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Chapter 1 - Vero
Chapter 1 - Vero
ASSESSMENT OF PATIENT/FAMILY
1.0. Introduction
Nursing assessment begins the nursing process with appraisal of the health status of the
patient. Through observation, questioning and examination, data about the patient and his
family is gathered and analysed. This chapter documents pertinent data obtained during
interaction with Madam P.A. and her family at the assessment phase of the nursing process. It
entails biographical data, developmental, past and present medical history, the family’s
medical and socioeconomic history as well as the patient’s lifestyle, literature review on
Hypertension as well as validation of the data obtained during this phase of the nursing
process.
Madam P.A. is a forty-year-old woman, born on 15th December 1980 to Mr. A. A. and Mrs. J.
A. Her father is alive whereas her mother is late. She is the first of six siblings of both
parents. Madam P. A. resides at North Kaneshie with her daughter. Madam P.A. is single
with no children. Madam P.A. is a Christian and a Catholic. Mrs J.A. is her next of kin. She
attended L/A primary school in Tsito Awodome but got to form four and proceeded to Accra
Girls where she read Accounting. She is dark in complexion and has a height of 183 cm, her
weight on admission was 93 kilograms (kg). Madam P.A. is a Ghanaian from Tsito
Awodome - Ave District and speaks Ewe as her main native language otherwise speaks Twi
According to Madam P.A, there is a paternal family history of Hypertension and Diabetes
mellitus. Maternal family history on the other hand has no records of diseases such as
Hypertension, Diabetes mellitus, asthma, sickle cell disease or any chronic illness. There is
no history of communicable disease and drug or food allergy as well. However the family
sometimes experience headaches and gastric disorders which are sometimes relieved on Out-
Patient Department (OPD) basis. Madam P.A and her entire household are enrolled on the
National Health Insurance Scheme (NHIS) which they deem it relevant for accessing quality
healthcare in Ghana. She owns a clothing store. She gets enough income from her job to
support her family. Madam P.A has a child who is a university student.
Madam P.A is her parent’s first child, hence she is actively involved in social/communal
Madam P.A. comes from a family of six children to Mr. A.A. and Mrs. J.A. She happens to
be the first of the six children and grew up with her parents. She was born through
spontaneous vaginal delivery (SVD) by a midwife at Tsito Awodome CHPS, located at Tsito
with no post-delivery complications. She said she was fortunate her mother practiced the
exclusive breast feeding (EBF) for her and got weaned off after two and half years with
supplemental feeds. According to Madam P.A, even though she cannot talk much about her
childhood, she could remember what her mother told him. She said she was given
immunization and even showed me a scar on her right shoulder. She is very healthy and
strong at her present age and attributed that to the exclusive breast feeding practiced by her
mother. She, therefore, encourages and promotes EBF among nursing mothers in and around
her residential area in North Kaneshie. Madam P.A. started crawling at 9 months and by age
12 months she was able to walk. By age 14years she had feminine features signifying onset
of puberty, at age 40years she realized she had developed grey hair.
1.4 Patient’s Lifestyle / Hobbies
According to Madam P.A, she sleeps around 10:00pm in the night and wakes up around
5:00am in the morning. After her early morning routines of ensuring her oral hygiene and
other activities of daily living, she usually leaves for work by 7:00am and usually gets home
by 5pm each day. She attends church service each Sunday. She usually takes porridge or tom
brown in the morning, boiled yam or plantain in the afternoon and she enjoys fufu with light
soup for supper. She loves to watch popular local Television series on the TV precisely UTV.
According to Madam P.A., she has been admitted to the hospital a couple of times on account
of hypertension. She was on prescribed medications for her condition but defaulted. She
usually gets over-the-counter drugs anytime she suffers from common cold, headaches and
abdominal upsets.
Madam P.A. is a known hypertensive patient but defaulted her usual treatment. On 2 nd April 2021, she
experienced severe headache, difficulty in breathing, dizziness, palpitations, anxiety, insomnia, cough, and
blurred vision and was sent to 37 Millitary Hospital Bandoh B at 3:20pm for medical management. Initial
assessment was done and her vital signs were checked and recorded as Temperature 36.5 oc, pulse 110bpm,
respiration 45cpm, blood pressure 200/120mmHg, oxygen saturation 90%. Initial laboratory tests of FBC, Lipid
profile and BUE/Cr were ran and appropriate treatment commenced. She was admitted at the Emergency
On 2nd April 2021, Madam P.A. an ambulant patient was brought to the Out-Patient
assessment, findings were difficulty in breathing, dizziness, palpitation, cough and severe
headache. She was examined by the leas Team A doctor. After critical examination, the
doctor recommended her to go and do laboratory test such as Full Blood Count, Lipid Profile
and BUE/CR.
After the laboratory results were shown to the doctor, he diagnosed the patient with
Hypertension and requested that she should be admitted at Bandoh B ward. Madam P.A. was
brought into the ward with her relatives accompanied by a nurse. They were warmly
welcomed to the nurses’ station. I welcomed Madam P.A. and her relatives and offered them
seats at the nurses’ station. Her identity was confirmed by collecting her folder from the
accompanied nurse to cross check with the information given about her on the record system.
