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I. INTRODUCTION

Hypertension, or commonly known as high blood pressure, is a medical

condition wherein the blood pressure of an individual is recurrently elevated.

Hypertension is an important contributor to morbidity and mortality from

cardiovascular disease. It is a an independent risk factor for stroke, myocardial

infarction, renal failure, congestive heart failure, progressive atherosclerosis,

dementia, coronary artery disease and peripheral vascular disease. Hypertension

affects approximately 50 million individuals in the United States and

approximately 1 billion individuals worldwide. As the population ages, the

prevalence of hypertension will increase even further broad and effective

preventive measures are implemented (1). In the Philippines, 9.6M are

hypertensive and 15.4M are predisposed to be hypertensive among adults, 20

years and over (2). Unfortunately, half of those who has hypertension are not

aware that they have the condition, only 13.1% of them has been treated and 19.3

% has been controlled (3). Since hypertension may be present in an individual in

years without noticeable symptoms, it is otherwise known as “The Silent Assasin”

(4) In the Philippines, for over 5 years, hypertension ranks as the fifth leading

cause of morbidity (5). This implies that hypertension is a chronic problem or

condition of the country and perhaps not much has been done on its control and

prevention. Prolonged and uncontrolled hypertension is very dangerous.

Unhealthy lifestyles which include cigarette smoking, unmanaged stress, salty

food consumption, physical inactivity, or being overweight are the common

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modifiable risk factors to having hypertension. Non modifiable factors include

genetic predisposition to hypertension and other disease condition like diabetes,

heart and kidney disease, high cholesterol level, or stroke and an increasing age.

Hypertension in its earlier stage is manageable. The simplest way of controlling

high blood pressure is through lifestyle modification by having healthy diet and

regular exercise. Discontinuation of smoking and alcohol consumption are also

advised to individuals with hypertension. However, medication is prescribed to

hypertensive individuals to control persistent rise in blood pressure.

Hypertensive urgency is defined as a severe elevation of BP, without evidence of

progressive target organ dysfunction. These patients require BP control over

several days to weeks. The most common hypertensive urgency is a rapid

unexplained rise in BP in a patient with chronic essential HTN.Other causes are

Renal parenchymal disease – Chronic pyelonephritis, primary glomerulonephritis,

tubulointerstitial nephritis (accounts for 80% of all  secondary causes) Systemic

disorders with renal involvement – Systemic lupus erythematosus, systemic

sclerosis,  vasculitides Renovascular disease – Atherosclerotic disease,

fibromuscular dysplasia, polyarteritis nodosa Endocrine – Pheochromocytoma,

Cushing syndrome, primary hyperaldosteronism Drugs – Cocaine, amphetamines,

cyclosporin, clonidine withdrawal, phencyclidine, diet pills, oral contraceptive

pills Drug interactions – Monoamine oxidase inhibitors with tricyclic

antidepressants, antihistamines, or  tyramine-containing food CNS – CNS trauma

or spinal cord disorders, such as Guillain-Barré syndrome Coarctation of the aorta

Preeclampsia/eclampsia Postoperative hypertension.

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II. GENERAL DATA

Name : Mrs. S A E M

Age : 47 years old

Address : Magsaysay Hills Toledo City Cebu

Sex : Female

Civil status: Married

Occupation: Teacher

Citizenship: Filipino

Religion: Roman Catholic

Hospital: Chung Hua Hospital

Room/bed number: C-322

Hospital number: 1P0000237751

Date of Admission: July 25, 2010

Date of Discharge: July 28, 2010

Time of admission: 10:28 pm

Attending Physician: Dr. Noval, Lerma Reston (Cardiologist)

Final Diagnosis: Hypertensive Urgency

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III .HISTORY OF PRECENT ILLNESS

A few hours prior to admission patient complain of chest discomfort with note of

elevated blood pressure of 150/80 mmHg. Patient self medicated with her maintenance

medication Atenolol 25 mg and was brought to Toledo Hospital and was referred to

Chung Hua Hospital for further management.

IV. PAST HEALTH HISTORY

The patient has no known allergies but according to her she was diagnosed last year

with heart enlargement due to her inherited condition to her father side which is

hypertension.

V. CLIENT CLINICAL COURSE OF THE UNIT

July 26, 2010

On the first day of care. Patient received lying on bed conscious coherent and awake,

with ongoing IVF # 1 PNSS 1L @ 40 cc/hr hooked at left arm infusing well. Patient

complains of chest discomfort upon rising up to her bed. Patient is anxious as evidenced

by verbalization of her concern upon her current condition. Patient also reported fatigue.

Upon assessing her she stated that she feels like her body was too heavy to carry, she feel

so weak and helpless. Vital signs were monitored as ordered by the physician. Report if

blood pressure is elevated.

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July 27, 2010

On the second day of care. Patient received lying on bed conscious awake and coherent

with ongoing IVF PNSS # 2 1L @ 40 cc/hr infusing well. Patient vital signs were still

monitored as ordered. Patient verbalized that sometimes during walking around the room

she can feel her heart beating so fast. Patient was advice to avoid activities that exerts too

much effort to avoid the risk of injuries. Blood pressure were taken every 2 hours and

reported for any elevation. Patient’s only concern at this time was her heart palpitations

during activities.

July 28, 2010

On the third day of care. Patient received conscious awake and coherent. Patient is

watching television with no IVF attached and was ready to be discharged. Patient state

that she feels well now. Vital signs were still monitored and all were on at the normal

range. Health teaching was provided. Patient was encouraged to low salt and low fat diet

and to avoid activities that exert too much effort. Before the shift, patient was discharged

via wheel chair. Patient verbalized that she will comply with the health teaching that was

being instructed to her.

