languha Ngati

Med surge

chapter 31 care plan, Hypertension

correction

11-21-2019
Case Study, Chapter 31, Assessment and Management of Patients With Hypertension

1. Joan Smith, 55 years of age, is a female patient who presents to the intensive care unit with the
diagnosis of intracranial hemorrhage. The patient stopped taking her antihypertensives suddenly
because of the cost of the medications and she recently lost her job to outsourcing. The patient is
slightly drowsy and complains of a headache and blurred vision. The patient’s blood pressure is
220/130 mm Hg upon presentation.
(Learning Objective 6)

a. According to the definitions set by the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), which
type of hypertensive crisis is the patient currently experiencing?

b. Describe the treatment goals for handling the hypertensive crisis and apply the goals to the
case study. Determine the current mean arterial pressure (MAP) and the goals for
treatment.

The physician orders nicardipine hydrochloride (Cardene) 25 mg/250 mL, NS for peripheral IV
starting at 2.5 mg/hr, and titrate by 2.5 mg/hr every 15 minutes to reach the goal for the first hour,
which is to achieve 25% reduction of the initial MAP. 
 Call the physician if the dosing range of 15 mg/hr has been reached and the MAP is still
not at target goal for the first hour of treatment, or up to four dose increases.
 Lower the BP within 6 hours to 160/100 mm Hg.
 Adjust the IV rate so that the IV fluids plus the nicardipine IV drip are equal to 100 mL/hr,
in total. Call the physician if the IV fluids must go above 100 mL/hr to provide the
nicardipine.

c. Explain what rate to set initially for both the nicardipine drip and the NS maintenance fluids.

d. Explain the process of titrating the nicardipine drip for the first hour to achieve the final MAP
goal of 25% reduction of the original MAP. 

2. The community health nurse is preparing a program about hypertension for a local community
center. The focus of the program is on the reduction of risk factors and compliance for those who
have been diagnosed with high blood pressure. The target population includes older adults.
(Learning Objectives 1 to 4) 

a. The nurse focuses on primary hypertension because it accounts for 90% to 95% of
hypertension in the United States. What risk factors does the nurse include for this
population?
b. The nurse prepares to discuss the changes in how the JNC 7 defines hypertension.
What ranges and descriptions should the nurse include?

c. Because this is a gerontologic audience, the nurse needs to review why blood pressure
increases with age. Explain how the structural and functional changes of aging
contribute to higher blood pressure in the older adult.

d. What information does the nurse include about lifestyle modifications that may
decrease risk of hypertension (or complications associated with diagnosed
hypertension)?
 Hypertension is the term used to describe high blood pressure. Hypertension is repeatedly

elevated blood pressure exceeding 140 over 90 mmHg. It is categorized as primary or

essential or secondary, which occurs as a result of an identifiable, sometimes correctable

pathological condition, such as renal disease or primary aldosteronism. However, hypertension is

commonly observe in People with family history of high blood pressure, diabetes and heart

diseases, people over 55 years of age, obese people, people with very little physical activities,

alcoholics, tobacco smokers, drug users such as cocaine, people who eat junk food excessively.

Signs and symptoms

Most people with high blood pressure have no signs or symptoms, even if blood pressure readings

reach dangerously high levels.

-A few people with high blood pressure may have headaches, shortness of breath,

nosebleeds, ringing or buzzing in the ears, Irregular heartbeat, Blurred vision, Confusion

or dizziness, Fatigue. but these signs and symptoms aren't specific and usually don't occur

until high blood pressure has reached a severe or life-threatening stage

Uncontrolled high blood pressure can lead to complications including:

- Heart attack or stroke. High blood pressure can cause hardening and thickening of the

arteries, which can lead to a heart attack, stroke or other complications.

-Aneurysm. Increased blood pressure can cause your blood vessels to weaken and bulge,

forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.

