Case Study

INTRODUCTION

HYPERTENSION

Hypertension (HTN) or high blood pressure is common disorder that is a

known cardiovascular disease risk factor, characterized by elevated blood

pressure over the normal values of 120/80 mm Hg in an adult over 18 years of

age. This elevation in blood pressure can be divided into three classes of

hypertension.

Prehypertension describes blood pressure measurements of greater than

120 mm Hg systolic or 80 mm Hg diastolic and less than 130 mm Hg systolic or

90 mm Hg diastolic. Persons exhibiting prehypertension are encouraged to

explore life-style modifications to lower blood pressure, but blood-pressure

lowering agents are not generally prescribed without compelling indications.

The second classification of hypertension is Stage 1 hypertension and is

defined by a blood pressure of over 130 mm Hg systolic or 90 mm Hg diastolic

but less than 160 mm Hg systolic or 100 mm Hg diastolic. Patients with Stage 1

hypertension are also encouraged to make life-style modifications, and initial

drug therapy may include thiazide-type diuretics, ACE inhibitors, calcium channel

blockers, beta blockers, and angiotensin-receptor blockers, or a combination of

these.

Stage 2 hypertension is defined by a blood pressure greater than 160 mm

Hg systolic or 100 mm Hg diastolic. Persons with Stage 2 hypertension are

encouraged to make life-style modifications. Two-drug combination therapies (of

thiazide-type diuretics, ACE inhibitors, calcium channel blockers, beta blockers,

and angiotensin-receptor blockers) are indicated for these patients.

Essential hypertension, the most common kind, has no single identifiable

cause, but risk for the disorder is increased by obesity, a high serum sodium

level, hypercholesterolemia, and a family history of high blood pressure. Known

causes of secondary hypertension include sleep apnea, chronic kidney disease,

primary aldosteronism, renovascular disease, chronic steroid therapy, Cushing's

syndrome, pheochromocytoma, coarctation of the aorta, and thyroid or

parathyroid disease.

The incidence of hypertension is higher in men than in women and is twice

as great in African-Americans as in Caucasians. People with mild or moderate

hypertension may be asymptomatic or may experience suboccipital headaches,

especially on rising; tinnitus; lightheadedness; ready fatigability; and palpitations.

With sustained hypertension, arterial walls become thickened, inelastic, and

resistant to blood flow, and the left ventricle becomes distended and

hypertrophied as a result of its efforts to maintain normal circulation against the

increased resistance. Inadequate blood supply to the coronary arteries may

cause angina or myocardial infarction. Left ventricular hypertrophy may lead to

congestive heart failure. Malignant hypertension, characterized by a diastolic

pressure higher than 120 mm Hg, severe headaches, blurred vision, and

confusion, may result in fatal uremia, myocardial infarction, congestive heart

failure, or a cerebrovascular insult. Patients with high blood pressure are advised

to follow a low-sodium, low-saturated-fat diet; to control obesity by reducing

caloric intake; to exercise; to avoid stress; and to have adequate rest.

PATIENT’S PROFILE

NAME: Medina, Crisanta Gamboa

BIRTHDAY: March 25,1948

AGE: 63 years old

SEX: Female

ADDRESS: Brgy. Marawoy, Lipa, City

RELIGION: Roman Catholic

NATIONALITY: Filipino

DATE OF ADMISSION: February 26, 2012

ATTENDING PHYSICIAN: Dra. Ma. Lovely M. Cacho

CHIEF COMPLAINT: chest pain, dizziness

HEALTH HISTORY

Present Health History

The present health history started 3 days prior to confinement at Metro

Lipa Medical Center when the patient, experienced general body weakness,

chest pain, and dizziness. She was admitted under the service of Dra. Ma.

Lovely M. Cacho and stayed at the said hospital for 2 days and was treated as a

case of hypertension stage II. Her physician ordered her to have some laboratory

examinations like Serum Test, Troponin Test, electrolytes, urinalysis, CBC and

ECG. She was given Betahistine, Losartan, Clopidogrel, Finofibrate, Vastarel,

Allopurinol, Vytorin, Corolan, NTG Patch, Omeprazole and Celebrex as her

medication.

