Hypertensive Crisis - Case Study

Mrs. Phillips, a 43-year old African American female, presents to the Emergency Department (ED)
complaining of the worst headache of her life. She says it started about 3 hours ago. She reports
taking 1,000 mg of Acetaminophen with no relief. Upon further questioning, Mrs. Phillips also
reports blurry vision. She denies any past medical history.

1. What initial nursing assessments need to be performed for Mrs. Phillips?

Upon further assessment, Mrs. Phillips’ lungs are clear, pulses are 2+ bilaterally in radial and pedal
pulses, S1/S2 are present with no extra sounds. Her vital signs were as follows:
BP 216/108 mmHg Ht 162 cm
HR 92 bpm and regular Wt 107 kg
RR 20 bpm SpO2 96% on Room Air
Temp 36.9°C

2. What are your top concerns for Mrs. Phillips at this time? Why?

3. What medications do you anticipate the provider ordering for Mrs. Phillips?

The ED provider orders the following:

Blood - CBC, BMP, BNP. Diagnostics - CT head, CXR. Interventions - Insert 2 large bore IV’s. Nasal
Cannula to keep SpO2> 92%. Meds - Metoprolol 5mg IV push x 1 dose now. Hydralazine 10mg IV
push, PRN q1h for SBP >200. Morphine 2 mg PRN q4h for pain.

4. Which order would you implement first? Why?

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You initiate two large bore IV’s for Mrs. Phillips and send off blood work. You administer 5 mg
Metoprolol over slow IV push and attach Mrs. Philips to a bedside cardiac monitor. She is still
complaining of 7/10 pain in her head, so you also administer 2 mg Morphine IV push. You return
30 minutes later to take another set of vital signs and find the following:
BP 204/102 mmHg Pain 7/10
HR 86 bpm SpO2 94% on Room Air
RR 14 bpm

Mrs. Phillips’s lab results have also resulted, the following abnormal values were reported:
Glucose 193 mg/dL
Hgb A1c 9.2%
BNP 160 pg/mL

5. Based on previous orders you have received, what action(s) should you take at this time?
Why?

6. What modifiable risk factors have you identified that put Mrs. Phillips at risk for
hypertensive crisis?

Mrs. Phillips’ blood pressure after the Hydralazine 10mg IV push went up to 218/110 and her
heart rate went up to 104 bpm. She is transferred to the ICU to be started on a Nicardipine
infusion, which is initiated at 2.5 mg/hr to keep her SBP between 180-200 mmHg.

7. Why don’t the providers want her SBP going below 180 mmHg at this time?

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Shortly after arriving in the ICU, Mrs. Phillips is no longer able to speak, the right side of her face is
drooping, and she cannot lift her right arm. You check another set of vital signs to find her BP is
208/112 mmHg, HR 110, SpO2 92%.

8. What, physiologically, is going on with Mrs. Phillips at this time?

Mrs. Phillips is taken to the OR to evacuate a large subarachnoid hematoma from around her
brain. You inform her family that she has had a hemorrhagic stroke because of her high blood
pressure. After 2 days in the ICU, she has recovered all movement in her arms, her speech and
facial symmetry are normal, and she has been transitioned from IV nicardipine to PO metoprolol,
amlodipine, and hydrochlorothiazide. She is tolerating these medications well and has been
ambulating to the bathroom easily needed. Her blood pressure is now averaging 140-150 systolic.
She tells you she had no idea that she had high blood pressure, she’s never been sick or even felt
bad until she got the headache. She reports not getting yearly check-ups because she “felt fine”.
She will be discharged on the same medications tomorrow.

9. What education topics would you want to provide to the patient before discharge?

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ANSWERS:

1. What initial nursing assessments need to be performed for Mrs. Phillips?

a. Full Pain assessment (PQRST or OLDCARTS)
b. Full set of Vital signs
i. Ensure proper fitting blood pressure cuff
c. Heart sounds, lung sounds
d. Peripheral perfusion (pulses, cap refill)
e. Pupillary assessment
2. What are your top concerns for Mrs. Phillips at this time? Why?
a. Her blood pressure is extremely high. This combined with the headache and vision
problems indicate she may be experiencing hypertensive crisis
3. What medications do you anticipate the provider ordering for Mrs. Phillips?
a. Beta blocker like Metoprolol to decrease contractility and blood pressure
b. Calcium channel blocker like Nicardipine to decrease contractility and BP
c. Possibly a vasodilator like Hydralazine to decrease afterload
d. Would NOT expect a diuretic because her lungs are clear and she is oxygenating
well - there’s no sign of volume overload
4. Which order should you implement first? Why?
a. The first intervention should be to insert two large bore IV’s. This will allow for
drawing of labs and administration of the Metoprolol IV. The top priority is to get
the blood pressure down using the scheduled dose of Metoprolol, but that can’t
happen until the patient has IV access.
b. You would not yet administer Hydralazine as there is a scheduled dose that should
be attempted first - you wouldn’t want to give multiple antihypertensives at the
same time without knowing how the patient will respond. It could bottom out their
blood pressure.
5. Based on previous orders you have received, what action(s) should you take at this time?
Why?
a. Administer 10 mg Hydralazine IV push (ordered PRN for SBP>200)
b. Recheck blood pressure in 30 minutes
c. Notify provider of blood pressure not responsive to medications
6. What risk factors have you identified that put Mrs. Phillips at risk for hypertensive
crisis?
a. Based on her weight, this patient is obese
b. Based on her A1c, this patient is a diabetic
c. She is an African American female which also puts her at higher risk
7. Why don’t the providers want her SBP going below 180 mmHg at this time?
a. Dropping the blood pressure too low too fast can cause perfusion issues. The
organs are used to perfusing at a higher blood pressure. This phenomenon is called
relative hypotension. The patient can experience signs of hypotension even with a
numerically high blood pressure because their body is used to the high pressures.

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 b. The goal is to decrease the blood pressure by max 20% for the first 6-12 hours,
then to aim for a SBP of 160 mmHg with IV or short-acting PO antihypertensives,
then to transition to long-acting PO meds to target a SBP < 140.
8. What, physiologically, is going on with Mrs. Phillips at this time?
a. Mrs. Phillips is in hypertensive crisis. Because her blood pressure is extremely
high, it has caused a bleed within the vessels of her brain - leading to a hemorrhagic
stroke.
9. What education topics would you want to provide to the patient before discharge?
a. Diet & Lifestyle changes - she needs to be on a low-sodium diet and needs to lose
weight. She should also cut caffeine and try to decrease stress.
b. Medication management - Mrs. Phillips should be taught how to prevent
orthostatic hypotension by rising slowly, and what symptoms to report to her
provider. Also, make sure she knows the schedule for taking her meds so that she
doesn’t take them all at the same time and experience hypotension.
c. Follow-Up - she needs to see a healthcare provider regularly and should probably
start checking her blood pressure at home or at a local pharmacy. Because
hypertension can be asymptomatic, it’s important that she continues to take her
medication and monitor her blood pressure even after she feels better. She will
also likely need to follow up with a neurologist because of her stroke.

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