BAUTISTA, DYANNE G. - Adult NursingHypertension Case Study

VIRGEN MILAGROSA UNIVERSITY FOUNDATION
Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420
CASE STUDY
NAME OF STUDENT: BAUTISTA, DYANNE G.
YEAR: BSN 4
I. GENERAL INFORMATION:
NAME: PATIENT D
ADMISSION DATE: MAY 6, 2021

ADMISSION TIME: 4:20PM
ADMITTING PHYSICIAN: DR. DINGDONG DANTES
CHIEF COMPLAINT: SEVERE HEADACHE AND DIZZINESS
ADMITTING DIAGNOSIS: HYPERTENSION

PATHOPHYSIOLOGY:
II. DEVELOPMENTAL DATA

ROBERT HAVIGHURST THEORY DEVELOPED 6 AGE GROUPS AND THE
PHYSICAL, PSYCHOLOGICAL AND SOCIAL TASKS ASSOCIATED WITH
EACH OF THESE 6 AGE GROUPS. THESE AGE GROUPS AND THEIR
ASSOCIATED DEVELOPMENTAL TASKS THAT IS ASSOCIATED WITH THE
PATIENT THAT A FEMALE PATIENT, 40 YEARS OLD IS LATER MATURITY
GROUP BECAUSE DURING LATER MATURITY, THE PERSON ADJUSTS TO
RETIREMENT, AGING AND THE LOSS OF LOVED ONES INCLUDING
SPOUSES AND FRIENDS
III. HEALTH HISTORY
A. FAMILY HISTORY:
-N/A
B. PAST HISTORY :
-TAKING MAINTENANCE MEDICINE FOR HYPERTENSION SUCH AS

LORATADINE WITH HYDROCHLOROTHIAZIDE 50MG/12.5 ONCE A DAY,
ATENOLOL 100MG BEFORE BEDTIME, LIPITOR 40MG HS, OMEGA FISH OIL
1,200MG OD AT LUNCH TIME.
C. PRESENT ILLNESS:
- PATIENT D IS EXPERIENCING PERSISTENT ELEVATION OF SYSTOLIC OR

DIASTOLIC BLOOD PRESSURE OF 160/100, SEVERE HEADACHE AND
DIZZINESS. ELEVATED BLOOD CHEMISTRY BUN, CREATININE AND
CHOLESTEROL LEVELS, BLOOD PRESSURE MEASUREMENTS RESULT IN
SUSTAINED READINGS HIGHER THAN 140/90 MMHG.CHEST X-RAY
REVEALS CARDIOMEGALY. ECG SHOWS LEFT VENTRICULAR
HYPERTROPHY. ECHOCARDIOGRAM SHOWS LEFT VENTRICULAR
HYPERTROPHY. OPHTHALMIC EXAMINATION SHOWS RETINAL CHANGES
SUCH AS ARTERIOLAR NARROWING, PAPILLEDEMA, AND HEMORRHAGE
AND URINALYSIS DISCLOSES PROTEINURIA, RED BLOOD CELL RBC’S /
WBC’S.
.
PHYSICAL EXAM
PHYSICAL EXAM:
VITAL SIGNS
TEMPERATURE: 36C
RESPIRATORY RATE: 18 B/P: 160/100
SPO2: 99%.
SKIN: VERY DRY
HEAD: NORMOCEPHALIC AND ATRAUMATIC
EYES: CONJUNCTIVA AND EOM ARE NORMAL. PUPILS ARE EQUAL, ROUND, AND
REACTIVE TO LIGHT. NO SCLERAL ICTERUS. PERIORBITAL EDEMA
BILATERAL.
NOSE: MOIST MUCOUS MEMBRANE
MOUTH: MOIST MUCOUS MEMBRANES, MACROGLOSSIA
THROAT: PATENT AND MOIST

