Case Study of A Client Diagnosed With Hypertensive

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GRAND CASE PRESENTATION
BS NURSING III SECTION B
SECOND SEMESTER AY 2009-2010
MARCH 11, 2010: THURSDAY
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Ms. MARILOU GENODIA, R.N.
Ms. GLENDA NAGALLO, R.N.

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Hypertensive Atherosclerotic
Cardiovascular Disease (HASCVD)
is an arterial disease characterized
by narrowing of the arteries by
atherosclerosis (plaque formation)
that obstruct (stenosis) or narrow
(sclerosis) necessary blood flow to
a specific part of the heart
accompanied with increased blood
pressure.
HASCVD is a medical way of
saying "blocked arteries secondary
to cholesterol plaques and in the
setting of hypertension." It
describes a common clinical
syndrome, where the walls of
coronary (heart) arteries are lined
with cholesterol plaques.
It¶s the progressive hardening of
the arteries due to long standing
hypertension. In this case
cardiovascular arteries are
hardened, compromising blood flow
to the heart muscle and tissue.
Complications include Angina
Pectoris, MI (Heart Attack) and
Heart failure.
Patient C.G., female, aged 55,
consulted the Medical Center
Muntinlupa (MCM) Emergency
Room (ER) last November 25, 2009
with chief complaint of numbness
on her left arm coincided with chest
pain which she described as
radiating from her sternum area
towards her xyphoid process.
She roughly estimated it lasting
about 10-15 minutes. A week prior
to admission, she reported
experiencing generalized body
weakness and occasional radiating
chest pain related to stress and
fatigue. She was accompanied by
her husband.
She stated that approximately 10
years ago (year 2000) she was first
diagnosed of hypertension. When
asked about medications she is
currently taking, she stated that she
takes µNeobloc¶, an anti
hypertensive drug belonging to the
classification of Calcium channel
blockers.
With this, she also claimed no
familial history of hypertension or
any related cardiovascular disease
but she stated a link in the
genealogy that manifested diabetes
on her paternal side.
When asked about her lifestyle,
she openly shared that when she
was at her peak age (she
approximated it between teens to
her late twenties) she lived carefree
and was engaging in vices like
smoking, drinking and eating foods
high in fat and sodium.
ày the time morning came, she
was so exhausted that she¶d doze
off through the day and listen to
music. Realization of her µsedentary
lifestyle¶ only dawned upon her
when she started her family.
þpon initial assessment, patient
was 57 inches tall and weighed
106.7 lbs. She is not in distress and
is conscious and coherent. Initial
vital signs T=36ÛC, PR= 120bpm,
RR=20 and àP=150/90 clearly
shows presence of hypertension. In
relation to this, she was confined to
rest and given a dose of
Nitroglycerin.
She was also ordered to undergo
several diagnostic tests such as: 1.
àlood Studies, 2. àþN, Creatinine,
3. Troponin T, 4. þrinalysis, 5. CT
Scan, 6. FàS and Cholesterol level.
þpon analysis of the data stated,
patient was diagnosed with
Hypertensive Atherosclerostic
Cardiovascular Disease (HASCVD).
A. General Objectives
This study aims to convey
familiarity and provide effective
nursing care to a patient diagnosed
with Hypertensive Atherosclerotic
Cardiovascular Disease (HASCVD)
through understanding the patient
history, disease process and
management.
B. Specific Objectives
j

1. Present a thorough assessment
regarding HASCVD, through Nursing
Health History, Gordon¶s Functional
Health Pattern, Physical Assessment,
and the interpretation of the laboratory
examinations done on the patient.
2. Discuss the anatomy and
physiology of the heart,
pathophysiology of the patient¶s
condition, usual clinical
manifestations and possible
complications of the condition.
3. Enumerate the necessary
medications needed and be familiar
to its mode of action.
4. Formulate a workable nursing care
plan on the subjective and objective
cues gathered through nurse-
patient interaction to be able to help
the patient towards wellness.
A. Biographical Data
á