 -Heart failure. To pump blood against the higher pressure in your vessels, the heart has to

work harder. This causes the walls of the heart's pumping chamber to thicken (left

ventricular hypertrophy). Eventually, the thickened muscle may have a hard time pumping

enough blood to meet your body's needs, which can lead to heart failure.

-Weakened and narrowed blood vessels in your kidneys. This can prevent these organs from

functioning normally.

-Thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.

Head to toe assessment.

General appearance

- Patient is alert and oriented to person, place, time, and situation.

- Patient is clean and well groomed,

- Patient standing upright erect and relaxed.

- No congenital or acquired physical deformities noted.

- Independent, mobile but experiencing some generalized weakness, no use of

assistive device. Full range of motion present in bilateral upper and lower

extremities.

- Patient is can speak without any difficulties.

- Vital signs: B/P 179/88, pulse 70, 02 96, Temp 97.3

Skin, hair, and nails:

- Patient skin is free of lesion, rashes and bruising.

 - Patient skin is warm and moist to touch.

- No pressure area noted.

- No edema noted

- No lice on hair.

- Patient Nails capillary refill less than 3 seconds bilateral and is consistent.

Head and Face

1. Scalp, hair, cranium

- Head is round, symmetric skull, and appropriate proposition to body size and

shape.

2. Face, stroke check

Face is symmetrical bilaterally , no facial skin pigmentation or abnormalities noted.

Client had calm and relaxed facial expression.

3. Temporomandibular joint

. No grunting sound heard or felt during jaw opening and closing.

4. Maxillary sinuses, frontal sinuses palpation

No visible or palpable maxillary and frontal sinus swelling noted.

 7 Facial expression, mood, and affect

Calm, cooperative, pleasant and maintain eye contact during conversation.

8 Speech

Patient is able to speak clearly, fluent and have meaningful conversation.

Eyes

- Vision is good with or without glasses.

- Sclera: Bilateral Sclera appears white in color. No redness or discharges noted.

- Cornea: Bilateral cornea clear bright smooth surface,

- Pupils: bilateral pupils equal, reactive, accommodation to light

Ears

1. External ear: Bilateral external ears symmetrical, no swelling or tenderness noted.

2. bilateral tympanic membrane intact,

3. Hearing: Able to hear two syllable words clearly.

Nose

1. External nose

External nose appears round symmetrical. No visible nasal skin abnormality noted.

2. Patency of nostrils
 Bilateral nostril patent, client can blow her nose as well as sniff without difficulty. no

septal deviation. Bilateral nasal mucosa is red, smooth, and moist. No visible trauma,

swelling, or discharge present.

Mouth and Throat

1. Lips and buccal mucosal

Lips and buccal mucosa are pink, moist, and free from lesion and cracks.

2. Teeth and gums

Teeth are white, evenly spaced, clean and free from decay. Upper and lower jaw

aligned evenly, normal occlusion upon bite.

Gums are pink moist and smooth. No gingival margins noted.

3. Hard/soft palate

Hard palate: pink irregular rugae present. No visible lesion present.

Soft Palate: Pink smooth and upwardly movable.

4. Tonsils
 Bilateral tonsils appears pink , same as oral mucus membrane. Bilateral tonsils are 1+

size at the scale of 4+.

5. Uvula

Pink consistent with buccal mucus membrane. Uvula Rises with phonation.

6. Tongue

Pink and even slightly rough at dorsal surface. No lesion or induration.

Neck

- Neck muscles symmetrical , present at midline. Full range of motion while turning

left, right, extending head backward and forward. No lumps or skin abnormalities

found.

1. Cervical lymph nodes

Lymph nodes are bilaterally smooth, movable, discrete, soft, and nontender.

2. Carotid pulse (palpation and auscultation)

Brisk upstroke slower downstroke, moderate and equal bilaterally. No bruit or

swishing noted.
 3. Trachea

No tracheal swelling or rigidity noted. Present at midline of shoulder and neck.

