CASE STUDY

CARDIOVASCULAR

HYPERTENSION
(Neurosurgery Ward Sarawak Government Hospital)

Name :Nursiah Binti Ramli

Course : Diploma in Nursing(Batch 3)

ID. Num : KCH-0907134

IC. Num :910103-13-6350

Lecturer : Madam Greta Hayward

Front Page................................................................1

Contents....................................................................2

Patient’s Data............................................................3

Medical Surgical Assesment.....................................4

Activity Daily Living...............................................5

Description Of Hypertension...................................6

Sign & Symptoms Hypertension.............................7

Pathophysiology of Hypertension...........................8

Diagnosis Of Hypertension...................................9

Prevention Of Hypertension..................................10

Treatment Of Hypertension...................................11

Summary................................................................12

Nursing Care plan................................................13-14

References.............................................................15
PATIENT’S DATA

Patient’s Name : MR M

Registration Number : 2010/031718

IC No : 500603-13-5141

Date Of Birth : 03 JUN 1950

Date Of Admission : 04/12/2010

Date Of Discharge : 22/12/2010

Address : Rumah Panjang Lugah Gian,Sri Aman.

Final Diagnosis : Ruptured right MCA bifurcation aneurysm.

k/c : Hypertension
MEDICAL SURGICAL ASSESMENT
1.Personal Social History
Name : MR M
Age: 60years
Race: Chinese
Religion : Iban
Occupation : Farmer
Address : rumah Panjang Lugah Gian,Sri Aman.
Stay with : wife and his childrens

2. Vital Sign
General Condition : patient unconsious
Height : 158cm
Weight : 67kg
Temperature : 36.5
Pulse : 82bpm
Respiration : 20 bpm
Blood Pressure : 180/106

3. Health Perception
Reason for hospitalisation : Aneurysm
Recent Ilness/hospitalisation : Hypertension
Other Health Problem : Nil
Smoking : Yes
Alcohol Consumption : Yes
Medication : Prescription /self prescription/traditional
Allergies :
1. Food : NIL
2. Medication : NIL

4. Nutrition :
Type of diet : Normal / Vegetarian / therapeutic
Appetite : Good / Poor / Nausea and Vomiting
Frequency Of Meal : Nil (patient on fluid restiction via NG (silicon) feeding)but allowed orally
9 days and eating an usually.
Food And Fluid preference : ENSURE 300mls (6 scoop) and normal diet.
Food And Fluid Dislike : Nil

5. Elimination
Bowel Pattern : Normal / Incontinence / Constipation / Diarrhoea
Frequency : 3x/day
Urinary Frequency : 8X perday
Urinary Pattern : Normal urine
*patient pass urine and pass motion in toilet and also use a urinal

6. Respiratory Status
Dyspnea : Nil
Nocturnal Dyspnea : Nil
S.O.B at rest : Nil
S.O.B On exertion : Nil
Oxygen Supplement : Nil
Cough : Yes
 ACTIVITY DAILY LIVING

1.Mobility status : 1st admitted patient is unconscious but after 12 days in the hospital patient can
walk but still must be accompany with somebody else.
Independant/Assistance needed on following activities :
- Feeding : (patient on fluid restiction via NG (silicon) feeding) and allowed orally after 9 days
- Bathing : Patient Bath in bed assist by family members and bath in bathroom after 12 days.
- Dressing Up : Patient still dressing up assist by family members

2. Coginitive/perceptual
Level Of Consciousness : Patient Unconscious 1st admitted and be conscious after 12 days his stay
In hospital.
Oriented to : All time
Eye/Sight : Patient can see very well
Ear/Hearing : Patient can hear very well

3. Rest and sleep

Sleeping pattern : Patient Slept 8 hour
Sleep disturbances : Always complain headache
Method to promote sleep : nil
Sedation : nil

4. Self Perception , relationship

Own Feeling regarding hospitalisation : patient can speak.
Family feeling regarding hospitalisation : feeling apprehensive
 HYPERTENSION

High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries
are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High
blood pressure does not mean excessive emotional tension, although emotional tension and stress
can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure
between 120/80 and 139/89 is called "pre-hypertension", and a blood pressure of 140/90 or above is
considered high.

