1

I.

INTRODUCTION
Hypertension, or commonly known as high blood pressure, is a medical
condition wherein the blood pressure of an individual is recurrently elevated.
Hypertension is an important contributor to morbidity and mortality from
cardiovascular disease. It is a an independent risk factor for stroke, myocardial
infarction, renal failure, congestive heart failure, progressive atherosclerosis,
dementia, coronary artery disease and peripheral vascular disease. Hypertension
affects approximately 50 million individuals in the United States and
approximately 1 billion individuals worldwide. As the population ages, the
prevalence of hypertension will increase even further broad and effective
preventive measures are implemented (1). In the Philippines, 9.6M are
hypertensive and 15.4M are predisposed to be hypertensive among adults, 20
years and over (2). Unfortunately, half of those who has hypertension are not
aware that they have the condition, only 13.1% of them has been treated and 19.3
% has been controlled (3). Since hypertension may be present in an individual in
years without noticeable symptoms, it is otherwise known as The Silent Assasin
(4) In the Philippines, for over 5 years, hypertension ranks as the fifth leading
cause of morbidity (5). This implies that hypertension is a chronic problem or
condition of the country and perhaps not much has been done on its control and
prevention. Prolonged and uncontrolled hypertension is very dangerous.
Unhealthy lifestyles which include cigarette smoking, unmanaged stress, salty
food consumption, physical inactivity, or being overweight are the common
modifiable risk factors to having hypertension. Non modifiable factors include

genetic predisposition to hypertension and other disease condition like diabetes,

heart and kidney disease, high cholesterol level, or stroke and an increasing age.
Hypertension in its earlier stage is manageable. The simplest way of controlling
high blood pressure is through lifestyle modification by having healthy diet and
regular exercise. Discontinuation of smoking and alcohol consumption are also
advised to individuals with hypertension. However, medication is prescribed to
hypertensive individuals to control persistent rise in blood pressure.
Hypertensive urgency is defined as a severe elevation of BP, without evidence of
progressive target organ dysfunction. These patients require BP control over
several days to weeks. The most common hypertensive urgency is a rapid
unexplained rise in BP in a patient with chronic essential HTN.Other causes are
Renal parenchymal disease Chronic pyelonephritis, primary glomerulonephritis,
tubulointerstitial nephritis (accounts for 80% of all secondary causes) Systemic
disorders with renal involvement Systemic lupus erythematosus, systemic
sclerosis,

vasculitides

Renovascular

disease

Atherosclerotic

disease,

fibromuscular dysplasia, polyarteritis nodosa Endocrine Pheochromocytoma,

Cushing syndrome, primary hyperaldosteronism Drugs Cocaine, amphetamines,
cyclosporin, clonidine withdrawal, phencyclidine, diet pills, oral contraceptive
pills Drug interactions Monoamine oxidase inhibitors with tricyclic
antidepressants, antihistamines, or tyramine-containing food CNS CNS trauma
or spinal cord disorders, such as Guillain-Barr syndrome Coarctation of the aorta
Preeclampsia/eclampsia Postoperative hypertension.
II. GENERAL DATA

Name :

Mrs. S A E M

Age

47 years old

Address
Sex

Civil status:
Occupation:

Magsaysay Hills Toledo City Cebu

Female
Married
Teacher

Citizenship:

Filipino

Religion:

Roman Catholic

Hospital:

Chung Hua Hospital

Room/bed number:

C-322

Hospital number:

1P0000237751

Date of Admission:

July 25, 2010

Date of Discharge:

July 28, 2010

Time of admission:

10:28 pm

Attending Physician:

Dr. Noval, Lerma Reston (Cardiologist)

Final Diagnosis:

Hypertensive Urgency

III .HISTORY OF PRECENT ILLNESS

A few hours prior to admission patient complain of chest discomfort with note of
elevated blood pressure of 150/80 mmHg. Patient self medicated with her maintenance
medication Atenolol 25 mg and was brought to Toledo Hospital and was referred to
Chung Hua Hospital for further management.

IV. PAST HEALTH HISTORY

The patient has no known allergies but according to her she was diagnosed last year
with heart enlargement due to her inherited condition to her father side which is
hypertension.

V. CLIENT CLINICAL COURSE OF THE UNIT

July 26, 2010
On the first day of care. Patient received lying on bed conscious coherent and awake,
with ongoing IVF # 1 PNSS 1L @ 40 cc/hr hooked at left arm infusing well. Patient
complains of chest discomfort upon rising up to her bed. Patient is anxious as evidenced
by verbalization of her concern upon her current condition. Patient also reported fatigue.
Upon assessing her she stated that she feels like her body was too heavy to carry, she feel
so weak and helpless. Vital signs were monitored as ordered by the physician. Report if
blood pressure is elevated.

July 27, 2010

On the second day of care. Patient received lying on bed conscious awake and coherent
with ongoing IVF PNSS # 2 1L @ 40 cc/hr infusing well. Patient vital signs were still
monitored as ordered. Patient verbalized that sometimes during walking around the room
she can feel her heart beating so fast. Patient was advice to avoid activities that exerts too
much effort to avoid the risk of injuries. Blood pressure were taken every 2 hours and
reported for any elevation. Patients only concern at this time was her heart palpitations
during activities.

July 28, 2010

On the third day of care. Patient received conscious awake and coherent. Patient is
watching television with no IVF attached and was ready to be discharged. Patient state
that she feels well now. Vital signs were still monitored and all were on at the normal
range. Health teaching was provided. Patient was encouraged to low salt and low fat diet
and to avoid activities that exert too much effort. Before the shift, patient was discharged
via wheel chair. Patient verbalized that she will comply with the health teaching that was
being instructed to her.