Vital Signs upon admission are as follows:

T = 36.2 PR = 120 bpm BP = 170/100 mmHg RR = 20 cpm

Past Health History

Prior to her hospitalization, she denies in having any record or medical

history of being admitted due to trauma, accident and disease. She also denies

having allergies to food and drugs.

Family Health History

The patient has family health history of hypertension on her mother’s side.

LABORATORY EXAMINATIONS

January 26, 2012

SERUM TEST

RESULTNORMAL VALUE

INTERPRETATION

Cholesterol 6.6mmol/L 0.0- 5.2mmol/L High cholesterol accelerates the progression of atherosclerosis of certain arteries that is thought to contribute significantly to hypertension.

Triglycerides 2.79 mmol/L 0.0- 1.69 mmol/L High triglyceride levels can increase your risk of arteriosclerosis that reduces the space available for blood flow, which can cause high blood pressure.

Uric Acid 408 umol/L 149- 369 umol/L Hyperuricemia has now beenfound to be an independent risk factor for hypertension.

ALT 4.42 mmol/L 3.59- 3.88 mmol/L

January 26, 2012

TROPONIN TEST

(-) Negative

January 26, 2012

CBC

RESULT NORMAL VALUE INTERPRETATION

Segmenters 0. 36 % Elevation of segmenters may indicate presence of infection; means that many band (immature) cells are present as the body fights infection.

Lymphocyte 0. 55 % A low lymphocyte count indicates that the body's resistance to fight infection has been substantially lost and one may become more susceptible to certain types of infection.

Monocyte 0. 09 %

January 26, 2012

Urinalysis – DONE. Result not secured.

ECG – DONE. Result not secured.

ANATOMY AND PHYSIOLOGY

CENTRAL NERVOUS SYSTEM

Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter.

Hypothalamus; controls and integrates activities of the autonomic nervous

system and pituitary gland. Regulates emotional and behavioral patterns and

circadian rhythms. Controls body temperature and regulates eating and drinking

behavior. Helps maintain the waking state and establishes patterns of sleep.

Produces the hormones oxytocin and antidiuretic hormone.

CARDIOVASCULAR SYSTEM

Baroreceptors, pressure-sensitive sensory receptors, are located in the aorta,

internal carotid arteries, and other large arteries in the neck and chest. They

send impulses to the cardiovascular center in the medulla oblongata to help

regulate blood pressure. The two most important baroreceptor reflexes are the

carotid sinus reflex and the aortic reflex.

Chemoreceptor, sensory receptors that monitor the chemical composition of

blood, are located close to the baroreceptors of the carotid sinus and the arch of

the aorta in small structures called carotid bodies and aortic bodies, respectively.

These chemoreceptor detect changes in blood level of O2, CO2, and H+.

Heart. The main functions of the heart can be summarized as follows: The right-

hand side of the heart receives de-oxygenated blood from the body tissues (from

the upper- and lower-body via the Superior Vena Cava and the Inferior Vena

Cava, respectively) into the right atrium. This de-oxygenated blood passes

through the tricuspid valve into the right ventricle. This blood is then pumped

under higher pressure from the right ventricle to the lungs via the pulmonary

artery The left-hand side of the heart receives oxygenated blood from the lungs

(via the pulmonary veins) into the left atrium. This oxygenated blood then passes

through the bicuspid valve into the left ventricle. It is then pumped to the aorta

under greater pressure (as explained below). This higher pressure ensures that

the oxygenated blood leaving the heart via the aorta is effectively delivered to

other parts of the body via the vascular system of blood vessels (incl. arteries,

arterioles, and capillaries).

Blood. Our blood carries oxygen to cells. It carries waste (carbon dioxide, Urea

and lactic acid - via diffusion) away from cells and carries various disease-

fighting cells such as the "white" blood cells. It is part of the body's self-repair

mechanism (blood clotting after an open wound in order to stop bleeding - using

'Platelets') and regulates our body PH. It also regulates our core body

temperature.