The top number, the systolic blood pressure, corresponds to the pressure in the arteries as the
heart contracts and pumps blood forward into the arteries. The bottom number, the diastolic
pressure, represents the pressure in the arteries as the heart relaxes after the contraction. The
diastolic pressure reflects the lowest pressure to which the arteries are exposed.
An elevation of the systolic and/or diastolic blood pressure increases the risk of developing
heart (cardiac) disease , kidney (renal) disease hardening of the arteries (atherosclerosis or
arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are
often referred to as end-organ damage because damage to these organs is the end result of chronic
(long duration) high blood pressure. For that reason, the diagnosis of high blood pressure is
important so efforts can be made to normalize blood pressure and prevent complications.
It was previously thought that rises in diastolic blood pressure were a more important risk
factor than systolic elevations, but it is now known that in people 50 years or older systolic
hypertension represents a greater risk.
Signs And Symptoms HYPERTENSION

Headache
Drowsiness
Confusion
Vision Disorder
Nausea and Vomiting
Pathophysiology Hypertension
The pathophysiology of high blood pressure is unknown in 95% of the cases in America. This
type of blood pressure where exact cause cannot be pinpointed is known as essential
hypertension. The hereditary factor may be one reason for essential hypertension. It is also
observed that it affects more men than women. Diet and lifestyle also play a role in the
pathophysiology. Overweight people often suffer from hypertension. Irregular sleep patterns
also led to hypertension. Hypertension is seen in people with excessive salt intake in their
diet. These people are called as 'salt sensitive'. Their bodies exhibit high blood pressure, when
the amount of salt in their blood is more than the body requirement. Low potassium and
calcium intake, stress are also the causes of with high pressure.

Secondary hypertension is the condition when one can pinpoint the exact cause of
hypertension. Kidney disease is the most common factor for secondary hypertension.
Hypertension can also be caused by tumors of the adrenal glands. These tumors or
abnormalities of the adrenal glands cause excessive secretion of hormones that led to
hypertension. Estrogen, the hormone found in birth control pills can also cause the blood
pressure to elevate.Pregnancy is another factor, that causes hypertension.

The development of arteriosclerosis and atherosclerosis are also affected by hypertension.

Hypertension reduces the elasticity of arteries causing other secondary conditions which lead
to decrease blood flow and ischemic diseases. Hypertension induced arteriosclerosis may led
to atrophy of renal glomeruli and tubules. This causes renal failure and may lead to death.
Another serious complication arising due to hypertension is Cerebrovascular diseases.
Coronary diseases are the most common cause of death for hypertensive patients.
 DIAGNOSIS
Hypertension is generally diagnosed on the basis of a persistently high blood pressure. Usually this requires
three separate sphygmomanometer (see figure) measurements at least one week apart (Often, this entails
three separate visits to the physician's office). Initial assessment of the hypertensive patient should include a
complete history and physical examination. Exceptionally, if the elevation is extreme, or if symptoms of
organ damage are present then the diagnosis may be given and treatment started immediately.

Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause
based on risk factors and other symptoms, if present. Secondary hypertension is more common in
preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more
common in adolescents and has multiple risk factors, including obesity and a family history of
hypertension. Laboratory tests can also be performed to identify possible causes of secondary hypertension,
and determine if hypertension has caused damage to the heart, eyes, and kidneys. Additional tests for
Diabetes and high cholesterol levels are also usually performed because they are additional risk factors for
the development of heart disease require treatment. Tests typically performed are classified as follows:

System Tests

Microscopic urinalysis, proteinuria, serum BUN (blood urea

Renal:
nitrogen) and/or creatinine

Endocrine Serum sodium, potassium, calcium, TSH (thyroid-stimulating hormone).

Metabolic Fasting blood glucose, total cholesterol, HDL and LDL cholesterol, triglycerides

Other Hematocrit, electrocardiogram, and chest radiograph

Sources: Harrison's principles of internal medicine and others.

