconstrictive effect secondary to nicotine content of cigarette played a significant role in the pathogenesis of Hypertension. Likewise, excess alcohol consumption may also increase client’s risks.

Nicotine caused vasoconstriction and consequently narrowing of the lumen of the blood vessels. These both increases the peripheral resistance which increases arterial blood pressure and decreased blood flow which deprived O2 to muscle cells causing muscle weakness and to brain cells which can cause disorientation and irritability.

SYNTHESIS OF THE DISEASE (electrolyte imbalance)

Factors that predisposed the client to having electrolyte imbalances include poor intake, GI losses (vomiting), excessive perspiration and chronic alcoholism. These factors caused decreased Sodium in extracellular spaces leading to osmotic shift of water. Osmosis can in turn result to increased intracellular edema. The most sensitive cells are the neurologic cells in the brain. Increased in the volume of these cells causes increased ICP which resulted to headache and seizure.

On the other hand, when there is decreased potassium in extracellular spaces due to the above factors, there will be a decreased nerve conduction and muscle contraction. This will lead to symptoms such as disorientation and muscle weakness respectively. Slowed smooth muscle contraction is also the reason for nausea and vomiting.

SIGNS AND SYMPTOMS WITH ETIOLOGY

Headache – because of increased in intracranial pressure caused by fluid shift

Seizures – increased ICP that exceeds seizure threshold

Irritability, dizziness, disorientation – caused by decrease Oxygen supply in the brain or decreased nerve conduction

Nausea and vomiting – resulted from decreased smooth muscle contraction

Muscle weakness – because of decreased muscle contraction secondary to low levels of potassium and sodium; caused also by decreased Oxygen supplies to muscle cells

CUES	NURSING DIAGNOSIS	SCIENTIFIC EXPLANATION	PLANNING	INTERVENTIONS	RATIONALE	EVALUATION
S> O O>conscious    >appears    weak    >irritable    and restless    at times    >(+) seizure    >with lab    results as      follows: Serum Na-101.2 mmol/l Serum K- 1.75 mmol/l    > with VS as    follows:    BP- 160/100    T- 35.9    P- 87    R-15	Risk for falls related to muscle weakness and episodes of seizures secondary to low levels of potassium in the blood	Because potassium and sodium are needed for normal nerve conduction and muscle function, low plasma potassium and sodium levels can often lead to weakness and can lead to falls or seizures Hypertension can cause deprivation of body cells of O2 secondary to decrease blood flow resulted from vasoconstriction. This can in turn causes weakness of the muscles and dizziness	After 8 hours of nurse-patient interaction, patient will be able to reduce risks of falls as evidenced by an absence of falls, bruises and seizures	1.        Establish rapport 2.        Assess general conditions 3.        Monitor VS 4.        Assist in treatments and provide information regarding patient’s present condition 5.        Discuss consequences of previously determined risk factors 6.        Discuss side effects of anti-hypertensive drugs 7.        Stress importance of monitoring conditions that may contribute to occurrence of falls 8.        Employ seizure precautions 9.        Keep bed in a low position with padded side rails up 10.     Before the client walk, clear the path of obstacles and place non-slippery shoes on the client	1.        To gain trust 2.        For baseline data 3.        To determine alterations which may indicate a need for interventions 4.        To determine individual risks 5.        For follow up instructions and interventions 6.        This can contribute to weakness and balance 7.        To reduce risks 8.        To minimize 9.        risk for injury	Goal met, patient was able to reduced risks of falls as evidenced by an absence of falls, bruises, contusions and seizures

NURSING MANAGEMENT (SOPIE)

DATE: 09/01/09

S> O

O>conscious

   >appears weak

   >(+)dyspnea

   >looks pale

   >irritable at times

   >with lab results of: Serum K= 1.75 mmol/min

   >with VS as follows: BP- 160/100; T- 35.9;   P- 87; R-15

A> Activity intolerance related to generalized muscle weakness secondary to decreased levels of potassium and sodium in the blood

P> After 8 hours of nursing interventions, patient will be able to deal with contributing factors of intolerances and manage activities within individual limits

I> Established rapport

 >Assessed general conditions

 >Monitored VS

 >Reduced intensity level or discontinued activities that cause undesired physiological changes

 >Provided supplemental O2

 >Planned care to carefully balance rest periods with activities

 >Provided positive atmosphere, while acknowledging difficulty of the situation for the client

 >Encouraged expression of feelings

 >Assisted with activities and provide use of assistive devices

 >Provided comfort measures

 >Assisted client in learning and demonstrating appropriate and safety measures

 >Administered medicines as ordered

E> Goal met, patient was able to deal with contributing factors of intolerances and managed activities within individual limits.