NUR 102 Hypertension

NUR 102 Hypertension Case Study- McKenzie Goodman Hypertension Assessment: George’s blood pressure is 189/110. His LDL Cholesterol is 200 mg/dL. He asks the student nurse if his blood pressure is something he should be concerned about 1. How should the student respond? A. Your blood pressure is very high. You need to see your healthcare provider today. B. You have hypertension. You need to start making some lifestyle changes. C. Please sit quietly for a few minutes. I need to recheck your blood pressure. D. I need you to remain seated. I am going to call for the emergency squad. *I chose C because you always want to recheck the BP if it’s running high, and it could’ve also been elevated to George being stressed or some recent physical activity. The student nurse asks George about his health history. George is 6 feet tall (182.88cm) and his weight is 190 pounds (86.18 kgs). George states that he has lost a lot of weight recently. He also reports feeling a lot of stress at work and that he often goes out with the crew after work to have several beers. He reports that his mother who had Diabetes Mellitus passed away recently which has also contributed to his emotional health. He believes his mom also had hypertension. George smokes a pack of cigarettes a day and drinks 4 to 5 cups of coffee a day too. 2. What significant risk factors for hypertension does the nursing student identify for George according to his reported health history? SELECT ALL THAT APPLY A. Family history of Diabetes B. Alcohol Consumption C. Smoking D. Stress E. Caffeine consumption *I chose alcohol consumption, smoking, and stress because these are all risk factors for hypertension. A family history of diabetes isn’t important in this scenario, and caffeine is not a risk factor for hypertension. The student retakes George’s blood pressure now that George has been sitting quietly for a few minutes. His blood pressure is 180/106 mmHg. 3. According to the assessment of this client, which recommendation is most important for the student nurse to provide George? A. See your Healthcare Provider as soon as possible within the next week for a blood pressure check. B. Limit his salt intake and start a weight loss program. C. Attend a stress reduction seminar offered in his community. D. Learn about high fiber foods and add more fiber to his diet. *I chose to have his BP rechecked because the previous two were taken in the same day, and taking another BP in a few days would be a better and accurate indicator of George having hypertension. The student nurse continues to talk to George about his blood pressure results. He states that he feels great physically and does not see why he needs to see his Doctor. 4. Which is the best response the student nurse can give to George about the urgent need to see a Healthcare Provider (HCP)? A. Your blood pressure is dangerously elevated. You could have a heart attack or stroke at any time. B. While often there are no symptoms, high blood pressure can damage many organs. C. Hypertension is called the silent killer. I am sure you do not want to die at your young age. D. It is always better to treat high blood pressure before you start having symptoms. *Hypertension could cause major organ damage to an individual, before they start to experience symptoms, so it is important for us to diagnose asap. A week later, George has an appointment with his HCP. After the exam the HCP explains to George that he has stage 2, primary, (essential) hypertension. 5. Which information obtained during the assessment supports this diagnosis? A. Blood Pressure of 184/98 mmHg B. Family history of Hypertension C. Irregular pulse rate of 110 beats/min. D. A auscultated heart murmur *Stage 2 hypertension is classified as a systolic reading of 140 or higher, and a diastolic reading of 90 or higher, so Georges reading helps us further understand that he has stage 2 hypertension. The HCP informs George that he needs to be on a low salt diet, stop smoking, limit his alcohol intake, decrease his stress level, and start taking Chlorothiazide (Diuril) and Atenolol (Tenormin). The nurse enters the room to give George his prescriptions and spends some time teaching him about his care and medications. When speaking with the nurse, George expresses some concern that the HCP did not prescribe any additional tests. He asks, “Shouldn’t the HCP find out why I have hypertension? History Note the following points when interviewing the hypertensive client: • Family history of hypertension, diabetes mellitus, cardiovascular disease, hyperlipidemia, or renal disease; smoking; stress; obesity; or sedentary lifestyle • Previous documentation of high blood pressure, including age at onset, level of elevation, and currently prescribed medical regimen • History of all prescribed and over-the-counter medications and the client's exact compliance with taking the medications. NOTE: Medications that may either raise blood pressure or interfere with the effectiveness of antihypertensive medications include oral contraceptives, steroids, nonsteroidal anti-inflammatory drugs, nasal decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants, monoamine oxidase inhibitors, and erythropoietin • History of any disease or trauma to target organs • Results and side effects of previous antihypertensive therapy • Clinical manifestations of cardiovascular disorders, such as angina, dyspnea, or claudication • History of or recent weight gain, exercise activities, sodium intake, fat intake, alcohol use, and smoking • Psychosocial and environmental factors (e.g., emotional stress, cultural food practices, economic status) that may influence blood pressure control Physical Examination Physical assessment should include an accurate determination of blood pressure as well as an evaluation of target organs: • Vital signs and weight • Blood pressure—because blood pressure is variable and can be affected by multiple factors, it should be measured so that readings are representative of the client's usual level; the following techniques are strongly recommended: The client should be seated with the arm bared, supported, and positioned at heart level. The