Blood vessels. The point of blood vessels is to carry blood throughout the body.

Arteries and veins are the largest of the blood vessels. Arteries move blood,

which contains oxygen and nutrients to muscles and organs and veins carry the

blood back to the heart.

RENAL SYSTEM

Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to

the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the

bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act

on their substrates to produce the active hormone angiotensin II, which raises

blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it

raises blood pressure by increasing systemic vascular resistance. Second, it

stimulates secretion of aldosterone, which increases reabsorption of sodium ions

and water by the kidneys. The water reabsorption increases total blood volume,

which increases blood pressure.

Antidiuretic hormone. ADH is produced by the hypothalamus and released from

the posterior pituitary in response to dehydration or decreased blood volume.

Among other actions, ADH causes vasoconstriction, which increases blood

pressure.

Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers

blood pressure by causing vasodilation and by promoting the loss of salt and

water in the urine, which reduces blood volume.

PATHOPHYSIOLOGY OF HYPERTENSION

RISK FACTORFamily History ObesityAge Excess Alcohol ConsumptionHigh Salt Intake Smoking Stress Low Potassium Intake

Changes in Arteriolar Bed Systemic Vascular Resistance

Afterload

Blood Flow to Organ

Blood Pressure

Juxtaglomerular cells

Renin

Angiotensin- Converting Enzyme (ACE)

Angiotensin(Renin substrate)

Angiotensin I(Renin substrate)

Angiotensin II

Aldosterone

Na+ Reabsorption

Blood Volume

Vasoconstriction

TPR

Pressure towards normal

Blood pressure is generated by cardiac contraction against the vascular resistance. Having one or more of the risk factors of hypertension contributes in some changes in arteriolar bed which will then increase the systemic vascular resistance. As the systemic vascular resistance increase, the afterload also increases, therefore heart works harder. Afterload is inversely proportional to stroke volume. During a heartbeat, the heart muscle contracts. This causes the blood to be pumped out, which causes increased pressure in the arteries. There is a stronger than normal force of contraction since the filling pressures is greater and so the SV is greater. Starling’s Law states that the greater the tension or stretch the greater the contraction. Therefore wall tension is chronically increased and this results in remodeling of the ventricular wall again but this time the CXR shape is elongated and off center. This thickness is also associated with an increase in radius to keep their ratio equal. The peripheral blood vessels will return their blood flow back to normal after a sudden increase within less than a minute. There is the metabolic theory that states when the art pressure becomes too great, there is an excess flow of oxygen and nutrients which causes the blood vessels to constrict and flow to return to normal and there is the myogenic theory that states the sudden stretch of small blood vessels cause the smooth muscle of the vessel wall to contract and this reduces the blood flow. Renin will then be released by the juxtoglomerular cells in afferent arterioles of the kidney in response to SNS stimulation. The receptors that mediate this are beta receptors on cells. Renin will then increase the production of angiotensin I which will lead to Angiotensin II which is a potent vasoconstrictor which then increases total peripheral resistance. Angiotensin II will also stimulate the release of aldosterone from the medulla which will increase sodium reabsorption so less Na leaves the body and more stays in which increase ECF volume. There is also progressive increase in TPR while at the same time the CO is decreased back to normal. (Changes almost certainly caused by the long-term blood flow autoregulation mechanism). CO has risen to high level and had initiated the hypertension, the excess blood flow through the tissues than caused progressive constriction of the local arterioles, thus returning the local blood flow and the CO almost back to normal, but simultaneously causing a secondary increase in TPR. The increased TPR occurs and will lead to increase pressure towards normal.

DRUG STUDY

GENERIC NAME: Betahistine

BRAND NAME: Serc

DOSAGE AND ROUTE: 24mg tab PO

CLASSIFICATION: Antiemetic/Antivertigo

ACTION: Betahistine has a very strong affinity as an antagonist

for histamine H3 receptors and a weak affinity as an

agonist for histamine H1 receptors. Betahistine seems

to dilate the blood vessels within the middle ear which

can relieve pressure from excess fluid and act on the

smooth muscle.