Chest and Lungs:

Anterior and posterior chest: symmetrical bilaterally. Elliptical shape with downward

sloping ribs. Patient is sitting in a relaxed posture.

Thoracic cage configuration : skeletal framework of the chest has 12 pairs of ribs and

sternum. Anterior/posterior transverse diameter is 1:2.

1. Symmetric expansion: symmetrical chest expansion bilaterally upon inhalation.

No Lumps or mass, no tenderness upon palpation, smooth and soft skin.

Breath sounds: Respiration is irregular, labored breathing at a rate of 20 breaths per

minute. Experiencing SOB and is on 2L oxygen.

2. Spinous processes: costal rib angle 90 degree and downward sloping ribs.

3. CVA tenderness: no costal vertebral angle tenderness noted bilaterally upon

percussion.
Upper Extremities

1. ROM and muscle strength: full range of motion bilaterally and are equal strength.

Able to circumduction, flex and extend bilateral shoulders, abduct and adduct bilateral

elbows, able to perform pronation and supination of bilateral wrists.

Fingers: full range of motion in all 10 digits.

2. Capillary refill less than 3 seconds bilaterally.

3. Handgrips: bilateral hand grips strong and equal.

Heart

1. Precordium: no pulsations, heaves visualized any palpable thrills present at this time.

2. Heart sounds x 5 cardiac landmarks:, no murmurs, no friction rub, no arterial gallops or

S4 gallops noted. S1 sound heard very prominent at apex. S2 sound was greater at base.

Abdomen

- Skin characteristics: abdominal skin smooth with no striae, scar, or lesion.

Umbilicus and pulsations: Umbilicus located at the center of abdomen. Umbilicus

is inverted, clean, and free from dirt and discharges. No pulsation noted.

- Bowel sounds bowel sound present, no bruit.

- Vascular sounds (aortic, ileac, renal) : Vascular is osculated via bell of stethoscope

no bruit or friction rub noted.

- Light and deep palpation: Abdomen soft and palpable, non-tender.

Lower Extremities

1. Symmetry: Bilateral lower extremities equal and symmetrical

 Skin characteristics: Skin appears to be smooth and warm, no swelling or lesions on

bilateral lower extremities.

Hair distribution: bilateral lower extremities have uniformed fine hair distribution.

2. Posterior tibial: 2+ pulse present bilaterally at the scale of 3+pulse. No edema noted.

3. Dorsalis pedis: 2+ pulse present bilaterally at the scale of 3+pulse. No edema noted.

4. Temperature: warm to touch bilateral lower extremities.

5. Pretibial edema: no edema present at this time.

6. Toes-capillary refill: less than 3 seconds bilateral toes.

7. ROM/Muscle Strength:

Hips: bilateral hip symmetrical at the level of iliac crest, bilateral hip joints are

stable .bilateral hip flexion at 90 degree.

Knees: full range of motion present on bilaterally. Able to flex and extend smoothly.

Ankles: full range of motion present at bilateral ankle bilaterally. Able to flex and

extend smoothly

Feet: full range of motion present at bilateral feet Able to flex and extend smoothly.

Skin (may assess with corresponding region)

1. Hands and nails

Bilateral upper extremities warm to touch. Skin appears smooth, firm, and evenly

surfaced.

Nails surface are slightly curved, angled close to 160 degree. Bilateral index figure

shows diamond shape upon touching each other. Edges are smooth, rounded, and

clean.

2. Color and pigmentation

 Skin pale and scattered senile lentiginous noted at bilateral upper arms. Skin looks

appropriate to ethnicity and age.

3. Temperature, moisture, texture

Skin warm to touch, appears smooth, firm, and evenly surfaced.

4. Turgor

- Elastic upon checking on skin from chest. Pulled chest skin and released it

returned to its previous state.

- No visible lesions present.

Neurological/Musculoskeletal

1. Sensation

Face: Able to sense touch on her face at forehead, left cheek and her chin. .