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B. Chief Complaint
Client experienced numbness on
her left arm coincided with chest
pain which she described as
radiating from her sternum area
towards her xyphoid process lasting
approximately for about 10-15
minutes which prompted consult.
She also stated that a week prior
to admission, she experienced
generalized body weakness and
occasional radiating chest pain
related to stress and fatigue.
ë

T = À . PR = '(&(
àP = /'0''( RR = '(
A. History of Present Illness
j week prior to admission, client
experienced generalized body
weakness and occasional radiating
chest pain related to stress and
fatigue. A day prior to admission
she claimed of same symptoms.
B. Past History
Õ Client was diagnosed about 10
years ago (year 2000) of
Hypertension.
Õ Client has a childhood illness of
allergic rhinitis related to dust that is
still presently manifested.
Õ Client hadn¶t encountered any form
of accident nor serious injuries at the
moment.
Õ Client was previously hospitalized
and undergone àilateral Tubal
Ligation approximately 21 years ago.
She was about 34 years old.
Õ Client takes multivitamins and
calcium channel blockers as
maintenance drugs.
C. Family History
Client claimed with familial
history of hypertension (maternal
side) and she stated a link in the
genealogy that manifested diabetes
on her paternal side.
ACTIVITIES OF DAILY LIVING (
)
Functional alth io to Duing Intptation
attn ospitalization ospitalization
" r She engages in She was more She manages her
Health Management simple exercises inclined to bed rest health well since her
Pattern such as brisk due to easy realization. She now
walking and jogging. fatigability but takes a higher
She also follows engages in ROM regard of health and
medication regimen. exercises. She eats has become more
hospital meals and ware of lifestyle
fruits. She closely changes
listens to the significances.
doctor¶s and nurse¶s
health advices.
° $ There were no
% 2 4 small frequent 2 4 small frequent significant changes
meals a day
meals a day in except for a
a. number of meals (meal regulated r
(usually s lot of low sodium and restriction of low
per day
fatty foods)with low fat) with good sodium and low fat
b. appetite appetite
good appetite diet.
2 6 - 8 glasses of
c. glass of water per 2 6 - 8 glasses of water a day
day water a day 2 Pear shaped
2 Pear shaped (àMI=23.15)
d. body built
(àMI=23.15) 2 Height: 57 in¶
e. height and weight 2 Weight: 106.7
2 Height: 57 in¶
lbs.
2 Weight: 106.7
lbs.
There were no
2 3-5 times per day 2 3-4 times per day significant changes
a. frequency of
2 Moderate 2 Moderate in except for a
urination
2 Once a day 2 Once a day stricter
b. amount of urine
2 Formed 2 Formed implementation of
per day
2 Moderate 2 Moderate low sodium and low
c. frequency of fat diet.
bowel movement
d. consistency of the
feces
e. amount defecated
per day
j $ Client is easily
2 Walking 2 ROM exercises fatigued due to
2 Get tired easily 2 Easy to get tired present disease
a. exercise
2 Light 2 None condition.
b. fatigability
housekeeping
c. ADL chores
$ Client reported Client still reports Sleep pattern is
alteration in sleep alteration in sleep altered due to
pattern pattern present disease
characterized by characterized by condition.
insomia episodes insomia episodes
once in while. She once in while.
also reported Though she
discomfort upon reported decrease
waking up. in discomfort upon
waking up.
Ô $ No significant
2 Oriented to
changes.
time, place and
2 Oriented to
a. orientation person
time, place and
2 Responds
b. responsiveness person
appropriately to
2 Responds
verbal and
appropriately to
physical stimuli
verbal and
physical stimuli
& $ Client has high Client still has high No significant
&Ô regard of self worth. regard of self worth changes.
despite of disease
process.
$ No significant
2 With good 2 Still with good
changes
relationship with relationship with
a. as a sister her siblings and her siblings and
provided support provided support
b. as a wife whenever whenever
needed needed
c. a mother and 2 With good 2 Still with good
grandmother relationship with relationship with
husband; husband;
performs duties performs duties
as housewife as housewife
2 With good 2 With good
relationship with relationship with
sons and sons and
daughters as well daughters as well
as with in-laws as with in-laws
and and
grandchildren grandchildren
Sexuality r Client was gifted with four children and Changes were
Reproductive was ligated approximately 21 years ago brought about by
when she was 34 years old. Due to age, three main factors:
she confessed that sexual contact is
2 Ligation
rarely done.
2 Age
2 Menopause
Coping r Stress In spite of challenges, she is enthusiastic This helps in a
Tolerance Pattern of overcoming them. She is a strong better prognosis of
willed person and her support system her disease
(family and friends) has strong condition.
foundation.
Value r àelief She is a devout Catholic and believes Moral belief have
Pattern that having faith in God will help us get developed and are
through challenges. She also believes applied which helps
that ³One should not abuse his/her body in better prognosis
for it will be ourselves who would reap its of her disease
effects later on.´. She bases it on her condition.
experience.
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The patient is conscious,
coherent and is not in distress. She
looks according to age and is calm
and engaging. One can see that
she is well nourished and practices
good hygiene.
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àody at Tchniqu jctual Finding Intptation
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Skin Inspection Skin color is fair and even Normal
Palpation Skin is smooth with fair skin Normal

