INTRODUCTION HYPERTENSION Hypertension (HTN) or high blood pressure is common disorder that is a known cardiovascular disease risk factor,

characterized by elevated blood pressure over the normal values of 120/80 mm Hg in an adult over 18 years of age. This elevation in blood pressure can be divided into three classes of hypertension. Prehypertension describes blood pressure measurements of greater than 120 mm Hg systolic or 80 mm Hg diastolic and less than 130 mm Hg systolic or 90 mm Hg diastolic. Persons exhibiting prehypertension are encouraged to explore life-style modifications to lower blood pressure, but blood-pressure lowering agents are not generally prescribed without compelling indications. The second classification of hypertension is Stage 1 hypertension and is defined by a blood pressure of over 130 mm Hg systolic or 90 mm Hg diastolic but less than 160 mm Hg systolic or 100 mm Hg diastolic. Patients with Stage 1 hypertension are also encouraged to make life-style modifications, and initial drug therapy may include thiazide-type diuretics, ACE inhibitors, calcium channel blockers, beta blockers, and angiotensin-receptor blockers, or a combination of these. Stage 2 hypertension is defined by a blood pressure greater than 160 mm Hg systolic or 100 mm Hg diastolic. Persons with Stage 2 hypertension are encouraged to make life-style modifications. Two-drug combination therapies (of thiazide-type diuretics, ACE inhibitors, calcium channel blockers, beta blockers, and angiotensin-receptor blockers) are indicated for these patients. Essential hypertension, the most common kind, has no single identifiable cause, but risk for the disorder is increased by obesity, a high serum sodium level, hypercholesterolemia, and a family history of high blood pressure. Known causes of secondary hypertension include sleep apnea, chronic kidney disease, primary aldosteronism, renovascular disease, chronic steroid therapy, Cushing's

syndrome, pheochromocytoma, coarctation of the aorta, and thyroid or parathyroid disease. The incidence of hypertension is higher in men than in women and is twice as great in African-Americans as in Caucasians. People with mild or moderate hypertension may be asymptomatic or may experience suboccipital headaches, especially on rising; tinnitus; lightheadedness; ready fatigability; and palpitations. With sustained hypertension, arterial walls become thickened, inelastic, and resistant to blood flow, and the left ventricle becomes distended and hypertrophied as a result of its efforts to maintain normal circulation against the increased resistance. Inadequate blood supply to the coronary arteries may cause angina or myocardial infarction. Left ventricular hypertrophy may lead to congestive heart failure. Malignant hypertension, characterized by a diastolic pressure higher than 120 mm Hg, severe headaches, blurred vision, and confusion, may result in fatal uremia, myocardial infarction, congestive heart failure, or a cerebrovascular insult. Patients with high blood pressure are advised to follow a low-sodium, low-saturated-fat diet; to control obesity by reducing caloric intake; to exercise; to avoid stress; and to have adequate rest.

PATIENTS PROFILE

NAME: BIRTHDAY: AGE: SEX: ADDRESS: RELIGION: NATIONALITY: DATE OF ADMISSION: ATTENDING PHYSICIAN: CHIEF COMPLAINT:

Medina, Crisanta Gamboa March 25,1948 63 years old Female Brgy. Marawoy, Lipa, City Roman Catholic Filipino February 26, 2012 Dra. Ma. Lovely M. Cacho chest pain, dizziness

HEALTH HISTORY Present Health History The present health history started 3 days prior to confinement at Metro Lipa Medical Center when the patient, experienced general body weakness, chest pain, and dizziness. She was admitted under the service of Dra. Ma. Lovely M. Cacho and stayed at the said hospital for 2 days and was treated as a case of hypertension stage II. Her physician ordered her to have some laboratory examinations like Serum Test, Troponin Test, electrolytes, urinalysis, CBC and ECG. She was given Betahistine, Losartan, Clopidogrel, Finofibrate, Vastarel, Allopurinol, Vytorin, Corolan, NTG Patch, Omeprazole and Celebrex as her medication. Vital Signs upon admission are as follows: T = 36.2 PR = 120 bpm BP = 170/100 mmHg RR = 20 cpm

Past Health History Prior to her hospitalization, she denies in having any record or medical history of being admitted due to trauma, accident and disease. She also denies having allergies to food and drugs.

Family Health History The patient has family health history of hypertension on her mothers side.