client should not have smoked tobacco or ingested caffeine within the previous 30 minutes. Measurement should begin after at least 5 minutes of quiet rest. The client's back should be supported, and both feet should be flat on the floor with the legs uncrossed. The client should not speak while the blood pressure is being monitored. Use of the appropriate cuff size will ensure an accurate measurement. The rubber bladder should encircle at least 80% of the limb being measured. The bladder's width should be one- third to one-half the circumference of the limb. Several sizes of cuffs (e.g., child, adult, large adult) should be available. • Measurements should be taken with a mercury sphygmomanometer, a recently calibrated aneroid manometer, or a validated electronic device. • Postural blood pressures should be measured and recorded according to position and arm used, including lying, sitting, and standing measurements from both arms. • Both systolic and diastolic blood pressures should be recorded. The disappearance of sound (phase V) should be used for the diastolic reading. Two or more readings should be averaged. If the first two readings differ by more than 5 mm Hg, additional readings should be obtained. • Funduscopic examination for retinal arteriolar narrowing, hemorrhages, exudates, and papilledema • Examination of the neck for distended veins, carotid bruits, and enlarged thyroid • Auscultation of the heart for increased heart rate, dysrhythmias, enlargement, precordial impulses, murmurs, and S3 and S4 heart sounds • Examination of the abdomen for bruits, aortic dilation, and enlarged kidneys • Examination of extremities for diminished or absent peripheral pulses, edema, and bilateral inequality of pulses • Neurologic evaluation for signs of cerebral thrombosis or hemorrhage Laboratory Studies Studies used in the routine evaluation of hypertension include a complete blood count, urinalysis, determinations of serum potassium and sodium levels, fasting blood glucose level, serum cholesterol level, blood urea nitrogen and serum creatinine levels, electrocardiogram, and chest radiography. These rests provide useful information in determining the severity of vascular disease, the extent of target organ damage, and the possible causes of hypertension. Clients with the potential for secondary hypertension may need more extensive studies. Algorithm for Treatment of Hypertension 6. How should the nurse respond to George’s question? A. “The HCP does not think we need to determine the cause now. Further tests may be done once your blood pressure is in the normal range.” B. “95% to 90% of all cases of hypertension are without an identified cause, so unless there is some indicator in your health history the HCP does not look for one.” C. “If there is a cause for your hypertension, it will become evident very soon. You will see your HCP frequently until the cause is determined” D. “Don’t worry! Stress causes your blood pressure to go up even more. The HCP knows what tests to order and when they should be done.” *Primary (essential) hypertension has no identifiable causes, but there are contributing risk factors. George also asks the nurse about his medications, Chlorothiazide (Diuril) and Atenolol Tenormin). The nurse review the medication, side effects, and the importance of taking medications on a daily basis. 7. While evaluating George’s understanding, which statements indicate that George understands the nurse’s instructions about his medications? SELECT ALL THAT APPLY A. “I will take Diuril early in the day” B. “I will be taking these medications for the rest of my life” C. “I can expect my heart rate to increase as my blood pressure goes down” D. “I may experience impotence with this drug regimen” E. “An irritating cough often develops but will subside in a few days” F. “I should avoid drinking alcohol” *Diuril is a diuretic, so taking at night may disrupt Georges sleeping pattern. Due to the side effects it is common for people to not want to take their medications. Side effects include dizziness, so avoiding alcohol will help decrease his chances of more dizziness. Evaluation The nurse shares with George that there are several things he can do besides taking the medication to improve his health. George says, “I know, the doctor told me to quit smoking, change my eating habits, decrease the stress in my life, and stop drinking so much alcohol. There is no way I can make all these changes. There would be nothing left to enjoy in life!” 8. When discussing these lifestyle changes with George, what is the most important information for the nurse to share? A. Use of tobacco products is linked with increased risk for cardiovascular disease. B. Drinking 24 ounces of beer a day or less is acceptable for clients with hypertension. C. Clients with hypertension respond differently to sodium restricted diets. D. There is evidence that stress only elevates blood pressure for a short time. *Smoking is known to have an effect on the cardiovascular system, so quitting smoking will decrease his BP. George expresses interest in reducing stress. George admits he has tried to quit smoking several times by using nicotine gum. 9. What is the most effective nursing intervention to help George be successful this time? A. Encourage George to make a quit plan. B. Give George free samples of nicotine gum. C. Talk with George’s wife about how she can help him quit. D. Review with George all the negative effects of cigarette smoking. *Allowing the patient to take hold of their plan of care helps them feel like they are in control and makes them mire engaged in the process of figuring out what will fit his lifestyle the best. As nurse we can also help determine the best ways to quit. George expresses concern about the problems that can arise if he doesn’t get his blood pressure under control. The nurse explains that hypertension can damage the kidneys, heart, lungs, and blood vessels. George states the he had an uncle and a grandfather who both died from an aortic aneurysm. He asks the nurse if high blood pressure can cause this problem. 