OVERVIEW OF THE DISEASE
INTRODUCTION
A hypertensive emergency is severe hypertension (high blood pressure ) with acute impairment of organ system 9 especially the central nervous system , cardiovascular system and/or renal system ) and the possibility of irreversible organ damage. In case of hypertensive emergency, the blood pressure should be lowered aggressively over minutes to hours with a hypertensive agent. Several classes of hypertensive agents are recommended and the choice of hypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated blood pressure and the patients usual blood pressure before the hypertensive crisis. In most cases, the administration of an intravenous Sodium Nitroprusside injection which has an almost immediate anti hypertensive effect is suitable but in many cases, oral agents are given like Captopril, Clonidine,
Labetalol, Prazosin, which all have a delayed onset of action by several
minutes compared to Sodium Nitroprusside, can can also be used.
DEFINITION
Generally, the terminology describing hypertensive emergencies can be confusing. Terms such as hypertensive crisis, malignant hypertension, hypertensive urgency, accelerated hypertension and severe hypertensions are all used to=in the literature and often overlap. As a specific term hypertensive emergency is primarily used as a crisis with a diastolic pressure of 120 mm hg and above plus end organ damage (Brain, Cardiovascular, renal) as described above in contrast to hypertensive urgency where as yet no end organ damage has developed. The
former requires immediate lowering of blood pressure as with Sodium Nitroprusside
infusions.
SIGNS AND SYMPTOMS y
Headache
y
High
y
Shortness of breath
y
Convulsion
y
Changes
y
Nausea
y
Vomiting
blood pressure usually 140/100 and above
in vision
1
y
Heart palpitations
DIAGNOSTIC EXAM y
Blood
pressure monitoring using sphygmomanometer
y
Electrocardiogram (ECG)
y
Complete Blood Count(CBC)
y
Physical
y
LDL-HDL Ratio
Examination
TREATMENT
The
usual treatment is to reduce blood pressure using anti hypertensive drugs, it includes:
ACE inhibitors; ARBs; Diuretics;
Beta-blockers; Calcium- blockers Diuretics
are usually recommended as the first line of therapy for most people who have high blood pressure. If one drug doesnt work or is disagreeable, other types of diuretics are available.
NUR SING INTERV INTERVENTION
The
primary responsibility of the nurse is to assess the condition of the patient during the treatment. It includes the following but are not limited to;
Vital
signs monitoring specifically blood pressure, Assessment for possible and sudden drop of blood pressure, Monitoring of adverse reactions to drugs, carr ying out doctors order. Tabulation of Input and Output when ordered and carrying
2
A.
C lients
profile:
Name:
Mr. AM
Address:
Abbay Maddela Quirino
Age:
26 years old
Sex Civil
:
Male
status :
Married
Nationality
:
Filipino
Religion
:
Born Again
BirthDate
:
November
Occupation
:
BaKer
5,1983
Date
of admission: May 4, 2010
Time
of admission: 2:45PM
Chief Complaint:
body weakness and pale looking
Diet
DAT
:
Diagnosis:
Anemia to consider Blood Dyscrasia
Physician:
Dr.X
MEDICAL
Present health
-
HISTORY:
history of illness: Two
weeks prior to admission the patient suffered body weakness
associated with pale looking. According to the patient he al so felt dizziness and severe headache; he take paracetamol to relieve the pain but then he was not relieve thats why they decided to have his check up at QPH and his Physician advised him for confinement with a diagnosis of Anemia. Admitted last May 4, 2010 @ 2:45pm
Past
medical history:
-
He
is not fully immunized thats why he occasionally experienced Childhood
diseases like; cough,colds and fever. His last confinement was on
October
2009 at Dundayong Hospital at part of Maddela Quirino. Also Last December
28, 2009 at QPH with an admitting diagnosis of Idiopathic
thrombocytopenia Purpura . Last April 16-22, 2010 he was confined at SIGH and was diagnosed with Anemia.