turgor
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HEENT Nos
Inspection PERRLA Normal
Palpation Normoset Normal
No discharge Normal
Non tender Normal
No presence of mass or nodules Normal
Symmetrical nasal folds
Nasal septum at midline
Mucosa is moist, pinkish, intact and no discharge
Airways patent on both nares
Non tender sinuses

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Hypertensive Arteriosclerotic
Cardiovascular disease
Atherosclerosis (also known as
Arteriosclerotic Vascular Disease or
ASVD) is the condition in which an
artery wall thickens as the result of
a build-up of fatty materials such as
cholesterol.
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It is commonly referred to as a
hardening or furring of the arteries.
It is caused by the formation of
multiple plaques within the arteries.
CAUSES

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Atherosclerosis typically begins
in early adolescence, and is usually
found in most major arteries, yet is
asymptomatic and not detected by
most diagnostic methods during
early stages of life.
÷HYSIOLOGIC FACTORS
THAT INCREASE RISK
Various anatomic, physiological &
behavioral risk factors for
atherosclerosis are known. These can
be divided into various categories:
congenital acquired, modifiable or
not, classical or non-classical. The
points labeled '+' in the following list
form the core components of
"metabolic syndrome".
Treatment
Some symptoms such as angina
pectoris can be treated. Non-
pharmaceutical means are usually
the first method of treatment, such
as cessation of smoking and
practicing regular exercise.
185
39%
,
8% ,3
11
,08
D1
9% %
110
HEMATOLOGY (NOVEMBER 25, 2009)
NORMj j R T INTRRTjTION

oglobin 11.0 15.0 g/ 1. g/ ukocyt and y
phocyt
count a slightly lat du
ythocyts ol T) F) ol% 6.0 ol%
to inla
ation pocss in th

ukocyts 5,000 10,000 10,00 atial lu
n. May also
ythocyt . 5.0 u/ 5.16 u/ indicat inctious pobl