NECK: SUPPLE. NO JVD PRESENT. NO MASSES OR SURGICAL SCARRING.
CHEST: NO RESPIRATORY STATUS DISTRESS AT THIS TIME, TACHYPNEA

PRESENT, (+) WHEEZING NOTED, BILATERAL RHONCHI, DECREASED AIR
MOVEMENT BILATERALLY. PATIENT BARELY ABLE TO FINISH A FULL SENTENCE
DUE TO SHORTNESS OF BREATH.
HEART: NORMAL RATE, REGULAR RHYTHM, AND NORMAL HEART SOUND WITH
NO MURMUR. 2+ PITTING EDEMA BILATERAL LOWER
EXTREMITIES AND STRONG PULSES IN ALL FOUR
EXTREMITIES.
LUNGS: HEART RATE 74 BPM, RESPIRATORY RATE 24, O2 SATURATION 90% ON

ROOM AIR.
ABDOMEN: SOFT. OBESE. BOWEL SOUNDS ARE NORMAL. NO DISTENSION AND

NO TENDERNESS
SKIN: VERY DRY
GENITO-URINARY SYSTEM: N/A
NEUROLOGIC: ALERT, AWAKE, ABLE TO PROTECT HER AIRWAY. MOVING ALL

EXTREMITIES. NO SENSATION LOSSES
IV. MEDICAL TREATMENT AND MANAGEMENT INCLUDING DIAGNOSTIC

PROCEDURES AND ITS INTERPRETATION TO NURSING.
TREATMENT IS SUGGESTED TO HAVE A REGULAR EXERCISE TO

REDUCE WEIGHT, LOW-SODIUM DIET AND LIMITATION OF ALCOHOL
INTAKE. THE FOLLOWING STEPPED-CARE APPROACHES TO
ANTIHYPERTENSIVE THERAPY.
STEP 1:
BEGIN LIFESTYLE MODIFICATIONS INCLUDING:
• WEIGHT REDUCTION
• MODERATION OF ALCOHOL INTAKE
• REGULAR PHYSICAL ACTIVITY
• REDUCTION OF SODIUM INTAKE

• SMOKING CESSATION
STEP 2
CONTINUE LIFESTYLE MODIFICATIONS AND BEGIN DRUG REGIME,
INCLUDING:
• BETA ADRENERGIC BLOCKER OR DIURETIC (INITIALLY)
• ANGIOTENSIN CONVERTING ENZYME INHIBITOR, CALCIUM
ANTAGONIST, AN ALPHA RECEPTOR, ADRENERGIC ANTAGONIST, OR A
MIXED ALPHA- AND BETA-ADRENERGIC ANTAGONIST (IF INITIAL
REGIMEN IS INEFFECTIVE).
STEP 3
INCREASE DRUG DOSAGE, SUBSTITUTE ANOTHER DRUG IN THE SAME
CLASS, OR ADD A SECOND ANTIHYPERTENSIVE FROM A DIFFERENT
CLASS.
STEP 4
ADD A SECOND OR THIRD HYPERTENSIVE OR A DIURETIC IF NOT
ALREADY PRESCRIBED. THESE AGENTS MAY INCLUDE DIRECT-ACING
VASODILATORS, ALPHA RECEPTOR ANTAGONISTS, AND PEROPHERA;;Y
ACTTING ADRENERGIC NEURON ANTAGONISTS.
DIAGNOSTIC TEST
DIAGNOSTIC EVALUATION ARE:

• ELEVATED BLOOD CHEMISTRY (BUN, CREATININE AND
CHOLESTEROL LEVELS)
• BLOOD PRESSURE MEASUREMENTS RESULT IN SUSTAINED
READINGS HIGHER THAN 140/90 MMHG.
• CHEST X-RAY REVEALS CARDIOMEGALY.
• ECG SHOWS LEFT VENTRICULAR HYPERTROPHY.
• ECHOCARDIOGRAM SHOWS LEFT VENTRICULAR HYPERTROPHY.
• OPTHALMIC EXAMINATION SHOWS RETINAL CHANGES SUCH AS
ARTERIOLAR NARROWING, PAPILLEDEMA, AND HEMORRHAGE.
• URINALYSIS DISCLOSES PROTEINURIA, RED BLOOD CELL RBC’S /
WBC’S.
V: DRUG STUDY (INCLUDE GENERIC NAME, ACTIONS, SE, AND

