CASE STUDY about HYPERTENSION

August 19-21, 26-28, 2010

NLA-II Group Members:

Balderas, Je-Ann Marie Cabanban, Daryl Jan Cruz, Rhaiz John Cuenca, Gernie Jean Dionisio, Jenielyn Gragasin, Kevin Hufana, Katley Lia Obaob, Jay Lawrence Sunga, Kenneth Tuazon, Jean Louise
Submitted to:

Mr. Joel Valencia

Clinical Instructor

INTRODUCTION
Hypertension is one of the most common worldwide diseases afflicting humans. Because of the associated morbidity and mortality and the cost to society, hypertension is an important public health challenge. Over the past several decades, extensive research, widespread patient education, and a concerted effort on the part of health care professionals have led to decreased mortality and morbidity rates from the multiple organ damage arising from years of untreated hypertension. Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause), congestive heart failure, end-stage renal disease, and peripheral vascular disease. Therefore, health care professionals must not only identify and treat patients with hypertension but also promote a healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the general population. Hypertension (HPN) or high blood pressure is a chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. It is classified as either primary (essential) or secondary. About 9095% of cases are termed "primary hypertension", which refers to high blood pressure for which no medical cause can be found. The remaining 510% of cases (Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart, or endocrine system. Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure. Moderate elevation of arterial blood pressure leads to shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment may prove necessary in patients for whom lifestyle changes prove ineffective or insufficient.

Patients Profile
Name: Home Address: Age: Birth Date: Birth Place: Sex: Nationality: Status: Occupation: Religion: Date Admitted: Time: Date discharged: Time: Patient X Ambalayos Tagudin 66 yr. old November 17, 1943 Tagudin Female Filipino Married n/a Roman Catholic August 26, 20010 7:10 pm August 28, 2010 2:00 pm

LAB RESULTS Result Hemoglobin: 134g/l RBC: WBC: 4.6 x 10 12/L 8.7 x 10 9/L Normal Values Male: 130-160 g/l Female: 120-140 g/l Male: Female: Adult : Infants: 4.5-6.2 x 10 12/L 4.0-5.5 x10 12/L 5.0-10.0 x 10 9/L 10.0-25.0 x 10 9/L

INTERPRETATION: The results obtained from the procedure shows that hemoglobin and RBC are within the normal range which indicates that the patient is not suffering from anemia and/or any other diseases involving these blood components. Also, the WBC count of the patient shows a value which is within the normal range which indicates that the patient is not suffering from infection or inflammation.

13 Areas of Assessment
I SOCIAL STATUS Patient X is a 66yrs. Old, born on November 17, 1943. She resides at Ambalayos Tagudin together with her husband. They have two daughters and one son. Her son is a vocational graduate and the two daughters were college graduates. Her eldest daughter is working in canada and the other two siblings lived in manila with their own family but sometimes visit their mother in times of need. Patient X medical expenses and other financial needs are supported by her siblings. Due to present illness her lifestyle is affected. Before she had this disease patients was socially active, but at present she was not able to mingle with her neighbors, go to other places where she wants to go, and cannot serve to the church where she used to do it during her younger years. Patient X also stated that she do not smoke and drink alcohol. Norms: Social status includes family relationships/friendships that state the patients support system in time of stress and in time of need. It meets a fundamental human need for social ties, making life less stressful and social support buffers the negative effects of stress, thus indicating indirectly contributing to good health outcomes. (Friedman and Smith 1988) Analysis: Based on the above statements Patient X social status is affected by her condition. Though she has a close family relationship and a very active social life before, her condition forces her to restrain from interactions outside home. II - MENTAL STATUS Patient X is oriented to time, place and person. She can identify things or names being asked. She can recall recent and remote memories she experienced. She is able to read and write with eye glasses and can speak English, Tagalog and Ilocano. She is responsive and answers to the questions being asked. Norms: The content of the patient message should make sense. The ability to read and write should match the patients educational level. The patient should be able to correctly respond to questions and to identify all the objects as requested. The patient should be able to evaluate and act appropriately in situations requiring judgment. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes)

Analysis: Being responsive and being able to answer questions accordingly are the major determinants which indicate patients mental capabilities are still functioning well. III EMOTIONAL STATUS Patient X is cooperative and relaxed while performing the interview. She stated that she does not feel any fear regarding her condition. She accepted it and stated that every individual has an end. She believes that everything has a reason and said that everything is in Gods plan. Patient X just prayed that she will not suffer too much pain from her condition. Norms: The old adult is in the stage where an issue of ego integrity vs. despair arises. Integrity manifests with wisdom and feelings of satisfaction with ones life while despair arises from remorse about what could have been. The presence of despair causes life to be viewed as meaningless. (Source: Nursing CEU.com: The process of human development) Analysis: The fact that shows the that patient she is shows acceptance stable regarding and her current accordingly. health She condition emotionally reacts