INDICATION: Meniere’s disease, Meniere-like syndrome (with

symptoms of vertigo, tinnitus and sensorineural

deafness) and vertigo of peripheral origin.

CONTRAINDICATION: Hypersensitivity to any component of the product.

ADVERSE

REACTION:

Headache.

Low level of gastric side effects.

Nausea can be a side effect, but the patient is

generally already experiencing nausea due to the

vertigo so it goes largely unnoticed.

Decreased appetite, leading to weight loss

NURSING

CONSIDERATION:

Avoid contact of oral solution or injection with skin

Raise bed rails, institute safety measures, supervise

ambulation

GENERIC NAME: Losartan

BRAND NAME: Anzar


CLASSIFICATION: Angiotensin II Antagonists

ACTION: Angiotensin II receptor blocker/antihypertensive.

INDICATION: Losartan is used in the management of hypertension

and may have a role in patients who are unable to

tolerate ACE inhibitors. It has also been tried in heart

failure and myocardial infarction.

CONTRAINDICATION: Patients who are hypersensitive to any component of

this product. Losartan also contraindicated in pregnancy

and breastfeeding. If pregnancy is detected, losartan

should discontinued immediately.

ADVERSE

REACTION:

Adverse effects of losartan have been reported to be

usually mild and transient, and include dizziness and

dose related orthostatic hypotension. Hypotension may

occur particularly in patient with volume depletion, (eg

those who have received high-dose diuretics).

NURSING

CONSIDERATION:

Observe for symptomatic hypotension and tachycardia

especially in patients with CHF; hyponatremia, high-

dose diuretics, or severe volume depletion

GENERIC NAME: Clopidogrel

BRAND NAME: Antiplar


CLASSIFICATION: Anticoagulants, Antiplatelets & Fibrinolytics

(Thrombolytics)

ACTION: Clopidogrel is an inhibitor of platelet aggregation. A

variety of drugs that inhibit platelet function have been

shown to decrease morbid events in people with

established cardiovascular atherosclerotic disease as

evidenced by stroke or transient ischemic attacks,

myocardial infarction, unstable angina or the need for

vascular bypass or angioplasty.

INDICATION: Prevention of atherosclerotic events in peripheral

arterial disease or w/in 35 days of MI, or w/in 6 mth of

ischemic stroke, or in acute coronary syndrome w/o ST-

segment elevation.

CONTRAINDICATION: Patients w/ active pathological bleeding eg peptic ulcer

or intracranial hemorrhage.

ADVERSE

REACTION:

Headache, dizziness, pain, fatigue, flu-like symptoms,

edema, HTN, abdominal pain, diarrhea, nausea,

hemorrhage, arthralgia, back pain, upper resp

infections, dyspnea, rhinitis, bronchitis, coughing,

purpura, epistaxis & skin rash.

NURSING

CONSIDERATION:

• Provide small, frequent meals if GI upset occurs (not

as common as with aspirin).

• Take daily as prescribed. May be taken with meals.

• Report skin rash, chest pain, fainting, severe

headache, abnormal bleeding.

GENERIC NAME: Allopurinol

BRAND NAME: Llanol


CLASSIFICATION: AntiGout

ACTION: Reduces uric acid production by inhibiting biochemical

reactions preceding its formation.

INDICATION: Primary uncomplicated hyperurecemia; mild gout;

severe tophaceous gout; uric acid nephropathy; uric

acid nephrolithiasis; and in the prevention of renal

Calcium oxalate stones.

CONTRAINDICATION: Hypersensitivity.

ADVERSE

REACTION:

Allergic skin reactions, GI disturbances, diarrhea, and

joint pains

NURSING

CONSIDERATION:

•Monitor serum uric acid levels to evaluate drug’s

effectiveness

•Monitor fluid intake and output; daily urine output of at

least 2 liters and maintenance of neutral or slightly

alkaline urine are desirable

•If the patient is taking allopurinol for treatment of

recurrent calcium oxalate stones, advise him to also

reduce his dietary intake of animal protein, sodium,

refined sugars, oxalate-rich foods, and calcium.