LABORATORY EXAMINATIONS January 26, 2012 SERUM TEST NORMAL VALUE RESULT Cholesterol 6.6mmol/L 0.0- 5.2mmol/L INTERPRETATION High cholesterol accelerates the progression of atherosclerosis of certain arteries that is thought to contribute significantly to hypertension. High triglyceride levels can increase your risk of arteriosclerosis that reduces the space available for blood flow, which can cause high blood pressure. Hyperuricemia has now been found to be an independent risk factor for hypertension.

Triglycerides

2.79 mmol/L

0.0- 1.69 mmol/L

Uric Acid

408 umol/L

149- 369 umol/L

ALT

4.42 mmol/L

3.59- 3.88 mmol/L

January 26, 2012 TROPONIN TEST (-) Negative

January 26, 2012 CBC RESULT Segmenters 0. 36 % NORMAL VALUE INTERPRETATION Elevation of segmenters may indicate presence of infection; means that many band (immature) cells are present as the body fights infection. A low lymphocyte count indicates that the body's resistance to fight infection has been substantially lost and one may become more susceptible to certain types of infection.

Lymphocyte

0. 55 %

Monocyte

0. 09 %

January 26, 2012 Urinalysis DONE. Result not secured. ECG DONE. Result not secured.

ANATOMY AND PHYSIOLOGY CENTRAL NERVOUS SYSTEM

Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter.

Hypothalamus; controls and integrates activities of the autonomic nervous system and pituitary gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body temperature and regulates eating and drinking behavior. Helps maintain the waking state and establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone.

CARDIOVASCULAR SYSTEM

Baroreceptors, pressure-sensitive sensory receptors, are located in the aorta, internal carotid arteries, and other large arteries in the neck and chest. They send impulses to the cardiovascular center in the medulla oblongata to help regulate blood pressure. The two most important baroreceptor reflexes are the carotid sinus reflex and the aortic reflex. Chemoreceptor, sensory receptors that monitor the chemical composition of blood, are located close to the baroreceptors of the carotid sinus and the arch of the aorta in small structures called carotid bodies and aortic bodies, respectively. These chemoreceptor detect changes in blood level of O2, CO2, and H+. Heart. The main functions of the heart can be summarized as follows: The righthand side of the heart receives de-oxygenated blood from the body tissues (from the upper- and lower-body via the Superior Vena Cava and the Inferior Vena Cava, respectively) into the right atrium. This de-oxygenated blood passes through the tricuspid valve into the right ventricle. This blood is then pumped under higher pressure from the right ventricle to the lungs via the pulmonary

artery The left-hand side of the heart receives oxygenated blood from the lungs (via the pulmonary veins) into the left atrium. This oxygenated blood then passes through the bicuspid valve into the left ventricle. It is then pumped to the aorta under greater pressure (as explained below). This higher pressure ensures that the oxygenated blood leaving the heart via the aorta is effectively delivered to other parts of the body via the vascular system of blood vessels (incl. arteries, arterioles, and capillaries). Blood. Our blood carries oxygen to cells. It carries waste (carbon dioxide, Urea and lactic acid - via diffusion) away from cells and carries various diseasefighting cells such as the "white" blood cells. It is part of the body's self-repair mechanism (blood clotting after an open wound in order to stop bleeding - using 'Platelets') and regulates our body PH. It also regulates our core body temperature. Blood vessels. The point of blood vessels is to carry blood throughout the body. Arteries and veins are the largest of the blood vessels. Arteries move blood, which contains oxygen and nutrients to muscles and organs and veins carry the blood back to the heart.

RENAL SYSTEM

Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by the kidneys. The water reabsorption increases total blood volume, which increases blood pressure. Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior pituitary in response to dehydration or decreased blood volume. Among other actions, ADH causes vasoconstriction, which increases blood pressure.

Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood pressure by causing vasodilation and by promoting the loss of salt and water in the urine, which reduces blood volume.

PATHOPHYSIOLOGY OF HYPERTENSION Family History Age High Salt Intake Stress RISK FACTOR Obesity Excess Alcohol Consumption Smoking Low Potassium Intake

Changes in Arteriolar Bed Systemic Vascular Resistance Afterload

Blood Flow to Organ

Blood Pressure

Juxtaglomerular cells

Renin Angiotensin (Renin substrate) Angiotensin- Converting Enzyme (ACE) Angiotensin I (Renin substrate) Angiotensin II