believes that her life is part of Gods will and everything that happens to her has a reason. IV SENSORY PERCEPTION She is using reading glasses due to blurring of vision. Her hearing ability is normal using whisper test with distance of two feet. Her sense of smell is normal and she can distinguish foul and fresh odor. Her lips are light brown in color. Her tongue is slightly pink and she can taste whatever food she eats. Norms: Each of the five senses becomes less efficient in older adult hood. Changes result in loss of visual acuity, less power of adaptation to darkness and dim light, decreased in accommodation to near and far objects. The loss of hearing ability related to aging affects people over age 65. Gradual loss of hearing is more common among man than women, perhaps because men are more frequently in noisy work environments. Older people have a poorer sense of taste and smell and are less stimulated by food than the young. Loss of skin receptors takes place gradually, producing an increased threshold for sensations of pain, touch, and temperature.(Fundamental of Nursing 7th edition Barbara Kozier) Analysis: Patient Xs blurring of her vision is due to aging process. The sense of smell, taste and hearing can perceive stimuli accordingly.

V MOTOR STABILITY Patient X is able to perform ADL with minimum assistance of her husband once admitted. She is comfortable as of she has a normal bp compare to at times increased blood pressure. She finds walking, sitting comfortable as shes changing position. Norms: Late adulthood in is in the flow. stage where neuron slow loss due continues to with associated levels of decrease Analysis: Due to her present condition and also due to old age, the patient has difficulty in coordinating movements as well as performing ADLs. VI BODY TEMPERATURE The table below shows the temperature of Patient X during the shift: Date August. 27, 2010 Time 8am 12pm Norms: Normal axillary temperature is within 36.4C to 37.4C. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes) VII RESPIRATORY STATUS Respirations were normal in pattern noted. Table below shows the respiratory rate of the patient. Date August 27, 2010 Norms: Normal respiratory rate for adults is 12-20cpm. Average is 18. In terms of pattern, normal respirations must be regular and even in rhythm. The normal depth of respirations is non exaggerated and effortless (Health assessment and physical examination 3rd edition Mary Ellen Zator Estes) Analysis: Patient X has normal repiratory status. Time 8am 12pm Respiratory rate 21cpm 20cpm Analysis Normal Normal Temperature 35.9 C 37.2 C Analysis Abnormal Normal cerebral Reaction times decreased

neurotransmitter. (Focus on Pathophysiology by Bullock and Henze)

VIII CIRCULATORY STATUS The circulatory status of the patient as well as blood pressure noted below: Date August 27, 2010 Time 8am 12pm Date August 27, 2010 Norms: Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood pressure is 120/80 mmHg. The working capacity of the heart diminishes with aging. The heart rate of older people is slow to respond to stress and slow to return to normal after stress. Reduced arterial elasticity results in diminished blood supply to the parts of the body especially the extremities. (Kozier et. al, 2004) Analysis: Patient X during the shift has an increased bp of 160/80 in the borderline of stage 2 high blood pressure which diminished after a few hours by due meds given. IX NUTRITIONAL STATUS Prior to admission Patient X meal intake is two to three times a day. The food served is usually vegetables, fish, and sometimes meat, high in sodium and fats. During admission, the food served to Patient X is low salt and low fat. She was advised by the ROD to eat low sodium and low fats. Patient X body weight is increased due to high fat and high sodium diet before she was admitted. Norms: Fluid, salt and fat restriction is the diet management for patients with hypertension. (Brunner and Suddarths Textbook of Medical-Surgical Nursing) Analysis: Salt restriction prevents water retention in the body while fat restriction prevents high blood pressure. X ELIMINATION STATUS Patient X usually defecates once a day. On august 27, 2010 from morning during the 7-3 shift she did urinate 2 times. Norms: An individual usually defecate one to two times a day or every 2 days and urinates 30 cc/hr. (Nutrition by Alex Abelos ) Analysis: Time 8am 12pm Blood Pressure 160/80 130/80 Pulse rate 75 bpm 76 bpm Analysis Abnormal Abnormal Analysis Normal Normal