s
occuing in oth syst
s.
g
nts 50 0
ythocyt count is slightly
osinophil 05 high du to body¶s
co
pnsation towads
àasophil 01 1
hypox
ia.
y
phocyt 20 0
Monocyt 0 6
latlt count 150, 000 00,000 jdquat
Man copuscula ol 80 0 8
Man copuscula h
oglobin 26 2
g 28.8
g
Man copuscula h
oglobin 2 6% 2.%
conc
CHEMISTRY (NOVEMBER 25, 2009)
NORMAL RESþLT INTERPRETATION
VALþE
àlood þrea 6.0 r 20.0 14.6 Serum Glucose is high due to
Nitrogen (àþN) mg/dL mg/dL ineffective lysis glucose into energy
which is indicative of diabetes.
Creatinine 0.5 r 1.7 1.2
mg/dL mg/dL
Sodium (NA)
135 r 145 137.8
Potassium (K)
mmol mmol
Hemoglucose
3.5 r 5.3 4.17
(HGT)
mmol mmol
80 r 120 190
TROPONIN T (NOVEMBER 25, 2009)
NORMAL VALþE RESþLT INTERPRETATION
< 0.03 mg/ml = (-) low risk < 0.03 Though having an episode of chest
mg/ml pain, patient has no myocardial
0.03 r 0.99 mg/ml =
infarction.
borderline
0.1 r 2.0 mg/ml = (+) high

risk
> 2.0 mg/ml = massive

myocardial damage
URINALYSIS (NOVEMBER 25, 2009)
PHYSICAL Hazy urine may indicate dehydration or fluid
conservation. As a compensatory mechanism for
Color Light yellow Light yellow
decreased cardiac perfusion, body may retain fluid in
Reaction 4.8 r 6.2 6.0 attempt to increase circulating blood volume.
Transparency Transparent Hazy Presence of pus in the urine is an indication on possible

þrinary Tract Infection (þTI).
Specific gravity 1.010 r 1.025 1.020
CHEMICAL Trace Trace
Albumin Negative (-) Negative (-)
Sugar None to Few Few
Amorphous urates None to Few Few
àacteria 1. r 5/hpf 10 r 15/hpf
MICROSCOPIC 0-2/hpf 1/hpf

CELLS
Few to moderate Moderate
Pus
RàC
Epithelial
PLAIN CRANIAL COMPUTED TOMOG RAPHY
(CT) SCAN (NOVEMBER 25, 2009)
RESþLT INTERPRETATION
1. Hypodense foci are seen in the The scan reveals that the left vertebral
anterior limb of the right internal artery has begun narrowing maybe due to
capsule, anterior limb of the left plaque formation and inflammatory
external capsule and left response. Consequently, blood supply to
periventricular white mater. the brain is compromised that if continued
to persist may eventually lead to
2. No midline shift or mass effect.
Cerebrovascular Accident (CVA) or
3. Sulci, sicterns, ventricles are not
stroke.
prominent.
4. Posterior fossa structures are

unreachable.
5. The left vertebral artery is

sclerotic.
TROPONIN T (NOVEMBER 26, 2009)
< 0.03 mg/ml = (-) low risk < 0.03 mg/ml Patient reported no chest
pain. Test was ordered to
0.03 r 0.99 mg/ml =
validate first finding.
borderline
Patient has no myocardial
0.1 r 2.0 mg/ml = (+) high
infarction.
risk
> 2.0 mg/ml = massive

myocardial damage
CHEMISTRY (NOVEMBER 26, 2009)
NORMAL RESþLT INTERPRETATION
VALþE
Magnesium (Mg) 1.6 r 3.0 2.0 mg/dL Serum fasting blood sugar is high
mg/dL which confirms the first finding of a
Fasting àlood Sugar 151.9 mg/dL
possibility of diabetes. Increased
(FàS) 74 r 109
8.4 mg/dL
mg/dL àlood þrea Nitrogen (àþN) indicates
àlood þrea Nitrogen
207.5 mg/dL decreased perfusion on kidneys.
(àþN) 2.4 r 5.7
mg/dL 185 mg/dL
Cholesterol
0 r 220 mg/dL 43.3 mg/dL
Triglyceride
40 r 190 127.2 mg/dL
High density lipoproteins
mg/dL 24 u/L
(HDL)
30 r 75 mg/dL
Low density lipoproteins
(LDL) < 130 mg/dL
SGPT (ALT) 0 r 47 u/L.