Arms and hands: able to feel and identify sharp and dull sensation on bilateral

arms. Able to feel and identify known objects with bilateral hands.

Legs and feet: able to feel and identify sharp and dull sensation bilaterally.
 2. Position sense: Able to perceive direction of passive movement of index finger

bilaterally

3. Stereognosis : able to feel and identify 3 known object via bilateral hands.

4. Cerebellar function: able to perform finger to nose repetitions.

5. Cerebellar function: able to perform heel to shin repetitions.

6. Deep tendon reflexes: no deep tendon reflexes present bilaterally.

7. Patellar : no patellar reflexes present bilaterally.

8. Babinski reflex: negative Babinski reflex.

1. Walk across room: able to walk with steady gait and stay balanced.

Able to touch heal to toe without any difficulty bilaterally.

2. Romberg sign : negative

3. Touch toes: able to bend and touch her bilateral toes without any difficulty.

4. ROM of spine: full range of motion against gravity present. full resistance and normal

spin curvature.

Lab Values

- Partial pressure of oxygen (PaO2): 75 - 100 mmHg

- Oxygen saturation (SaO2): 94 - 100%.

- Arterial blood pH: 7.38 - 7.42

- Creatinine: 0.8-1.3 mg/dL

- Glucose: 65-110 mg/dL

- Potassium: 3.5-5 mmol/L

 - Uric acid: 0.18-0.48 mmol/L

- Sodium: 135-145 mmol/L

- Total calcium: 2-2.6 mmol/L

- Platelets: 150-400 x 10^9/L

- Hemoglobin: 13-17 g/dL (men), 12-15 g/dL (women)

- pH: 7.35-7.45

- White blood cells (WBC) 4-10 x 10^9/L

- Hematocrit 40%-52% (men), 36%-47%

Expected changes

- Hypertriglyceridemia
- Triglycerides, mg/dL
- HDL.

All Nanda diagnosis

- Risk for decreased cardiac output

- Acute pain (typically headache)

- Activity intolerance

- Ineffective coping

- Imbalanced nutrition (more than body requirements)

- Knowledge deficit

3 NANDA priority nursing diagnoses

- Risk for decreased cardiac output

- Imbalanced nutrition (more than body requirements

 - Acute pain (typically headache)

Goals for decrease cardiac output.

- Participate in activities that reduce BP/cardiac workload.

- Maintain BP within individually acceptable range.

- Demonstrate stable cardiac rhythm and rate within patient’s normal range.

- Participate in activities that will prevent stress (stress management, balanced

activities and rest plan).

Intervention and Rationale.

- Review clients at risk as noted in Related Factors as well as individuals with

conditions that stress the heart.

-Rationale : Persons with acute or chronic conditions may compromise circulation

and place excessive demands on the heart

- Check patient’s lab data (cardiac markers, blood cell count, electrolytes, ABGs, etc.) to

determine contributing factor

Rationale: To identify contributing factors

- Monitor and record BP. Measure in both arms and thighs three times, 3–5 min apart

while patient is at rest, then sitting, then standing for initial evaluation. Use correct

cuff size and accurate technique

 Rationale: Comparison of pressures provides a more complete picture of vascular

involvement or scope of problem. Severe hypertension is classified in the adult as a

diastolic pressure elevation to 110 mmHg; progressive diastolic readings above 120

mmHg are considered first accelerated, then malignant (very severe). Systolic

hypertension also is an established risk factor for cerebrovascular disease and ischemic

heart disease, when diastolic pressure is elevated.

- Note presence, quality of central and peripheral pulses.

Rationale: Bounding carotid, jugular, radial, and femoral pulses may be observed

and palpated. Pulses in the legs and feet may be diminished, reflecting effects of

vasoconstriction (increased systemic vascular resistance [SVR]) and venous

congestion.

- Maintain activity restrictions (bedrest or chair rest); schedule periods of uninterrupted

rest; assist patient with self-care activities as needed

Rationale: Lessens physical stress and tension that affect blood pressure and the

course of hypertension.

