Case Presentation

Mary Johnson is a 39 year old African American woman who presents today for a routine
check up. She has no specific complaints. She has been a patient of this practice for six
years.

Patient Chart | Mary Johnson

Past Medical History – None. Vaccinations are up to date.
Medications – None.
Gynecologic History – Menarche age 12. No history of menstrual irregularities.
Menses every 28 days and has normal flow for 4 days. Last period was two weeks ago.
She is gravida 2 para 2 having two children via normal spontaneous vaginal deliveries in
the past. No history of STIs. Pap smears and breast exams are all normal in past years.
She uses condoms only as contraception.
Past Surgical History – None
Social History – She speaks English. Married to her husband and 2 children (all of
whom are your patients). She works as a banking department manager. She is sexually
active with her husband only. She drinks 2 glasses of wine on weekends. She has never
smoked. Denies any drug use. Has good emotional support from her family and her
parents live nearby (and they are also your patients).
Family History – Father has blood pressure and cholesterol problems. Mother is
overweight but generally healthy. Sister is healthy. No other problems reported.
ROS – Completely negative
Vital Signs - BP 145/80 | P 73 | R 20 | T 98.6 | Weight 190 | Height 5 feet 8 inches |
Waist circumference 35 inches | BMI 28.9
Patient Assessment Database

ACTIVITY/REST

May report:

Weakness, fatigue, shortness of breath, sedentary lifestyle

May exhibit:
Elevated heart rate
Change in heart rhythm
Tachypnea; shortness of breath with exertion

CIRCULATION

May report:
History of intermittent or sustained elevation of diastolic or systolic blood pressure; presence
of atherosclerotic, valvular, or coronary artery heart disease (including myocardial infarction
[MI], angina, heart failure [HF]) and cerebrovascular disease (reflecting TOD)
Episodes of palpitations, diaphoresis

May exhibit:
Elevated blood pressure (BP) (serial elevated measurements are necessary to confirm
diagnosis) Note: Postural hypotension, when present, may be related to drug regimen or
reflect dehydration or reduced ventricular function.

Pulse:
Bounding carotid, jugular, radial pulsations; pulse disparities, e.g., femoral delay as
compared with radial or brachial pulsation; absence of/diminished popliteal, posterior tibial,
pedal pulses

Apical pulse:
Point of maximal impulse (PMI) possibly displaced and/or forceful

Rate/rhythm:
Tachycardia, various dysrhythmias

Heart sounds:
Accentuated S2 at base; S3 (early HF); S4 (rigid left ventricle/left ventricular hypertrophy)
Murmurs of valvular stenosis
Vascular bruits audible over carotid, femoral, or epigastrium (artery stenosis); jugular
venous distension (JVD) (venous congestion)

Extremities:
Discoloration of skin, cool temperature (peripheral vasoconstriction); capillary refill possibly
slow/delayed (vasoconstriction)

Skin:
Pallor, cyanosis, and diaphoresis (congestion, hypoxemia); flushing (pheochromocytoma)

EGO INTEGRITY

May report:
History of personality changes, anxiety, depression, euphoria, or chronic anger (may
cerebral impairment)
Multiple stress factors (relationship, financial, job-related)
May exhibit:
Mood swings, restlessness, irritability, narrowed attention span, outbursts of crying
Emphatic hand gestures, tense facial muscles (particularly around the eyes), quick physical
movement, expiratory sighs, accelerated speech pattern

ELIMINATION

May report:
Past or present renal insult (e.g., infection/obstruction or past history of kidney disease)
FOOD/FLUID

May report:
Food preferences, which include high-salt, high-fat, high-cholesterol foods (e.g., fried foods,
cheese, eggs); licorice; high caloric content; low dietary intake of potassium, calcium, and
magnesium
Nausea, vomiting
Recent weight changes (gain/loss)
Current/history of diuretic use

May exhibit:
Normal weight or obesity
Presence of edema (may be generalized or dependent); venous congestion, JVD
Glycosuria (almost 10% of hypertensive patients are diabetic, reflecting TOD)

NEUROSENSORY

May report:
Fainting spells/dizziness
Throbbing, suboccipital headaches (present on awakening and disappearing spontaneously
after several hours)
Episodes of numbness and/or weakness on one side of the body, brief periods of confusion
or difficulty with speech (transient ischemic attack [TIA]); or history of cerebrovascular
accident (CVA)
Visual disturbances (diplopia, blurred vision)
Episodes of epistaxis

