VIRGEN MILAGROSA UNIVERSITY FOUNDATION

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

Case Study

Name Of Student: Jeezrel Parubrub

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:
 VIRGEN MILAGROSA UNIVERSITY FOUNDATION
Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

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

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

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).
 VIRGEN MILAGROSA UNIVERSITY FOUNDATION
Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

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.
 VIRGEN MILAGROSA UNIVERSITY FOUNDATION
Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

• 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 Intervention Rationale Evaluation

Subjective: Decreased Stg: 1.Monitor Bp 1. Changes In Stg:

“Madalas Ako Mahilo”, Cardiac After 6 Hrs Every 1-2 Bp May After 6 Hrs Of
As Verbalized By The Output R/T Of Nursing Hours, Or Indicates Nursing
Patient. Malignant Interventions, Every 5 Changes In Interventions, The
Hypertension The Client Minutes Patient Status Client Had No
As Will Have No During Actve Requiring Elevation In Blood
Objective: Manifested Elevation In Titration Of Prompt Pressure Above
>Lethargic By Decreased Blood Vasoactive Attention. Normal Limits And
>Decreased Cardiac Stroke Pressure Drugs. 2. Decrease In Will Maintain Blood
Output Volume. Above 2. Monitor Ecg Cardiac Output Pressure Within
>Decreased Stroke Normal For May Result In Acceptable Limits.
Volume Limits And Dysrrhythmias, Changes In Goal Was Met.
>Increased Peripheral Will Maintain Conduction Cardiac
Vascular Resistance Blood Defects And Perfusion Ltg:
>Vs Taken As Follows: Pressure For Heart Rate. Causing After 5 Days Of
T: 37.2 Within Dysrhythmias. Nursing
Pr: 83 Acceptable 3. It May Interventions, The
Rr: 18 Limits. 3. Suggest Decreases Client Maintained An
Bp: 180/100 Frequent Peripheral Adequate Cardiac
Ltg: Position Venous Output And Cardiac
After 5 Days Changes. Pooling That Index.
Of Nursing May Be Goal Was Met.
Interventions, Potentiated By
The Client Vasodilators
Will Maintain And Prolonged
Adequate Sitting Or
Cardiac 4.Encourage Standing.
Output And Patient To 4. Caffeine Is
Cardiac Decrease A Cardiac
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Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

Index. Intake Of Stimulant And

Caffeine, Cola May Adversely
And Affect Cardiac
Chocolates. Function.
5. Peripheral
5. Observe Vasoconstricti
Skin Color, on May Result
Temperature, In Pale, Cool,
Capillary Clammy Skin,
Refill Time With
And Prolonged
Diaphoresis. Capillary
Refill Time
Due To
Cardiac
Dysfunction
And Decreased
Cardiac
6.Auscultate Output.
Heart Tones. 6.
Hypertensive
Patients Often
Have S4
7. Administer Gallops
Medicines As Caused By
Prescribed By Atrial
The Physician. Hypertrophy.
8. Instruct 7. To Promote
Client & Wellness.
Family On
Fluid And Diet
Requirements 8. Restrictions
And Can Assist
Restrictions Of With Decrease
Sodium. In Fluid
Retention And
 VIRGEN MILAGROSA UNIVERSITY FOUNDATION
Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

9. Instruct Hypertension,
Client And Thereby
Family On Improving
Medications, Cardiac
Side Effects, Output.
Contraindicatio 9. Promotes
ns And Signs Knowledge
To Report. And
Compliance
With Drug
Regimen.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective Stg: 1. Monitor Vs 1.To Monitor Stg:

“ Laging Tissue After 8 Hrs At Least Q 1- Baseline Data. After 8 Hrs
Sumasakit Ang Perfusion: Of Nursing 2 Hrs And Of Nursing
Aking Ulo At Cardiopulmon Interventio Prn.. 2. Caffeine Is Interventio
Parang ary, ns, Blood 2. Encourage A Cardiac ns, Blood
Nanlalabo Ang Gastrointestina Pressure Patient To Stimulant And Pressure
Aking l And Will Be Decrease May Maintained
Paningin”, As Peripheral R/T Within Set Intake Of Adversely Within Set
Verbalized By Hypertension Parameters Caffeine, Affect Cardiac Parameters
The Patient. And For The Cola And Function. For The
Decreased Client. Chocolates. 3. These Frugs Client.
Objective: Cardiac Have Rapid Goal Was
 Tachyca Output As Ltg: .3. Action And Met.
rdia Manifested By After 6 Administer May Decrease
 Shortnes Blurred Vision Days Of Vasoactive The Blood Ltg:
s Of And Increased Nursing Drugs And Pressure Too After 6
Breath Blood Interventio Titrate As Rapidly, Days Of
 >Rales Pressure.. ns, The Ordered To Resulting In Nursing
 Restless Client Will Maintain Complications Interventio
 VIRGEN MILAGROSA UNIVERSITY FOUNDATION
Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

ness Have An Pressures At . ns, The

 Cool, Adequate Set Client Had
Clammy Tissue Parameters 4. May An
Skin Perfusion For Patient. Indicate Adequate
 Optic To His 4. Observe Cyanide Tissue
Disc Body For Toxicity From Perfusion
Papilled Systems. Complaints Increasing To His
ema Of Blurred Intracranial Body
 Increase Vision, Pressure. Systems.
d Blood Tinnitus Or 5. I&O Will Goal Was
Pressure. Confusion. Give An Met.
5. Monitor Indication Of
I&O Status. Fluic Balance
Or Imbalance,
Thus
Allowing For
Changes In
Treatment
Regimen
When
Required.
6. Monitor
For Sudden
Onset Of 6. May
Chest Pain. Indicate
Dissecting
7. Monitor Aortic
Ecg For Aneurysm.
Changes In
Rate, 7. Decreased
Rhythm, Perfusion May
Dysrhythmias Result In
And Dysrhythmias
Conduction Caused By
Defects. Decrease In
8. Observe Oxygen.
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Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

Extremities 8.Bedrest
For Swelling, Promotes
Erythema, Venous Statis
Tenderness Which Can
And Pain. Increase The
Observe For Risk Of
Decreased Thromboemb
Peripheral olus
Pulses, Formation. If
Pallor, Treatment Is
Coldness And Too Rapid
Cyanosis. And
Aggressive In
Decreasing
The Blood
9. Instruct Pressire,
Client In Tissue
Signs/Sympto Perfusion Will
ms To Report Be Impaired
To Physician And Ischemia
Such As Can Result.
Headache 9. Promotes
Upon Rising, Knowledge
Increased And
Blood Compliance
Pressure, With
Chest Pain, Treatment.
Shortness Of Promotes
Breath, Prompt
Increased Detection And
Heart Rate, Facilitates
Visual Prompt
Changes, Intervention.
Edema,
Muscle
Cramps And
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Martin P. Posadas Avenue San Carlos City, Pangasinan, Philippines, 2420

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

Viii. Referral And Follow Up (If Any): None

Discussed With Student By: Certified By:

Erlinda Paz, Rn,Man Ma. Theresa Aguilan, Rn, Man

Clinical Instructor Dean College Of Nursing

Submitted By:

Jeezrel Parubrub Bsn-Iv

Signature Over Printed Name Of Student