CARDIAC DIAGNOSTIC TEST -
ELECTROCARDIOGRAM (ECG)
RESULT (NOVEMBER 25, 2009)
DIMENSION NORMAL RESþLT FþNCTION NORMAL RESþLT
VALþE VALþE
(ed) 4.5 r 5.0 4.2 LVEPV
(es) 2.2 r 3.5 3.0 LVESV (55 r 77%) 44 ml
RV (ed) 3.0 r 3.5 3.1 Stroke Volume (28 r 92% 0 2 L/min

(SV)
LA (es) 3.5 3.1 (0.8 r 1.1) 55%
Cardiac Output
RA (es) 3.5 3.1 (< 195) 28%
(CO)
Aorta 3 2.9 (< OOD) 1
EF%
PA (0.8 r 1.1) 2.5 1.7
FS%
IVS (ed) (0.8 r 1.1) 1.1
VSF
IIS (es) 1.3
EPSS
LVPW (ed) 1.1
Wall Stress
LVPW (es) 1.3
Wall Stress
MV ANNþ
LVWMSI
LVTD
ELECTROCAR RESþLT INTERPRETATION
DIOGRAM
Rate 60¶s Electrocardiogram results show that values are within the
normal limits though there are changes in the Q, T and ST
Rhythm Sinus
segment. This indicates dysrhythmia and is significant in
Axis 0.04 determining ventricular enlargement (Left Ventricular
P Wave 0.20 Hypertrophy). It is also indicative of a conduction
abnormality, may be mechanical, which explains S3 sound
T wave 0.12
upon auscultation or chemical, electrolyte abnormalities
QRS Complex (none). No drug toxicity has been detected.
ST Segment
Others
IMR ION: IN TjjRDIj

NAME OF CLASSIFICATION DOSAGE ROUTE MECHANISM OF INDICATION NURSING
DRUG /FREQUENCY ACTION RES÷ONSIBILITY
(GENERIC AND
BRAND NAME)
Glimipiride Anti diabetes 2mg PO Lowers blood Adjunct to 1. Advise
(Amaryl) Glucagon OD glucose level. diet and patient to
Stimulates release exercise to take it with
of insulin from lower first main
functioning glucose meal of
pancreatic beta level (DM the day.
cells and lead to type 2) 2. Teach
increased whose patient to
sensitivity of hyperglyce carry
peripheral tissues mia can¶t be candy or
to insulin. managed simple
by diet and sugars to
exercise treat mild
alone. episodes
of low
sugar
level.
(GENERIC AND
BRAND NAME)
Clopidogrel Antiplatelet 75mg/tab PO Inhibits the binding Reduce 1. Inform
àisulfate drug OD of adenosine thrombotic patient
(Plavix) diphosphate (ADP) events in that drug
to its platelet patients may be
receptor, with taken
impending ADP- atheroscler without
mediated osis. regard to
activation. meals.
2. Instruct
patient to
notify
physician
if unusual
bleeding
or bruising
occurs
(GENERIC AND
BRAND NAME)
Lactulose Laxative 30cc PO Produces an Constipatio 1. Inform
(Duphalac) OD Hs osmotic effect in n; prevent patient about
colon; stimulation adverse effect
Promote peristalsis, of the vagal and to notify
decrease ammonia nerve physician once
as a result of it occurs
bacterial
degradation which
lowers the pH of
the colon contents.
(GENERIC AND
BRAND NAME)
Simvastatin Anti lipemics 40g/tab PO Inhibits HMG-COA Reduce risk 1. Instruct
(Synvinolin) OD reductase, an of death from patient to take
early and rate cardiovascul drug with
limiting step in ar disease evening
cholesterol and meals
biosynthesis. cardiovascul because
ar events in taking this
patients at enhances
high risk for absorption
coronary and increase
events; cholesterol
Reduce total biosynthesis.
LDL 2. Instruct
cholesterol patient to
inform
physician if
adverse
reactions
occur
particularly
muscle pains
(GENERIC AND
BRAND NAME)
Clonidine Anti 75mcg/tab SL Stimulates alpha Hypertension 1. Tell patient to
Hydrochloride hypertensive PRN for receptors and greater than take the last
(Catapres) àP> 150/90 inhibits the central 150/90mmH dose
mmHg vasomotor centers, g immediately
decreasing before at
sympathetic outflow bedtime.
to the heart, kidneys 2. Inform patient
and peripheral that dizziness
vasculature and upon standing
lowering peripheral (orthostatic
vascular resistance, hypotension)
blood pressure and can be
heart rate. minimized by
rising slowly
from a sitting
position or lying
position and
avoiding
sudden position
changes.
(GENERIC AND
BRAND NAME)
Nitroglycerin Vasodilator, 5mg. Patch Decreases oxygen To prevent 1. Closely
Antianginal OACW q 8 demand by or minimize monitor
NFI decreasing preload anginal V/S esp.
and afterload attacks àP
before 2. Applied to
stressful any
events nonhairy
parts of
the skin
except
distal parts
of the
arms and
legs
(GENERIC AND
BRAND NAME)
Humulin R Anti diabetic 4u SQ Increase glucose Prevent 1. Take with
(Regular, Glucagon Sliding transport across moderate to first main
crystalline scale muscle and fat cell severe meal of the
Zinc Insulin) membranes to Hyperosmol day.
reduce glucose ar
level. Hyperglyce
mia state as
well as
hyperkalemi
a.
(GENERIC AND
BRAND NAME)
Levofloxacin Anti infective 1 tablet PO Inhibits bacterial Acute bacterial 1. Tell patient to
(Levaquin) TID DNA gyrase and infections take medication
prevents DNA caused by 1 hr before or 2
replication, susceptible hrs after eating
transcriptions, strains of for increased
repair and streptococcus absorption.
recombination in
(GENERIC AND
BRAND NAME)
Isosobide Anti angina 60g/1/2 tab SL Reduces cardiac Prevent 1. Tell patient
Mononitrate OD oxygen demand acute to take
(Indur) by decreasing anginal sublingual
preload and attacks; tablet at first
afterload; Acute sign of attack.
Increases blood anginal 2. Wet tablet
flow through the attacks with saliva
collateral and place
coronary under tongue
vessels. until
absorbed.
3. Take in
sitting down
and at rest.
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Case Study of A Client Diagnosed With Hypertensive