May exhibit:
Mental status: changes in alertness, orientation, speech pattern/content, affect, thought
process, or memory
Motor responses: decreased strength, hand grip, and/or deep tendon reflexes
Optic retinal changes: from mild sclerosis/arterial narrowing to marked retinal and sclerotic
changes with edema or papilledema, exudates, hemorrhages, and arterial nicking,
dependent on severity/duration of hypertension (TOD)

PAIN/DISCOMFORT

May report:
Angina (coronary artery disease/cardiac involvement)
Intermittent pain in legs/claudication (indicative of arteriosclerosis of lower extremity
arteries)
Severe occipital headaches as previously noted
Abdominal pain/masses (pheochromocytoma)

RESPIRATION

(Generally associated with advanced cardiopulmonary effects of sustained/severe

hypertension)
May report:
Dyspnea associated with activity/exertion
Tachypnea, orthopnea, paroxysmal nocturnal dyspnea
Cough with/without sputum production
Smoking history (major risk factor)

May exhibit:
Respiratory distress/use of accessory muscles
Adventitious breath sounds (crackles/wheezes)
Pallor or cyanosis

SAFETY

May report/exhibit:
Impaired coordination/gait
Transient episodes of numbness, unilateral paresthesias
Light-headedness with position changes
sexuality

May report:
Postmenopausal (major risk factor)
Erectile dysfunction (medication related)

TEACHING/LEARNING

May report:
Familial risk factors: hypertension, atherosclerosis, heart disease, diabetes mellitus,
cerebrovascular/kidney disease
Ethnic/racial risk factors, e.g., more prevalent in African-American and Southeast Asian
populations
Use of birth control pills or other hormones; drug/alcohol use

Discharge plan considerations:

DRG projected mean length of inpatient stay: 3.5 days
Assistance with self-monitoring of BP
Periodic evaluation of and alterations in medication therapy
Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES
Hemoglobin/hematocrit: Not diagnostic but assesses relationship of cells to fluid volume
(viscosity) and may indicate risk factors such as hypercoagulability, anemia.
Blood urea nitrogen (BUN)/creatinine: Provides information about renal perfusion/function.
Glucose: Hyperglycemia (diabetes mellitus is a precipitator of hypertension) may result from
elevated catecholamine levels (increases hypertension).
Serum potassium: Hypokalemia may indicate the presence of primary aldosteronism (cause)
or be a side effect of diuretic therapy.
Serum calcium: Imbalance may contribute to hypertension.
Lipid panel (total lipids, high-density lipoprotein [HDL], low-density lipoprotein [LDL],
cholesterol, triglycerides, phospholipids): Elevated level may indicate predisposition
for/presence of atheromatousplaquing.
Thyroid studies: Hyperthyroidism may lead or contribute to vasoconstriction and
hypertension.
Serum/urine aldosterone level: May be done to assess for primary aldosteronism (cause).
Urinalysis: May show blood, protein, or white blood cells; or glucose suggests renal
dysfunction and/or presence of diabetes.
Creatinine clearance: May be reduced, reflecting renal damage.
Urine vanillylmandelic acid (VMA) (catecholamine metabolite): Elevation may indicate
presence of pheochromocytoma (cause); 24-hour urine VMA may be done for assessment of
pheochromocytoma if hypertension is intermittent.
Uric acid: Hyperuricemia has been implicated as a risk factor for the development of
hypertension.
Renin: Elevated in renovascular and malignant hypertension, salt-wasting disorders.
Urine steroids: Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary
dysfunction, Cushing’s syndrome.
Intravenous pyelogram (IVP): May identify cause of secondary hypertension, e.g., renal
parenchymal disease, renal/ureteral calculi.
Kidney and renography nuclear scan: Evaluates renal status (TOD).
Excretory urography: May reveal renal atrophy, indicating chronic renal disease.
Chest x-ray: May demonstrate obstructing calcification in valve areas; deposits in and/or
notching of aorta; cardiac enlargement.
Computed tomography (CT) scan: Assesses for cerebral tumor, CVA, or encephalopathy or to
rule out pheochromocytoma.
Electrocardiogram (ECG): May demonstrate enlarged heart, strain patterns, conduction
disturbances. Note: Broad, notched P wave is one of the earliest signs of hypertensive heart
disease.

