1

Case Study
Hypertension

Name:
Jay Villasoto
BSN-3 STEM
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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

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

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

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

Preeclampsia/eclampsia Postoperative hypertension.

GENERAL DATA

Name : Mrs J. B

Age : 55 years old

Address : Brgy. Bato Roxas CIty

Sex : Female

Civil status: Married

Citizenship: Filipino

Religion: Roman Catholic

.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 St Anthony.

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.
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PHYSICAL ASSESSMENT

. PHYSICAL ASSESSMENT

NURSING REVIEW OF SYSTEM PHYSICAL ASSESSMENT

HEAD 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

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 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 Nose is located at the midline of the face with no

lesion or redness noted. Client report no tenderness.

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Can breathe through the nose clearly. Septums are

not perforated.

MOUTH 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 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.

RESPIRATORY SYSTEM Respiratory rate ranges from 21-22 cycles per

minute, lungs expansion is symmetrical, clear breath

sounds are present.

CARDIOVASCULAR SYSTEM Heart rate is 78 beats per minute, blood pressure is

130/80 mmHg.

GASTROINTESTINAL SYSYTEM Patient reported no abdominal pain. Patient was able

to pass bowel during the shift. Bowel sounds are

normal.

URINARY SYSTEM 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 Patient can move her legs and other extremities.
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Doesn’t need assistance upon walking and

ambulation.

NEUROLOGIC SYSTEM 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.

GENETO-URINARY SYSTEM

. ANATOMY, PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY

ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED

“THE HEART”
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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

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

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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.

 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
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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

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.

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 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

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.

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 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.

“THE KIDNEY”
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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

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.

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 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

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

collecting duct and then into the renal pelvis.

PATHOPHYSIOLOGY

Risk factors;

-Family history -Obesity

-Age -Alcohol consumption
-High salt intake -Smoking
-Low potassium intake -Stress
AGENT; HOST; ENVIRONMENT;

No etiologic -family history Not related

factor
-stress

-Age

Affects arteriolar bed

Arteriolar bed
constriction

Increase systemic
vascular resistance

Increase after load of

the heart

Decreased Blood flow

towards the organ
 Juxtaglomerular cells Angiotensinogen
secretes renin

Angiotensin I

Arteriolar Angiotensin II
vasoconstriction

Increased phireperal Adrenal cortex

resistance secretes aldosterone

Increased Blood Increase aldosterone

pressure
 Increase reabsortion
of water and sodium

Laboratory and Diagnosis

IDEAL ACTUAL

→Complete Blood Count

–Hematologic Report TEST RESULT NORMAL UNIT

RANGE

RBC 5.51 4.2-5.4 m/uL

Hemoglobin 12.70 12-16 g/dL

Hematocri 37-48 o/o

48.6

Lymphocyte 14 20-40 o/o

MVP 10.6 0-100 F/L

 Platelets 161 140-440 K/uL

Neotrophils 77.3 40.70 o/o

Monocyte 5 2-8 o/o

Monocyte 2.1 3.4-9.0 o/o

RDC

Monocyte 0.13 0.16-1.00 10^3/uL

ADC
–Urinalysis Report

PHYSICAL RESULT NORMAL UNIT

RANGE
CHARACTERISTIC

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

C. MEDICATION

ACTUAL
- 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.
NURSING CARE PLAN
ASSESSMENT NURSING GOALS AND OUTCOME NURSING RATIONALE EVALUATION
DIAGNOSES CRITERIA INTERVENTIONS
ASSESSMENT NURSING GOALS AND OUTCOME NURSING RATIONALE EVALUATION
Subjective: DIAGNOSES After 8 CRITERIA
hours of nursing Independent:
INTERVENTIONS
interventions the patient
“Luya jud kayo
Subjective: Decreased After
will be8 able
hourstoofmaintain
nursing 1. Monitor blood
Independent: -Comparison of After 8 hours of
ko karon” as Cardiac Output interventions the patient
blood pressure/cardiac pressure in both blood pressure nursing
“Dali jud kayoby
verbalized Activity
related to altered will be able to report 1. arms.
Note client - Symptoms
provides a more intervention
workload.
ko
thekutasan
patient. intolerance
stroke volume measurable increase in reports of may result
complete or
picture
dong” as related to body Specifically the patient weakness and contribute to
of vascular Goals met.
energy and will
verbalized by weakness. will be able to:
participate in necessary difficulty in tolerance of
involvement or The patient was
the patient. desired activities. accomplishing activity.
scope of the
Objective: 1.Participate an activity able to maintain
task. problem.
that reduces blood - Adequate a stable blood
-PR=54 Bpm Specifically the patient
2.Assess pressure
will pressure.
be able to: 2. Provide a calm -Helps reduce
energy
Objective: nutritional 120/70mmHg.
-shortness of and restful sympathetic
reserves are
2.Demonstrate stable
1.Participate an activity status. stimulation,
requirement
breath
-BP=150/80 upon environment.
cardiac rhythm ofand
without shortness promotes
for activity.
exertion
mmHg
rate within
breath. the patient 3.Provide a
relaxation.
-Body normal range. positive - Helps
-PR=54malaise
Bpm
2.Participate activity 3.Provide comfort
atmosphere -Decreased
minimize
-Restlessness
-shortness of without the increase measures
while ( eg… discomfort andand
frustration
breath upon of blood pressure. back and neck
acknowledging may reduce
rechanneled
exertion massage,
difficulty of the sympathetic
energy.
3. Report relief of elevation of the
situation for stimulation.
-Report of dizziness and fatigue. head.)
client.
dizziness and
fatigue. 4.Instruct
4.Monitorin - To monitor the
relaxation
response to -Can reduce
effect of the
technique.
medication and stressful stimuli;
medication.
change in provide calming
regimen. effect thereby
reducing blood
pressure.
 DRUG NAME DOSAGE MECHANISM INDICATION CONTRAINDICAT SIDE EFFECTS NURSING
AND OF ACTION ION RESPONSIBILITIES
FREQUENCY