VI. FAMILY PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

A. FAMILY HISTORY

Table 1: Patients immediate family members:

NAME

POSITION IN

AGE

OCCUPATION

THE FAMILY

Mr. D E

Grand Father

Deceased

Farmer

Mrs. J E

Grand Mother

Deceased

Tailor

Mrs. M E F

Fathers sister

69 years old

Teacher

Mr. A E

Father

72 years old

Businessman

Mr. R E

Fathers Brother

65 years old

Government employee

Mrs. S A E M

Patient

47 years old

Teacher

Mr. A E

Brother

45 years old

Teacher

FAMILY GENOGRAM:
Legend:

= Normal (male)
= Hypertensive

= Normal (female)
= Hypertensive

Grand
Father

Fathers
Sister

Grand
Mother

Father

Patient

Fathers
Brother

Patients
Brother

B. PERSONAL AND SOCIAL HISTORY

Mrs. S A E M 47 years old a female and a Filipino. She is a roman catholic and
a pure Cebuano recently residing at Magsaysay Hills Toledo City Cebu. Mrs. S

A E M was a very loving and responsible wife to her husband. She is a very
friendly person. Shes always attending to the needs of her family. She always
sees to it that she can provide the needed things for her family. She wanted to
give her best to her family. If she doesnt have any chores in the house or
doesnt have any work, she does gardening on her little garden in their house.
She is also fun on watching television especially noon time shows.

C. ENVIRONMENTAL HEALTH HISTORY

Mrs. S A E M and her family are living in their own house at Magsaysay Hills
Toledo City Cebu and their house is made up of concrete materials. Their house
is just about enough for her family to live in and to protect them from stranger
and for hot and cold environment. They also have a backyard and she made a
little garden in order to help in their family in terms of fresh vegetables as food.
Their house is equipped with electricity. Their water supply is in their deep
wheel for laundry and mineral water is for drinking. Their house has its own
toilet facility; according to her it was well maintained and cleaned always.
Their garbage is dispose through compose pit on their backyard. Their house is
surrounded with trees that are planted by her fathers parents.
VII. PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEM
Physical assessment was also known as the physical examination is the
evaluation of a body to determine its state of health. This method involves the use of the
five senses of the medical care provider since it uses the technique of inspection,

palpation, percussion, and the last was the auscultation. Physical assessment findings
provide objectives data in determining correct diagnosis and devising for the appropriate
interventions and treatment if the physical assessment is a medical practitioner-based
data, nursing review of system is a patient based data or commonly known as the
subjective data. This is a method of assessing a condition by asking a set of questions to
the patient that pertains to the particular parts or system of the body.
It is usually supported by the results from the physical assessment. Both physical
assessment and nursing review of system are vital in achieving a plan of care to the
patient and assuring a optimal care being rendered.
The table below shows the results and findings from the physical assessment and the
nursing review of system conducted to patient, Mrs. S A E M:
Table 2. PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEM:
NURSING REVIEW OF SYSTEM

PHYSICAL ASSESSMENT

HEAD

Head is proportion to the patients body. Some hair

wala raman bukol bukol ako ulo dong as

vervalized by the patient.
EYES
depektado na jud ako panan-aw dong, dili ko ka
klaru og basa kong dili ko mag eyeglass as
verbalized by the patient.

is gray and evenly distributed. No lesions are

visible. Dandruff was noted.
Patient eyes are symmetrical, eyebrows are free
from scaling, pupils constricted when light is
focused, sclera is white, conjunctiva is clear, and
eye movement and blinking reflex are in good
condition. Teary eyes noted. Patients eyeglass grade
is 180.

EARS

Patient ears are symmetrical, equal in size and same

in appearance. No foul smelly sticky discharged in

10
ok raman ako pan dungog as verbalized by the

both ears. Patient was able to her whispered words.

patient.
NOSE
ok raman, wala man sad nag ping-ot ako ilong as
verbalized by the patient.

Nose is located at the midline of the face with no

lesion or redness noted. Client report no tenderness.
Can breathe through the nose clearly. Septums are
not perforated.

MOUTH
wala na koy bag-ang sa taas og ubos as
verbalized by the patient.

Lips are pale without lesions or swelling. Teeth are

incomplete, left and right molars are absent. Gums
and tongue are pale and slightly dry. No lesions and
ulcers noted. Tonsillar pillar are symmetrical, tonsils
are present, vulvula at the midline and gag reflex are
in good condition.

NECK
ok raman ako pag tulon dong as verbalized by the
patient.

Patients neck is smooth, controlled movement,

cervical lymph nodes are palpable, patients thyroid
are at the midline, smooth, firm, tender and no
lesion noted.

INTEGUMENTARY SYSTEM
Normal raman ako gipamati karon dong as
verbalized by the patient.
RESPIRATORY SYSTEM
Usahay maglisod ko og ginhawa as verbalized by
the patient.
CARDIOVASCULAR SYSTEM
ma feel nako nga paspas ang pinitik sa ako kasingkasing as verbalized by the patient.

Skin is fair in complexion, no presence of marks or

scars. Nails are short and with capillary refill time of
2-3 seconds.
Respiratory rate ranges from 21-22 cycles per
minute, lungs expansion is symmetrical, clear breath
sounds are present.
Heart rate is 78 beats per minute, blood pressure is
130/80 mmHg.

11
GASTROINTESTINAL SYSYTEM
wala raman problema dong, makalibang raman ko
kada adlaw as verbalized by the patient.
URINARY SYSTEM

Patient reported no abdominal pain. Patient was able

to pass bowel during the shift. Bowel sounds are
normal.
Patients urinary output ranges from 660-750 cc in a

dili man ko mag lisod og pangihi dong as

day thats approximately 20-30 cc/hr. Patient urine

is amber in color.

verbalized by the patient.

MUSCULOSKELETAL SYSYTEM
Usahay murag lay-lay ako pamati as verbalized by

Patient can move her legs and other extremities.

Doesnt

need

assistance

upon

walking

and

ambulation.

the patient.
NEUROLOGIC SYSTEM

Patient is conscious, coherent and responsive.

ok lng man as verbalized by the patient.

Response with environmental stimuli and interact

with other persons in the room. Answered questions
correctly. Patient is aware of time date and place
when admitted.

GENETO-URINARY SYSTEM
Patient refuses.

VIII. DEVELOPMENTAL DATA

Developmental history refers to the series or sets of events that an individual
usually undergoes in the specific age and specific time of growth. The purpose of
gathering the developmental history or data is to determine the patients physical,
mental, and psychosocial developmental development in order to assess any
developmental delays.
Psychosocial Developmental Theory

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Stage and age

Central task

Indications

of Patients

positive

resolution

resolutions
INFANCY

Trust

Birth to 1 year

vs.

