Liceo de Cagayan University RN. Pelaez Blvd. Kauswagan, Cagayan de Oro City
College of Nursing NCM501202
A Case Study of a 44 year old male diagnosed with
Hypertensive Urgency Submitted to: Ms. Michelle Jacalan RN Clinical Instructor Submitted By: By: Kier John Aboy Student
January 25, 2010
I. Introduction a. Overview of the Study Hypertensive urgency is elevated blood pressure (usually over 180/110) without evidence of end organ damage. Hypertensive Urgency is a severe elevation in blood pressure without progressive target organ dysfunction. It is a crucial step in distinguishing between hypertensive emergency and urgency for an appropriate management. Patients with hypertension or hypertensive urgency do not need to go to the emergency department for treatment if they have reliable follow up with their primary care doctor. Several classes of antihypertensive agents are recommended and the choice for the antihypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated blood pressure and the patient's usual blood pressure before the hypertensive crisis. In most cases, the administration of an intravenous sodium nitroprusside injection which has an almost immediate antihypertensive effect is suitable but in many cases not readily available. In less urgent cases, oral agents like captopril, clonidine, labetalol, prazosin, which all have a delayed onset of action by several minutes compared to sodium nitroprusside, can also be used. It is also important that the blood pressure is lowered not too abruptly, but smoothly. The initial goal in hypertensive emergencies is to reduce the pressure by no more than 25% (within minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 2–6 hours. Excessive reductions in pressure may precipitate coronary, cerebral, or renal ischemia. The diagnosis of a hypertensive emergency is not only based on the absolute level of blood pressure, but also on the individual regular level of blood pressure before the hypertensive crisis. Individuals with a history of chronic hypertension may not tolerate a "normal" blood pressure.
b. Objective of the Study This study aims to: • Conduct and evaluate an assessment for the client • Determine the causes, predisposing and precipitating factors that constitute the onset of the disease process. • Render series of nursing interventions for the client’s care • Provide and disseminate important information as teachings to the client and the significant others to boost the knowing and understanding of the nature of the said health condition. • Improve skills and knowledge as health care providers in the clinical area.
c. Scope and Limitation of the Study This study includes the collection of information specifically to the patient’s health condition. The study also includes the assessment of the physiological and psychological status, adequacy of support systems and care given by the family as well as other health care providers. The scope of this study would include: a. Data collected via assessment, interviews with the patient and family members. b. Actual problems for 1 day including appropriate nursing intervention that would be applied within her stay in the hospital at Polymedic General Hospital. c. Developing a plan of care that will reduce identified predicaments and complications. d. Coordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health. An array of factors influencing the limitations of this study includes: a. Data collected is limited only to assessment and interview to the patient’s significant others. b. The interaction, assessment and care were only limited to a total of 12 hours with actual nursing intervention done.
II. Heath History a. Patients Profile Name: Abraham Olegario Jr. Weight: 11 lbs Age: 44 Years old Temperature: 36.5 oc Date of Birth: June 15, 1965 PR: 82 bpm Sex: Male RR: 22 cpm Civil Status: Married Height: 163 cm Religion: Roman Catholic Nationality: Filipino Address: 14th – 21 st. Macasandig, Cagayan de Oro City Informants: Roselyn Olegario Allergy: No Known Foods and Drugs Allergy Date of Admission: December 14, 2009 Time of Admission: 3:00 am Chief complaints: Nosebleeding Diagnosis: Hypertensive Urgency
b. Family and Personal health History According to his wife, both of the family side has a history of Hypertension.
1. History of Present Illness Abraham Olegario Jr. a 44 yrs old. live in 14th – 21 st. Macasandig, Cagayan de Oro City. PTA patient suffers nosebleeding, hypertension was noted that it started December 14, 2009 at 1am in the morning. The night before admission patient had experience sleep difficulties. Consequently, around 3:00 am patient was rushed to the hospital with the Diagnosis of Hypertensive Urgency.
Chief Complaints The patient was admitted because of nosebleeding, BP – 150/100.
III.