Aldosterone

Vasoconstriction

Na+ Reabsorption

TPR

Blood Volume

Pressure towards normal

Blood pressure is generated by cardiac contraction against the vascular resistance. Having one or more of the risk factors of hypertension contributes in some changes in arteriolar bed which will then increase the systemic vascular resistance. As the systemic vascular resistance increase, the afterload also increases, therefore heart works harder. Afterload is inversely proportional to stroke volume. During a heartbeat, the heart muscle contracts. This causes the blood to be pumped out, which causes increased pressure in the arteries. There is a stronger than normal force of contraction since the filling pressures is greater and so the SV is greater. Starlings Law states that the greater the tension or stretch the greater the contraction. Therefore wall tension is chronically increased and this results in remodeling of the ventricular wall again but this time the CXR shape is elongated and off center. This thickness is also associated with an increase in radius to keep their ratio equal. The peripheral blood vessels will return their blood flow back to normal after a sudden increase within less than a minute. There is the metabolic theory that states when the art pressure becomes too great, there is an excess flow of oxygen and nutrients which causes the blood vessels to constrict and flow to return to normal and there is the myogenic theory that states the sudden stretch of small blood vessels cause the smooth muscle of the vessel wall to contract and this reduces the blood flow. Renin will then be released by the juxtoglomerular cells in afferent arterioles of the kidney in response to SNS stimulation. The receptors that mediate this are beta receptors on cells. Renin will then increase the production of angiotensin I which will lead to Angiotensin II which is a potent vasoconstrictor which then increases total peripheral resistance. Angiotensin II will also stimulate the release of aldosterone from the medulla which will increase sodium reabsorption so less Na leaves the body and more stays in which increase ECF volume. There is also progressive increase in TPR while at the same time the CO is decreased back to normal. (Changes almost certainly caused by the long-term blood flow autoregulation mechanism). CO has risen to high level and had initiated the hypertension, the excess blood flow through the tissues than caused progressive constriction of the local arterioles, thus returning the local blood flow and the CO almost back to normal, but simultaneously causing a secondary increase in TPR. The increased TPR occurs and will lead to increase pressure towards normal.

DRUG STUDY GENERIC NAME: Betahistine BRAND NAME: Serc DOSAGE AND ROUTE: 24mg tab PO CLASSIFICATION: ACTION: Antiemetic/Antivertigo Betahistine has a very strong affinity as an antagonist for histamine H3 receptors and a weak affinity as an agonist for histamine H1 receptors. Betahistine seems to dilate the blood vessels within the middle ear which can relieve pressure from excess fluid and act on the INDICATION: smooth muscle. Menieres disease, Meniere-like syndrome (with symptoms of vertigo, tinnitus and sensorineural deafness) and vertigo of peripheral origin. CONTRAINDICATION: Hypersensitivity to any component of the product. ADVERSE REACTION: Headache. Low level of gastric side effects. Nausea can be a side effect, but the patient is generally already experiencing nausea due to the vertigo so it goes largely unnoticed. NURSING CONSIDERATION: Decreased appetite, leading to weight loss Avoid contact of oral solution or injection with skin Raise bed rails, institute safety measures, supervise ambulation

GENERIC NAME: Losartan

BRAND NAME: Anzar DOSAGE AND ROUTE: 50mg tab PO CLASSIFICATION: ACTION: Angiotensin II Antagonists Angiotensin II receptor blocker/antihypertensive.

INDICATION:

Losartan is used in the management of hypertension and may have a role in patients who are unable to tolerate ACE inhibitors. It has also been tried in heart

failure and myocardial infarction. CONTRAINDICATION: Patients who are hypersensitive to any component of this product. Losartan also contraindicated in pregnancy and breastfeeding. If pregnancy is detected, losartan ADVERSE REACTION: should discontinued immediately. Adverse effects of losartan have been reported to be usually mild and transient, and include dizziness and dose related orthostatic hypotension. Hypotension may occur particularly in patient with volume depletion, (eg NURSING CONSIDERATION: those who have received high-dose diuretics). Observe for symptomatic hypotension and tachycardia especially in patients with CHF; hyponatremia, highdose diuretics, or severe volume depletion

GENERIC NAME: Clopidogrel BRAND NAME: Antiplar

DOSAGE AND ROUTE: 5mg tab PO CLASSIFICATION: ACTION: Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics) Clopidogrel is an inhibitor of platelet aggregation. A variety of drugs that inhibit platelet function have been shown to decrease morbid events in people with established cardiovascular atherosclerotic disease as evidenced by stroke or transient ischemic attacks, myocardial infarction, unstable angina or the need for INDICATION: vascular bypass or angioplasty. Prevention of atherosclerotic events in peripheral arterial disease or w/in 35 days of MI, or w/in 6 mth of ischemic stroke, or in acute coronary syndrome w/o STsegment elevation. CONTRAINDICATION: Patients w/ active pathological bleeding eg peptic ulcer ADVERSE REACTION: or intracranial hemorrhage. Headache, dizziness, pain, fatigue, flu-like symptoms, edema, HTN, abdominal pain, diarrhea, nausea, hemorrhage, arthralgia, back pain, upper resp infections, dyspnea, rhinitis, bronchitis, coughing, NURSING CONSIDERATION: purpura, epistaxis & skin rash. Provide small, frequent meals if GI upset occurs (not as common as with aspirin). Take daily as prescribed. May be taken with meals. Report skin rash, chest pain, fainting, severe headache, abnormal bleeding.