Oral- sensory

Mistrust

-Infants develop trust

-Patient related that

in self, others, and in

she have any clear

the environment when

memory during those

caregiver is responsive

times, but she said

to basic needs and

that her mother told

provides comfort.

her that she loved to

-Consistency of care
must be given from

be cuddled and eager

to have her feeding.

same care provider.

-IF NOT MET, infants
become uncooperative
and aggressive and
show decreased
interest to
environment.
TODDLER

Autonomy

1-3 years old

Vs.

Muscular-anal

Shame/Doubt

-Toddlers learn to

The patient claimed

control while

that the she cries

mastering skills such

when she cant have

as toileting, feeding

those things that she

and dressing when

wants.

caregivers provide
reassurance.
-IF NOT MET,

13
toddlers feel ashamed
and doubt own
abilities, which leads
to lack of self
confidence.
PRESCHOOL

Initiative

3-6 years old

Vs.

Locomotors

Guilt

-Child begins to

-Patient loved to go to

initiates activities in

school because she

place of just imitating

wanted to learn new

activities; uses

things and meet

imagination to play;

classmates and friends

learns what is allowed

and what is not
allowed to develop
self conscience.
-Caregivers must
allow child to be
responsible while
providing assurance.
-IF NOT MET, child
feels guilty and
hesitant.
SCHOOL AGE

Industry

6-12 years old

Vs.
Inferiority

-Childs becomes

-Patient engaged in

productive by

some school activities

mastering learning

like volleyball and

success; child learns to

participated in other

deal with academics,

academics matters.

group activities, and

14
friends.
-IF NOT MET, child
develops sense of
inferiority and
incompetence.
ADOLESCENCE

Identity

12-18 years old

vs.
Role Confusion

-Adolescents reach for

-Patient is really sure

self-identity by

that she is a true girl.

making choices about

She starts to engaged

occupation, sexual

in a relationship at

orientation, lifestyle

this time.

and adult role; relies

on peer group for
support and
reassurance to create
self-image separate
from parents.
-IF NOT MET,
Adolescent
experiences role
confusion and loss of
self-belief.

YOUNG

Intimacy

-Young adults learn to

- Patient states that at

ADULTHOOD

vs.

make a personal

this time she started to

19-25 years old

Isolation

commitment to others

build relationship to

and share life events

opposite sex.

15
with others.
-IF NOT MET, adults
may fear relationship
and isolates self from
others.

MIDDLE AGE
ADULT

Generativity vs.

-middle age adults

-patient state that she

Stagnation

prioritize in

is more concern about

establishing needs for

herself and her family.

25-40 years old

self and others.

-IF NOT MET,
persons might be more
concern of one-self in
spite of the needs of
others.
OLDER ADULTS
40-60 years old

Integrity
Vs.
despair

-Older adults uses past

- Patient state that she

experience to assist

always makes sure

others. At this time

that her children will

they already accept

grow up as a

their limitation in life.

respective person, she

-IF NOT MET, Older

adults might not
accept changes in life;
they will be
demanding
unnecessary assistance

always reminds her

about their future.

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and attention to others.

IX. ANATOMY, PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY

A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED
THE HEART

Human heart is a muscular pump, which is located between the lungs, but
slightly to the left side. The heart of an adult weighs between 250 to 300 grams in
females, and 300 to 350 grams in males. The length of a human heart is around
six inches, and the width is roughly four inches. An average human heart beats
approximately 72 times per minute, and pumps 4-5 liters of blood (per minute) at
rest.

17

Human Heart Location

The human heart is located in the middle of the chest - anterior to the spine
and posterior to the sternum or breastbone (long flat bone in the center of the
chest). The heart lies slightly to the left, from the center of the thorax (region
between head and abdomen). Hence, the left lung is smaller compared to the right
lung.
Parts of the Human Heart
The heart is divided into two cavities (left cavity and right cavity) by a
wall of muscle called septum. The two cavities consist of two chambers each.
Upper chambers are called atrium and the lower ones are called ventricles. The
right cavity receives de-oxygenated blood from various parts of the body (except
the lungs) and pumps it to the lungs, whereas the left cavity receives oxygenated
blood from the lungs, which is pumped throughout the body. Let us discuss the
anatomy of this amazing organ in detail.

Outer Covering - Pericardium: The heart and the roots of its major blood vessels
are surrounded and enclosed by a sac-like structure called pericardium. It
comprises of two parts - the outer fibrous pericardium, made of dense fibrous
connective tissue and an inner double-layered membrane (parietal and visceral
pericardium). The fibrous pericardium is attached to the spinal column,
diaphragm and other parts of the body, by ligaments. The double-layered
membrane consists of an inner layer called visceral pericardium, outer layer called

18

parietal pericardium (fused to fibrous pericardium) and a pericardial cavity

(between the two layers), which contains serous fluid - pericardial fluid. This fluid
helps in reducing the friction caused by the contractions of the heart.

Heart Wall: The wall of the heart is made up of three layers of tissues - outer
epicardium, middle myocardium and the inner endocardium. The outer
epicardium functions as a protective outer layer, which includes blood capillaries,
lymph capillaries and nerve fibers. It is similar to the visceral pericardium, and
consists of connective tissues covered by epithelium (membranous tissue covering
internal organs and other internal surfaces of the body). The inner layer called
myocardium, which forms the major part of the heart wall, consists of cardiac
muscle tissues. These tissues are responsible for the contractions of the heart,
which facilitates the pumping of blood. Here, the muscle fibers are separated with
connective tissues that are richly supplied with blood capillaries and nerve fibers.
The inner layer called endocardium, is formed of epithelial and connective tissue
that contains many elastic and collagenous fibers (collagen is the main protein of
connective tissues). These connective tissues contain blood vessels and
specialized cardiac muscle fibers called Purkinje fibers. This layer lines the
chambers of the heart and covers heart valves. It is similar to the inner lining of
blood vessels called endothelium.