CONTRAINDICATION
ASSESSMENT DIAGNOSIS PLANNING INTERVENTI RATIONALE EVALUATION
ON
SUBJECTIVE: DECREASE STG: 1.MONITOR 1. CHANGES STG:

“MADALAS AKO D CARDIAC AFTER 6 BP EVERY 1- IN BP MAY AFTER 6 HRS OF
MAHILO”, AS OUTPUT R/T HRS OF 2 HOURS, OR INDICATES NURSING
VERBALIZED BY MALIGNAN NURSING EVERY 5 CHANGES IN INTERVENTIONS,
THE PATIENT. T INTERVENT MINUTES PATIENT THE CLIENT HAD
HYPERTENS IONS, THE DURING STATUS NO ELEVATION IN
ION AS CLIENT ACTVE REQUIRING BLOOD PRESSURE
OBJECTIVE: MANIFESTE WILL HAVE TITRATION PROMPT ABOVE NORMAL
>LETHARGIC D BY NO OF ATTENTION. LIMITS AND WILL
>DECREASED DECREASE ELEVATION VASOACTIV 2. DECREASE MAINTAIN BLOOD
CARDIAC OUTPUT D STROKE IN BLOOD E DRUGS. IN CARDIAC PRESSURE WITHIN
>DECREASED VOLUME. PRESSURE 2. MONITOR OUTPUT ACCEPTABLE
STROKE VOLUME ABOVE ECG FOR MAY LIMITS.

>INCREASED NORMAL DYSRRHYTH RESULT IN GOAL WAS MET.
PERIPHERAL LIMITS AND MIAS, CHANGES IN
VASCULAR WILL CONDUCTIO CARDIAC LTG:
RESISTANCE MAINTAIN N DEFECTS PERFUSION AFTER 5 DAYS OF
>VS TAKEN AS BLOOD AND FOR CAUSING NURSING
FOLLOWS: PRESSURE HEART DYSRHYTH INTERVENTIONS,
T: 37.2 WITHIN RATE. MIAS. THE CLIENT
PR: 83 ACCEPTABL 3. IT MAY MAINTAINED AN
RR: 18 E LIMITS. DECREASES ADEQUATE
BP: 180/100 3. SUGGEST PERIPHERAL CARDIAC OUTPUT
LTG: FREQUENT VENOUS AND CARDIAC
AFTER 5 POSITION POOLING INDEX.
DAYS OF CHANGES. THAT MAY GOAL WAS MET.
NURSING BE
INTERVENT POTENTIATE
IONS, THE D BY
CLIENT VASODILAT
WILL ORS AND
MAINTAIN 4.ENCOURA PROLONGED
ADEQUATE GE PATIENT SITTING OR
CARDIAC TO STANDING.
OUTPUT DECREASE 4. CAFFEINE
AND INTAKE OF IS A
CARDIAC CAFFEINE, CARDIAC
INDEX. COLA AND STIMULANT
CHOCOLATE AND MAY
S. ADVERSELY
AFFECT
5. OBSERVE CARDIAC
SKIN FUNCTION.
COLOR, 5.
TEMPERATU PERIPHERAL
RE, VASOCONST
CAPILLARY RICTION
REFILL TIME MAY
AND RESULT IN
DIAPHORESI PALE, COOL,
S. CLAMMY
SKIN, WITH
PROLONGED
CAPILLARY
REFILL TIME
DUE TO
CARDIAC
6.AUSCULTA DYSFUNCTI
TE HEART ON AND
TONES. DECREASED
CARDIAC
OUTPUT.
6.
7. HYPERTENSI
ADMINISTER VE
MEDICINES PATIENTS
AS OFTEN
PRESCRIBED HAVE S4
BY THE GALLOPS
PHYSICIAN. CAUSED BY
8. INSTRUCT ATRIAL
CLIENT & HYPERTROP
FAMILY ON HY.
FLUID AND 7. TO
DIET PROMOTE
REQUIREME WELLNESS.
NTS AND
RESTRICTIO
NS OF 8.
SODIUM. RESTRICTIO
NS CAN
9. INSTRUCT ASSIST WITH
CLIENT AND DECREASE
FAMILY ON IN FLUID
MEDICATIO RETENTION
NS, SIDE AND
EFFECTS, HYPERTENSI
CONTRAIND ON,
ICATIONS THEREBY
AND SIGNS IMPROVING
TO REPORT. CARDIAC
OUTPUT.
9.
PROMOTES
KNOWLEDG
E AND
COMPLIANC
E WITH
DRUG
REGIMEN.
ASSESSMEN DIAGNOSIS PLANNIN INTERVEN RATIONALE EVALUAT