GENERIC NAME: Allopurinol BRAND NAME: Llanol DOSAGE AND ROUTE: 140mg tab PO

CLASSIFICATION: ACTION:

AntiGout Reduces uric acid production by inhibiting biochemical reactions preceding its formation.

INDICATION:

Primary uncomplicated hyperurecemia; mild gout; severe tophaceous gout; uric acid nephropathy; uric acid nephrolithiasis; and in the prevention of renal

Calcium oxalate stones. CONTRAINDICATION: Hypersensitivity. ADVERSE REACTION: NURSING CONSIDERATION: Allergic skin reactions, GI disturbances, diarrhea, and joint pains Monitor serum uric acid levels to evaluate drugs effectiveness Monitor fluid intake and output; daily urine output of at least 2 liters and maintenance of neutral or slightly alkaline urine are desirable If the patient is taking allopurinol for treatment of recurrent calcium oxalate stones, advise him to also reduce his dietary intake of animal protein, sodium, refined sugars, oxalate-rich foods, and calcium. Tell patient to discontinue at first sign of rash, which may precede severe hypersensitivity or other adverse reaction. Rash is more common in patient taking diuretics and in those with renal disorders. Tell the patient to report all adverse reactions. GENERIC NAME: Allopurinol BRAND NAME: Simvastatin DOSAGE AND ROUTE: 10mg tab PO

CLASSIFICATION: ACTION:

Dyslipidaemic Agents Simvastatin is a prodrug metabolised in the liver to form the active -hydroxyacid derivative. This inhibits the conversion of HMG-CoA to mevalonic acid by blocking HMG-CoA reductase, an early and rate-limiting step in cholesterol biosynthesis. It reduces total cholesterol, LDL-cholesterol and triglycerides and increases HDLcholesterol levels. Hyperlipidaemias, Prevention of cardiovascular events and Homozygous familial hypercholesterolaemia

INDICATION:

CONTRAINDICATION: Acute liver disease or unexplained persistent elevations of serum transaminases. Pregnancy, lactation. ADVERSE REACTION: Porphyria. Headache, nausea, flatulence, heartburn, abdominal pain, diarrhoea/constipation, dysgeusia; myopathy features like myalgia and muscle weakness; serum transaminases and CPK elevations; hypersensitivity; lens opacities; blurring of vision; dizziness; sexual dysfunction; insomnia; depression and upper respiratory NURSING CONSIDERATION: symptoms. Advise patients that blood and eye tests will be necessary throughout treatment. Blurred vision, severe gastrointestinal problems, dizziness or headaches must be reported.

REVIEW OF SYSTEMS Body Part Assessed Skin Technique Used Inspection Palpation HEENT Head Inspection Palpation Eyes Inspection Actual Finding Skin color is fair and even. Skin is smooth with fair skin turgor. Normocephalic Evenly distributed hair, no dandruff, lesions nor infection. Sinuses non-tender Symmetrical eyelids Pinkish conjunctiva Anicteric sclera Cornea and lens slightly cloudy PERRLA presence Nose Inspection Palpation PERRLA Normoset No discharge Non tender Normal Normal Normal Normal of new retinal hemorrhages, exudates, or papilledema Normal Normal Normal Signs of Aging Normal suggests a hypertensive urgency. Interpretation Normal Normal Normal Normal

Body Part Assessed HEENT

Technique Used

Actual Finding No presence of mass or nodules Symmetrical nasal folds Nasal septum at midline Mucosa is moist, pinkish, intact and no discharge Airways patent on both nares Non tender sinuses

Interpretation Normal Normal Normal Normal Normal Normal

Mouth, Pharynx and Neck

Mouth Inspection Lips pinkish and dry Tongue at midline Gums and mucosa pink Presence of dentures Pharynx Inspection Neck Inspection Uvula at midline Tonsils not inflamed Neck symmetrical with full ROM Normal Normal Normal Normal Normal Normal Aging (decalcification)