Family health history:
Father
+ -
Possible hereditary HPN Asthma Cancer DM 3
Mother + -
II GORDONS HEALTH FUNCTIONAL PATTERN
1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN BEFORE HOSPITALIZATION: the Pt. verbalized that he is healthy. He can actually maintain his body healthy without any problems. DURING HOSPITALIZATION: when he was admitted at QPH he still thinks that he is okay because he feel good still but easily feel tiredness. 2. NUTRITIONAL-METABOLIC PATTERN BEFORE HOSPITALIZATION: Pt.AM prefers vegetables than meat. He rarely eats meat because he thinks those are the reason that¶s why he is suffering anemia. DURING HOSPITALIZATION: the doctor ordered DAT diet. And the hospital usually serves meat as their vian. 3. ELIMINATION PATTERN BEFORE HOSPITALIIZATION: PTA, the pt. urinates 7-8x a day with colorless - light yellow urine with no foul odor. DURING HOSPITALIZATION: when he was admitted, he urinates 67x a day. And perspires at all times bec.of warm environment in the hospital.
4. ACTIVITY-EXERCISE PATTERN
4
BEFORE HOSPITALIZATION: The pt. is fun of playing basketball and this serve as his exercise. DURING HOSPITALIZATION: He can¶t play basketball because o f his condition . 5. SLEEP-REST PATTERN BEFORE HOSPITALIZATION: Sometimes his number of sleep ranges from 6-7 hours a day. But mostly he has hard time on getting his sleep with unknown cause.
he mentioned that, since his DURING OSPITALIZATION: confinement here in QPH, he felt as though he was refreshed than that as compared with before because he had enough time to sleep without any interruptions. he had no more worries about his routine act ivities. 6. COGNITIVE PERCEPTUAL PATTERN
Pt. AM is only a high school undergraduate but he can read and write. He can easily understood and respond to our questions directly. 7.
SELF PERCEPTION/ SELF CONCEPT PATTERN BEFORE HOSPITALIZATION: He sees himself as a very busy person and responsible father on his two child. DURING HOSPITALIZATION:
8. ROLE RELATIONSHIP PATTERN
5
Because of her stay at QPH, his anxiety about his daily routines/activities at home is temporarily relieved.
BEFORE HOSPITALIZATION: He is a responsible father and husband. He is a baker on a small bakery at Zamora. DURING HOSPITALIZATION:
he can¶t work anymore because of his condition.
9. SEXUALITY-REPRODUCTIVE PATTERN
He was 7 years old when he was circumcised by what they call ³de pok-pok´before.
10. COPING STRESS MANAGEMENT BEFORE HOSPITALIZATION: Due to his routine Activities, he was not aware that he was under stress. he had been encountering it every day which may trigger t he disease. DURING HOSPITALIZATION:
he now understand that having enough rest when he is tired and stressed is very indispensable to overcome his condition. He a lso recognizes though our health teachings are the essence of taking of multivitamins rich in iron to strengthen his immune system.
11. VALUE BELIFE PATTERN BEFORE HOSPITALIZATION: He was a devoted Born again. He sometimes attends mass together with his wife and children at their nearby church. DURING HOSPITALIZATION:
6
Now that he is confined, he can¶t attend mass anymore but still prays all the time.
PHYSICAL ASSESSMENT
Date: May 06,2010@10:00am General Appearance: conscious BODY PARTS
TECHNIQUE
FINDIN GS
INTERPRETATIO N
HEAD y
Hair
Inspection
Black in color No lice
Normal
y
Scalp
Inspection Palpation
Normal Normal
y
Ears
Inspection
y
Earlobes
Inspection
y
Ear Canacl
Inspection
Eyes (Conjunctiva)
Inspection
Lips
Inspection
No presen ce of dandr uff No masse s No tender ness With norma l hearin g Beanshape d No abnor mal discha rges PERRLA With pale conju nctiva Pale in color (white)
y
y
7
Normal
Normal
Normal
Normal Due to lack of red blood cell Due to lack of red blood cell
y
Teeth
y
Gums
Inspection
y
Tongue
Inspection Inspection Palpation
FACE
NECK
presen ce of dental carrie s Pinkish in color Moist Pale in color No masse s Symmetri cal and pale in color No lesion and pale in color Symmetri cal, no bones disloc ated
Inspection
UPPER EXTREMITIES
y
With
Inspection
Fingernails
Inspection Palpation
Clean
and prope rly cut Slightly poor capill ary refill
Inspection Palpation
y
Shoulder
symmetri cal and
Inspection
8
Due to poor hygiene
Normal Normal Due to lack of red blood cell Normal Normal Due to present condition
Due to present condition
Normal
Normal Due to lack of red blood cell
Normal Due to present
pale in color. y
y
Heart Thorax and lungs
Auscultation Palpation Auscultation
y
Abdomen
Auscultation Palpation
Percussion
LOWER EXTREMITIES
Inspection
Palpation
y
Legs
bpm
Normal
No tender ness No wheez ing sound
Normal
115
Flat,
Inspection
Sym metric al slightl y pale in color Normoact ive sound No tender ness Resonant Symmetri cal Pale in color
Hairy and slightl y pale. And with compl ain of pain on the
Inspection
9
condition
Normal
Due to present condition
Normal Normal Normal
Normal Due to lack of red blood cell
Due to lack of red blood cell Due to basketball accident.