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VI. FAMILY PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

A. FAMILY HISTORY

Table 1: Patient’s immediate family members:

NAME POSITION IN

THE FAMILY

AGE OCCUPATION

Mr. D E Grand Father Deceased Farmer

Mrs. J E Grand Mother Deceased Tailor

Mrs. M E F Father’s sister 69 years old Teacher

Mr. A E Father 72 years old Businessman

Mr. R E Father’s Brother 65 years old Government employee

Mrs. S A E M Patient 47 years old Teacher

Mr. A E Brother 45 years old Teacher

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FAMILY GENOGRAM:

Legend: = Normal (male)

= Hypertensive

= Normal (female)

= Hypertensive

Grand Mother

Grand Father

Father Father’s Sister

Father’s Brother

PatientPatient’s Brother

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B. PERSONAL AND SOCIAL HISTORY

Mrs. S A E M 47 years old a female and a Filipino. She is a roman catholic and

a pure Cebuano recently residing at Magsaysay Hills Toledo City Cebu. Mrs. S

A E M was a very loving and responsible wife to her husband. She is a very

friendly person. She’s always attending to the needs of her family. She always

sees to it that she can provide the needed things for her family. She wanted to

give her best to her family. If she doesn’t have any chores in the house or

doesn’t have any work, she does gardening on her little garden in their house.

She is also fun on watching television especially noon time shows.

C. ENVIRONMENTAL HEALTH HISTORY

Mrs. S A E M and her family are living in their own house at Magsaysay Hills

Toledo City Cebu and their house is made up of concrete materials. Their house

is just about enough for her family to live in and to protect them from stranger

and for hot and cold environment. They also have a backyard and she made a

little garden in order to help in their family in terms of fresh vegetables as food.

Their house is equipped with electricity. Their water supply is in their deep

wheel for laundry and mineral water is for drinking. Their house has its own

toilet facility; according to her it was well maintained and cleaned always.

Their garbage is dispose through compose pit on their backyard. Their house is

surrounded with trees that are planted by her father’s parents.

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VII. PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEM

Physical assessment was also known as the physical examination is the

evaluation of a body to determine its state of health. This method involves the use of the

five senses of the medical care provider since it uses the technique of inspection,

palpation, percussion, and the last was the auscultation. Physical assessment findings

provide objectives data in determining correct diagnosis and devising for the appropriate

interventions and treatment if the physical assessment is a medical practitioner-based

data, nursing review of system is a patient based data or commonly known as the

subjective data. This is a method of assessing a condition by asking a set of questions to

the patient that pertains to the particular parts or system of the body.

It is usually supported by the results from the physical assessment. Both physical

assessment and nursing review of system are vital in achieving a plan of care to the

patient and assuring a optimal care being rendered.

The table below shows the results and findings from the physical assessment and the

nursing review of system conducted to patient, Mrs. S A E M:

Table 2. PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEM:

NURSING REVIEW OF SYSTEM PHYSICAL ASSESSMENT

HEAD

“wala raman bukol bukol ako ulo dong” as

vervalized by the patient.

Head is proportion to the patient’s body. Some hair

is gray and evenly distributed. No lesions are

visible. Dandruff was noted.

EYES Patient eyes are symmetrical, eyebrows are free

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“ depektado na jud ako panan-aw dong, dili ko ka

klaru og basa kong dili ko mag eyeglass” as

verbalized by the patient.

from scaling, pupils constricted when light is

focused, sclera is white, conjunctiva is clear, and

eye movement and blinking reflex are in good

condition. Teary eyes noted. Patient’s eyeglass

grade is 180.

EARS

“ok raman ako pan dungog” as verbalized by the

patient.

Patient ears are symmetrical, equal in size and same

in appearance. No foul smelly sticky discharged in

both ears. Patient was able to her whispered words.

NOSE

“ ok raman, wala man sad nag ping-ot ako ilong” as

verbalized by the patient.

Nose is located at the midline of the face with no

lesion or redness noted. Client report no tenderness.

Can breathe through the nose clearly. Septums are

not perforated.

MOUTH

“ wala na koy bag-ang sa taas og ubos” as

verbalized by the patient.

Lips are pale without lesions or swelling. Teeth are

incomplete, left and right molars are absent. Gums

and tongue are pale and slightly dry. No lesions and

ulcers noted. Tonsillar pillar are symmetrical,

tonsils are present, vulvula at the midline and gag

reflex are in good condition.

NECK

“ok raman ako pag tulon dong” as verbalized by the

patient.

Patient’s neck is smooth, controlled movement,

cervical lymph nodes are palpable, patients thyroid

are at the midline, smooth, firm, tender and no

lesion noted.

INTEGUMENTARY SYSTEM Skin is fair in complexion, no presence of marks or

scars. Nails are short and with capillary refill time

of 2-3 seconds.

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“Normal raman ako gipamati karon dong” as

verbalized by the patient.

RESPIRATORY SYSTEM

“Usahay maglisod ko og ginhawa” as verbalized by

the patient.

Respiratory rate ranges from 21-22 cycles per

minute, lungs expansion is symmetrical, clear breath

sounds are present.

CARDIOVASCULAR SYSTEM

“ma feel nako nga paspas ang pinitik sa ako kasing-

kasing” as verbalized by the patient.

Heart rate is 78 beats per minute, blood pressure is

130/80 mmHg.

GASTROINTESTINAL SYSYTEM

“wala raman problema dong, makalibang raman ko

kada adlaw” as verbalized by the patient.

Patient reported no abdominal pain. Patient was able

to pass bowel during the shift. Bowel sounds are

normal.

URINARY SYSTEM

“dili man ko mag lisod og pangihi dong” as

verbalized by the patient.

Patients urinary output ranges from 660-750 cc in a

day that’s approximately 20-30 cc/hr. Patient urine

is amber in color.

MUSCULOSKELETAL SYSYTEM

Usahay murag lay-lay ako pamati” as verbalized by

the patient.

Patient can move her legs and other extremities.

Doesn’t need assistance upon walking and

ambulation.

NEUROLOGIC SYSTEM

“ok lng man” as verbalized by the patient.

Patient is conscious, coherent and responsive.

Response with environmental stimuli and interact

with other persons in the room. Answered questions

correctly. Patient is aware of time date and place

when admitted.

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GENETO-URINARY SYSTEM

Patient refuses.

