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

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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-Barré syndrome Coarctation of the aorta

Preeclampsia/eclampsia Postoperative hypertension.

II. GENERAL DATA

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Name : Mrs. S A E M

Age : 47 years old

Address : Magsaysay Hills Toledo City Cebu

Sex : Female

Civil status: Married

Occupation: 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

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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

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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. Patient’s 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
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Table 1: Patient’s 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 Father’s sister 69 years old Teacher

Mr. A E Father 72 years old Businessman

Mr. R E Father’s 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
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= Normal (female)

= Hypertensive

Grand
Father Grand
Mother

Father Father’s
Father’s Brother
Sister

Patient’s
Patient 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
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A E M was a very loving and responsible wife to her husband. She is a very

friendly person. She’s 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 doesn’t have any chores in the house or

doesn’t 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 father’s 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,
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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 patient’s body. Some hair

is gray and evenly distributed. No lesions are

“wala raman bukol bukol ako ulo dong” as
visible. Dandruff was noted.
vervalized by the patient.

EYES Patient eyes are symmetrical, eyebrows are free

from scaling, pupils constricted when light is

“ depektado na jud ako panan-aw dong, dili ko ka
focused, sclera is white, conjunctiva is clear, and
klaru og basa kong dili ko mag eyeglass” as
eye movement and blinking reflex are in good
verbalized by the patient.
condition. Teary eyes noted. Patient’s eyeglass

grade is 180.

EARS Patient ears are symmetrical, equal in size and same

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“ok raman ako pan dungog” as verbalized by the in appearance. No foul smelly sticky discharged in

patient. both ears. Patient was able to her whispered words.

NOSE Nose is located at the midline of the face with no

lesion or redness noted. Client report no tenderness.

“ ok raman, wala man sad nag ping-ot ako ilong” as
Can breathe through the nose clearly. Septums are
verbalized by the patient.
not perforated.

MOUTH Lips are pale without lesions or swelling. Teeth are

incomplete, left and right molars are absent. Gums

“ wala na koy bag-ang sa taas og ubos” as
and tongue are pale and slightly dry. No lesions and
verbalized by the patient.
ulcers noted. Tonsillar pillar are symmetrical, tonsils

are present, vulvula at the midline and gag reflex are

in good condition.

NECK Patient’s neck is smooth, controlled movement,

cervical lymph nodes are palpable, patients thyroid

“ok raman ako pag tulon dong” as verbalized by the
are at the midline, smooth, firm, tender and no
patient.
lesion noted.

INTEGUMENTARY SYSTEM Skin is fair in complexion, no presence of marks or

scars. Nails are short and with capillary refill time of

“Normal raman ako gipamati karon dong” as
2-3 seconds.
verbalized by the patient.

RESPIRATORY SYSTEM Respiratory rate ranges from 21-22 cycles per

minute, lungs expansion is symmetrical, clear breath

“Usahay maglisod ko og ginhawa” as verbalized by
sounds are present.
the patient.

CARDIOVASCULAR SYSTEM Heart rate is 78 beats per minute, blood pressure is

130/80 mmHg.
“ma feel nako nga paspas ang pinitik sa ako kasing-

kasing” as verbalized by the patient.

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GASTROINTESTINAL SYSYTEM Patient reported no abdominal pain. Patient was able

to pass bowel during the shift. Bowel sounds are

“wala raman problema dong, makalibang raman ko
normal.
kada adlaw” as verbalized by the patient.

URINARY SYSTEM Patients urinary output ranges from 660-750 cc in a

day that’s approximately 20-30 cc/hr. Patient urine

“dili man ko mag lisod og pangihi dong” as
is amber in color.
verbalized by the patient.

MUSCULOSKELETAL SYSYTEM Patient can move her legs and other extremities.

Doesn’t need assistance upon walking and

Usahay murag lay-lay ako pamati” as verbalized by
ambulation.
the patient.

NEUROLOGIC SYSTEM Patient is conscious, coherent and responsive.

Response with environmental stimuli and interact

“ok lng man” as verbalized by the patient.
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 patient’s 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 Patient’s

positive resolution

resolutions
INFANCY Trust -Infants develop trust -Patient related that

in self, others, and in she have any clear

Birth to 1 year vs.
the environment when memory during those

Oral- sensory Mistrust caregiver is responsive times, but she said

to basic needs and that her mother told

provides comfort. her that she loved to

be cuddled and eager

-Consistency of care
to have her feeding.
must be given from

same care provider.

-IF NOT MET, infants

become uncooperative

and aggressive and

show decreased

interest to

environment.