NURSING PRIORITIES

1. Maintain/enhance cardiovascular functioning.

2. Prevent complications.
3. Provide information about disease process/prognosis and treatment regimen.
4. Support active patient control of condition.

DISCHARGE GOALS

1. BP within acceptable limits for individual.

2. Cardiovascular and systemic complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Necessary lifestyle/behavioral changes initiated.
5. Plan in place to meet needs after discharge.

Full Nursing Care Plan Hypertension

DIAGNOSIS

The following nursing diagnoses are made for Mrs. Spezia.

• Fatigue related to effects of hypertension and stresses of daily

life

• Imbalanced nutrition: More than body requirements related to

excessive food intake

• Ineffective health maintenance related to inability to modify

lifestyle

• Deficient knowledge related to effects of prescribed treatment

EXPECTED OUTCOMES

The expected outcomes specify that Mrs. Spezia will:

• Reduce blood pressure readings to less than 150 systolic and 90

diastolic by return visit next week.

• Incorporate low-sodium and low-fat foods from a list provided

into her diet.

• Develop a plan for regular exercise.

• Verbalize understanding of the effects of prescribed drug, dietary restrictions,

exercise, and follow-up visits to help control

hypertension.

PLANNING AND IMPLEMENTATION

The following nursing interventions are planned and implemented.

• Teach to take own blood pressure daily and record it, bringing

the record to scheduled clinic visits.

• Teach name, dose, action, and side effects of her antihypertensive medication.

• Instruct to walk for 15 minutes each day this week, and to investigate swimming
classes at the local pool.

• Discuss strategies for achieving a realistic weight loss goal.

 • Refer for a dietary consultation for further teaching about fat

and sodium restrictions.

• Discuss stress-reducing techniques, helping identify possible

choices.

Physical exam for high blood pressure

The extent of the physical exam and the level of detail in your doctor's questions depend on how high
your blood pressure is and whether you have other risk factors for heart disease. People who have many
risk factors may have a more detailed evaluation.
The physical exam includes:
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• Your medical history to evaluate risk factors.
• Two or more blood pressure measurements. Measurements may be taken from both the left and right
arms and legs and may be taken in more than one position, such as lying down, standing, or sitting.
Multiple measurements may be taken and averaged.
• Measurement of your weight and height.
• Exam of the retina, the light-sensitive lining at the back of the eye.
• A heart exam.
• Exam of your legs for fluid buildup (edema), and the pulse in several areas, including the neck.
• Exam of your abdomen using a stethoscope. A doctor will listen to the blood vessels in the abdomen for
abnormal sounds. These sounds may be caused by blood flow through a narrowed artery in the abdomen
(abdominal bruits).

• Exam of your neck for an enlarged thyroid , distended neck veins, and bruitsin the carotid arteries.
Why It Is Done

The physical exam and medical history are done to:

• Confirm that you have high blood pressure.
• Check for effects of high blood pressure on organs such as the kidneys and heart.
• Determine whether you have risk factors for heart disease or stroke.
• Rule out other causes of high blood pressure (secondary hypertension), such as medicines or other
medical conditions.
Results
 Blood pressure measurements are classified as follows.
Normal (optimal)
• Systolic 119 millimeters of mercury (mm Hg) or below
• Diastolic 79 mm Hg or below
Prehypertension
• Systolic 120–139 mm Hg
• Diastolic 80–89 mm Hg
High blood pressure (hypertension)
• Systolic 140 mm Hg or above
• Diastolic 90 mm Hg or above
High blood pressure is also classified into stages.
• Stage 1 high blood pressure:
○ Systolic 140–159 mm Hg
○ Diastolic 90–99 mm Hg
• Stage 2 high blood pressure:
○ Systolic 160 mm Hg or higher
○ Diastolic 100 mm Hg or higher

Other exams
The physical exam may look for evidence that high blood pressure has already caused damage to blood
vessels or other organs or for signs of other disease. Your doctor may examine your:
• Eyes.
• Heart, torso, arms, and legs.
If prehypertension or high blood pressure is diagnosed, lifestyle changes and/or drug treatment may be
started.
You may need more tests to check for secondary high blood pressure or damage to other organs, such
as the kidneys, if:
• You are young and your blood pressure is 160/100 or higher.
• You had many treatments and medicines but your blood pressure is still 160/100 or higher.
What To Think About

In most cases of high blood pressure, the person does not have any signs of complications or secondary
causes of high blood pressure.
A diagnosis of high blood pressure usually is based on an average of two or more readings taken during
two or more visits after an initial screening.
• Except in very severe cases, the diagnosis is not based on a single reading.
• Two or more blood pressure measurements, taken at follow-up doctor visits, may be needed to confirm
an initial high blood pressure reading.
• Single blood pressure readings taken a week apart may vary, due to normal changes in blood pressure
and to differences in how it is measured.
Complete the medical test information form (PDF) (What is a PDFdocument?) to help you
prepare for this test.