T G TION ION
SUBJECTIVE: INEFFECTIV STG: 1. 1.TO STG:

“ LAGING E TISSUE AFTER 8 MONITOR MONITOR AFTER 8
SUMASAKIT PERFUSION: HRS OF VS AT BASELINE HRS OF
ANG AKING CARDIOPUL NURSING LEAST Q 1- DATA. NURSING
ULO AT MONARY, INTERVE 2 HRS AND INTERVE
PARANG GASTROINTE NTIONS, PRN.. 2. CAFFEINE NTIONS,
NANLALAB STINAL AND BLOOD 2. IS A BLOOD
O ANG PERIPHERAL PRESSUR ENCOURA CARDIAC PRESSURE
AKING R/T E WILL BE GE STIMULANT MAINTAI
PANINGIN”, HYPERTENSI WITHIN PATIENT AND MAY NED
AS ON AND SET TO ADVERSEL WITHIN
VERBALIZE DECREASED PARAMET DECREASE Y AFFECT SET
D BY THE CARDIAC ERS FOR INTAKE CARDIAC PARAMET
PATIENT. OUTPUT AS THE OF FUNCTION. ERS FOR

MANIFESTE CLIENT. CAFFEINE, 3. THESE THE
OBJECTIVE: D BY COLA AND FRUGS CLIENT.
 TACH BLURRED LTG: CHOCOLA HAVE GOAL
YCAR VISION AND AFTER 6 TES. RAPID WAS MET.
DIA INCREASED DAYS OF ACTION
 SHOR BLOOD NURSING .3. AND MAY LTG:
TNESS PRESSURE.. INTERVE ADMINIST DECREASE AFTER 6
OF NTIONS, ER THE BLOOD DAYS OF
BREA THE VASOACTI PRESSURE NURSING
TH CLIENT VE DRUGS TOO INTERVE
 >RALE WILL AND RAPIDLY, NTIONS,
S HAVE AN TITRATE RESULTING THE
 RESTL ADEQUAT AS IN CLIENT
ESSNE E TISSUE ORDERED COMPLICAT HAD AN
SS PERFUSIO TO IONS. ADEQUAT
 COOL, N TO HIS MAINTAIN E TISSUE
CLAM BODY PRESSURE 4. MAY PERFUSIO
MY SYSTEMS. S AT SET INDICATE N TO HIS
SKIN PARAMET CYANIDE BODY
 OPTIC ERS FOR TOXICITY SYSTEMS.
DISC PATIENT. FROM GOAL
PAPIL 4. INCREASIN WAS MET.
LEDE OBSERVE G
MA FOR INTRACRAN
 INCRE COMPLAIN IAL
ASED TS OF PRESSURE.
BLOO BLURRED 5. I&O WILL
D VISION, GIVE AN
PRESS TINNITUS INDICATION
URE. OR OF FLUIC
CONFUSIO BALANCE
N. OR
5. IMBALANC
MONITOR E, THUS
I&O ALLOWING
STATUS. FOR
CHANGES
IN
TREATMEN
T REGIMEN
WHEN
REQUIRED.
6. 6. MAY
MONITOR INDICATE
FOR DISSECTING
SUDDEN AORTIC
ONSET OF ANEURYSM.
CHEST
PAIN. 7.
DECREASED
7. PERFUSION
MONITOR MAY
ECG FOR RESULT IN
CHANGES DYSRHYTH
IN RATE, MIAS
RHYTHM, CAUSED BY
DYSRHYT DECREASE
HMIAS IN OXYGEN.
AND 8.BEDREST
CONDUCTI PROMOTES
ON VENOUS
DEFECTS. STATIS
8. WHICH CAN
