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    Case Summary - Hypertension

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    Marie Kelsey Acena Macaraig
    It indicates that the community is affected by the educational attainment and background of the working class in terms of knowledge and skills by adjusting with their level of understanding. This will also reflect their health perception in keeping themselves healthy.

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    Case Summary - Hypertension

    Uploaded by

    Marie Kelsey Acena Macaraig
    113 views4 pages
    It indicates that the community is affected by the educational attainment and background of the working class in terms of knowledge and skills by adjusting with their level of understanding. This will also reflect their health perception in keeping themselves healthy.

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    It indicates that the community is affected by the educational attainment and background of the working class in terms of knowledge and skills by adjusting with their level of understanding. This will also reflect their health perception in keeping themselves healthy.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    113 views4 pages

    Case Summary - Hypertension

    Uploaded by

    Marie Kelsey Acena Macaraig
    It indicates that the community is affected by the educational attainment and background of the working class in terms of knowledge and skills by adjusting with their level of understanding. This will also reflect their health perception in keeping themselves healthy.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    St.

    Paul College of Ilocos Sur


    (Member, St. Paul University System)
    St. Paul Avenue 2727, Bantay, Ilocos Sur

    DEPARTMENT OF NURSING

    NAME: MARIE KELSEY A. MACARAIG


    SECTION: BSN3A

    Case Summary: Hypertension

    July 23, 2021


    1:15 pm
    About the px:
    Patient’s General Information
    Name: P.P.M. Age: 65 Gender: Female
    Address: Zone V. Bantay, Ilocos Sur Date of Birth: August 19, 1956
    Civil Status: Single Educational Attainment: Highschool Graduate
    Religion: Roman Catholic Occupation: Retired teacher
    Hospital: St. James’ Hospital

    Prior admission:
    Patient complains elevated blood pressure of 160/100 mm Hg, episodes of severe headaches,
    fatigue, dizziness, and sometimes chest discomforts.
    On admission:
    July 23, 2021
    Interviewed revealed that she does not know why her blood pressure is high however stated
    that she have a family history of hypertension from paternal side and her father died from heart
    stroke.
    Px is always at her home watching TV , smokes half to 1 pack of cigarettes every day and
    drinks alcohol during the
    She states that she always eat outside or buy foods from fast food chain because she said that
    she lives alone.

    Doctors order:
    CBC, BUN/Crea, Renal function test, Urinalysis, Serum lipid profile, Na K determination.
    Intravenous Infusion of PNSS 500 ml to run for 8 hours started.
    To administer amlodipine 10mg OD. If SBP >200 start nicardipine drip x 15 gtts/min and titrate
    accordingly. Further diagnostic examination of ECG and Cranial CT – Scan was ordered.

    Laboratory Findings:
    Mild left ventricular hypertrophy
    Heat CT – Scan unremarkable plain CT scan of the head.
    Elevated sodium levels of 155mmol/L
    Total cholesterol 236 mg/dl
    Triglycerides 202 mg/dl
    HDL – C 61.6 mg/dl
    C- LDL 133.6 mg/dl.

    Summary of Abnormal Findings:


    1. Elevated Blood Pressure of 160/100 mm Hg
    2. Heart rate of 114 bpm
    3. Respiratory rate of 24 bpm
    4. Episodes of severe headaches, dizziness, fatigue, and chest discomfort.
    5. Mild left hypertrophy
    6. Sodium levels of 155 mmol/L
    7. Total cholesterol 236 mg/dl
    8. Triglycerides 202 mg/dl
    9. HDL -C 61.8 mg/dl
    10. C-LDL 133.8 mg/dl
    11. Blurring of eyesight
    12. Tooth decay
    Medical Diagnosis: Primary Hypertension, Stage 2
    Nursing Diagnoses:
    1. Decreased Cardiac Output related to altered contractility as evidenced by left ventricular
    hypertrophy
    2. Acute pain related to physical agent [ increased cerebral vascular pressure]
    as evidenced by verbal reports of episodes of severe headache, rated pain as 8/10, and
    grimace expression.
    3. Imbalanced nutrition: more than requirement related to obesity and average daily
    physical activity is less than recommended, sedentary behaviors, poor dietary habits as
    evidenced by the patient’s body mass index of 26.8 and verbal reports frequent fast food
    and restaurant food consumption and poor physical exercise.
    4. Ineffective health management related to insufficient knowledge about risk factors and
    management of hypertension as evidenced by unhealthy habits and unexpected
    acceleration of illness symptoms
    5. Risk for activity Intolerance related to generalized weakness as evidenced by verbal
    report of fatigue, dizziness weakness, elevated blood pressure of 160/100 mm Hg and
    heart rate 114 bpm.

    Medications:

    Amlodipine 10mg P.O 1 tab OD

    Nicardipine 20 mg IVF q8 (If SBP >200)

    Atorvastatin 20mg P.O OD

    Take home medications:

     Amlodipine (Norvasc) 10 mg P.O OD


    o Take 1 tablet orally every morning once a day.
     Nifedipine (Adalat) 20 mg P.O PRN
    o Take 1 tablet orally IF BP 200>
     Atorvastatin 20mg P.O OD

    July 25, 2021 10:19 a.m.

    The patient was discharged

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