VIII. DEVELOPMENTAL DATA

Developmental history refers to the series or sets of events that an individual

usually undergoes in the specific age and specific time of growth. The purpose of

gathering the developmental history or data is to determine the patient’s physical,

mental, and psychosocial developmental development in order to assess any

developmental delays.

Psychosocial Developmental Theory

Stage and age Central task Indications of

positive

resolutions

Patient’s

resolution

INFANCY

Birth to 1 year

Oral- sensory

Trust

vs.

Mistrust

-Infants develop trust

in self, others, and in

the environment when

caregiver is responsive

to basic needs and

provides comfort.

-Consistency of care

must be given from

same care provider.

-Patient related that

she have any clear

memory during those

times, but she said

that her mother told

her that she loved to

be cuddled and eager

to have her feeding.

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-IF NOT MET, infants

become uncooperative

and aggressive and

show decreased

interest to

environment.

TODDLER

1-3 years old

Muscular-anal

Autonomy

Vs.

Shame/Doubt

-Toddlers learn to

control while

mastering skills such

as toileting, feeding

and dressing when

caregivers provide

reassurance.

-IF NOT MET,

toddlers feel ashamed

and doubt own

abilities, which leads

to lack of self

confidence.

The patient claimed

that the she cries

when she can’t have

those things that she

wants.

PRESCHOOL

3-6 years old

Locomotors

Initiative

Vs.

Guilt

-Child begins to

initiates activities in

place of just imitating

activities; uses

imagination to play;

learns what is allowed

and what is not

-Patient loved to go to

school because she

wanted to learn new

things and meet

classmates and friends

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allowed to develop

self conscience.

-Caregivers must

allow child to be

responsible while

providing assurance.

-IF NOT MET, child

feels guilty and

hesitant.

SCHOOL AGE

6-12 years old

Industry

Vs.

Inferiority

-Childs becomes

productive by

mastering learning

success; child learns to

deal with academics,

group activities, and

friends.

-IF NOT MET, child

develops sense of

inferiority and

incompetence.

-Patient engaged in

some school activities

like volleyball and

participated in other

academics matters.

ADOLESCENCE

12-18 years old

Identity

vs.

Role Confusion

-Adolescents reach for

self-identity by

making choices about

occupation, sexual

orientation, lifestyle

-Patient is really sure

that she is a true girl.

She starts to engaged

in a relationship at

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and adult role; relies

on peer group for

support and

reassurance to create

self-image separate

from parents.

-IF NOT MET,

Adolescent

experiences role

confusion and loss of

self-belief.

this time.

YOUNG

ADULTHOOD

19-25 years old

Intimacy

vs.

Isolation

-Young adults learn to

make a personal

commitment to others

and share life events

with others.

-IF NOT MET, adults

may fear relationship

and isolates self from

others.

- Patient states that at

this time she started to

build relationship to

opposite sex.

MIDDLE – AGE

ADULT

Generativity vs. -middle age adults

prioritize in

-patient state that she

is more concern about

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25-40 years old Stagnation establishing needs for

self and others.

-IF NOT MET,

persons might be more

concern of one-self in

spite of the needs of

others.

herself and her

family.

OLDER –ADULTS

40-60 years old

Integrity

Vs.

despair

-Older adults uses past

experience to assist

others. At this time

they already accept

their limitation in life.

-IF NOT MET, Older

adults might not

accept changes in life;

they will be

demanding

unnecessary assistance

and attention to others.

- Patient state that she

always makes sure

that her children will

grow up as a

respective person, she

always reminds her

about their future.

IX. ANATOMY, PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY

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A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED

“THE HEART”

Human heart is a muscular pump, which is located between the lungs, but

slightly to the left side. The heart of an adult weighs between 250 to 300 grams in

females, and 300 to 350 grams in males. The length of a human heart is around

six inches, and the width is roughly four inches. An average human heart beats

approximately 72 times per minute, and pumps 4-5 liters of blood (per minute) at

rest.

Human Heart – Location

The human heart is located in the middle of the chest - anterior to the spine

and posterior to the sternum or breastbone (long flat bone in the center of the

chest). The heart lies slightly to the left, from the center of the thorax (region

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between head and abdomen). Hence, the left lung is smaller compared to the right

lung.

Parts of the Human Heart

The heart is divided into two cavities (left cavity and right cavity) by a

wall of muscle called septum. The two cavities consist of two chambers each.

Upper chambers are called atrium and the lower ones are called ventricles. The

right cavity receives de-oxygenated blood from various parts of the body (except

the lungs) and pumps it to the lungs, whereas the left cavity receives oxygenated

blood from the lungs, which is pumped throughout the body. Let us discuss the

anatomy of this amazing organ in detail.

Outer Covering - Pericardium: The heart and the roots of its major blood vessels

are surrounded and enclosed by a sac-like structure called pericardium. It

comprises of two parts - the outer fibrous pericardium, made of dense fibrous

connective tissue and an inner double-layered membrane (parietal and visceral

pericardium). The fibrous pericardium is attached to the spinal column,

diaphragm and other parts of the body, by ligaments. The double-layered

membrane consists of an inner layer called visceral pericardium, outer layer called

parietal pericardium (fused to fibrous pericardium) and a pericardial cavity

(between the two layers), which contains serous fluid - pericardial fluid. This fluid

helps in reducing the friction caused by the contractions of the heart.

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Heart Wall: The wall of the heart is made up of three layers of tissues - outer

epicardium, middle myocardium and the inner endocardium. The outer

epicardium functions as a protective outer layer, which includes blood capillaries,

lymph capillaries and nerve fibers. It is similar to the visceral pericardium, and

consists of connective tissues covered by epithelium (membranous tissue covering

internal organs and other internal surfaces of the body). The inner layer called

myocardium, which forms the major part of the heart wall, consists of cardiac

muscle tissues. These tissues are responsible for the contractions of the heart,

which facilitates the pumping of blood. Here, the muscle fibers are separated with

connective tissues that are richly supplied with blood capillaries and nerve fibers.