The patient has a regular elimination status. XI REPRODUCTIVE STATUS Patient X had her first menstrual period at age 12. She got married at age 21. She had her first pregnancy at age 22. Her childrens have 2 to 3 yrs. age gap. Norms: Menarche, which is the first menstruation occur at an average age of onset between 9 to 17 years old. Pregnancy may occur from stage of menarche up to cessation of menstrual period. Menopause occurs with age range of 40 to 55. (Maternal and Child Health nursing fourth Edition by Pilliterri) Analysis: As based from the above information, patient has a normal reproductive status. XII SLEEP-REST PATTERN She usually sleeps 7 to 8 hours a day. She stated that sometimes her sleep is interrupted when nurse get vital signs early in the morning. She usually watches television at home during rest hours. Norms: Sleep refers to altered consciousness with general slowing of physiologic process while rest refers to relaxation and calmness, both mental and physical. A typical sleeper will pass through 7 to 9 hours of sleep and take a rest using some relaxation activities such as reading, telling stories and others. (Nursing Fundamentals by Rick Daniels Analysis: Patient X sleeps and rest pattern is normal. XIII STATE OF SKIN APPEARANCE Patient X skin is brown in color, wrinkled and dry. Her hair is thin, fine and black with some gray hair. Her conjunctiva is slightly pale, and sclera is white in color. She has a bruise on the left upper extremity forearm. Her nail beds are pale in color. Norms: Obvious changes occur in the integumentary system (skin, hair, nails) with age. The skin becomes drier and more fragile, the hair loses color, the finger nails and toe nails become thickened and brittle, and in woman over 60, facial hair increases. These integumentary system changes accompany progressive losses of subcutaneous fat and muscle tissue, muscle atrophy, and loss of elastic fibers. (Fundamental of Nursing 7th edition by Barbara Kozier) The palpebral conjunctiva should appear pink and moist. Normally, the skin is a uniform whitish pink or brown color, depending on the patients race. Normally, the nails have a pink cast in

light-skinned individuals and are brown in dark-skinned individuals.(Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes) Analysis: Based from the above information the color of her conjunctiva and nail beds are not normal.

PATHOPHYSIOLOGY

Unknown cause, but may have several risk factors (familial, genetic, increased age, sedimentary lifestyle) Increased production of contracting factors such as endothelin-1 and thromboxane A2

Increased activity of signaling pathways of vascular smooth muscle contraction

Enhances vasoconstriction

Significant increase in the peripheral vascular resistance and arterial pressure

Increases in the heart rate and stroke volume

Increased plasma volume, and cardiac output

Essential hypertension

Ineffective tissue perfusion related to decrease oxygen in the blood secondary to essential hypertension.

Activity intolerance related to body weakness secondary to essential hypertension.

Essential hypertension (also called primary or idiopathic hypertension) is the form of hypertension that by definition has no identifiable cause. It is the most common type of

hypertension, affecting 95% of hypertensive patients; it tends to be familial genetic, increased age, and sedimentary lifestyle. Essential hypertension is characterized by significant and persistent elevations in arterial pressure. Short-term and long-term regulation of arterial pressure is influenced by changes in cardiac function, the peripheral vascular resistance, and the renal control mechanisms of plasma electrolytes and volume. Increases in the heart rate and stroke volume lead to increases in the cardiac output and could contribute to increases in arterial pressure particularly in relatively young individuals. Vascular endothelial cell dysfunction could lead to reduction in endothelium-derived relaxing factors such as nitric oxide, prostacyclin, and endothelium-derived hyperpolarizing factor, or increased production of contracting factors such as endothelin-1 and thromboxane A2. Also, increased activity of signaling pathways of vascular smooth muscle contraction such as [Ca(2+)]i, protein kinase C, mitogen-activated protein kinase, and Rho kinase could enhance vasoconstriction. The decreased vascular relaxation and excessive vasoconstriction lead to significant increases in the peripheral vascular resistance and arterial pressure over time, particularly with aging. Alterations in body fluid regulation by the kidneys could lead to salt and water retention, increased plasma volume, and cardiac output. Also, activation of the renin-angiotensin system increases the levels of angiotensin II in the plasma, leading to generalized vasoconstriction, or locally in the kidneys, leading to salt and water retention. Individual changes in cardiac, vascular, or renal function seldom occur separately, and, if so, they may lead to mild or moderate increases in arterial pressure. Combined alterations in cardiac, vascular, and renal functions are more common and are often associated with pathologic increases in arterial pressure and established hypertension.

PRIORITIZATION

Identified Problem
Ineffective tissue perfusion related to decreased

Category
ACTUAL PROBLEM

Rationale
According to Virginia Henderson, breathing normally is given top priority. According to Maslow's Hierarchy of Needs physiologic needs should be attended 1st before moving up the ladder. 2nd prioritized to certain

oxygen carrying capacity of the blood secondary to hypertension

Activity Intolerance related to body weakness secondary to hypertension

ACTUAL PROBLEM

problem,

since

prolonged immobilization will lead complications. Henderson's human caring theory suggest that moving and maintaining a desirable position should be given importance

Risk for deficient fluid volume related to fluid volume loss secondary to vomiting

POTENTIAL PROBLEM

This is the 1st to be prioritized under the potential problems, because according to OFFTERAS as a basis for prioritization "FLUID" is the 2nd basic human need. As a consequence for ignoring this problem might lead to dehydration which can be so fatal and leads to death.

Risk for decreased cardiac output related to increased vascular resistance secondary to hypertension

POTENTIAL PROBLEM

ABC's of life suggest that circulation should be given priority even though it is only a potential problem.