Developmental Data
Sigmund Freud’s Psychosexual Theory: Freud advanced a theory of personality development that centered on the effects of the sexual pleasure drive on the individual psyche. At particular points in the developmental process, he claimed, a single body part is particularly sensitive to sexual, erotic stimulation. These erogenous zones are the mouth, the anus, and the genital region. The child's libido centers on behavior affecting the primary erogenous zone of his age; he cannot focus on the primary erogenous zone of the next stage without resolving the developmental conflict of the immediate one. A child at a given stage of development has certain needs and demands, such as the need of the infant to nurse. Frustration occurs when these needs are not met; Overindulgence stems from such an ample meeting of these needs that the child is reluctant to progress beyond the stage. Both frustration and overindulgence lock some amount of the child's libido permanently into the stage in which they occur; both result in a fixation. If a child progresses normally through the stages, resolving each conflict
and moving on, then little libido remains invested in each stage of development. But if he fixates at a particular stage, the method of obtaining satisfaction which characterized the stage will dominate and affect his adult personality.
FREUD’S PSYCHOSEXUAL THEORY Age
Name
Pleasure Source
Conflict
puberty onwards
Genital
Physical sexual Social Rules changes reawaken repressed needs. Direct sexual feelings towards others lead to sexual gratification.
Eric Erickson’s Psychosocial Theory:
Erik Erikson (1902-1994) said we develop in psychosocial stages. Erikson emphasized developmental change throughout the human life span. In Erikson’s theory, eight stages of development unfold as we go through the life span. Each stage consists of a crisis that must be faced. According to Erikson, this crisis is not a catastrophe but a turning point of increased vulnerability and enhanced potential. Generativity is the concern of establishing and guiding the next generation. Socially valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity. Stages
Developmental Task or Conflict to be Resolved
Adulthood (35-50 years)
Generativity vs. stagnation. Middle aged adults are productive, performing meaningful work, and raising a family, or become stagnant and inactive.
Jean Piaget’s Cognitive Theory: Swiss biologist and psychologist Jean Piaget (1896-1980) observed his children (and their process of making sense of the world around them) and eventually developed a four-stage model of how the mind processes new information encountered. He posited that children progress through 4 stages and that they all do so in the same order. These four stages are: •
•
•
•
Sensorimotor stage (Birth to 2 years old). The infant builds an understanding of himself or herself and reality (and how things work) through interactions with the environment. It is able to differentiate between itself and other objects. Learning takes place via assimilation (the organization of information and absorbing it into existing schema) and accommodation (when an object cannot be assimilated and the schemata have to be modified to include the object. Preoperational stage (ages 2 to 4). The child is not yet able to conceptualize abstractly and needs concrete physical situations. Objects are classified in simple ways, especially by important features. Concrete operations (ages 7 to 11). As physical experience accumulates, accomodation is increased. The child begins to think abstractly and conceptualize, creating logical structures that explain his or her physical experiences. Formal operations (beginning at ages 11 to 15). Cognition reaches its final form. By this stage, the person no longer requires concrete objects to make rational judgements. He or she is capable of deductive and hypothetical reasoning. His or her ability for abstract thinking is very similar to an adult.
Robert Havighurst Developmental Task Theory Another Psychologist that further elaborated on Erickson's view on personality development was Robert. J Havighurst. He asserted that "Erickson's analysis of stages of development could be applied in a different way to shed light on other facets of development. He suggested some development tasks for different age, levels, starting from the pre-school and kindergarten age. According to Havighurst, this age ushers in an era of formation of simple concepts of societal and physical reality. It is a familiarity seeking stage with the social surroundings including every day objects. Children are curious at this stage asking questions. The questions if answered expose them to experiences they hitherto do not have. The child would want to relate emotionally with his parents, siblings and other people around mostly through imitation. He would like to distinguish right from wrong and develop a conscience. Secondary grades: At the secondary grade, nine (9) developmental tasks have been similarly identified by Havighurst, which are related mostly to adolescents and adult behaviors. The list comprises of : Achieving new and mature relations with age mates of both sexes; Achieving masculine or feminine social role; Accepting one's physique and using the body effectively; Achieving emotional independence from parents and other adults; Achieving assurance of economic independence and selecting and preparing for occupation; Preparing for marriage and family life; Developing intellectual skills and concepts necessary for civic competence; Desiring and achieving socially responsible behavior; and Acquiring a set of values and an ethical system as a guide to behavior. Havighurst emphasized the importance of timing and teachable moments in addressing issues related to the achievement of the developmental tasks, failing which there would be an adverse repercussion in later aspects of development. These issues have also been discussed under psychology of adolescence.