OBSERVE INCREASE
EXTREMIT THE RISK
IES FOR OF
SWELLING THROMBOE
, MBOLUS
ERYTHEM FORMATIO
A, N. IF
TENDERN TREATMEN
ESS AND T IS TOO
PAIN. RAPID AND
OBSERVE AGGRESSIV
FOR E IN
DECREASE DECREASIN
D G THE
PERIPHER BLOOD
AL PRESSIRE,
PULSES, TISSUE
PALLOR, PERFUSION
COLDNESS WILL BE
AND IMPAIRED
CYANOSIS AND
. ISCHEMIA
CAN
RESULT.
9.
9. PROMOTES
INSTRUCT KNOWLEDG
CLIENT IN E AND
SIGNS/SY COMPLIANC
MPTOMS E WITH
TO TREATMEN
REPORT T.
TO PROMOTES
PHYSICIA PROMPT
N SUCH AS DETECTION
HEADACH AND
E UPON FACILITATE
RISING, S PROMPT
INCREASE INTERVENT
D BLOOD ION.
PRESSURE,
CHEST
PAIN,
SHORTNES
S OF
BREATH,
INCREASE
D HEART
RATE,
VISUAL
CHANGES,
EDEMA,
MUSCLE
CRAMPS
AND
NAUSEA
AND
VOMITING
.
V. NURSING IMPLICATIONS
A. NURSING PRACTICE
- MONITOR AND RECORD BP. MEASURE IN BOTH ARMS AND THIGHS

THREE TIMES, 3–5 MIN APART WHILE PATIENT IS AT REST, THEN
SITTING, THEN STANDING FOR INITIAL EVALUATION. USE CORRECT
CUFF SIZE AND ACCURATE TECHNIQUE.
B. NURSING EDUCATION
- NURSING CARE PLANNING GOALS FOR HYPERTENSION INCLUDES FOCUS

ON LOWERING OR CONTROLLING BLOOD PRESSURE, ADHERENCE TO THE
THERAPEUTIC REGIMEN, LIFESTYLE MODIFICATIONS, AND PREVENTION
OF COMPLICATIONS.
C. NURSING RESEARCH
- RESEARCH-BASED EVIDENCE MATERIAL PROVIDES AN EVIDENCE-BASED

NURSING PRACTICE GUIDELINE WITH SPECIFIC NURSING PROCESS
COMPONENTS ON THE TOPIC. THE EVIDENCE-BASED NURSING PRACTICE
GUIDELINE DEVELOPED FROM THIS REFERENTIAL STUDY FOR
PROMOTING HEALTH OF ADULTS WITH HYPERTENSION SHOULD BE
REFLECTED IN NURSING PRACTICE IN PRIMARY HEALTHCARE SETTINGS.
FOR A FUTURE STUDY, FOCUS GROUPS AND KEY INFORMANT INTERVIEW
ARE RECOMMENDED WITH NURSES WHO ACTUALLY PROVIDE NURSING
SERVICES IN PRIMARY HEALTHCARE SETTINGS TO CLIENTS WHO ARE
DIAGNOSED WITH HIGH BLOOD PRESSURE.
VIII. REFERRAL AND FOLLOW UP (IF ANY): NONE
DISCUSSED WITH STUDENT BY:
ERLINDA PAZ, RN,MAN
CLINICAL INSTRUCTOR
CERTIFIED BY: SUBMITTED BY:
MA. THERESA AGUILAN, RN, MAN DYANNE G. BAUTISTA BSN-IV
DEAN COLLEGE OF NURSING SIGNATURE OVER PRINTED NAME OF