TODDLER Autonomy -Toddlers learn to The patient claimed

control while that the she cries

1-3 years old Vs.
mastering skills such when she can’t have

Muscular-anal Shame/Doubt as toileting, feeding those things that she

and dressing when wants.

caregivers provide

reassurance.

-IF NOT MET,

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toddlers feel ashamed

and doubt own

abilities, which leads

to lack of self

confidence.

PRESCHOOL Initiative -Child begins to -Patient loved to go to

initiates activities in school because she

3-6 years old Vs.
place of just imitating wanted to learn new

Locomotors Guilt 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 -Childs becomes -Patient engaged in

productive by some school activities

6-12 years old Vs.
mastering learning like volleyball and

Inferiority success; child learns to participated in other

deal with academics, academics matters.

group activities, and

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friends.

-IF NOT MET, child

develops sense of

inferiority and

incompetence.

ADOLESCENCE Identity -Adolescents reach for -Patient is really sure

self-identity by that she is a true girl.

12-18 years old vs.
making choices about She starts to engaged

Role Confusion 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

Isolation commitment to others build relationship to

19-25 years old
and share life events opposite sex.
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with others.

-IF NOT MET, adults

may fear relationship

and isolates self from

others.

MIDDLE – AGE Generativity vs. -middle age adults -patient state that she

ADULT Stagnation prioritize in is more concern about

25-40 years old establishing needs for herself and her family.

self and others.

-IF NOT MET,

persons might be more

concern of one-self in

spite of the needs of

others.

OLDER –ADULTS Integrity -Older adults uses past - Patient state that she

experience to assist always makes sure

40-60 years old Vs.
others. At this time that her children will

despair they already accept grow up as a

their limitation in life. respective person, she

always reminds her

-IF NOT MET, Older
about their future.
adults might not

accept changes in life;

they will be

demanding

unnecessary assistance
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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.
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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
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• 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
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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
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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
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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 water-

impermeable 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
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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; ENVIRONME

NT;
No etiologic -family history
factor Not related
-stress

-Age

Affects arteriolar
bed

Arteriolar bed
constriction

Increase systemic
vascular
resistance

Increase after
load of the heart
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Decreased Blood
flow towards the
Juxtaglomerular Angiotensinogen
organsecretes
cells
renin

Angiotensin I

Arteriolar Angiotensin II
vasoconstriction

Increased Adrenal cortex

phireperal secretes
resistance aldosterone

Increased Blood Increase

pressure aldosterone

Increase
reabsortion of
water and sodium
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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.

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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 ACTUAL SIGNS AND SCIENTIFIC BASIS

SYMPTOMS SYMPTOMS

MANIFESTED BY

PATIENT

Nosebleeds Patient stated nose is the relatively common

bleeding prior to occurrence of

admission. hemorrhage from the

nose, usually 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

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vision prior to admission. is an ocular symptom.

Confusion - Buzzing In Not manifested by the Confusion may result

The Ears - Blood In Your patient. from a relatively sudden

Urine brain dysfunction

Lose Weight 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 of several

the student nurse. conditions.

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Fatigue Patient verbalized body Is a state of awareness

weakness during her stay describing a range of

in the hospital. afflictions, usually

associated with physical

and/or mental weakness,

though varying from a

general state of lethargy

to a specific work-

induced burning

sensation within one's

muscles.
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Anxiety Patient is anxious as Anxiety is a

observed by the student psychological and

nurse during his first physiological state

contact by the patient characterized by

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 an

identifiable triggering

stimulus

X. MEDICAL MANAGEMENT

IDEAL ACTUAL
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→Complete Blood Count

–Hematologic Report TEST RESULT NORMAL UNIT

RANGE

RBC 5.51 4.2-5.4 m/uL

Hemoglobin 12.70 12-16 g/dL

Hematocri 37-48 o/o

48.6

Lymphocyte 14 20-40 o/o

MVP 10.6 0-100 F/L

Platelets 161 140-440 K/uL

Neotrophils 77.3 40.70 o/o

Monocyte 5 2-8 o/o

Monocyte 2.1 3.4-9.0 o/o

RDC

Monocyte 0.13 0.16-1.00 10^3/uL

ADC

–Urinalysis Report
PHYSICAL RESULT NORMAL UNIT
RANGE
CHARACTERISTIC

Color Yellow

Appearance Cloudy

Ph 7.5 5.0-8.0

Specific gravity 1.010 1.003-

1.033

CHEMICAL
CHARACTERISTIC

Creatinine 1.0 0.6-1.5 Mg/dL

SG-PT-ALT 25 5.0-50.0 u/L

Sodium (serum) 138.0 134-148.0 mmoL/L

Potassium 4.0 3.3-5.3 mmoL/L

 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
clubs, may be appropriate. -Medication administration

- 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 - Paracetamol ( Tylenol) p.o

If patient is young (<55) and non-black
start with:
• (A) ACE inhibitor or Angiotensin II
receptor antagonist (ACE II)
If patient is black or aged ≥55 years use:
• (C) Calcium channel blocker or
• (D) Diuretic (thiazide)
for temperature more 38 oC.
- 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.