The inner layer called endocardium, is formed of epithelial and connective tissue

that contains many elastic and collagenous fibers (collagen is the main protein of

connective tissues). These connective tissues contain blood vessels and

specialized cardiac muscle fibers called Purkinje fibers. This layer lines the

chambers of the heart and covers heart valves. It is similar to the inner lining of

blood vessels called endothelium.

Chambers of the Heart: As discussed earlier, the human heart has four chambers,

the upper chambers known as the left and right atria, and the lower chambers

called left and right ventricle. Two blood vessels called the superior vena cava

and the inferior vena cava, brings deoxygenated blood to the right atrium from the

upper half and the lower half of the body, respectively. The right atrium pumps

this blood to the right ventricle through tricuspid valve. Right ventricle pumps this

blood through pulmonary valve to the pulmonary artery, which carries it to the

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lungs (to get re-oxygenated). The left atrium receives oxygenated blood from the

lungs through the pulmonary veins, and pumps it to the left ventricle through the

bicuspid or mitral valve. The left ventricle pumps this blood through the aortic

valve to various parts of the body via aorta, which is the largest blood vessel in

the body. The heart muscles are also supplied with oxygenated blood through

coronary arteries. The atria are thin-walled, as compared to the ventricles. The left

ventricle is the largest of the four chambers of the heart, and its walls have a

thickness of half inch.

Valves of the Heart: Basically the valves in the heart can be classified into two

types – antrioventricular or cuspid valves and semilunar valves. The former are

the valves between the atria and ventricles, whereas the latter are located at the

base of the ventricles. Tricuspid and bicuspid (mitral) valves are antrioventricular

valves, and pulmonary and aortic valve are semilunar valves.

These valves allow the blood to flow only in one direction and prevent reverse

flow. The human heart pumps around five liters of blood per minute

The Cardiovascular System

Your heart and circulatory system make up your cardiovascular system. Your

heart works as a pump that pushes blood to the organs, tissues, and cells of your

body. Blood delivers oxygen and nutrients to every cell and removes the carbon

dioxide and waste products made by those cells. Blood is carried from your heart

to the rest of your body through a complex network of arteries, arterioles, and

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capillaries. Blood is returned to your heart through venules and veins. If all the

vessels of this network in your body were laid end-to-end, they would extend for

about 60,000 miles (more than 96,500 kilometers), which is far enough to circle

the earth more than twice!

The one-way circulatory system carries blood to all parts of your body. This

process of blood flow within your body is called circulation. Arteries carry

oxygen-rich blood away from your heart, and veins carry oxygen-poor blood back

to your heart.

In pulmonary circulation, though, the roles are switched. It is the pulmonary

artery that brings oxygen-poor blood into your lungs and the pulmonary vein that

brings oxygen-rich blood back to your heart.

In the diagram, the vessels that carry oxygen-rich blood are colored red, and the

vessels that carry oxygen-poor blood are colored blue.

Twenty major arteries make a path through your tissues, where they branch into

smaller vessels called arterioles. Arterioles further branch into capillaries, the true

deliverers of oxygen and nutrients to your cells. Most capillaries are thinner than a

hair. In fact, many are so tiny, only one blood cell can move through them at a

time. Once the capillaries deliver oxygen and nutrients and pick up carbon

dioxide and other waste, they move the blood back through wider vessels called

venules. Venules eventually join to form veins, which deliver the blood back to

your heart to pick up oxygen.

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“THE KIDNEY”

Structure of the kidney:

On sectioning, the kidney has a pale outer region- the cortex- and a

darker inner region- the medulla.The medulla is divided into 8-18 conical

regions, called the renal pyramids; the base of each pyramid starts at the

corticomedullary border, and the apex ends in the renal papilla which merges to

form the renal pelvis and then on to form the ureter. In humans, the renal pelvis

is divided into two or three spaces -the major calyces- which in turn divide into

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further minor calyces. The walls of the calyces, pelvis and ureters are lined with

smooth muscle that can contract to force urine towards the bladder by

peristalisis.

The cortex and the medulla are made up of nephrons; these are the functional

units of the kidney, and each kidney contains about 1.3 million of them

The nephron is the unit of the kidney responsible for ultrafiltration of the blood

and reabsorption or excretion of products in the subsequent filtrate. Each

nephron is made up of:

A filtering unit- the glomerulus. 125ml/min of filtrate is formed by the kidneys as

blood is filtered through this sieve-like structure. This filtration is uncontrolled.

The proximal convoluted tubule. Controlled absorption of glucose, sodium, and

other solutes goes on in this region.

The loop of Henle. This region is responsible for concentration and dilution of

urine by utilising a counter-current multiplying mechanism- basically, it is water-

impermeable but can pump sodium out, which in turn affects the osmolarity of the

surrounding tissues and will affect the subsequent movement of water in or out of

the water-permeable collecting duct.

The distal convoluted tubule. This region is responsible, along with the collecting

duct that it joins, for absorbing water back into the body- simple maths will tell

you that the kidney doesn't produce 125ml of urine every minute. 99% of the

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water is normally reabsorbed, leaving highly concentrated urine to flow into the

collecting duct and then into the renal pelvis.

B. PATHOPHYSIOLOGY CONCEPTUAL FRAMEWORK

Risk factors;

-Family history

-Age

-High salt intake

-Low potassium intake

-Obesity

-Alcohol consumption

-Smoking

-Stress

AGENT;

No etiologic factor

HOST;

-family history

-stress

-Age

ENVIRONMENT;

Not related

Affects arteriolar bed

Arteriolar bed constriction

Increase systemic vascular resistance

Increase after load of the heart

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Decreased Blood flow towards the organ

Adrenal cortex secretes aldosterone

Angiotensin I

Angiotensin II

AngiotensinogenJuxtaglomerular cells secretes renin

Increase reabsortion of water and sodium

Increased Blood pressure

Increase aldosterone

Increased phireperal resistance

Arteriolar vasoconstriction

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C. DISCUSSION OF PATHOPHYSIOLOGY

Patient condition was an inherited one from her father side which is

hypertension. Patient has a past health history of heart enlargement due to his

current disease. Her blood pressure increases was also due to a related factor

which is stress, stress could cause constriction of the arteriolar bed. If there will

be constriction of the arteriolar bed there will be increase systemic vascular

resistance. It will affect the heart because the left ventricle in the heart will try to

compensate first for the altered systemic circulation. After load of the heart will

increase so there will be a decreased blood flow towards the organs of the body

because of increased resistance in the arteries. Decreased blood flow will enter to

the kidneys, the juxtaglomerular cells in the kidney will try to compensate for the

decreasing blood that enters to the kidney by secreting renin into the blood

stream. Renin travels towards the liver in a form of angiotensinogen in order to be

converted as angiotensin I, through an angiotensin converting enzyme.