left leg.
II.
The
ANATOMY & PHYSIOLOGY
heart pumps oxygenated blood to the body and
deoxygenated to the lungs. In the human heart there is one atrium and one ventricle for its circulation, and with both a systemic and pulmonary circulation there are four chambers in total; left atrium, left ventricle, right atrium and right ventricle. The
right atrium is the upper chamber of the right side of the
heart. The blood that is returned to the right atrium is deoxygenated (poor in oxygen) and passed in to the right ventricle to be pumped through the pulmonary artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly oxygenated blood from the lugs as well as the pulmonary vein which is passed into the strong ventricle to
10
be pumped through the aorta to the different organs of the body.
III.
PATHOPHYSIOLOGY
M ERG ENCY HYPERTENSIVE E
ETIOLOGIC FACTOR: Increased
RISK FACTORS:
BP
Stressor initiated
Reni
is released by the kidney
Angiotensin is produced
Angiotensin I is converted to Angiotensin II
11
Obesity Age Stress
IV.
COURSE IN THE WARD
DOCTORS ORDER
RATIONALE
5/4/10 2:45 pm >pls. admit to male medicare Ward > Record TPR >DAT >CBC >BT >PNSS1L- 25 gtts/min >Secure 4 units of FWB type O+ & transfused after crossmatching > refer accordingly
>To treat underlying condition > for baseline data > applicable diet to the patient > to check any abnormalities > to replace components of blood loss > for electrolytes and fluid balance >to check for compatibility of blood
5/5/10 10:10 am >TF: PNSS1L at KVO > For Peripheral blood smear > for referral to Hematologist > continue for BT > refer
to evaluate the condition
for electrolytes and fluid balance to check abnormalities of blood for further evaluation and management To replace components of blood loss To evaluate condition
To
replace components of blood loss
To
replace components of blood loss
For
5/6/10 9:30am Continue BT 5/7/10 Still for BT Continue IVF PNSS1L x 24hrs 5/7/10 3:00pm For referral to Hematologist D5NM1L x 25 gtts/min Multivit. + Iron 1 capsule TID refer
further evaluation and management For electrolytes and fluid balance To boost immune system For further evaluation
12
V.
LABORATORY RESULTS
Name: Mr AM Result WBC
Normal values
3.5
13
URINALYSIS
Date: 11- 30- 09 Chemical Color:
Examination
yellow
Clarity:
clear
MICROSCOPIC EXAMINATIONS:
Pus cells:
0-2/hpf
Red cells:
5-7/hpf
Epithelial cells:
moderate/hpf
Amorphous urates:
few/hpf
Mucus threads:
+/hpf
Bacteria:
+/hpf
Dr. Nathanael B. Vidad, MD, FPSP Photologist ( 59251)
14
CHEMISTRY
Date: Nov. 30, 2009 TEST Fasting
REFERENCE VALUE blood sugar:
5.97
mmol/L
3.89-5.83
mmol/L
Cholesterol:
7.33 mmol/L
3.87-6.71
mmol/L
Triglycerides:
1.35
mmol/L
up to 1.7
mmol/L
Blood urea Nitrogen:
5.78
mmol/L
2.5-6.5
mmol/L
Creatinine:
87.9 mmol/L
150-357
mmol/L
Dr. Nathanael B. Vidad, MD, FPSP Photologist ( 59251)
15
16
SER UM ELECTROLYTES
Date: Nov. 30, 2009 Test
Reference Value
Sodium: 133.7 mmol/L
135.0-155.0
mmol/L
Potassium: 2.89 mmol/L
3.60-5.50 mmol/L
Dr. Nathanael B. Vidad, MD, FPSP Photologist ( 59251)
HEMATOLOGY DATE: Nov. 29, 2009
Reference Value
WBC:
7.6
3.5-10
RBC:
5.14
3.80-5.80
HGB:
152
110-165
HCT:
.470
.350-.500
PLT:
289
150-390
PCT:
.198
.100-.500
WBC FLAGS:
G3
Reference Value
LYM- 23-8%
17.0-48.0%
MON- 7.0-%
4.0- 10.0%
GRA- 69.2%
43.0-76.0%
17
XII.