Second Drug Choices - Clopidogrel ( plavix ) 75 mg

tablet, one talet orally once
daily.

• (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 -Monitoring patient’s vital

with emphasis on Blood pressure and pulse

signs.
rate. Monitor patient's weight daily and
-Bedside care was included.
keep proper record. This is to help detect

edema or weight loss. Check for side - Changing of linens.

effects of drugs e.g. orthostatic

- Monitoring patient’s intake
hypotension.
and output.
2. Rest: Patient should be advised to avoid

stress and tension. He should therefore - Monitoring of patient’s 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.
- Health teaching was given.
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

 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 I’m 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

 39

Dr. Carmine P. Villarante

Dean College of Nursing

University of Cebu Lupu-Lapu & Mandaue

Dear Ma’am,

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

Patient’s 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 Pertinent Data

Assessment: Chief Complaint:

Received Patient lying on bed conscious awake Chest Discomfort

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.
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 Past health History:

The patient has no known allergies but according to her she was
diagnosed last year with heart enlargement due to hypertension.
Blood Pressure: 150/80 mmHg

Pulse Rate: 54 Bpm

Vital signs during admission:

Vital signs: ( During first contact with the patient )
Blood Pressure: 150/80 mmHg
Blood Pressure: 120/70 mmHg
o
Temperature: 38.1 oC
Temperature: 36.6 C
Heart Rate: 78 Bpm
Heart Rate: 54 Bpm
Respiratory Rate: 26 Cpm
Respiratory Rate: 20 Cpm

Diagnostics Procedure Done:

Hematology, Urinalysis, Complete Blood Count, Chemical Chemistry

Report.
ASSESSMENT NURSING SCIENTIFIC BASIS GOALS AND OUTCOME NURSING RATIONALE EVALUATION
DIAGNOSES CRITERIA INTERVENTIONS

Subjective: Increased blood After 8 hours of nursing Independent:

pressure could interventions the patient
“Luya jud kayo Decreased cause vasospasm will be able to maintain 1. Monitor blood -Comparison of After 8 hours of
ko karon” as Cardiac Output that lead to blood pressure/cardiac pressure in both blood pressure nursing
verbalized by related to altered increased workload. arms. provides a more intervention
the patient. stroke volume complete picture
vascular Goals met.
Specifically the patient of vascular
resistance of the
will be able to: involvement or
arteries. There The patient was
scope of the
Objective: will be difficulty of 1.Participate an activity able to maintain
problem.
the heart to pump that reduces blood a stable blood
-PR=54 Bpm pressure
blood so there will pressure. 2. Provide a calm -Helps reduce
be an Increased sympathetic 120/70mmHg.
-shortness of and restful
breath upon cardiac workload 2.Demonstrate stable environment. stimulation,
exertion that could lead to cardiac rhythm and promotes
a decreased rate within the patient relaxation.
-Body malaise cardiac output normal range.
3.Provide comfort -Decreased
-Restlessness measures ( eg… discomfort and
back and neck may reduce
massage, sympathetic
elevation of stimulation.
head.)