Angiotensin I travel towards the lungs via blood flow in order to be converted into

the lungs as an angiotensine II, then angiotensin II will travel towards the adrenal

glands and stimulate the adrenal ducts to secrete aldosterone. Aldosterone that is

secreted by the adrenal ducts will reabsorb water and sodium in the body in order

to increase the blood pressure.

The RAAS or rennin angiotensine aldosterone system is responsible for the fluid

balance and for the regulation of blood pressure in the body.

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D. SYMPTOMATOLOGY

Symptomatology is a branch of science that deals with the study of different signs

and symptoms of a certain condition or body processes. Its main purposes are to

facilitate the identification of a disease and its process among others.

IDEAL SIGNS AND

SYMPTOMS

ACTUAL SIGNS AND

SYMPTOMS

MANIFESTED BY

PATIENT

SCIENTIFIC BASIS

Nosebleeds Patient stated nose

bleeding prior to

admission.

is the relatively common

occurrence of

hemorrhage from the

nose, usually noticed

when the blood drains

out through the nostrils

Irregular Heartbeat Patient stated that she can

feel her heart beating so

fast.

Abnormal electrical

activity in the heart. The

heart beat may be too fast

or too slow, and may be

regular or irregular.

Blurred Vision Patient stated blurring of Is a type of vision loss, it

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vision prior to admission. is an ocular symptom.

Confusion - Buzzing In

The Ears - Blood In Your

Urine

Not manifested by the

patient.

Confusion may result

from a relatively sudden

brain dysfunction

Lose Weight Not manifested by the

patient.

Is a reduction of the total

body mass, due to a mean

loss of fluid, body fat or

adipose tissue and/or lean

mass, namely bone

mineral deposits, muscle,

tendon and other

connective tissue

chest pain Patient complains of

chest discomfort.

Occurs when blood flow

to the arteries that supply

the heart becomes

blocked. With decreased

blood flow, the muscle of

the heart does not receive

enough oxygen. This can

cause damage.

Headache Patient verbalized

dizziness and headache

Is a pain anywhere in the

region of the head. It is a

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Dizziness during the first contact by

the student nurse.

symptom of several

conditions.

FatiguePatient verbalized body

weakness during her stay

in the hospital.

Is a state of awareness

describing a range of

afflictions, usually

associated with physical

and/or mental weakness,

though varying from a

general state of lethargy

to a specific work-

induced burning

sensation within one's

muscles.

AnxietyPatient is anxious as

observed by the student

nurse during his first

contact by the patient

Anxiety is a

psychological and

physiological state

characterized by

cognitive, somatic,

emotional, and

behavioral components.[2]

These components

combine to create an

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unpleasant feeling that is

typically associated with

uneasiness,

apprehension, fear, or

worry. Anxiety is a

generalized mood

condition that can often

occur without an

identifiable triggering

stimulus

X. MEDICAL MANAGEMENT

IDEAL ACTUAL

–Hematologic Report

→Complete Blood Count

TEST RESULT NORMAL RANGE

UNIT

RBC 5.51 4.2-5.4 m/uL

Hemoglobin 12.70 12-16 g/dL

Hematocri

48.6

37-48 o/o

Lymphocyte 14 20-40 o/o

MVP 10.6 0-100 F/L

31

–Urinalysis Report

Platelets 161 140-440 K/uL

Neotrophils 77.3 40.70 o/o

Monocyte 5 2-8 o/o

Monocyte RDC

2.1 3.4-9.0 o/o

Monocyte ADC

0.13 0.16-1.00 10^3/uL

PHYSICAL

CHARACTERISTIC

RESULT NORMAL RANGE

UNIT

Color Yellow

Appearance Cloudy

Ph 7.5 5.0-8.0

Specific gravity 1.010 1.003-1.033

CHEMICAL CHARACTERISTIC

Creatinine 1.0 0.6-1.5 Mg/dL

SG-PT-ALT 25 5.0-50.0 u/L

Sodium (serum) 138.0 134-148.0 mmoL/L

Potassium 4.0 3.3-5.3 mmoL/L

B. TREATMENT AND PROCEDURES

IDEAL ACTUAL

32

- Patients should stop smoking (offer help nicotine replacement therapy).

- Weight reduction should be suggested if necessary, to maintain ideal BMI of 20-25 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help e.g. dieting clubs, may be appropriate.

- Reduce their salt, total fat, saturated fat and cholesterol intake, while increasing consumption of polyunsaturated, monosaturated fats and oily fish. Encourage fruit, vegetables, legumes and whole grains; and low fat (or zero-fat) dairy, poultry meat, fish and shellfish products.

- Cut alcohol intake to no more than 21 units (male) or 14 units (female) of alcohol per week.

- Encourage regular dynamic exercise tailored to age and capabilities of patient. This may mean three vigorous training sessions per week for a young adult, or brisk walking for ≥30 minutes most days for the older individuals.

- Do not offer supplements of calcium, magnesium or potassium to reduce BP.