Chambers of the Heart: As discussed earlier, the human heart has four chambers,
the upper chambers known as the left and right atria, and the lower chambers
called left and right ventricle. Two blood vessels called the superior vena cava and
the inferior vena cava, brings deoxygenated blood to the right atrium from the

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upper half and the lower half of the body, respectively. The right atrium pumps
this blood to the right ventricle through tricuspid valve. Right ventricle pumps this
blood through pulmonary valve to the pulmonary artery, which carries it to the
lungs (to get re-oxygenated). The left atrium receives oxygenated blood from the
lungs through the pulmonary veins, and pumps it to the left ventricle through the
bicuspid or mitral valve. The left ventricle pumps this blood through the aortic
valve to various parts of the body via aorta, which is the largest blood vessel in
the body. The heart muscles are also supplied with oxygenated blood through
coronary arteries. The atria are thin-walled, as compared to the ventricles. The left
ventricle is the largest of the four chambers of the heart, and its walls have a
thickness of half inch.

Valves of the Heart: Basically the valves in the heart can be classified into two
types antrioventricular or cuspid valves and semilunar valves. The former are
the valves between the atria and ventricles, whereas the latter are located at the
base of the ventricles. Tricuspid and bicuspid (mitral) valves are antrioventricular
valves, and pulmonary and aortic valve are semilunar valves.

These valves allow the blood to flow only in one direction and prevent reverse
flow. The human heart pumps around five liters of blood per minute

The Cardiovascular System

Your heart and circulatory system make up your cardiovascular system. Your
heart works as a pump that pushes blood to the organs, tissues, and cells of your
body. Blood delivers oxygen and nutrients to every cell and removes the carbon

20

dioxide and waste products made by those cells. Blood is carried from your heart
to the rest of your body through a complex network of arteries, arterioles, and
capillaries. Blood is returned to your heart through venules and veins. If all the
vessels of this network in your body were laid end-to-end, they would extend for
about 60,000 miles (more than 96,500 kilometers), which is far enough to circle
the earth more than twice!

The one-way circulatory system carries blood to all parts of your body. This
process of blood flow within your body is called circulation. Arteries carry
oxygen-rich blood away from your heart, and veins carry oxygen-poor blood back
to your heart.

In pulmonary circulation, though, the roles are switched. It is the pulmonary

artery that brings oxygen-poor blood into your lungs and the pulmonary vein that
brings oxygen-rich blood back to your heart.

In the diagram, the vessels that carry oxygen-rich blood are colored red, and the
vessels that carry oxygen-poor blood are colored blue.

Twenty major arteries make a path through your tissues, where they branch into
smaller vessels called arterioles. Arterioles further branch into capillaries, the true
deliverers of oxygen and nutrients to your cells. Most capillaries are thinner than a
hair. In fact, many are so tiny, only one blood cell can move through them at a
time. Once the capillaries deliver oxygen and nutrients and pick up carbon
dioxide and other waste, they move the blood back through wider vessels called

21

venules. Venules eventually join to form veins, which deliver the blood back to
your heart to pick up oxygen.
THE KIDNEY

Structure of the kidney:

On sectioning, the kidney has a pale outer region- the cortex- and a
darker inner region- the medulla.The medulla is divided into 8-18 conical
regions, called the renal pyramids; the base of each pyramid starts at the
corticomedullary border, and the apex ends in the renal papilla which merges to

22

form the renal pelvis and then on to form the ureter. In humans, the renal pelvis
is divided into two or three spaces -the major calyces- which in turn divide into
further minor calyces. The walls of the calyces, pelvis and ureters are lined with
smooth muscle that can contract to force urine towards the bladder by
peristalisis.
The cortex and the medulla are made up of nephrons; these are the functional
units of the kidney, and each kidney contains about 1.3 million of them
The nephron is the unit of the kidney responsible for ultrafiltration of the blood
and reabsorption or excretion of products in the subsequent filtrate. Each
nephron is made up of:

A filtering unit- the glomerulus. 125ml/min of filtrate is formed by the kidneys as

blood is filtered through this sieve-like structure. This filtration is uncontrolled.

The proximal convoluted tubule. Controlled absorption of glucose, sodium, and

other solutes goes on in this region.

The loop of Henle. This region is responsible for concentration and dilution of
urine by utilising a counter-current multiplying mechanism- basically, it is waterimpermeable but can pump sodium out, which in turn affects the osmolarity of the
surrounding tissues and will affect the subsequent movement of water in or out of
the water-permeable collecting duct.

The distal convoluted tubule. This region is responsible, along with the collecting
duct that it joins, for absorbing water back into the body- simple maths will tell

23

you that the kidney doesn't produce 125ml of urine every minute. 99% of the
water is normally reabsorbed, leaving highly concentrated urine to flow into the
collecting duct and then into the renal pelvis.
B. PATHOPHYSIOLOGY CONCEPTUAL FRAMEWORK
Risk factors;
-Family history

-Obesity

-Age

-Alcohol consumption

-High salt intake

-Smoking

-Low potassium intake

-Stress

AGENT;

HOST;

No etiologic
factor

-family history
-stress
-Age

Affects arteriolar
bed

Arteriolar bed
constriction

Increase systemic
vascular
resistance

Increase after load

of the heart

ENVIRONME
NT;
Not related

24

Decreased Blood
flow towards the
Juxtaglomerular
organsecretes
cells

Angiotensinogen

renin

Angiotensin I

Arteriolar
vasoconstriction

Angiotensin II

Increased
phireperal
resistance

Adrenal cortex
secretes
aldosterone

Increased Blood
pressure

Increase
aldosterone

Increase
reabsortion of
water and sodium

25

C. DISCUSSION OF PATHOPHYSIOLOGY
Patient condition was an inherited one from her father side which is
hypertension. Patient has a past health history of heart enlargement due to his
current disease. Her blood pressure increases was also due to a related factor
which is stress, stress could cause constriction of the arteriolar bed. If there will
be constriction of the arteriolar bed there will be increase systemic vascular
resistance. It will affect the heart because the left ventricle in the heart will try to
compensate first for the altered systemic circulation. After load of the heart will
increase so there will be a decreased blood flow towards the organs of the body
because of increased resistance in the arteries. Decreased blood flow will enter to
the kidneys, the juxtaglomerular cells in the kidney will try to compensate for the
decreasing blood that enters to the kidney by secreting renin into the blood
stream. Renin travels towards the liver in a form of angiotensinogen in order to be
converted as angiotensin I, through an angiotensin converting enzyme.
Angiotensin I travel towards the lungs via blood flow in order to be converted into
the lungs as an angiotensine II, then angiotensin II will travel towards the adrenal
glands and stimulate the adrenal ducts to secrete aldosterone. Aldosterone that is
secreted by the adrenal ducts will reabsorb water and sodium in the body in order
to increase the blood pressure.
The RAAS or rennin angiotensine aldosterone system is responsible for the fluid
balance and for the regulation of blood pressure in the body.