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VIRGEN MILAGROSA UNIVERSITY FOUNDATION

Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

NAME OF STUDENT: BAUTISTA, DYANNE G.

ADMISSION DATE: MAY 6, 2021

ADMITTING PHYSICIAN: DR. DINGDONG DANTES

CHIEF COMPLAINT: SEVERE HEADACHE AND DIZZINESS

ADMITTING DIAGNOSIS: HYPERTENSION

II. DEVELOPMENTAL DATA

-TAKING MAINTENANCE MEDICINE FOR HYPERTENSION SUCH AS

- PATIENT D IS EXPERIENCING PERSISTENT ELEVATION OF SYSTOLIC OR

RESPIRATORY RATE: 18 B/P: 160/100

SKIN: VERY DRY

HEAD: NORMOCEPHALIC AND ATRAUMATIC

NOSE: MOIST MUCOUS MEMBRANE

MOUTH: MOIST MUCOUS MEMBRANES, MACROGLOSSIA

THROAT: PATENT AND MOIST

NECK: SUPPLE. NO JVD PRESENT. NO MASSES OR SURGICAL SCARRING.

CHEST: NO RESPIRATORY STATUS DISTRESS AT THIS TIME, TACHYPNEA

LUNGS: HEART RATE 74 BPM, RESPIRATORY RATE 24, O2 SATURATION 90% ON

ABDOMEN: SOFT. OBESE. BOWEL SOUNDS ARE NORMAL. NO DISTENSION AND

SKIN: VERY DRY

GENITO-URINARY SYSTEM: N/A

NEUROLOGIC: ALERT, AWAKE, ABLE TO PROTECT HER AIRWAY. MOVING ALL

IV. MEDICAL TREATMENT AND MANAGEMENT INCLUDING DIAGNOSTIC

TREATMENT IS SUGGESTED TO HAVE A REGULAR EXERCISE TO

• REDUCTION OF SODIUM INTAKE

DIAGNOSTIC EVALUATION ARE:

V: DRUG STUDY (INCLUDE GENERIC NAME, ACTIONS, SE, AND

SUBJECTIVE: DECREASE STG: 1.MONITOR 1. CHANGES STG:

STROKE VOLUME ABOVE ECG FOR MAY LIMITS.

ASSESSMEN DIAGNOSIS PLANNIN INTERVEN RATIONALE EVALUAT

SUBJECTIVE: INEFFECTIV STG: 1. 1.TO STG:

PATIENT. OUTPUT AS THE OF FUNCTION. ERS FOR

- MONITOR AND RECORD BP. MEASURE IN BOTH ARMS AND THIGHS

- NURSING CARE PLANNING GOALS FOR HYPERTENSION INCLUDES FOCUS

- RESEARCH-BASED EVIDENCE MATERIAL PROVIDES AN EVIDENCE-BASED

VIII. REFERRAL AND FOLLOW UP (IF ANY): NONE

DISCUSSED WITH STUDENT BY:

ERLINDA PAZ, RN,MAN

CERTIFIED BY: SUBMITTED BY:

MA. THERESA AGUILAN, RN, MAN DYANNE G. BAUTISTA BSN-IV

DEAN COLLEGE OF NURSING SIGNATURE OVER PRINTED NAME OF

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