Goals for Imbalanced nutrition

- Identify correlation between hypertension and obesity.

- Demonstrate change in eating patterns (e.g., food choices, quantity) to attain desirable

body weight with optimal maintenance of health.

- Initiate/maintain individually appropriate exercise program.

Intervention and rationale

 - Assess risk or presence of conditions associated with obesity

Rationale: Obesity is an added risk with high blood pressure because of the

disproportion between fixed aortic capacity and increased cardiac output associated

with increased body mass.

- Assess the patient’s understanding of the relationship between hypertension and

obesity.

Rationale: Reduction in weight may obviate the need for drug therapy or decrease

the amount of medication needed for control of BP. Faulty eating habits contribute to

atherosclerosis and obesity, which predispose to hypertension and subsequent

complications (stroke, kidney disease, heart failure)

- Discuss the need for a decreased caloric intake, as well as a limited intake of salt,

sugar, and fat.

Rationale: Excessive salt intake expands the intravascular fluid volume and

may damage kidneys, which can further aggravate hypertension.

- Establish a realistic weight reduction plan with the patient such as 1 lb weight loss per

wk.

Rationale: Reducing caloric intake by 500 calories daily theoretically yields a

weight loss of 1 lb per wk. Slow reduction in weight is therefore indicative of fat loss with muscle

sparing and generally reflects a change in eating habits.

- Determine patient’s desire to lose weight.

 Rationale: Motivation for weight reduction is internal. The individual must want

to lose weight, or the program most likely will not succeed.

Goals for Acute pain (typically headache)

- Report pain/discomfort is relieved/controlled.

- Verbalize methods that provide relief.

- Follow prescribed pharmacological regimen.

- Demonstrate use of relaxation skills and diversional activities, as indicated, for

individual situation.

Intervention and rationale

- Note the patient’s attitude towards pain and any history of substance abuse.

Rationale : To assess etiology or precipitating contributory factors.

- Determine the specifics of the pain, such as intensity, where it is located, and how long

it has been going on.

Rationale: Facilitates diagnosis of problem and initiation of appropriate therapy.

Helpful in evaluating effectiveness of therapy.

- Provide or recommend nonpharmacological measures for relief of headache such as

cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques

(guided imagery, distraction); and diversional activities

Rationale: Measures that reduce cerebral vascular pressure and that slow or

block sympathetic response are effective in relieving headache and associated

complications.
 - Encourage and maintain bed rest during acute phase.

Rationale: Minimizes stimulation and promotes relaxation.

Medications

- Lisinopril, and enalapril are ACE Inhibitors. These meds inhibit conversion of

angiotensin 1 to angiotensin 11. It also lower peripheral resistance. Side effects

include Dizziness, lightheadedness, or faintness upon rising, sweating, Blurred vision

Loop diuretics: Lasix (furosemide) is a loop diuretic (water pill) that prevents your body from

absorbing too much salt. This allows the salt to instead be passed in your urine. Side effect is risk

of volume and electrolyte depletion from the profound diuresis.

Thiazide diuretics: (hydrochlorothiazide) is a thiazide diuretic (water pill) that helps prevent your

body from absorbing too much salt, which can cause fluid retention. Side effects is include dry

mouth, thirst, weakness, drowsiness.

Teaching

- In regards to Lasix teach patient to expect increased frequency/volume of urination,

report palpitations and signs of electrolyte imbalances, report hearing abnormalities.

Teach patient to eat foods high in potassium such as bananas.

- Regarding hydrochlorothiazide teach patient to reduce hypotensive effect by going

from lying to standing slowly, eats food high in potassium such as whole grains

- With lisinopril teach patient to limit alcohol intake. Report vomiting, diarrhea,

diaphoresis, swelling of face/lips/tongue.

- With enalapril teach patient that skipping doses or voluntarily discontinuing drug may

produce severe / rebound hypertension . limit alcohol.