26

D. SYMPTOMATOLOGY
Symptomatology is a branch of science that deals with the study of
different signs and symptoms of a certain condition or body processes. Its main
purposes are to facilitate the identification of a disease and its process among
others.
IDEAL SIGNS AND
SYMPTOMS

ACTUAL SIGNS AND

SCIENTIFIC BASIS

SYMPTOMS
MANIFESTED BY
PATIENT

Nosebleeds

Patient stated nose

is the relatively common

bleeding prior to

occurrence

admission.

hemorrhage
nose,

of
from

usually

the

noticed

when the blood drains

out through the nostrils
Irregular Heartbeat

Patient stated that she can

Abnormal

electrical

feel her heart beating so

activity in the heart. The

fast.

heart beat may be too fast

or too slow, and may be
regular or irregular.

Blurred Vision

Patient stated blurring of

Is a type of vision loss, it

27

vision prior to admission.

is an ocular symptom.

Confusion - Buzzing In Not manifested by the

Confusion

The Ears - Blood In Your patient.

from a relatively sudden

Urine

brain dysfunction

Lose Weight

may

result

Not manifested by the

Is a reduction of the total

patient.

body mass, due to a mean

loss of fluid, body fat or
adipose tissue and/or lean
mass,

namely

bone

mineral deposits, muscle,

tendon

and

other

connective tissue
chest pain

Patient complains of

Occurs when blood flow

chest discomfort.

to the arteries that supply

the

heart

becomes

blocked. With decreased

blood flow, the muscle of
the heart does not receive
enough oxygen. This can
cause damage.
Headache

Patient verbalized

Is a pain anywhere in the

Dizziness

dizziness and headache

region of the head. It is a

during the first contact by

symptom

the student nurse.

conditions.

of

several

28

Patient verbalized body

Is a state of awareness

weakness during her stay

describing a range of

in the hospital.

afflictions,

Fatigue
usually

associated with physical

and/or mental weakness,
though varying from a
general state of lethargy
to

specific

induced
sensation
muscles.

workburning

within

one's

29

Patient is anxious as

Anxiety

is

observed by the student

psychological

and

nurse during his first

physiological

state

contact by the patient

characterized

by

Anxiety

cognitive,

somatic,

emotional,

and

behavioral components.[2]
These

components

combine to create an
unpleasant feeling that is
typically associated with
uneasiness, apprehension,
fear, or worry. Anxiety is
a

generalized

mood

condition that can often

occur

without

identifiable
stimulus

X. MEDICAL MANAGEMENT

IDEAL

ACTUAL

an

triggering

30

Complete Blood Count

Hematologic Report

TEST

RESULT

RBC
Hemoglobin

5.51
12.70

Hematocri

NORMAL
RANGE

UNIT

4.2-5.4

m/uL

12-16

g/dL

37-48

o/o

20-40

o/o

48.6
Lymphocyte

14

MVP

10.6

0-100

F/L

Platelets

161

140-440

K/uL

Neotrophils

77.3

40.70

o/o

Monocyte

2-8

o/o

Monocyte
RDC

2.1

3.4-9.0

o/o

Monocyte
ADC

0.13

0.16-1.00

10^3/uL

Urinalysis Report
PHYSICAL

RESULT

CHARACTERISTIC
Color
Appearance
Ph

NORMAL
RANGE

UNIT

Yellow
Cloudy
7.5

5.0-8.0

1.010

1.0031.033

Creatinine

1.0

0.6-1.5

Mg/dL

SG-PT-ALT

25

5.0-50.0

u/L

134-148.0

mmoL/L

3.3-5.3

mmoL/L

Specific gravity
CHEMICAL
CHARACTERISTIC

Sodium (serum)
Potassium

138.0
4.0

31

B. TREATMENT AND PROCEDURES

IDEAL

ACTUAL

- Patients should stop smoking (offer help -Vital signs taken every 4 hours
nicotine replacement therapy).
-Blood pressure taken every 2 hours
- Weight reduction should be suggested if
necessary, to maintain ideal BMI of 20-25 -Intake and output monitoring every shift
kg/m2. Offer a diet sheet and/or dietetic -Laboratory test taken
appointment. Dietary self-help e.g. dieting
-Medication administration
clubs, may be appropriate.
- Reduce their salt, total fat, saturated fat
and cholesterol intake, while increasing
consumption
of
polyunsaturated,
monosaturated fats and oily fish.
Encourage fruit, vegetables, legumes and
whole grains; and low fat (or zero-fat)
dairy, poultry meat, fish and shellfish
products.
- Cut alcohol intake to no more than 21
units (male) or 14 units (female) of alcohol
per week.
- Encourage regular dynamic exercise
tailored to age and capabilities of patient.
This may mean three vigorous training
sessions per week for a young adult, or
brisk walking for 30 minutes most days
for the older individuals.

32

- Do not offer supplements of calcium,

magnesium or potassium to reduce BP.
Relaxation therapy can help
As well as the targets above, strive for a
happy, well-informed patient. Remember to
look for and treat any underlying cause in
your initial assessment

C. MEDICATION
IDEAL

ACTUAL

33

Initial Drug Choices

If patient is young (<55) and non-black

start with:

Paracetamol ( Tylenol) p.o

for temperature more 38 oC.