Relaxation therapy can help

As well as the targets above, strive for a happy, well-informed patient. Remember to look for and treat any underlying cause in your initial assessment

-Vital signs taken every 4 hours

-Blood pressure taken every 2 hours

-Intake and output monitoring every shift

-Laboratory test taken

-Medication administration

33

C. MEDICATION

IDEAL ACTUAL

Initial Drug Choices

If patient is young (<55) and non-black start with:

(A) ACE inhibitor or Angiotensin II receptor antagonist (ACE II)

If patient is black or aged ≥55 years use:

(C) Calcium channel blocker or

(D) Diuretic (thiazide)

Second Drug Choices

(A+C) ACE inhibitor or Angiotensin II receptor antagonist with Calcium channel blocker or

(A+D) ACE inhibitor or Angiotensin II receptor antagonist with Diuretic (thiazide)

Third Drug Choices

(A+C+D) ACE inhibitor or Angiotensin II receptor antagonist (ACE II) and Calcium channel blocker and Diuretic (thiazide)

- Paracetamol ( Tylenol) p.o for temperature more 38 oC.

- Plasil 10 mg, 1 ampule, IVTT route, STAT.

- Losartan K ( lifezartan ) 50 mg tablet, once daily.

- Rusovastatin ( crestor ) 20 mg tablet, 1 tablet once a daily at bed time.

- Clopidogrel ( plavix ) 75 mg tablet, one talet orally once daily.

D. DIET : Low salt low cholesterol diet

XI. NURSING MANAGEMENT

34

IDEAL ACTUAL

35

1. Vital signs should be checked 2 hourly

with emphasis on Blood pressure and pulse

rate. Monitor patient's weight daily and

keep proper record. This is to help detect

edema or weight loss. Check for side

effects of drugs e.g. orthostatic

hypotension.

2. Rest: Patient should be advised to avoid

stress and tension. He should therefore

have physical and mental rest in order to

conserve energy. Encourage moderate

exercise e.g. walking if there is no dyspnea.

Mild tranquilizers may be given to enable

patient sleep. Should there be dizziness

patient should be protected from falls and

injury.

3. Diet: Restrict sodium intake to about

4grams daily. Give light, easily digestible

diet. Fatty food and excessive carbohydrate

that can increase weight and cholesterol

should be avoided. Coffee, tea, kola nuts,

alcohol should be avoided or minimized.

4. Physical care: Assist patient with

-Monitoring patient’s vital

signs.

-Bedside care was included.

- Changing of linens.

- Monitoring patient’s intake

and output.

- Monitoring of patient’s IVF.

- Low salt and low cholesterol

diet was instructed.

- Health teaching was given.

36

physical care if patient is very weak. Where

there is blurred vision patient may require

the use of medicated eye glasses. If there is

bleeding from the nose (epistaxis) apply ice

pack to the bridge of the nose and back of

the neck. When the ice pack cannot control

bleeding the nose may be packed. The pack

should however be removed within few

days. Make sure patient does not lie on one

side of his body for several days in bed. If

he is to be admitted for days, his position

should be changed every 2-4 hours to

prevent pressure sore from developing.

5. Elimination: Constipation should be

avoided because it makes the patient strain

at defecation thereby further elevating the

blood pressure. Food rich in fiber should be

given to prevent constipation.

B. PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION

OF NURSING CARE

37

There were no major problems encountered during the implementation of nursing

care. The patient was very cooperative and was aware of her health care needs. My only

problem is that I’m still a student and still on the process of learning and acquiring more

knowledge.

C. RESTORATIVE MEASURES USE

I was able to build rapport to the patient and her family members, I was able to

maintain calm and a relaxing environment, assisted patient and encourages her for

verbalization of her concerns about her condition. Patient was able to gain enough rest

and sleep hours. A low salt and low cholesterol diet were given. Medication was given

at exact time and route.

D. EVALUATION

The patient was very appreciative of the care extended to her. She was grateful for

the time and effort given to help in her condition. She was attentive to what is needed for

her health and verbalize that she will practice what are being thought to her during her

stay in the hospital. She verbalized that she will refrain from activities that will exert too

much effort; she will continue the diet that was recommended to her and to take her

medication at exact time.

E. PATIENT TEACHING

38

The patient was encouraged to avoid activities that will exert to much efforts,

avoid food that are high in sodium and cholesterol, avoid being stress because stress can

trigger in increasing the blood pressure. Patient was also instructed to have enough hours

of rest and sleep and to take medication as prescribed by her physician and emphasizes to

the patient the importance of medication as much as lots of client went to stroke.

XII. CONCLUSION AND RECOMMENDATION

A. CONCLUSION

In this study knowledge is basically the important factors to provide proper

provision of health care. The knowledge towards this condition can promote early

detection and can aid in early treatment and proper intervention towards the

progressing illness.

B. RECOMMENDATION

Nurses working with adults with hypertension must have the appropriate

knowledge and skills acquired through basic nursing education curriculum,

ongoing professional development opportunities and orientation to new

work places. Blood pressure should be measured in both arms.

XIII. IMPLICATION OF THE STUDY TO:

39

A. NURSING EDUCATION

This care study emphasizes the importance of theory in rendering

optimal care. This study shows information of the basic insight in Medical

Surgical Nursing. As a student Nurse, it is very important to our

profession that we consolidate both knowledge we gained and skills we

acquired because in real life situation, we might experience on the spot

decisions.

B. NURSING PRACTICE

Nursing practice is an ever increasing variety of ways and settings.

The focused of all nursing practice is the client, who may be individual, a

family or a community. This care study made me knowledgeable in

dealing with my patient and more confident in rendering my nursing care

and service. Aside from that this care study enhances my skills and

knowledge. It also adds to my own significant experiences.

C. NURSING RESEARCH

Nursing research revealed that the care of a hypertensive client has

gradually improved. But we should not end here. We should encourage

ourselves and other individuals to learn more about this condition by

attending seminars and medical missions for this could aid and help in

improving the care for our client.

40

August 20, 2010

Dr. Carmine P. Villarante

Dean College of Nursing

University of Cebu Lupu-Lapu & Mandaue

Dear Ma’am,

I, Jeffrey R. pescadero, would like to ask permission from your good office to allow me to take the case of Mrs. Sonia Asuncion Espadilla Madrid , 47 years old, Female admitted at Chung Hua Hospital as my subject to my care study. This is in partially fulfillment of the requirement of Medical Surgical Nursing NCM 103.