IV Medical Management
a. Medical Orders and Rationale Doctors Order
Rationale
December 14, 2009
•
•
Admitted to Semi private room at Station 6 under the supervise and sevice of Dr. Bedayo At Low salt , Low fat diet
•
• •
FF IVF D5W 500cc 1 amp with nicardipine @40 cc/hr
• •
Labs
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CBC
•
•
•
Urinalysis •
•
For management and treatment of condition
To supply nutrients and prevent wait loss
To provide access for intravenous medications To screen patients blood components and to detect for any abnormalities like infection. These results will serve as a guide for evaluation and to counteract with the existing problem. To screen patients urine components and to detect for any abnormalities To screen patients feces and to detect for abnormalities.
Fecalysis
o
•
v/s q 1 hour
For baseline date purposes and to monitor patients condition
Drug Study Generic Name of Ordered Drug: Nifedipine Brand Name: Adalat Date Ordered: December 14, 2009 Classification: Antianginal, Antihypertensive Dose/Frequency/Route: 30mg 1 tab OD PO Mechanism of Action: inhibits calcium transport into myocardial smooth cells Contraindication: Hypersensitivity to Adalat Side Effects/Toxic Effects: headache, abnormal dreams, dizziness, drowsiness Nursing Precaution: severe hepatic imapairement
Drug Study Generic Name of Ordered Drug: Nasathera Date Ordered: December 14, 2009 Classification: cough and cold remedies Dose/Frequency/Route: 1 capsule OD PO Mechanism of Action: to help to minimize the cough and colds Specific Indication: Nasal congestion, headache & fever associated w/ sinusitis, rhinitis, common cold & flu. Contraindication:
Hyperthyroidism;
HTN,
coronary
disease;
MAOIs;
nephropathy; benign prostatic hypertrophy & closed-angle glaucoma. Side Effects/Toxic Effects: Giddiness, headache; GI upsets; sweating, thirst; tachycardia, precordial pain, palpitations; difficulty in micturition; muscle weakness; tremors, anxiety, insomnia; skin eruptions. Nursing Precaution: Cardiac disease or decompensation, angina, diabetes; hepatic or renal impairment
Drug Study Generic Name of Ordered Drug: Sodium Bicarbonate Brand Name: Date Ordered: December 14, 2009 Classification: Antiulcer agents Dose/Frequency/Route: 250mg 1 tab bid PO Mechanism of Action: Take this medication by mouth as directed. Chewable tablets are to be chewed thoroughly before swallowing followed by a glass of water. Take this medication exactly as directed. Do not increase the dose, take it more often or continue taking this for longer than prescribed. Contraindication: Hypersensitivity to this drug Side Effects/Toxic Effects: This medication is generally well tolerated. However, high doses may cause headache, nausea or irritability. If any of these effects continue or become bothersome, inform your doctor. Notify your doctor if you develop: muscle weakness, slow reflexes, confusion, swelling of the feet or ankles, black tarlike stools, coffee-ground vomit. If you notice other effects not listed above, contact your doctor or pharmacist. Nursing Precaution: Tell your doctor if you have: pre-existing heart disease, kidney disease, liver disease, high blood pressure, any allergies. Because this medication contains a large amount of sodium, remind your doctor if you are on a low sodium diet. This medication should be used only if clearly needed during pregnancy . Discuss the risks and benefits with your doctor. Since small amounts of this medication appear in breast milk, consult your doctor before breast-feeding.
V. Pathophysiology Name Of Patient: Abraham Olegario Jr. Diagnosis: Hypertensive urgency Definition: Hypertensive Urgency is a severe elevation in blood pressure without progressive target organ dysfunction. It is a crucial step in distinguishing between hypertensive emergency and urgency for an appropriate management. Predisposing Factors: environment, hygiene and stress Precipitation Factors: all ages, male and female
BIBLIOGRAPHY Doenges, Marilynn E., et. al. Nursing Care Plans: Guidelines for Individualizing Patient Care, 6th Edition. Thailand: F.A. Davis Company, 2002. Kozier, Barbara, et. al. Fundamentals of Nursing, 7th Edition. Philippines: Pearson Education, 2004. Smeltzer, Suzanne and Bare, Brenda, ed. Medical-Surgical Nursing, 10th Edition. New York: Lippincott Williams & Wilkins, 2004. “Acute Gastritis” [Online] Available http://www.3m.com/us/healthcare/pdfs/acute_gastritis.pdf, July 28, 2006. Adelle Pilliteri, Maternal and Child Nursing y Volume 1, 5 th Edition Doenges et al. Nurses pocket guide; nursing diagnoses with intervention: Fourth Edition Nursing 2006 Drug Handbook (26 th ed.), Philadelphia, J.B. Company, 2006