(A) ACE inhibitor or Angiotensin II

receptor antagonist (ACE II)

Plasil 10 mg, 1 ampule,

IVTT route, STAT.

Losartan K ( lifezartan ) 50
mg tablet, once daily.

Rusovastatin ( crestor ) 20
mg tablet, 1 tablet once a
daily at bed time.

Clopidogrel ( plavix ) 75 mg
tablet, one talet orally once
daily.

If patient is black or aged 55 years use:

(C) Calcium channel blocker or

(D) Diuretic (thiazide)

Second Drug Choices

(A+C)
ACE
inhibitor
or
Angiotensin II receptor antagonist
with Calcium channel blocker or

(A+D)
ACE
inhibitor
or
Angiotensin II receptor antagonist
with Diuretic (thiazide)

Third Drug Choices

(A+C+D) ACE inhibitor or

Angiotensin II receptor antagonist
(ACE II) and Calcium channel
blocker and Diuretic (thiazide)

D. DIET :

Low salt low cholesterol diet

XI. NURSING MANAGEMENT

IDEAL

ACTUAL

34

1. Vital signs should be checked 2 hourly

with emphasis on Blood pressure and pulse

-Monitoring patients vital

signs.

rate. Monitor patient's weight daily and

keep proper record. This is to help detect
edema or weight loss. Check for side
effects

of

drugs

e.g.

orthostatic

hypotension.

-Bedside care was included.

- Changing of linens.
- Monitoring patients intake
and output.

2. Rest: Patient should be advised to avoid

stress and tension. He should therefore

- Monitoring of patients IVF.

have physical and mental rest in order to

- Low salt and low cholesterol

conserve

energy.

Encourage

moderate

diet was instructed.

exercise e.g. walking if there is no dyspnea.

Mild tranquilizers may be given to enable
patient sleep. Should there be dizziness
patient should be protected from falls and
injury.
3. Diet: Restrict sodium intake to about
4grams daily. Give light, easily digestible
diet. Fatty food and excessive carbohydrate
that can increase weight and cholesterol
should be avoided. Coffee, tea, kola nuts,
alcohol should be avoided or minimized.
4. Physical care: Assist patient with

- Health teaching was given.

35

physical care if patient is very weak. Where

there is blurred vision patient may require
the use of medicated eye glasses. If there is
bleeding from the nose (epistaxis) apply ice
pack to the bridge of the nose and back of
the neck. When the ice pack cannot control
bleeding the nose may be packed. The pack
should however be removed within few
days. Make sure patient does not lie on one
side of his body for several days in bed. If
he is to be admitted for days, his position
should be changed every 2-4 hours to
prevent pressure sore from developing.
5. Elimination: Constipation should be
avoided because it makes the patient strain
at defecation thereby further elevating the
blood pressure. Food rich in fiber should be
given to prevent constipation.

B. PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION

OF NURSING CARE

36

There were no major problems encountered during the implementation of nursing

care. The patient was very cooperative and was aware of her health care needs. My only
problem is that Im still a student and still on the process of learning and acquiring more
knowledge.
C. RESTORATIVE MEASURES USE
I was able to build rapport to the patient and her family members, I was able to
maintain calm and a relaxing environment, assisted patient and encourages her for
verbalization of her concerns about her condition. Patient was able to gain enough rest
and sleep hours. A low salt and low cholesterol diet were given. Medication was given
at exact time and route.
D. EVALUATION
The patient was very appreciative of the care extended to her. She was grateful for
the time and effort given to help in her condition. She was attentive to what is needed for
her health and verbalize that she will practice what are being thought to her during her
stay in the hospital. She verbalized that she will refrain from activities that will exert too
much effort; she will continue the diet that was recommended to her and to take her
medication at exact time.

E. PATIENT TEACHING

37

The patient was encouraged to avoid activities that will exert to much efforts,
avoid food that are high in sodium and cholesterol, avoid being stress because stress can
trigger in increasing the blood pressure. Patient was also instructed to have enough hours
of rest and sleep and to take medication as prescribed by her physician and emphasizes to
the patient the importance of medication as much as lots of client went to stroke.
XII. CONCLUSION AND RECOMMENDATION
A. CONCLUSION
In this study knowledge is basically the important factors to provide proper
provision of health care. The knowledge towards this condition can promote early
detection and can aid in early treatment and proper intervention towards the
progressing illness.
B. RECOMMENDATION
Nurses working with adults with hypertension must have the appropriate
knowledge and skills acquired through basic nursing education curriculum,
ongoing professional development opportunities and orientation to new
work places. Blood pressure should be measured in both arms.

XIII. IMPLICATION OF THE STUDY TO:

38

A. NURSING EDUCATION
This care study emphasizes the importance of theory in rendering
optimal care. This study shows information of the basic insight in Medical
Surgical Nursing. As a student Nurse, it is very important to our profession
that we consolidate both knowledge we gained and skills we acquired
because in real life situation, we might experience on the spot decisions.
B. NURSING PRACTICE
Nursing practice is an ever increasing variety of ways and settings.
The focused of all nursing practice is the client, who may be individual, a
family or a community. This care study made me knowledgeable in
dealing with my patient and more confident in rendering my nursing care
and service. Aside from that this care study enhances my skills and
knowledge. It also adds to my own significant experiences.
C. NURSING RESEARCH
Nursing research revealed that the care of a hypertensive client has
gradually improved. But we should not end here. We should encourage
ourselves and other individuals to learn more about this condition by
attending seminars and medical missions for this could aid and help in
improving the care for our client.

August 20, 2010

Dr. Carmine P. Villarante

39

Dean College of Nursing

University of Cebu Lupu-Lapu & Mandaue

Dear Maam,
I, Jeffrey R. pescadero, would like to ask permission from your good office to allow me
to take the case of Mrs. Sonia Asuncion Espadilla Madrid , 47 years old, Female admitted
at Chung Hua Hospital as my subject to my care study. This is in partially fulfillment of
the requirement of Medical Surgical Nursing NCM 103.
Diagnosis of Mrs. Sonia Asuncion Espadilla Madrid is Hypertensive Urgency.
I am hoping for your kind and consideration and approval regarding this matter
Thank you.