Creatinine (renal function) testing is done to determine if kidney disease is present, which can be either the
cause or result of hypertension. In addition, it provides a baseline measurement of kidney function that can
be used to monitor for side-effects of certain antihypertensive drugs on kidney function. Additionally, testing
of urine samples for protein is used as a secondary indicator of kidney disease. Glucose testing is done to
determine if diabetes mellitus is present. Electrocardiogram (EKG/ECG) testing is done to check for
evidence of the heart being under strain from high blood pressure. It may also show if there is thickening of
the heart muscle (left ventricular hypertrophy) or has experienced a prior minor heart distubance such as a
silent heart attack. A chest X-ray may be performed to look for signs of heart enlargement or damage to heart
tissue
PREVENTION

Step 1: Following a Healthy Eating Pattern

Research has shown that following a healthy eating plan can both reduce the risk of developing high
blood pressure and lower an already elevated blood pressure.

Step 2: Reducing Salt and Sodium in Your Diet

A key to healthy eating is choosing foods lower in salt and sodium. Most Americans consume more
salt than they need. The current recommendation is to consume less than 2.4 grams (2,400
milligrams[mg] ) of sodium a day. That equals 6 grams (about 1 teaspoon) of table salt a day. The 6
grams include ALL salt and sodium consumed, including that used in cooking and at the table. For
someone with high blood pressure, the doctor may advise eating less salt and sodium, as recent
research has shown that people consuming diets of 1,500 mg of sodium had even better blood
pressure lowering benefits. These lower-sodium diets also can keep blood pressure from rising and
help blood pressure medicines work better.

Step 3: Maintaining a Healthy Weight

Being overweight increases your risk of developing high blood pressure. In fact, blood pressure
rises as body weight increases. Losing even 10 pounds can lower blood pressure — and it has the
greatest effect for those who are overweight and already have hypertension.

Step 4: Being Physically Active

Being physically active is one of the most important steps you can take to prevent or control high
blood pressure. It also helps reduce your risk of heart disease. It doesn't take a lot of effort to
become physically active.

Step 5: Limiting Alcohol Intake

Drinking too much alcohol can raise blood pressure. It also can harm the liver, brain, and heart.
Alcoholic drinks also contain calories, which matter if you are trying to lose weight. If you drink
alcoholic beverages, have only a moderate amount — one drink a day for women; two drinks a day
for men.

Step 6: Quitting Smoking

Smoking injures blood vessel walls and speeds up the process of hardening of the arteries. This
applies even to filtered cigarettes. So even though it does not cause high blood pressure, smoking is
bad for anyone, especially those with high blood pressure. If you smoke, quit. If you don't smoke,
don't start. Once you quit, your risk of having a heart attack is reduced after the first year. So you
have a lot to gain by quitting
HYPERTENSION DIET

Begin your Hypertension Diet by choosing foods low in saturated fat, low in sodium and low in
calories:
• Try fat free (skim) milk or lowfat (1%) milk
• Only buy cheeses marked "lowfat" or "fat free" on the package
• Choose to eat fruits and vegetables without butter or sauce
• Serve rice, beans, cereals, pasta, whole grains (e.g., couscous, barley, bulgar, etc.)
• Choose lean cuts of meat, fish, and skinless turkey and chicken
• When available, buy low– or reduced–sodium or no–salt–added versions of foods
Use these recipe substitutions for your Hypertension Diet:
• Use two egg whites for each whole egg and margarine or oil instead of butter
• Use light mayonnaise instead of the regular variety
• Use nonfat yogurt instead of sour cream
• Use lowfat cheese instead of regular cheese
• Use 1 percent or skim milk instead of whole milk
• Use fresh poultry, fish and lean meat rather than canned or processed types
Try these meal tips for your Hypertension Diet:
• Make a meatloaf with lean ground turkey
• Make tacos with skinless chicken breast
• Cool soups and gravies and skim off fat before reheating them
• Try adding salsa on a baked potato instead of butter
• Make a spicy baked fish — season with green pepper, onion, garlic, oregano, lemon, or
cilantro
• Eat fruit for dessert, instead of pie or cake.
TREATMENT (MEDICATION)