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Case Study of A Client Diagnosed With Hypertensive

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| 

MARCH 11, 2010: THURSDAY

j   

# 1 2

Palpation Skin is smooth with fair skin Normal

Inspection PERRLA Normal

Palpation Normoset Normal

Non tender Normal

No presence of mass or nodules Normal

Symmetrical nasal folds

Nasal septum at midline

Mucosa is moist, pinkish, intact and no discharge

Airways patent on both nares

Non tender sinuses

% |3 ,9%

 % 3 

Palpation  

% %31 A20

ation pocss in th

ythocyt .  5.0 u/ 5.16 u/ indicat in ctious pobl

latlt count 150, 000  00,000 jdquat

0.1 r 2.0 mg/ml = (+) high

> 2.0 mg/ml = massive

Transparency Transparent Hazy Presence of pus in the urine is an indication on possible

CHEMICAL Trace Trace

Albumin Negative (-) Negative (-)

Sugar None to Few Few

Amorphous urates None to Few Few

àacteria 1. r 5/hpf 10 r 15/hpf

MICROSCOPIC 0-2/hpf 1/hpf

4. Posterior fossa structures are

5. The left vertebral artery is

> 2.0 mg/ml = massive

SGPT (ALT) 0 r 47 u/L.

(es) 2.2 r 3.5 3.0 LVESV (55 r 77%) 44 ml

RV (ed) 3.0 r 3.5 3.1 Stroke Volume (28 r 92% 0 2 L/min

IMR ION: IN TjjRDIj

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| 6 Acute Pain

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% %31 A20

ythocyt . 5.0 u/ 5.16 u/ indicat inctious pobl

latlt count 150, 000 00,000 jdquat

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