Respectfully yours,
Jeffrey R. Pescadero
BSN 3-A
Noted by:
Ms. Edna L. Estandarte, RN
Clinical Instructor
Ms. Estela R. It-It, RN
Level 3 chairperson
Ms. Mary Jane Sabaldica, RN
Nursing Education Coordination
Dr. Carmenn P. Villarante
Dean College of Nursing

NURSING CARE PLAN

Patients name: Sonia Asuncion Espadilla Madrid

Date of admission: July 25, 2010

Ag e: 47 years old

Room No. : C-322

Impression: Hypertensive Urgency

Physician : Dr. Lerma Noval

Clinical Portrait

Assessment:
Received Patient lying on bed conscious awake
and coherent with ongoing IVF # 1 PNSS 1L @ 40
cc/hr hooked at left arm infusing well. Vital signs were
taken and monitored as ordered. Patient verbalized
Body malaise and sudden chest discomfort upon rising
up to bed.

Pertinent Data

Chief Complaint:
Chest Discomfort
History of present Illness:
A few hours prior to admission, patient complain of chest
discomfort with note of elevated blood pressure of 150/80 mmHg. Patient
self medicated with her maintenance medication atenolol 25 mg and was
brought to Toledo Hospital and was referred to Chung Hua Hospital for
further management.

Significant Findings

Blood Pressure: 150/80 mmHg

Past health History:

The patient has no known allergies but according to her she was
diagnosed last year with heart enlargement due to hypertension.

Pulse Rate: 54 Bpm

Vital signs: ( During first contact with the patient )

Blood Pressure: 120/70 mmHg
o

Temperature: 36.6 C
Heart Rate: 54 Bpm
Respiratory Rate: 20 Cpm

Vital signs during admission:

Blood Pressure: 150/80 mmHg
Temperature: 38.1 oC
Heart Rate: 78 Bpm
Respiratory Rate: 26 Cpm

Diagnostics Procedure Done:

Hematology, Urinalysis, Complete Blood Count, Chemical Chemistry
Report.

Subjective:
Luya jud kayo
ko karon as
verbalized by
the patient.

Objective:
-PR=54 Bpm
-shortness
of
breath
upon
exertion
-Body malaise
-Restlessness

Decreased
Cardiac Output
related to altered
stroke volume

Increased blood
pressure could
cause vasospasm
that lead to
increased
vascular
resistance of the
arteries. There
will be difficulty of
the heart to pump
blood so there will
be an Increased
cardiac workload
that could lead to
a decreased
cardiac output

After 8 hours of nursi

interventions the patie
will be able to mainta
blood pressure/cardia
workload.

Specifically the patien

will be able to:

1.Participate an activ
that reduces blood
pressure.

2.Demonstrate
s
cardiac rhythm
rate within the pa
normal range.

Subjective:
ASSESSMENT

NURSING
DIAGNOSES

SCIENTIFIC BASIS

GOALS AND OUTCOME

nag-guol jud
CRITERIA
ko
sa
ako

Anxiety related
to situational
sitwasyun
crisis as
karon
as evidenced by
verbalized by express
the patient.
concerned
regarding
changes in life
events.
Objective:
-Restlessness
-Blank stares or
inattention.

Anxiety is a feeling of
apprehension or fear.
The body prepares to
deal with a threat:
blood pressure and
heart rate are
increased, sweating is
increased, blood flow
to the major muscle
groups is increased,
and immune and
digestive system
functions are inhibited
(the fight or flight
response).

After 8 hours of nursi

interventions the patie
will be able verbalized
awareness of feelings
anxiety and healthy w
to deal with them.

Specifically the patien

will be able to:

1. Report anxiety is
reduced to a
manageable state
2.

Demonstrate
effective coping
strategies to red
anxiety.

ASSESSMENT

NURSING
DIAGNOSES

SCIENTIFIC BASIS

GOALS AND OUTCO

CRITERIA

Subjective:
Dali jud kayo
ko kutasan
dong as
verbalized by
the patient.

Objective:
-BP=150/80
mmHg
-PR=54 Bpm
-shortness of
breath upon
exertion
-Report of
dizziness and
fatigue.

Activity
intolerance
related to body
weakness.

Muscle cells work by

detecting a flow of
electrical impulses
from the brain which
signals them to
contract through the
release of calcium by
the sarcoplasmic
reticulum. Fatigue
(reduced ability to
generate force) may
occur due to the nerve,
or within the muscle
cells themselves.
Muscle fatigue is
caused by calcium
leaking out of the
muscle cell. These
causes there to be less
calcium available for
the muscle cell. In
addition an enzyme is
proposed to be
activated by this
released calcium
which eats away at
muscle fibers.

After 8 hours of nursing

interventions the patient
will be able to
measurable increase in
energy and will
participate in necessary
desired activities.
Specifically the patient
will be able to:
1.Participate an activity
without shortness of
breath.
2.Participate activity
without the increase
of blood pressure.
3. Report relief of
dizziness and fatigue.

DRUG NAME

DOSAGE
AND
FREQUENCY

MECHANISM
OF ACTION

INDICATION

CONTRAINDICAT
ION

SIDE EFFECTS

CNS: Headache
GENERIC NAME:
Paracetamol

PATIENT
DOSE:

BRAND NAME:
Biogesic
CLASSIFICATION:

Antipyretic,
Analgesic

1 tab PO q4 for
temperature
more than 38
0
C

Reduces fever
by acting
directly on the
hypothalamic
heat-regulating
center to cause
vasodilation and
sweating, which
helps dissipate
heat.

- Analgesicantipyretic in
patients with
aspirin allergy,
hemostatic
disturbances,
bleeding
diatheses, upper
GI disease, gouty
arthritis
- Arthritis and
rheumatic
disorders
involving
musculoskeletal
pain (but lacks
clinically
significant
antirheumatic
and antiinflammatory
effects)

- Contraindicated
with allergy to
acetaminophen.
- Use cautiously with
impaired hepatic
function, chronic
alcoholism,
pregnancy, lactation.