•Tell patient to discontinue at first sign of rash, which

may precede severe hypersensitivity or other adverse

reaction. Rash is more common in patient taking

diuretics and in those with renal disorders. Tell the

patient to report all adverse reactions.

GENERIC NAME: Allopurinol

BRAND NAME: Simvastatin


CLASSIFICATION: Dyslipidaemic Agents

ACTION: Simvastatin is a prodrug metabolised in the liver to form

the active β-hydroxyacid derivative. This inhibits the

conversion of HMG-CoA to mevalonic acid by blocking

HMG-CoA reductase, an early and rate-limiting step in

cholesterol biosynthesis. It reduces total cholesterol,

LDL-cholesterol and triglycerides and increases HDL-

cholesterol levels.

INDICATION: Hyperlipidaemias, Prevention of cardiovascular events

and Homozygous familial hypercholesterolaemia

CONTRAINDICATION: Acute liver disease or unexplained persistent elevations

of serum transaminases. Pregnancy, lactation.

Porphyria.

ADVERSE

REACTION:

Headache, nausea, flatulence, heartburn, abdominal

pain, diarrhoea/constipation, dysgeusia; myopathy

features like myalgia and muscle weakness; serum

transaminases and CPK elevations; hypersensitivity;

lens opacities; blurring of vision; dizziness; sexual

dysfunction; insomnia; depression and upper

respiratory symptoms.

NURSING

CONSIDERATION:

Advise patients that blood and eye tests will be

necessary throughout treatment.

Blurred vision, severe gastrointestinal problems,

dizziness or headaches must be reported.

REVIEW OF SYSTEMS

Body Part Assessed Technique Used Actual Finding Interpretation

Skin Inspection Skin color is fair and even. Normal

Palpation Skin is smooth with fair skin turgor. Normal

HEENT Head

Inspection

Normocephalic

Evenly distributed hair, no dandruff, lesions

nor infection.

Normal

Normal

Palpation Sinuses non-tender Normal

Eyes

Inspection

Symmetrical eyelids

Pinkish conjunctiva

Anicteric sclera

Cornea and lens slightly cloudy PERRLA

presence of new retinal hemorrhages,

exudates, or papilledema

Normal

Normal

Signs of Aging

Normal

suggests a hypertensive

urgency.

Nose

Inspection PERRLA Normal

Palpation Normoset

No discharge

Non tender

Normal

Normal

Normal


HEENT No presence of mass or nodules

Symmetrical nasal folds

Nasal septum at midline

Mucosa is moist, pinkish, intact and no

discharge

Airways patent on both nares

Non tender sinuses

Normal

Normal

Normal

Normal

Normal

Normal

Mouth, Pharynx and

Neck

Mouth

Inspection Lips pinkish and dry

Tongue at midline

Gums and mucosa pink

Presence of dentures

Normal

Normal

Normal

Aging (decalcification)

Pharynx

Inspection Uvula at midline

Tonsils not inflamed

Normal

Normal

Neck

Inspection

Neck symmetrical with full ROM Normal


Palpation Trachea at midline

Lymph nodes non tender

Thyroid gland non palpable

Normal

Normal

Normal

Pulmonary Inspection Symmetric AP:L ratio = 1:2 Normal

Palpation Symmetrical lung expansion Normal

Percussion Symmetrical tactile fremitus

Resonant

Normal

Normal

Auscultation Clear lung sounds

No adventitious breath sounds

Normal

Normal

Cardiovascular Inspection Jugular venous distension, Peripheral edema

presence of heart failure

Auscultation Apical pulse at 5thICS MCL

Presence of palpitation

Normal

Due to cardiac

compensation

Abdomen Inspection Flat and symmetrical

No lesions

Normal

Normal

Auscultation Normoactive burbogorhythmic sounds (26 on

4 quadrants in 1 full min)

Normal


Percussion Tympanic over LLQ Dull at RUQ, LUQ and

RLQ

Normal

Palpation No tenderness Normal

Extremities Inspection Skin smooth

Skin intact

Nails convex curved

Pink nail beds

Normal

Normal

Normal

Normal

Palpation Normal capillary refill

Skin cool to touch

Bounding pulses

Muscles with slight atrophy

Fair muscle strength

Full active ROM

<3 sec.