VITAL SIGNS Admitted: Initial vital sign
November 29, 2009 bp- 220/140
November 29, 2009 8am-4 pm 9:25 am bp-160/ 100 PR-90bpm bp-160/100 PR-86bpm 10:30 am bp-160/100 PR-86bpm 11:40 am bp-130/90 PR-86bpm 12:50pm 2:00pm bp-160/100 PR-88bpm 3:45 pm bpPR-98bpm 170/100
November 29, 2009 4 pm-12am bp-190/110 5:00pm 6:30pm bp-200/130 8:15 pm 120 9:50pm bp-180/120 bp-210/130 11:00pm
PR-96bpm PR-102bpm bp-200/ PR-98bpm PR-100bpm PR-98bpm
November 30, 2009 12am-8am bp-190/120 1:00 2:00 bp-220/110 3:00 bp-200/110 bp-180/120 5:30 7:30 bp-190/120
PR-96bpm PR-98bpm PR-84 bpm PR88bpm PR-80bpm
November 30, 2009 8am-4 pm 9:30am bp-190/120 bp-190/130 12:00pm bp-200/120 1:00pm 2:30pm bp-180/130 3:30pm bp-190/120
PR-72bpm PR-84 bpm PR-89bpm PR-83bpm PR-68bpm
18
November 30, 2009 4 pm-12am 6:00pm bp-150/100 8:30pm bp-170/100 9:40pm bp-140/100 bp-140/100 10:40pm bp-160/100 11:30pm
PR-58bpm PR-64 bpm PR-60bpm PR-57bpm PR-60bpm
December 1, 2009 12am-8am bp-170/110 1:30am 2:30am bp-160/110 3:30am bp-180/120 bp-170/100 4:30am bp-170/110 5:30am
PR-62bpm PR-64 bpm PR-57bpm PR-58bpm PR-62bpm
December 1, 2009 8am-4 pm 9:00ambp-160/100 PR-80bpm bp-180/110 PR-86bpm 10:00am bp-170/100 PR-83bpm 10:15am bp-160/100 PR-86bpm 10:30am bp-160/100 PR-85 bpm 10:45am bp-170/100 PR-80bpm 11:00am bp-160/100 PR-66bpm 11:15am bp-160/100 PR-64 bpm 11:30am bp-170/110 PR-63bpm 11:45am bp-160/110 PR-60bpm 12:30pm bp-160/110 PR-68bpm 1:00pm pm bpPR-67bpm 1:15 160/ 110 2:00pm bp-160/110 PR-65 bpm 2:30pm bp-160/110 PR-64 bpm 3:30pm bp-170/110 PR-66bpm
19
December 1, 2009 4 pm-12am bp-170/110 5:00pm 6:45 pm 180/110 9:30pm bp-180/110 bp-140/110 10:00pm bp-170/110 11:00pm
PR-66bpm bpPR-68bpm PR-61 bpm PR-64 bpm PR-65 bpm
December 2, 2009 12am-8am bp-180/120 1:00am 2:30am bp-180/90 bp-160/110 5:30am 7:30am bp-160/100
PR-72bpm PR-70bpm PR-80bpm PR-79bpm
December 2, 2009 8am-4 pm 9:00am bp-160/110 bp-150/90 10:00am bp-160/100 11:00am bp-150/100 12:00pm 2:00pm bp-150/100
PR-62bpm PR-64 bpm PR-66bpm PR-62bpm PR-63bpm
December 2, 2009 4 pm-12am 6:30pm bp-170/110 7:00pm bp-160/110 9:00pm bp-140/90 bp-150/110 10:00
PR-80bpm PR-94 bpm PR-87bpm PR-92bpm
December 3, 2009 12am-8am
1:30am
5:30am
7:00am
bp-140/100 bp-150/110 bp-140/100
PR-98bpm PR-84 bpm PR-84 bpm
20
December 3, 2009 8am-4 pm 9:30am bp-140/100 bp-140/100 10:30am bp-160/100 11:30am bp-140/100 12:30pm bp-140/90 1:30pm 2:00pm bp-140/90 2:30pm bp-140/100
PR-89bpm PR-87bpm PR-90bpm PR-93bpm PR-86bpm PR-78bpm PR-68bpm
December 3, 2009 4 pm-12am 6:00pm bp-140/90 bp-130/90 10:00pm
PR-66bpm PR-68bpm
December 4, 2009 12am-8am bp-160/120 12:30am bp-150/120 1:15am bp-140/100 1:30am bp-140/100 1:45am 2:00am bp-140/100 2:15am bp-140/100 6:00am bp-140/100