4.Instruct in
relaxation -Can reduce
technique. stressful stimuli;
provide calming
effect thereby
reducing blood
pressure.
ASSESSMENT NURSING SCIENTIFIC BASIS GOALS AND OUTCOME NURSING RATIONALE
RATIONALE EVALUATION
EVALUATION
DIAGNOSES CRITERIA 5.Monitor response
INTERVENTIONS -To determine the
to medication to effectiveness of
Subjective: After 8 hours of nursing Independent:
control blood the medication.
interventions the patient pressure.
“nag-guol
“Dali jud
jud kayo Anxiety
Activity related Anxiety is a feeling
Muscle cells work by of will be able verbalized
to report 1.Promote
1. Note client -Verbalization
- Symptoms of After 8 hours of
sa
ko kutasan ako to situational
intolerance apprehension
detecting a flow or fear.
of awareness of feelingsinof
measurable increase expression
reports of of concerns reduces
may result or nursing
sitwasyun
dong” as crisis
relatedasto body The body impulses
electrical prepares to anxiety and will
energy and healthy way feelings
weaknessandand tension.
contribute to intervention
karon”
verbalized by as evidenced
weakness. by deal
fromwith a threat:
the brain which Dependent:
fears.
difficulty in tolerance of
to deal withinthem.
participate necessary
verbalized
patient. by express blood Goals met.
the signalspressure
them toand desired activities. accomplishing activity.
Administer
2.Proved
the patient. concerned heart ratethrough
contract are the Specifically the patient task. rest -Aids in
-Conserved The patient was
medication
period andas - Adequate
regarding increased,
release of calcium byis
sweating will be able to:
Specifically the patient controlling
prescribed
2.Assess by the
uninterrupted energy and
energy able to
changes in life increased, blood flow
the sarcoplasmic will be able to: increase coping
blood
Objective: 1. Report anxiety is physician.
sleep.
nutritional enhance
reserves are verbalized a
events. to the majorFatigue
reticulum. muscle pressure.
Objective: 1. reduced to a an
Participate status. mechanism.
requirement reduce of
-BP=150/80 groups
(reducedis ability
increased,
to 3. Provide a tension that she
and immune andmay manageable
activity withoutstate. forin
activity.
-Restlessness
mmHg generate force) relaxing aand
3.Provide -Aids reducing is feeling.
digestive
occur duesystem shortness of breath. Collaborative: tension
-Blank stares
to the nerve, 2. Demonstrate quiet
positive - Helpsand can
-PR=54 Bpm or functions are muscle
or within the inhibited promote
effective activity
2.Participate coping environment.
atmosphere
Refer to a dietitian minimize
inattention. (the
cellsfight or flight relaxation
-shortness of
themselves. strategies
without to reduce
the increase while -provide ato the
frustration and
response).
Muscle fatigue is patient.
healthy diet that
breath upon ofanxiety.
blood pressure. acknowledging rechanneled
caused by calcium difficulty of the could avoid the
energy.
exertion 4.Provide -helps in
leaking out of the 3. Report relief of situation for the risk of further
muscle cell. These relaxation reducing anxiety.
-Report of dizziness and fatigue. client. complication.
causes there to be less techniques. (eg..
dizziness and
calcium available for listening music,
4.Monitor - To monitor the
fatigue.
the muscle cell. In massage.)
response to effect of the
addition an enzyme is medication and medication.
Dependent:
proposed to be change in
activated by this regimen.
Administer -medication
released calcium medication as given by the
which eats away at prescribed by physician can
muscle fibers. the physician. help control the
tension.
 DRUG NAME DOSAGE MECHANISM INDICATION CONTRAINDICAT SIDE EFFECTS NURSING
AND OF ACTION ION RESPONSIBILITIES
Assist client with - To prevent over
FREQUENCY
the Activity exertion.
CNS: Headache - Monitor liver function
Monitor vital signs. - To obtain a studies; may cause
GENERIC NAME: PATIENT Reduces fever - Analgesic- - Contraindicated CV: Chest pain, dyspnea, hepatic toxicity at
baseline data.
DOSE: by acting antipyretic in with allergy to Dependent:
myocardial damage when doses >4g/day
Paracetamol directly on the patients with acetaminophen. doses of 5–8 g/day are - Monitor renal
hypothalamic aspirin allergy, Administer
ingested daily for several function studies;
BRAND NAME: - Use cautiously with
medication albumin indicates
heat-regulating hemostatic weeks oraswhen doses of 4 nephritis
1 tab PO q4 for impaired hepatic prescribed
Biogesic center to cause disturbances, byingested
g/day are the for 1 - Monitor blood
temperature function, chronic physician. -Aids in
vasodilation and bleeding yr studies, especially
more than 38 alcoholism, controlling CBC and pro-time
CLASSIFICATION: 0
sweating, which diatheses, upper
C pregnancy, lactation. GI: Hepatic toxicityincrease
and bloodif patient is on long-
helps dissipate GI disease, gouty
heat. arthritis failure, jaundice pressure. term therapy.
Collaborative: - Check I&O ratio;
Antipyretic, - Arthritis and GU: Acute kidney decreasing output
Analgesic failure, renal tubular may indicate renal
rheumatic
necrosis failure.
disorders -Assess for fever and
involving Refer to a dietitian
Hematologic: pain
musculoskeletal -provide a - Assess
Methemoglobinemia— healthy diet that
pain (but lacks hepatotoxicity: dark
cyanosis; hemolytic urine, clay-colored
clinically could avoid the
anemia—hematuria,
significant risk of furtherstools
anuria; neutropenia, Assess allergic
antirheumatic complication.
leucopenia, pancytopenia, reactions: rash,
and anti-
thrombocytopenia, urticaria
inflammatory
hypoglycemia
effects)
Hypersensitivity: Rash,
fever
 DRUG NAME DOSAGE MECHANISM INDICATION CONTRAINDICAT SIDE EFFECTS NURSING
AND OF ACTION ION RESPONSIBILITIES
FREQUENCY