Diagnosis of Mrs. Sonia Asuncion Espadilla Madrid is Hypertensive Urgency.

I am hoping for your kind and consideration and approval regarding this matter

Thank you.

Respectfully yours,

Jeffrey R. Pescadero

BSN 3-A

Noted by:

Ms. Edna L. Estandarte, RN Clinical Instructor

Ms. Estela R. It-It, RN Level 3 chairperson

Ms. Mary Jane Sabaldica, RNNursing Education Coordination

Dr. Carmenn P. Villarante Dean College of Nursing

NURSING CARE PLAN

Patient’s name: Sonia Asuncion Espadilla Madrid Date of admission: July 25, 2010

Ag e: 47 years old Room No. : C-322

Impression: Hypertensive Urgency Physician : Dr. Lerma Noval

Clinical Portrait Pertinent Data

Assessment:

Received Patient lying on bed conscious awake and coherent with ongoing IVF # 1 PNSS 1L @ 40 cc/hr hooked at left arm infusing well. Vital signs were taken and monitored as ordered. Patient verbalized Body malaise and sudden chest discomfort upon rising up to bed.

Chief Complaint:

Chest Discomfort

History of present Illness:

A few hours prior to admission, patient complain of chest discomfort with note of elevated blood pressure of 150/80 mmHg. Patient self medicated with her maintenance medication atenolol 25 mg and was brought to Toledo Hospital and was referred to Chung Hua Hospital for further management.

Significant Findings

Blood Pressure: 150/80 mmHg

Pulse Rate: 54 Bpm

Vital signs: ( During first contact with the patient )

Blood Pressure: 120/70 mmHg

Temperature: 36.6 oC

Heart Rate: 54 Bpm

Respiratory Rate: 20 Cpm

Past health History:

The patient has no known allergies but according to her she was diagnosed last year with heart enlargement due to hypertension.

Vital signs during admission:

Blood Pressure: 150/80 mmHg

Temperature: 38.1 oC

Heart Rate: 78 Bpm

Respiratory Rate: 26 Cpm

Diagnostics Procedure Done:

Hematology, Urinalysis, Complete Blood Count, Chemical Chemistry Report.

ASSESSMENT NURSING DIAGNOSES

SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Luya jud kayo ko karon” as verbalized by the patient.

Objective:

-PR=54 Bpm

-shortness of breath upon exertion

-Body malaise

-Restlessness

Decreased Cardiac Output related to altered stroke volume

Increased blood pressure could cause vasospasm that lead to increased vascular resistance of the arteries. There will be difficulty of the heart to pump blood so there will be an Increased cardiac workload that could lead to a decreased cardiac output

After 8 hours of nursing interventions the patient will be able to maintain blood pressure/cardiac workload.

Specifically the patient will be able to:

1.Participate an activity that reduces blood pressure.

2.Demonstrate stable cardiac rhythm and rate within the patient normal range.

Independent:

1. Monitor blood pressure in both arms.

2. Provide a calm and restful environment.

3.Provide comfort measures ( eg…back and neck massage, elevation of head.)

4.Instruct in relaxation technique.

-Comparison of blood pressure provides a more complete picture of vascular involvement or scope of the problem.

-Helps reduce sympathetic stimulation, promotes relaxation.

-Decreased discomfort and may reduce sympathetic stimulation.

-Can reduce stressful stimuli; provide calming effect thereby reducing blood pressure.

After 8 hours of nursing intervention

Goals met.

The patient was able to maintain a stable blood pressure 120/70mmHg.

5.Monitor response to medication to control blood pressure.

Dependent:

Administer medication as prescribed by the physician.

Collaborative:

Refer to a dietitian

-To determine the effectiveness of the medication.

-Aids in controlling increase blood pressure.

-provide a healthy diet that could avoid the risk of further complication.

ASSESSMENT NURSING DIAGNOSES

SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“nag-guol jud ko sa ako sitwasyun karon” as verbalized by the patient.

Objective:

-Restlessness

-Blank stares or inattention.

Anxiety related to situational crisis as evidenced by express concerned regarding changes in life events.

Anxiety is a feeling of apprehension or fear. The body prepares to deal with a threat: blood pressure and heart rate are increased, sweating is increased, blood flow to the major muscle groups is increased, and immune and digestive system functions are inhibited (the fight or flight response).

After 8 hours of nursing interventions the patient will be able verbalized awareness of feelings of anxiety and healthy way to deal with them.

Specifically the patient will be able to:

1. Report anxiety is reduced to a manageable state.

2. Demonstrate effective coping strategies to reduce anxiety.

Independent:

1.Promote expression of feelings and fears.

2.Proved rest period and uninterrupted sleep.

3. Provide a relaxing and quiet environment.

4.Provide relaxation techniques. (eg.. listening music, massage.)

Dependent:

Administer medication as prescribed by the physician.

-Verbalization of concerns reduces tension.

-Conserved energy and enhance coping mechanism.

-Aids in reducing tension and can promote relaxation to the patient.

-helps in reducing anxiety.

-medication given by the physician can help control the tension.

After 8 hours of nursing intervention

Goals met.

The patient was able to verbalized a reduce of tension that she is feeling.

ASSESSMENT NURSING DIAGNOSES

SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Dali jud kayo ko kutasan dong” as verbalized by the patient.

Objective:

-BP=150/80 mmHg

-PR=54 Bpm

-shortness of breath upon exertion

-Report of dizziness and fatigue.

Activity intolerance related to body weakness.

Muscle cells work by detecting a flow of electrical impulses from the brain which signals them to contract through the release of calcium by the sarcoplasmic reticulum. Fatigue (reduced ability to generate force) may occur due to the nerve, or within the muscle cells themselves. Muscle fatigue is caused by calcium leaking out of the muscle cell. These causes there to be less calcium available for the muscle cell. In addition an enzyme is proposed to be activated by this released calcium which eats away at muscle fibers.

After 8 hours of nursing interventions the patient will be able to report measurable increase in energy and will participate in necessary desired activities.

Specifically the patient will be able to:

1.Participate an activity without shortness of breath.