1. Tablet Nimodiphine 60mg QID :

use is in the prevention of cerebral vasospasm and resultant ischemia, a complication
of subarachnoid hemorrhage (a form of cerebral bleed), specifically from ruptured intracranial berry
aneurysms irrespective of the patient's post-ictus neurological condition. Its administration begins
within 4 days of a subarachnoid hemorrhage and is continued for three weeks. If blood
pressure drops by over 5%, dosage is adjusted. There is still controversy regarding the use of
intravenous nimodipine on a routine basis.

2. Tablet nifediphine 10mg TDS :

the long-term treatment of hypertension (high blood pressure) and angina pectoris. In hypertension,
recent clinical guidelines generally favour diuretics and ACE inhibitors, although calcium channel
antagonists, along with thiazide diuretics, are still favoured as primary treatment for over 55's and
black patients.[4]
Sublingual nifedipine has previously been used in hypertensive emergencies. This was found to be
dangerous, and has been abandoned. Sublingual nifedipine causes blood-pressure lowering through
peripheral vasodilation. It can cause an uncontrollable decrease in blood pressure, reflex
tachycardia, and a steal phenomenon in certain vascular beds. There have been multiple reports in
the medical literature of serious adverse effects with sublingual nifedipine, including cerebral
ischemia/infarction, myocardial infarction, complete heart block, and death. As a result of this, the
FDA reviewed all data regarding the safety and efficacy of sublingual nifedipine for hypertensive
emergencies in 1995, and concluded that the practice should be abandoned because it was neither
safe nor efficacious

3. IV Rocephin 2 g BD
for the treatment of community-acquired or mild to moderate health care-associated pneumonia. It
is also a choice drug for treatment of bacterial meningitis. In pediatrics, it is commonly used
in febrile infants between 4 and 8 weeks of age who are admitted to the hospital to exclude sepsis.
The dosage for acute ear infection in the very young is 50 mg/kg IM, one dose only. It has also been
used in the treatment of Lyme disease, typhoid fever andgonorrhea.

4. Tablet Folic Acid 5mg OD:

Folic Acid is effective in the treatment of megaloblastic anemias due to a deficiency of Folic Acid
(as may be seen in tropical or nontropical sprue) and in anemias of nutritional origin, pregnancy,
infancy, or childhood.

5. Paracetamol 1g QID :
The preparation is indicated in diseases manifesting with pain and fever: headache, toothache, mild
and moderate postoperative and injury pain, high temperature, infectious diseases and chills (acute
catarrhal inflammations of the upper respiratory tract, flu, small-pox, parotitis, etc.).

6.Tablet captopril 25 mg OD
1) Hypertension
2) Cardiac conditions such as post myocardial infarction and congestive heart failure
3) Preservation of kidney function in diabetic nephropathy
Summary
Mr. M a 60 year-old,have hypertension(HPT),presented with headache for 2 days associated with
one episode of writing,reduced level of consciousness and generalized body weakness.There was no
history of trauma,No fit.

Progress in ward
He underwent right craniotomy and clipping of aneurysm on 05/12/10.Operative finding;brain was
tense upon elevation of bone,flap blood stained CSF brain under high pressure,aneurysm was
readling seen on dissection of sylvian fissure,the artery was much atheribsclerotic at the
bifurcation,the M1 and M2 that are going temporally noted as per scan,however,multiple small
perforaters which was preserved,two more small branches of M2 at the bifurcation,was not shown
on CTA.Aiming lateral and slight superiorly,curve titanium clip(934-06) used with slight residual of
aneurysm neck to prevent occlusion of the small M2 branches.No other structures clipped,no
ruptured intra-operatively.Brain was lax and pulsating well upon closure.Total temporal Clipping 10
minutes.Postoperatively,he was admitted to ICU,extubated on day one and transferred back to
Nuerosurgical ward on day two.He develops high grade fever in ward with copious amount of
secretion from lung.IV rocephin 2 g ODx1 days was given.He responded well to the treatment
given.Upon discharge,he was afebrile,comfortable,tolerating well orally and ambulating.His GCS
E4V5M6 pupil:3R/3R,wound over scalp:clean mild bogginess over sourrounding skin due to
underlying emphysema BP 145/75 mmHg Pulse:60/min.No neck stiffness muscle power 5?5 over
all four limbs.