GENERIC NAME: PATIENT It stimulates Hypertension contraindicated in - “colds” (upper Take blood blood pressure
DOSE: aldosterone patients who are respiratory infection) before giving the
Losartan secretion by the Hypertensive hypersensitive to any - - dizziness medication.
50 mg tablet adrenal cortex. Patients with component of this
BRAND NAME: once daily Left Ventricular - stuffy nose
Losartan and its product
principal active Hypertrophy
Lifesar tan - back pain
metabolite
CLASSIFICATION: block the pregnancy
vasoconstrictor
angiotensin II and
receptor (type AT1) aldosterone-
antagonist secreting effects
of angiotensin
II by selectively
blocking the
binding of
angiotensin II to
the AT1
receptor found
in many tissues.
 DRUG NAME DOSAGE MECHANISM INDICATION CONTRAINDICAT SIDE EFFECTS NURSING
AND OF ACTION ION RESPONSIBILITIES
FREQUENCY

GENERIC NAME: PATIENT The drug works -Prevention of - Hypersensitivity to -hemorrhage, severe Advise patient to do not
DOSE: by irreversibly vascular the drug substance or neutropenia, and perform other possibly
Clopedogrel inhibiting a [[ischemic] any component of the Thrombotic unsafe tasks until you
75 mg Tablet receptor called events in product. thrombocytopenic know how you react to it.
BRAND NAME:
P2Y12, an patients with purpura (TTP).
adenosine symptomatic - Active pathological
Plavix
diphosphate atherosclerosis bleeding such as Avoid activities that may
ADP peptic ulcer or cause bruising or injury
chemoreceptor. -Acute coronary intracranial
syndrome hemorrhage
without ST-
CLASSIFICATION: segment -you are allergic to
elevation any ingredient in
coagulant Clopidogrel
(NSTEMI),

-ST elevation -you have an active

MI (STEMI) bleeding disorder,
such as a stomach
ulcer or bleeding in
the brain

DRUG NAME DOSAGE MECHANISM INDICATION CONTRAINDICAT SIDE EFFECTS NURSING

 AND OF ACTION ION RESPONSIBILITIES
FREQUENCY

Instruct patient to:

GENERIC NAME: PATIENT it increases the Hyperlipidemia • you are allergic to • headache; - Avoid using antacids
DOSE: number of and Mixed any ingredient in without your doctor's
Rusovastatin hepatic LDL Dyslipidemia Crestor • mild muscle advice.
receptors on the
BRAND NAME: Hypertriglycerid •you have liver -Do not increase or
cell-surface to
20 mg tab once emia problems or • pain; decrease the amount of
Crestor enhance uptake unexplained
daily grapefruit products in your
and catabolism abnormal liver
Primary • joint pain; diet without first talking to
of LDL. function tests
Dysbetalipoprote your doctor
Second, • constipation;
CLASSIFICATION: inemia (Type III
rosuvastatin • you are pregnant
Hyperlipoprotein or breast-feeding -Do not perform other
inhibits hepatic • mild nausea; or
HMG CoA emia) possibly unsafe tasks until
synthesis of
reductase inhibitors, • you are taking • stomach pain or you know how you react
VLDL, which Homozygous
or "statins." itraconazole, indigestion. to it.
reduces the total Familial mibefradil, or
number of Hypercholesterol telithromycin Follow the diet and
VLDL and LDL emia exercise program given to
particles
you by your health care
Slowing of the
provider
Progression of
Atherosclerosis
Do NOT take more than
the recommended dose
without checking with
your doctor
Type of Classification Content Mechanism of Indications Contraindications How supplied Dose Nursing
solution action responsibilities
PNSS Hypertonic 100mL Hypertonic For Hypersensitivity to Intravenous Before:
solutions replacement or any of the infusion 1. Use sterile
contain a high maintenance components. infusion set.
concentration of fluid and 2. Use only if
of solute electrolytes. solution is clear
relative to and container is
another not leaking.
solution ( e.g. 3. Assess patient’s
the cell’s hydration status.
cytoplasm ) During:
when a cell is 1. Perform time
placed in a taping.
hypertonic 2. Regulate IVF as
solution, the prescribed.
water diffuses 3. Check from time
out of the cell, to time the
causing the cell positioning of the
to shrivel. patient.
After:
(Wikipedia 1. Chart the date and
encyclopedia, time the solution
5th edition). 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.