Her vital signs, weight and height were checked and recorded as follows:
Spo2 90%
Weight 93 kilograms
All these were recorded on the observation sheets. A simple unoccupied bed was made for
the patient. Patient was oriented to the ward and its annexes. I introduced the other staffs on
duty to Madam P.A. and the other patients on the ward. She was shown to places like the
nurses’ office, toilet, facilities and bathroom. After that she was allowed to ask questions
bothering her mind. I explained to Madam P.A. and relatives that the National Health
Insurance will cover her bills throughout hospitalization and in case the insurance does not
cover any treatment she would be made to pay for it. I explained to her Madam P.A. and her
daughter the visiting hours as 5:30am to 7:30am in the morning and 3:30pm to 5:30pm in the
evening. Client relatives were oriented to the ward environment and allowed to say goodbye
to the client. The ward routines such as time for doctor’s rounds, serving of medications,
checking of vital signs and others were also explained to the patient. She was then informed
of the need to sign consent form before further treatment could be carried on her. She was
then assisted to change into a hospital gown and put into a prepared bed. The properties of the
patient like wrist watch, patient’s bag containing different kinds of substances were collected
and were nicely arranged in the patient’s bedside locker. The sister and daughter were
allowed to bid her goodbye and inform other relatives at home. Patient’s name, sex, address,
diagnoses were entered into admission and discharge book and also on the daily ward state.
The following drugs were prescribed by the doctor and administered to Madam P.A during
Oxygen 4L/min
1.8 Patient Concept of Illness
Madam P.A. does not attribute her illness to superstitions or someone being the cause of her
problems. She understands the causes and risk factors for hypertension. She believes that
with good medical and nursing care she will be better to go home.
1.9 LITERATURE REVIEW ON CONDITION – HYPERTENSION
Definition
Hypertension is defined as a systolic blood pressure greater than 140mmHg and a diastolic
pressure greater than 90mmHg based on the average of two or more accurate blood pressure
measurement taken during two or more contact with a health care provider. (Hinkle and
Cheever, 2014)
identifiable cause and common among persons between the ages of 30 and 50 years. It is
underlying cause. Common causes include renal diseases, endocrine disorders, and drugs.
Renal Disease
such as nephritis, stenosis of the kidney and polycystic disease bring about changes in blood
flow in the kidney structures to cause hypertension. With a reduced blood flow to the kidney,
the kidney reacts by producing a proteolytic enzyme called rennin. In the blood stream,
rennin acts upon plasma protein to produce angiotensin I which is converted to angiotensin II.
This has a vasoconstrictive effect that leads to increase in blood pressure. Rennin also
stimulate the adrenal glands to secrete aldosterone which causes water and sodium retention.
Endocrine Disorders
A tumor of the adrenal medulla called pheocromocytoma secretes adrenaline that has a vaso-
constrictive effect which results in a raise in the blood pressure. Increased aldosterone
secretion also increases reabsorption of sodium and water to cause a raise in blood pressure.
hypertension.
Certain medications
Drugs such as oral contraceptives are known to contain oestrogen. In the liver, oestrogen
increase angiotensin to cause hypertension. If the drug is discontinued for 6 months, blood
Malignant Hypertension
fibrinoid necrosis of the small arteries of the heart, kidneys, brain and eyes (target organ).
Dysfunction of the organ ensues and without medical treatment the course of malignant
hypertension is rapidly fatal. Most persons do not survive longer than two years. This
condition is seen most often in black men under the age of 40.Patient may experience
headache, seizures, papilloedema and retinal haemorrhage. (Smelter and Bare, 1992)
Incidence
About 20% of the entire population develops hypertension. More than 90% of these have
essential (primary) hypertension which is a type of the condition without medical or specific
cause. The remaining 10% develops the condition with specific cause (secondary
hypertension) such as renal disease, certain drugs, organs dysfunctions, tumours, and
pregnancy. It is more common in men above 50years and women above 65years and the
obese. It is high among the black race. It is more in urban dwellers than those in the rural
Aetiology
The cause of essential hypertension has not yet been identified. Primary may develop as a
2. Obesity
5. Over intake of stimulants like coffee, tobacco and other stimulating drugs
6. Old age
7. Emotional disturbances
8. Stress
9. Genetics
Prognosis
It is based upon several factors including genetics, dietary habits and overall lifestyle choices.
If individuals are conscious of their condition and take the necessary preventive measures to
lower their blood pressure, they are more likely to have a much better outcome than those
Pathophysiology
Stimulation of vasomotor centre in the medulla of the brain sends emotional impulses that
travel down through the sympathetic nerve to the sympathetic ganglion. At this point,
neurons release acetylcholine which stimulate the nerve fibers in the blood vessels where
Concurrently, the adrenal gland is stimulated due to emotional stimuli, the adrenal medulla
secrete epinephrine which causes vasodilatation. The adrenal cortex secretes cortisol and
other steroids which enhance vasoconstriction. The vasoconstriction results in reduced blood
flow to the kidney causing the release of rennin. Rennin acts on angiotensinogen causing the
by the adrenal cortex. This hormone promotes sodium and water retention in the kidney
tubules causing increase in the intravascular volume, raising the blood pressure.