CV: Chest pain, dyspnea,

myocardial damage when
doses of 58 g/day are
ingested daily for several
weeks or when doses of 4
g/day are ingested for 1
yr
GI: Hepatic toxicity and
failure, jaundice
GU: Acute kidney failure,
renal tubular necrosis
Hematologic:
Methemoglobinemia
cyanosis; hemolytic
anemiahematuria,
anuria; neutropenia,
leucopenia, pancytopenia,
thrombocytopenia,
hypoglycemia

NURSING
RESPONSIBILITIES
- Monitor liver function
studies; may cause
hepatic toxicity at
doses >4g/day
- Monitor renal
function studies;
albumin indicates
nephritis
- Monitor blood
studies, especially
CBC and pro-time
if patient is on longterm therapy.
- Check I&O ratio;
decreasing output
may indicate renal
failure.
-Assess for fever and
pain
- Assess
hepatotoxicity: dark
urine, clay-colored
stools
Assess allergic
reactions: rash,
urticaria

Hypersensitivity: Rash,
fever

DRUG NAME

GENERIC NAME:
Losartan
BRAND NAME:
Lifesar tan
CLASSIFICATION:
angiotensin II
receptor (type AT1)
antagonist

DOSAGE
AND
FREQUENCY

MECHANISM
OF ACTION

PATIENT
DOSE:

It stimulates
aldosterone
secretion by the
adrenal cortex.
Losartan and its
principal active
metabolite
block the
vasoconstrictor
and
aldosteronesecreting effects
of angiotensin
II by selectively
blocking the
binding of
angiotensin II to
the AT1
receptor found
in many tissues.

50 mg tablet
once daily

INDICATION

Hypertension
Hypertensive
Patients with
Left Ventricular
Hypertrophy

CONTRAINDICAT
ION

SIDE EFFECTS

NURSING
RESPONSIBILITIES

contraindicated in
patients who are
hypersensitive to any
component of this
product

- colds (upper
respiratory infection)
- - dizziness

Take blood blood pressure

before giving the
medication.

- stuffy nose
- back pain

pregnancy

DRUG NAME

GENERIC NAME:
Clopedogrel
BRAND NAME:
Plavix

CLASSIFICATION:
coagulant

DOSAGE
AND
FREQUENCY

MECHANISM
OF ACTION

INDICATION

CONTRAINDICAT
ION

PATIENT
DOSE:

The drug works

by irreversibly
inhibiting a
receptor called
P2Y12, an
adenosine
diphosphate
ADP
chemoreceptor.

-Prevention of
vascular
[[ischemic]
events in
patients with
symptomatic
atherosclerosis

- Hypersensitivity to
the drug substance or
any component of the
product.

75 mg Tablet

-Acute coronary
syndrome
without STsegment
elevation
(NSTEMI),
-ST elevation
MI (STEMI)

- Active pathological
bleeding such as
peptic ulcer or
intracranial
hemorrhage
-you are allergic to
any ingredient in
Clopidogrel
-you have an active
bleeding disorder,
such as a stomach
ulcer or bleeding in
the brain

SIDE EFFECTS

-hemorrhage, severe
neutropenia, and
Thrombotic
thrombocytopenic
purpura (TTP).

NURSING
RESPONSIBILITIES

Advise patient to do not

perform other possibly
unsafe tasks until you
know how you react to it.

Avoid activities that may

cause bruising or injury

DRUG NAME

DOSAGE
AND
FREQUENCY

MECHANISM
OF ACTION

INDICATION

CONTRAINDICAT
ION

SIDE EFFECTS

NURSING
RESPONSIBILITIES
Instruct patient to:

GENERIC NAME:
Rusovastatin

PATIENT
DOSE:

BRAND NAME:
Crestor

CLASSIFICATION:
HMG CoA
reductase inhibitors,
or "statins."

20 mg tab once
daily

it increases the
number of
hepatic LDL
receptors on the
cell-surface to
enhance uptake
and catabolism
of LDL.
Second,
rosuvastatin
inhibits hepatic
synthesis of
VLDL, which
reduces the total
number of
VLDL and LDL
particles

Hyperlipidemia
and Mixed
Dyslipidemia

you are allergic to

any ingredient in
Crestor

Hypertriglycerid
emia

Primary
Dysbetalipoprote
inemia (Type III
Hyperlipoprotein
emia)
Homozygous
Familial
Hypercholesterol
emia
Slowing of the
Progression of
Atherosclerosis

you have
liver problems or
unexplained
abnormal liver
function tests

you are pregnant

or breast-feeding
you are taking
itraconazole,
mibefradil, or
telithromycin

headache;

mild muscle

pain;

joint pain;

constipation;

mild nausea; or

stomach pain or
indigestion.

- Avoid using antacids

without your doctor's
advice.
-Do not increase or
decrease the amount of
grapefruit products in your
diet without first talking to
your doctor
-Do not perform other
possibly unsafe tasks until
you know how you react
to it.
Follow the diet and
exercise program given to
you by your health care
provider
Do NOT take more than
the recommended dose
without checking with

your doctor

Type of
solution

Classification

Content

Mechanism of
action

Indications

Contraindications

How supplied

Dose

Nursing
responsibilities

PNSS

Hypertonic

100mL

Hypertonic
solutions
contain a high
concentration
of solute
relative to
another
solution ( e.g.
the cells
cytoplasm )
when a cell is
placed in a
hypertonic
solution, the
water diffuses
out of the cell,
causing the cell
to shrivel.
(Wikipedia
encyclopedia,
5th edition).

Research Paper help

For
replacement or
maintenance
of fluid and
electrolytes.

Hypersensitivity to
any of the
components.

Intravenous
infusion

Before:
1. Use sterile
infusion set.
2. Use only if
solution is clear
and container is
not leaking.
3. Assess patients
hydration status.
During:
1. Perform time
taping.
2. Regulate IVF as
prescribed.
3. Check from time
to time the
positioning of the
patient.
After:
1. Chart the date and
time the solution
was consumed.
2. Discard empty
bottles and tubing
to their proper
container.
3. Dispose the sharps
not together with
the bottle but to its
correct box for
sharps.

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