PR-85 bpm PR-86bpm PR-89bpm PR-86bpm PR-83bpm PR-86bpm PR-79bpm
December 3, 2009 8am-4 pm bp-140/100 10:00am
PR-86bpm
21
VI.
NURSING CARE PLAN
Assessment
Diagno sis
Planni ng
Interventi on
SUBJECTIVE: ³Lagi sumasakit ulo ko.´ as verbalized by the pt. OBJECTIVE: Body weakness Irritable Oily face
elevated blood press ure
After 14° of nursi ng inter venti on the pts head ache will be relie ved.
Independent: -Established rapport
Rational e
-To gain pt trust and cooperation -Monitored -For baseline BP and data PR -To lessen anxiety and -Instructed pt stress on proper -For pts comfort deep breathing -Positioned the pt on a comforta -To relief ble headache position -To lessen fat deposit and Dependent: retention of NaCl ions. -Due meds given -On low fat, and low salt diet
22
Evaluatio n Goal met as evidence by the pts verbalizat ion of ³hindi na masakit ulo ko.´
23
NURSING CARE PLAN
Assessment
Diagno sis
Planni ng
Interventi on
SUBJECTIVE: -Ø
Knowled ge defici t r/t self care
After 12° of nursi ng inter venti on the pt will be
Independent: -Established rapport -Monitored v/s
OBJECTIVE: -guarded behavior -diaphoretic
-Instructed pt to have adequate rest periods
Rational e -To gain pt trust and cooperat ion -For baseline data -For comfort and
Evaluatio n Goal met as evidence by the pts verbalizat ion of ³ gagawin ko yung itinuro mo.´
NURSING CARE PLAN
Assessment
Diagno sis
Planni ng
Interventi on
SUBJECTIVE: -Ø
Knowled ge defici t r/t self care
After 12° of nursi ng inter venti on the pt will be able to dem onstr ate all incre asin g
Independent: -Established rapport -Monitored v/s
OBJECTIVE: -guarded behavior -diaphoretic
-Instructed pt to have adequate rest periods -Emphasized the importan ce of proper hygiene, grooming and feeding
24
inter est / parti cipat ion of self care.
Rational e -To gain pt trust and cooperat ion -For baseline data -For comfort and relaxatio n. -To promote cleanlin ess
Evaluatio n Goal met as evidence by the pts verbalizat ion of ³ gagawin ko yung itinuro mo.´
inter est / parti cipat ion of self care.
25
NURSING CARE PLAN
Assessment SUBJECTIVE: ³limang araw na akong hindi ngdudume,kaya nanghihina ako´ ask verbalized by the pt. OBJECTIVE: -facial grimace -minimal movement
Diagno sis
Planni ng
Constipat
After 13° of nursi ng inter venti on the pt. will be able to defe cate and
ion
Interventi on Independent: -Established rapport -Monitored v/s -Palpated abdomen
-Instructed to increased fluid intake -Encouraged pt to eat nutritious
Rational e -To gain pt trust and cooperation -For baseline data -To check for presence of distention. -to promote hydration -To promote moist/ soft stool.