Decreased perfusion

Cardiac compensation

Aging process

Normal

Normal

Motor Sensory Inspection 100% intact

12 cranial nerves responsive

Normal

Normal

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S> “Nanghihina ako at

madaling mapagod kaya

maghapoh lang akong

nakahiga,” as verbalized

by the client.

O>

Generalized weakness

Extreme stress

Lethargic

Decreased stroke

volume

Increased peripheral

vascular resistance

VS taken as follows:

T: 37.2 PR: 83

RR: 18 BP: 180/100

Activity Intolerance

related to disease

process as manifested

by generalized body

weakness.

After a shift of nursing

interventions, the patient

will be able to

report/demonstrate an

increase in activity

tolerance as evidenced

by increased movement

and increased

participation to activities.

Monitor the patient’s

condition.

Note client’s report of

weakness, fatigue,

difficulty accomplishing

tasks, and/or insomnia.

Assist client to adjust

activities to prevent

over exertion.

Increase exercise/

activity level gradually.

Provide patient

adequate rest periods

to conserve energy.

Promote comfort

measures to alleviate

pain if any and

alleviation of pain

leads to increase

activity tolerance

Provide an

environment

Goal met: After a shift of

nursing interventions,

the patient was able to

report/demonstrate an

increase in activity

tolerance as evidenced

by increased movement

and increased

participation to activities.

conducive for rest

Instruct client to

increase oral fluid

intake

Instruct client to have

proper hygiene

Advise client to eat

nutritious foods

Administer medication

as per doctors order:

- Serc 24mg PO

- Ansar 50mg tab PO

- Antiplar 75mg tabPO

- Llanol 140mg tab PO

- Simvastatin 10mgPO

Encourage client to

maintain a positive

attitude

Encourage

participation in

recreation, social

activities, and hobbies

appropriate for

situation.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S> “ Laging sumasakit

ang aking ulo at parang

nanlalabo ang aking

paningin”, as verbalized

by the patient.

O>

Extreme stress

Lethargic

Restlessness

Cool, clammy skin

Optic disc

papilledema

Increased blood

pressure

Decreased stroke

vol.

Increased peripheral

vascular resistance

VS taken as follows:

T: 37.2 PR: 83

RR: 18 BP: 180/100

Ineffective Tissue

Perfusion: related disease

process as manifested by

blurred vision and

increased blood pressure.

STG: After 8 hrs of


blood pressure will be

within set parameters

for the client

LTG: After 6 days of


the client will have an

adequate tissue

perfusion to his body

systems.

Monitor VS at least q

1-2 hrs

Encourage patient to

decrease intake of

caffeine, cola and

chocolates.

Administer vasoactive

drugs and titrate as

ordered to maintain

pressures at set

parameters for

patient.

Observe for

complaints of blurred

vision, tinnitus or

confusion.

Monitor I&O status

Monitor for sudden

onset of chest pain.

Monitor ECG for

changes in rate,

rhythm, dysrhythmias

STG: After 8 hrs of


blood pressure

maintained within set

parameters for the client.

Goal was met.

LTG: After 6 days of

nursing interventions, the

client had an adequate

tissue perfusion to his

body systems.

Goal was met.

and conduction

defects.

Observe extremities

for swelling, erythema,

tenderness and pain.

Observe for

decreased peripheral

pulses, pallor,

coldness and

cyanosis.

Instruct client in

signs/symptoms to

report to physician

such as headache

upon rising, increased

blood pressure, chest

pain, shortness of

breath, increased

heart rate,

visual changes,

edema, muscle

cramps and nausea

and vomiting.

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Case Study