GENERIC NAME: PATIENT It stimulates Hypertension contraindicated in - “colds” (upper Take blood blood pressure
DOSE: aldosterone patients who are respiratory infection) before giving the
Losartan secretion by the Hypertensive hypersensitive to any - - dizziness medication.
50 mg tablet adrenal cortex. Patients with component of this
BRAND NAME: once daily Left Ventricular - stuffy nose
Losartan and its product
principal active Hypertrophy
Lifesar tan - back pain
metabolite
CLASSIFICATION: block the pregnancy
vasoconstrictor
angiotensin II and
receptor (type AT1) aldosterone-
antagonist secreting effects
of angiotensin
II by selectively
blocking the
binding of
angiotensin II to
the AT1
receptor found
in many tissues.
 DRUG NAME DOSAGE MECHANISM INDICATION CONTRAINDICAT SIDE EFFECTS NURSING
AND OF ACTION ION RESPONSIBILITIES
FREQUENCY

GENERIC NAME: PATIENT The drug works -Prevention of - Hypersensitivity to -hemorrhage, severe Advise patient to do not
DOSE: by irreversibly vascular the drug substance or neutropenia, and perform other possibly
Clopedogrel inhibiting a [[ischemic] any component of the Thrombotic unsafe tasks until you
75 mg Tablet receptor called events in product. thrombocytopenic know how you react to it.
BRAND NAME:
P2Y12, an patients with purpura (TTP).
adenosine symptomatic - Active pathological
Plavix
diphosphate atherosclerosis bleeding such as Avoid activities that may
ADP peptic ulcer or cause bruising or injury
chemoreceptor. -Acute coronary intracranial
syndrome hemorrhage
without ST-
CLASSIFICATION: segment -you are allergic to
elevation any ingredient in
coagulant Clopidogrel
(NSTEMI),

-ST elevation -you have an active

MI (STEMI) bleeding disorder,
such as a stomach
ulcer or bleeding in
the brain
 DRUG NAME DOSAGE MECHANISM INDICATION CONTRAINDICAT SIDE EFFECTS NURSING
AND OF ACTION ION RESPONSIBILITIES
FREQUENCY

Instruct patient to:

GENERIC NAME: PATIENT it increases the Hyperlipidemia  you are allergic to  headache; - Avoid using antacids
DOSE: number of and Mixed any ingredient in without your doctor's
Rusovastatin hepatic LDL Dyslipidemia Crestor  mild muscle advice.
receptors on the
BRAND NAME: Hypertriglycerid  you have -Do not increase or
cell-surface to
20 mg tab once emia liver problems or  pain; decrease the amount of
Crestor enhance uptake unexplained
daily grapefruit products in your
and catabolism abnormal liver  joint pain;
Primary diet without first talking to
of LDL. function tests
Dysbetalipoprote your doctor
Second,  constipation;
CLASSIFICATION: inemia (Type III  you are pregnant
rosuvastatin
Hyperlipoprotein or breast-feeding -Do not perform other
inhibits hepatic  mild nausea; or
HMG CoA emia) possibly unsafe tasks until
synthesis of
reductase inhibitors,  you are taking  stomach pain or you know how you react
VLDL, which Homozygous
or "statins." itraconazole, indigestion. to it.
reduces the total Familial mibefradil, or
number of Hypercholesterol telithromycin Follow the diet and
VLDL and LDL emia exercise program given to
particles
you by your health care
Slowing of the
provider
Progression of
Atherosclerosis
Do NOT take more than
the recommended dose
without checking with
your doctor
Type of Classification Content Mechanism of Indications Contraindications How supplied Dose Nursing
solution action responsibilities
PNSS Hypertonic 100mL Hypertonic For Hypersensitivity to Intravenous Before:
solutions replacement or any of the infusion 1. Use sterile
contain a high maintenance components. infusion set.
concentration of fluid and 2. Use only if
of solute electrolytes. solution is clear
relative to and container is
another not leaking.
solution ( e.g. 3. Assess patient’s
the cell’s hydration status.
cytoplasm ) During:
when a cell is 1. Perform time
placed in a taping.
hypertonic 2. Regulate IVF as
solution, the prescribed.
water diffuses 3. Check from time
out of the cell, to time the
causing the cell positioning of the
to shrivel. patient.
After:
(Wikipedia 1. Chart the date and
encyclopedia, time the solution
5th edition). 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.