Evaluatio n Goal met as evidence by the pts verbalizat ion of ³´nagdu mi na ako.
NURSING CARE PLAN
Assessment SUBJECTIVE: ³limang araw na akong hindi ngdudume,kaya nanghihina ako´ ask verbalized by the pt.
Diagno sis
Planni ng
Constipat
After 13° of nursi ng inter venti on the pt. will be able to defe cate and regai n stren gth.
ion
OBJECTIVE: -facial grimace -minimal movement
Interventi on Independent: -Established rapport -Monitored v/s -Palpated abdomen
-Instructed to increased fluid intake -Encouraged pt to eat nutritious foods. Dependent: administered Bisacodyl as ordered.
Rational e -To gain pt trust and cooperation -For baseline data -To check for presence of distention. -to promote hydration
Evaluatio n Goal met as evidence by the pts verbalizat ion of ³´nagdu mi na ako.
-To promote moist/ soft stool.
26
VII.
DRUG STUDY
DRUG NAME
CLASSIFICATIO N
INDICATION/ACT ION
Generic name:
Non- steroidal
Short term management of moderately severe, acute pain for single dose treatment
Ketorolac
antiinflammatory
Brand name: Stock:
Doctors order:
SIDE EFFECTS
NSG. RESPONSIBI
y
Headache
y
y
Dyspepsia
y
GI pain Constipation Flatulence
y
y y y
Correct Hypov
Alert: Maximu parenteral and When appropr injection. Pt m site which can bags.
VII.
DRUG STUDY
DRUG NAME
CLASSIFICATIO N
INDICATION/ACT ION
Generic name:
Non- steroidal
Short term management of moderately severe, acute pain for single dose treatment
Ketorolac
antiinflammatory
Brand name: Stock:
Generic name: Ranitidine
Doctors order:
SIDE EFFECTS
y
Headache
y
y
Dyspepsia
y
GI pain Constipation Flatulence
y
Anaphylaxis Headache Blurred vision
y
y y y
y y
Anti ulcer drugs Gastric irritation
Brand Name:
NSG. RESPONSIBI
y
y
Stock:
Generic Name: metoclopramide
Generic name: Furosemide
Alert: Maximu parenteral and When appropr injection. Pt m site which can bags.
Assess pt for a presence of bl gastric aspirat Drug may be a solutions.
Doctors order:
y
Anti-emetics Nausea and
vomiting
Brand name: plasil Stock:10mg/2ml
Correct Hypov
y
Doctors order:
1 amp IV now then q8° PRN
y
Bradycardia,sup ravetricular tachycardia Neuroleptic malignant syndrome,seizu res, suicide ideation.
27
y
Monitor bowe Safety and effe established for weeks.
Vertigo,
headache, dizziness.
Diuretics
y
y
To
prevent noct
Hypertension
y
Brand name:
Panceatitis, thrombocytope nia.
y
preparations in the early aftern Watch for signs weakness and c
Stock: Doctors order:
1 amp IV now then OD
Generic name: Paracetamol
y
Non
Brand name:
opiod analgesic and anti pyretics
Mild pain and/or fever
Neutropenia,
leucopenia, pancytopenia and hypoglycemia
y
Alert: Many OT contain acetami when calculatin
Stock:
Doctors order:
1 amp IV stat Generic name: Losartan potassium
Headache,
Anti hypertensives
For hypertension
Brand name: getzar
dizziness, fatigue, abdominal pain, nausea, back pain or leg pain, cough and respiratory infection
Drugs
can be used a antihypertensiv
Monitor patients B therapy and mo taking diuretics
Generic name: Bisacodyl Diphenyl
Brand name: Dulcolax
methane derivative
Chronic
constipation
28
Dizziness, faintness,
muscle weakness with
Give drugs at times scheduled activi Before giving for co patient has ade
excessive use Abdominal cramps Electrolyte imbalance
29
diet.