The raised blood pressure commonly causes rapture of certain arteries especially the cerebral
arteries leading to cerebral haemorrhage. Increase blood volume increases the burden of the
heart and tends to sustain an increase blood pressure. (Hinkle and Cheever, 2014)
Persons with hypertension can remain asymptomatic for many years. The appearance of
symptoms usually indicates vascular damage and symptoms are related to the organ involved.
4. Tachycardia
5. Anxiety
6. Nocturia
7. Palpitations
8. Insomnia
9. Coma
10. Papilloedema
11. Seizures
Diagnostic Investigations
1. History from patient and clinical features can assist to establish diagnosis
7. Urinalysis
Medical Management
If the hypertension is secondary to a condition, that condition is treated to return the blood
pressure to normal. However if the hypertension is of the primary type, treatment is aimed at
lowering the blood pressure, and assisting patient to adjust lifestyle to reduce the demand on
Drug Treatment
slow IV injection over 20mins, 5-10mg diluted with 10mls normal saline, sodium
nitroprusside, nitroglycerine.
5. Centrally Acting Agents; displace noradrenalin from receptor sites decreasing SNS
activity e.g. Methyldopa; 250mg 2-3 times daily max 3g daily, Serpasil, Clonidine.
6. Calcium Channel Blockers; slows down the movement of calcium into cells of the
heart and blood vessels thereby reducing contractility. E.g. Nifedipine 10-40mg oral bd.
divided doses
8. Beta Blockers; Blocks the beta adrenergic receptors of SNS slowing down the heart
rate. E.g. Atenolol 50-100mg oral daily, Propranolol 180-320mg daily in divided doses.
Nursing Management
Psychological Care
Patient and relatives should be reassured not to panic because the condition will be controlled
Patient and family should be made to understand that with their maximum co-operation, the
Patient is given a complete bed rest for the first two weeks because of dizziness experienced
by patient. A serene atmosphere is enhanced such as quiet environment, ensuring dim light,
adequate ventilation and a comfortable bed free from creases and cramps. This is done to
Position
Patient is made to assume a suitable position which is not contrary to her condition. However,
for an effective respiration, patient should be in a sitting up position supported with back rest
or pillows.
Observation
1 Check vital signs every four hours especially the blood pressure and record accurately
4 Assess for mental state of patient to know if he is oriented to time, place and person
Personal Hygiene
1. Patient should be assisted to take his/her bath twice daily including his oral hygiene
2 Patient hair should be washed with shampoo and blow-dried if female to prevent hair
3 Care of the mouth is done by use of toothbrush and paste, and in an unconscious state
4 Hand and feet are cared for by soaking them in water to soften it after which it
6 Ensure proper hand washing with soap and water before and after eating and also after
Nutrition
Patient’s nutritional level is met by serving patient with a well-balanced diet that is low in
sodium; low carbohydrate, low protein, low fat to prevent hyperlipidemia, enough potassium
Exercise
The patient is encouraged to undertake passive exercises by assisting patient to stretch her
hands and legs, turning of the head gradually whiles sitting up in bed. Active exercises like
Elimination
Bladder elimination is ensured by serving urinals on patient’s request. Where patient is not
able to pass urine, application of cold compresses on the abdomen and catheterization can be
carried out. Bowel elimination is also ensured by serving bedpan on patient’s request. More
Health Education
Health education is given on hypertension, taking into consideration the definition, the cause,
treatment and most especially the dietary changes. Patient should be educated on the drug
chronicity of the disease condition and specific instruction concerning prescribed therapy
should also be emphasized. Patient who smokes must be educated on the effect of smoking
on hypertension. A balance between activity and relaxation should be touched on. Because
the condition is hereditary, other members of the family should be educated to go for regular
Medication
Diuretics are also given to get rid of excess fluid in the body. Drugs should be served in their
right dose, right time, right route, right patient, right drug, and also the patient’s right to
Complications
1. Cardiovascular accident
2. Renal failure
3. Myocardial infarction
6. Cerebral oedema
7. Hypertension cardiomyopathy
8. Blindness
9. Impotence in men
10. Arrhythmias
Information utilized in rendering care to the patient as reported in this care study has been gathered from well
informed sources and efforts were made to ensure that they are accurate and valid. Subjective data was taken
from the patient himself while objective data is obtained from significant others (relatives) and various tests to
identify the patient’s problems and their sources. Data about the plan and progress of treatment as instituted by
the physician team was collected from the patient’s folder, as well as from direct discussion with the doctors.
Literature reviews on the conditions were obtained from textbooks, and articles. Others were obtained through
my own observation and questioning and examination of the patient. The data collected were free from