Patient Evaluation| The Physical

Examination for Patients with
Essential Hypertension
The elements of a proper initial physical
examination for patient with new essential
hypertension
Initial Patient Physical Exam Form:
What are the elements of a proper initial physical examination for a patient with new
hypertension as per JNC 7? (Choose all that apply)
Top of Form

A) Two blood pressure measurements 2 minutes apart on each arm

B) Calculate the BMI (body mass index)

C) Fundiscopic exam

D) Assess the tympanic membranes

E) Examine the thyroid

F) Check for neck bruits

G) Ausculate the heart for rate and murmurs

H) Check the PMI (point of maximal impact)

I) Check for abdominal bruits

 J) Check for hepatosplenomegaly

K) Perform a genital examination

L) Assess peripheral veins

M) Evaluate for lower extremity edema

N) Neurological evaluation

O) Perform a general skin examination

Bottom of Form

Assess
Weight—BMI, waist circumference and weight history
Laboratory values and blood pressure
Risk for Metabolic Syndrome
Diet history
Alcohol intake
Physical activity history and limitations
Readiness for lifestyle change
Weight—BMI, waist circumference and weight history
• Use Body Mass Index (BMI) to determine if patient is overweight or obese.
• Consider measuring waist circumference to assess abdominal obesity.
• Assess recent weight changes, and if BMI>25, assess history of obesity, i.e., age of onset,
and previous weight loss attempts and successes.

BMI is used to define obesity

• BMI=Weight divided by height squared (Wt kg/Ht m2)
• Standards are the same for both adult men and adult women
• Correlates with body fat
• Determines degree of obesity and health risk
 • Can be used to track treatment results for obesity
• May overestimate body fat in athletes and others who have a muscular build
• May underestimate body fat in older persons and others who have lost muscle mass
• May be inaccurate for patients with edema

The US Preventive Services Task Force recommends including BMI as a vital sign.
BMI tables
BMI calculator
BMI calculator to download to PDA
BMI Classification
Underweight <18.5
Normal weight 18.5-24.9
Overweight 25-29.9
Obesity =>30
Extreme obesity =>40
Classification of Overweight and Obesity
Waist circumference predicts health risk
• Measures excess abdominal fat
• Predicts abdominal fat better than waist:hip ratio
• Independently predicts risk when BMI not markedly increased (If BMI>35, no need to
measure waist circumference)
• Is important in diagnosing Metabolic Syndrome
• Measure waist circumference correctly for accurate assessment. See Measuring Tape
Position for Waist (Abdominal) Circumference
High Risk Waist Circumference
Men >40 in (102 cm)
Women >35 in (88 cm)
Measuring Waist Circumference

Return to Top
Laboratory values and blood pressure
• Fasting lipid profile
• Fasting blood sugar
• Blood pressure
 Return to Top
Risk for Metabolic Syndrome
Assess patient's risk for Metabolic Syndrome.
Criteria for Metabolic Syndrome
Three or More of the Following Risk Factors
Risk Factor Defining Level
Abdominal obesity* Waist circumference+
Men >102 cm (>40 in)
Women >88 cm (>35 in)
Triglycerides >150 mg/dL or drug treatment for elevated triglycerides
HDL cholesterol <40 mg/dl
Men <50 mg/dl
Women or drug treatment for reduced HDL-C
Blood pressure >130/85 mmHg or drug treatment for hypertension
Fasting glucose >100 mg/dL or drug treatment for elevated blood glucose
*Abdominal obesity is more highly correlated with metabolic risk factors than is an elevated BMI.
+Guidelines for measuring waist circumference
Source: Diagnosis & Management of the Metabolic Syndrome: AHA/NHLBI Scientific
Statement. Circulation2005;112:2735-52.