Investigation
FBC(13/12/10):Hb:11.3,WBC:13.56,Platelet:436k
PT/INR/PTT(06/12/10):15.9/1.3/43.3
BUSE?CREAT(13/12/10):Na:133,K:3.3,Cl:97,Urea:5.5,Creatinine:72
LFT(06/12/10):T.bil:11,D.bil:1,AST:29,ALT:9
T,Prot:61,Alb:29,glob:32,ALP:48
CTB(16/12/10):SAH with intraventricular extension and hydrocephalus
CTA(06/12/10)Right MCA M2 aneurysm noted
GB(06/12/10):mild to moderate hydrocephalus,radiology improvement seen with evidence of
Reduced in size of ventricles,right parietal scalp emphysema.
Blood C&S(10/12/10):No growth after 5 days incubation.
Urine C&S(08/12/10):No growth after 24 hours incubation.
CSF C&S(10/12/12)No growth after 72 hours incubation.
CSF analysis(09/12/10) total cell count,blood stained,not suitable for cell count.
Protein 0.518:Glucose 4.1 Pandy test:Positive Chloride:120
 NURSING CARE PLAN
Nursing Objective Nursing Intervention Evaluation
Diagnosis
1.Potential / Patient will 1. Assess level of anxiety
actual anxiety verbalise 2. Orientate patient to ward surrounding
/fear related reduced 3. Inform patient regarding his/her treatment and
to hospital anxiety and any procedure perform
fear 4. Provide emotional support by talking to patient
and keep patient accompanied
5. Collaborate with family members to give moral
support
6. refer Doctor to explain about the nature of the
disease and treatment
7. Explain to patient the pre-operative preparation
and postoperative care.
2.Potential Patient will be 1. Assess patient's condition
actual injury free of injury 2. Nurse patient on a lower bed
related to during stay in 3. Put up side rails
weakness ward 4. Pad the side and head with pillows.
5. Stay with patient when agitated
6. Prepare padded tongue blade,airway at bedside
7. Assist with ambulating.produce personal care as
needed/provide personal care as needed
8. Administer drug as ordered . Provide nutritional
support (NG Feeding)

3.Potential / Patient will be 1. Assess oral mucous membrane O.D for signs or
actual altered not develop infection and ulceration
oral mucous oral infection 2. Carry out orall toilet B.D
membrane or ulceration 3. give saline gargle or thymol gargle or plain water
related to throughout 4 hourly or after meal
poor oral his/her stay in 4. apply medication as prescribed
hygiene hospital

4.Potential / Patient will be 1. Assess the patient physical condition and give
actual injury free of injury appropriate advise to avoid acident.
related to throughout 2. Assess patient in sitting up every 4 hourly
prolonged his/her stay in 3. Instruct patient to do limbs exercise while she/he
immobility hospital is confined to the bed
4. Advice patient not to ambulate if she/he is giddy
5. Keep the enviroment clear of obstacles
6. Maintain good lighting.
Nursing Objective Nursing Intervention Evaluation
Diagnosis
5.Potential / Patient will 1. Set up intravenous infusion or total parenteral
actual altered maintain nutrition if ordered
nutrition less her/his 2. Feed the patient with nourishing fluid through
than body nutritional NG tube as ordered .
requirement status 3. Serve patient with well balanced diet with
related to required calorie and protein
inability to 4. Give small amount but frequent meals
swallow 5. Allow patient's relatives to bring nourshing food
from home
6. Serve food at correct temperature
References
i. Case note patient.
ii. Patient son and wife.
iii. Nursing care plan.