2.Participate activity without the increase of blood pressure.

3. Report relief of dizziness and fatigue.

Independent:

1. Note client reports of weakness and difficulty in accomplishing task.

2.Assess nutritional status.

3.Provide a positive atmosphere while acknowledging difficulty of the situation for the client.

4.Monitor response to medication and change in regimen.

- Symptoms may result or contribute to tolerance of activity.

- Adequate energy reserves are requirement for activity.

- Helps minimize frustration and rechanneled energy.

- To monitor the effect of the medication.

DRUG NAME DOSAGE AND

FREQUENCY

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

SIDE EFFECTS NURSING RESPONSIBILITIES

GENERIC NAME:

Paracetamol

BRAND NAME:

Biogesic

CLASSIFICATION:

Antipyretic, Analgesic

PATIENT DOSE:

1 tab PO q4 for temperature more than 38 0C

Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat.

- Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis

- Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and anti-inflammatory effects)

- Contraindicated with allergy to acetaminophen.

- Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

CNS: Headache

CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr

GI: Hepatic toxicity and failure, jaundice

GU: Acute kidney failure, renal tubular necrosis

Hematologic: Methemoglobinemia—cyanosis; hemolytic anemia—hematuria, anuria; neutropenia, leucopenia, pancytopenia, thrombocytopenia, hypoglycemia

Hypersensitivity: Rash, fever

- Monitor liver function studies; may cause hepatic toxicity at doses >4g/day

- Monitor renal function studies; albumin indicates nephritis

- Monitor blood studies, especially CBC and pro-time if patient is on long-term therapy.

- Check I&O ratio; decreasing output may indicate renal failure.

-Assess for fever and pain

- Assess hepatotoxicity: dark urine, clay-colored stoolsAssess allergic reactions: rash, urticaria

DRUG NAME DOSAGE AND

FREQUENCY

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

SIDE EFFECTS NURSING RESPONSIBILITIES

GENERIC NAME:

Losartan

BRAND NAME:

Lifesar tan

CLASSIFICATION:

angiotensin II receptor (type AT1) antagonist

PATIENT DOSE:

50 mg tablet once daily

It stimulates aldosterone secretion by the adrenal cortex. Losartan and its principal active metabolite block the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor found in many tissues.

Hypertension

Hypertensive Patients with Left Ventricular Hypertrophy

contraindicated in patients who are hypersensitive to any component of this product

pregnancy

- “colds” (upper respiratory infection) - - dizziness

- stuffy nose

- back pain

Take blood blood pressure before giving the medication.

DRUG NAME DOSAGE AND

FREQUENCY

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

SIDE EFFECTS NURSING RESPONSIBILITIES

GENERIC NAME:

Clopedogrel

BRAND NAME:

Plavix

CLASSIFICATION:

coagulant

PATIENT DOSE:

75 mg Tablet

The drug works by irreversibly inhibiting a receptor called P2Y12, an adenosine diphosphate ADP chemoreceptor.

-Prevention of vascular [[ischemic] events in patients with symptomatic atherosclerosis

-Acute coronary syndrome without ST-segment elevation (NSTEMI),

-ST elevation MI (STEMI)

- Hypersensitivity to the drug substance or any component of the product.

- Active pathological bleeding such as peptic ulcer or intracranial hemorrhage

-you are allergic to any ingredient in Clopidogrel

-you have an active bleeding disorder, such as a stomach ulcer or bleeding in the brain

-hemorrhage, severe neutropenia, and Thrombotic thrombocytopenic purpura (TTP).

Advise patient to do not perform other possibly unsafe tasks until you know how you react to it.

Avoid activities that may cause bruising or injury

DRUG NAME DOSAGE AND

FREQUENCY

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

SIDE EFFECTS NURSING RESPONSIBILITIES

GENERIC NAME:

Rusovastatin

BRAND NAME:

Crestor

CLASSIFICATION:

HMG CoA reductase inhibitors, or "statins."

PATIENT DOSE:

20 mg tab once daily

it increases the number of hepatic LDL receptors on the cell-surface to enhance uptake and catabolism of LDL. Second, rosuvastatin inhibits hepatic synthesis of VLDL, which reduces the total number of VLDL and LDL particles

Hyperlipidemia and Mixed Dyslipidemia

Hypertriglyceridemia

Primary Dysbetalipoproteinemia (Type III Hyperlipoproteinemia)

Homozygous Familial Hypercholesterolemia

Slowing of the Progression of Atherosclerosis

you are allergic to any ingredient in Crestor

you have liver problems or unexplained abnormal liver function tests

you are pregnant or breast-feeding

you are taking itraconazole, mibefradil, or telithromycin

headache;

mild muscle

pain;

joint pain;

constipation;

mild nausea; or

stomach pain or indigestion.

Instruct patient to:

- Avoid using antacids without your doctor's advice.

-Do not increase or decrease the amount of grapefruit products in your diet without first talking to your doctor

-Do not perform other possibly unsafe tasks until you know how you react to it.

Follow the diet and exercise program given to you by your health care provider

Do NOT take more than the recommended dose without checking with your doctor

Type of solution

Classification Content Mechanism of action

Indications Contraindications How supplied Dose Nursing responsibilities

PNSS Hypertonic 100mL Hypertonic solutions contain a high concentration of solute relative to another solution ( e.g. the cell’s cytoplasm ) when a cell is placed in a hypertonic solution, the water diffuses out of the cell, causing the cell to shrivel.

(Wikipedia encyclopedia, 5th edition).

For replacement or maintenance of fluid and electrolytes.

Hypersensitivity to any of the components.

Intravenous infusion

Before:1. Use sterile

infusion set.2. Use only if

solution is clear and container is not leaking.

3. Assess patient’s hydration status.

During:1. Perform time

taping.2. Regulate IVF as

prescribed.3. Check from time

to time the positioning of the patient.

After:1. Chart the date and

time the solution was consumed.

2. Discard empty bottles and tubing to their proper container.

3. Dispose the sharps not together with the bottle but to its correct box for sharps.