Body Part Assessed

Technique Used

Actual Finding

Interpretation

Palpation

Trachea at midline Lymph nodes non tender

Normal Normal Normal Normal Normal Normal Normal Normal Normal presence of heart failure Normal Due to cardiac compensation Normal Normal Normal

Pulmonary

Inspection Palpation Percussion Auscultation

Thyroid gland non palpable Symmetric AP:L ratio = 1:2 Symmetrical lung expansion Symmetrical tactile fremitus Resonant Clear lung sounds No adventitious breath sounds

Cardiovascular

Inspection Auscultation

Jugular venous distension, Peripheral edema Apical pulse at 5thICS MCL

Presence of palpitation
Abdomen Inspection Auscultation Flat and symmetrical No lesions Normoactive burbogorhythmic sounds (26 on 4 quadrants in 1 full min)

Body Part Assessed

Technique Used
Percussion

Actual Finding Tympanic over LLQ Dull at RUQ, LUQ and

RLQ

Interpretation
Normal

Palpation Extremities Inspection

No tenderness Skin smooth Skin intact Nails convex curved

Normal Normal Normal Normal Normal <3 sec. Decreased perfusion Cardiac compensation Aging process Normal Normal Normal Normal

Palpation

Pink nail beds Normal capillary refill Skin cool to touch Bounding pulses Muscles with slight atrophy Fair muscle strength

Motor Sensory

Inspection

Full active ROM 100% intact 12 cranial nerves responsive

NURSING CARE PLAN ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S> Nanghihina ako at Activity Intolerance madaling mapagod kaya related to disease maghapoh lang akong process as manifested nakahiga, as verbalized by generalized body by the client. O> Generalized weakness Extreme stress Lethargic Decreased stroke volume Increased peripheral vascular resistance VS taken as follows: T: 37.2 RR: 18 PR: 83 BP: 180/100 weakness.

After a shift of nursing interventions, the patient will be able to report/demonstrate an increase in activity tolerance as evidenced by increased movement and increased participation to activities.

Monitor the patients condition. Note clients report of weakness, fatigue, difficulty accomplishing tasks, and/or insomnia. Assist client to adjust activities to prevent over exertion. Increase exercise/ activity level gradually. Provide patient adequate rest periods to conserve energy. Promote comfort measures to alleviate pain if any and alleviation of pain leads to increase activity tolerance Provide an

Goal met: After a shift of nursing interventions, the patient was able to report/demonstrate an increase in activity tolerance as evidenced by increased movement and increased participation to activities.

environment conducive for rest Instruct client to increase oral fluid intake Instruct client to have proper hygiene Advise client to eat nutritious foods Administer medication as per doctors order: Serc 24mg PO Ansar 50mg tab PO Antiplar 75mg tabPO Llanol 140mg tab PO Simvastatin 10mgPO Encourage client to maintain a positive attitude Encourage participation in recreation, social activities, and hobbies appropriate for situation.

NURSING CARE PLAN ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S> Laging sumasakit ang aking ulo at parang nanlalabo ang aking paningin, as verbalized by the patient. O> Extreme stress Lethargic Restlessness Cool, clammy skin Optic disc papilledema Increased blood pressure Decreased stroke vol. Increased peripheral vascular resistance VS taken as follows: PR: 83 T: 37.2

Ineffective Tissue Perfusion: related disease process as manifested by blurred vision and increased blood pressure.

STG: After 8 hrs of nursing interventions, blood pressure will be within set parameters for the client LTG: After 6 days of nursing interventions, the client will have an adequate tissue perfusion to his body systems.

Monitor VS at least q 1-2 hrs Encourage patient to decrease intake of caffeine, cola and chocolates. Administer vasoactive drugs and titrate as ordered to maintain pressures at set parameters for patient. Observe for complaints of blurred vision, tinnitus or confusion. Monitor I&O status Monitor for sudden onset of chest pain. Monitor ECG for

STG: After 8 hrs of nursing interventions, blood pressure maintained within set parameters for the client. Goal was met. LTG: After 6 days of nursing interventions, the client had an adequate tissue perfusion to his body systems. Goal was met.

RR: 18

BP: 180/100

changes in rate, rhythm, dysrhythmias and conduction defects. Observe extremities for swelling, erythema, tenderness and pain. Observe for decreased peripheral pulses, pallor, coldness and cyanosis. Instruct client in signs/symptoms to report to physician such as headache upon rising, increased blood pressure, chest pain, shortness of breath, increased heart rate, visual changes, edema, muscle cramps and nausea and vomiting.