10. How should the nurse respond to George’s concern? A. Reassure him that there is no need for concern since aortic aneurysms only occur in about 5% to 7% of people older than 60. B. Advise him that his HCP may want to do further testing because of his family history. C. Instruct him that a symptom of an abdominal aortic aneurysm is a pulsating mass in the abdomen. D. Encourage George to share his concern with his HCP on his next scheduled visit. *Hypertension can be passed down genetically, so having the HCP run more tests because of his family history will help put George at ease knowing the HCP will look into his concerns. Abdominal Aortic Aneurysm During the initial visit, George is scheduled for an abdominal ultrasound to determine the presence of an aneurysm. The nurse notes that the HCP has asked George to follow-up in one month. 11. Considering the overall plan of care, what is the primary reason for the nurse to encourage George to keep his one month appointment? A. Discussion of the results of the ultrasound. B. Evaluation of George’s lifestyle changes. C. Follow-up measurement of his blood pressure. D. Scheduling for follow up testing. *We want to reassess the BP to see if it has lowered at all. Us setting up his plan of care will help his BP as long as he sticks to the regimen. We always want to reassess the BP, especially if it is high. George returns in one month with his wife. The ultrasound showed the presence of a 3cm Fusiform aneurysm on the abdominal aorta. 12. In teaching George about the aneurysm, what information should the nurse include? A. This aneurysm is a weakness in the wall of the aorta causing an outpouching. B. Immediate surgery to repair the aneurysm is the recommended treatment. C. Further testing is needed immediately to determine if it is enlarging. D. Maintaining a normal blood pressure can effectively treat the size of the aneurysm. *Based on the size of the aneurysm, the HCP may choose to put them on a BP medication, and monitor the BP. A great way to keep the size of an aneurysm is to also maintain a healthy BP, as well as avoiding smoking. George’s vital signs are T 98.4, P 78, R 20, and B/P 150/90. George states that he has been feeling fine but he seems more tired than usual and has trouble sleeping. George states that he has cut down to only one pack of cigarettes a week and he has signed up for a stress management class. 13. What assessment finding is of most concern to the nurse? A. Current blood pressure reading of 150/90 B. Commitment to a stress reduction class. C. He reduced smoking but continues to smoke. D. Fatigue and difficulty sleeping *This reading is still showing us that George is hypertensive, and since he has the aneurysm this BP reading is showing great concern to us, since the BP is still not under control. This is putting George at risk knowing the aneurysm could keep growing. Anti-Hypertensive Therapy The HCP adds Nifedipine (Procardia) to George’s other prescriptions. 14. What instruction related to this medication is essential for the nurse to provide George? A. Do not take any NSAIDS (Nonsteroidal Inflammatory drugs). B. Discontinue the medication if he gets lightheaded when he gets up suddenly C. Notify the HCP if he has any urinary retention D. Avoid eating fresh grapefruit or grapefruit juice. *While he is taking Nifedipine, a calcium channel blocker, the grapefruit affects the body by increasing the amount of medicine that is absorbed in your bloodstream. This could cause an undesirable lower than normal blood pressure. 15. What statement by George indicates to the nurse that he understands his current plan of care? A. “I should take my blood pressure frequently. If it is low I quit taking my medications.” B. “If I quit smoking, eat a low sodium diet, decrease my alcohol intake, and get my stress levels down, I can quit taking these medications.” C. “If my blood pressure is in the normal range on my next visit, I will probably continue on these medications for at least one year” D. “This combination of medications is used frequently. I do not need to worry about drug interactions.” *With any medication, we want to discontinue the medication slowly, this could cause George to go into withdrawal, and we do not want that for our patients. We also want to make sure that he wouldn’t need the medications anymore, and to see that his HTN was treated fully. George and his wife leave the office feeling comfortable with their knowledge about hypertension and lifestyle modifications they need to make. A complication occurs Six months later George’s wife takes an overdose of Valium and alcohol. She is brought to the upset and very angry. As George is giving information to the registration clerk he becomes pale and complains of a sudden onset of back pain. George is taken to the Triage Nurse. 16. Which assessment data obtained during the triage assessment alerts the nurse that George needs immediate medical evaluation? A. History of hypertension and a B/P of 175/90. B. Respiratory rate of 26 and a pulse of 96. C. Headache on and off last week with nausea. D. History of 3cm aortic aneurysm and sudden onset of back pain. *A ruptured aortic aneurysm could lead to internal bleeding. Some symptoms of that include persistent chest or back pain. This would indicate to the nurse that the aneurysm has possibly ruptured. The HCP suspects that George’s aorta is dissecting. Aortic dissection is thought to be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall. Degeneration of the aortic media may be the primary cause for this condition, with hypertension being an important contributing factor. After examining George, the HCP writes several orders. 17. Which order should the nurse complete first? A. STAT 12 lead EKG (electrocardiogram) B. CT scan of the abdomen C. IV of 0.9% Normal Saline with large bore angiocath D. Type and cross match for 4 units of packed red blood cells. *Because of the suspected rupture aortic aneurysm, we would want to make sure George is receiving enough fluids to help maintain his BP, if not it could fall and lead to serious injury. 18. What other interventions should the nurse perform prior to sending George to the OR (Operating Room)? SELECT ALL THAT APPLY A. Begin continuous cardiac monitoring. B. Check blood pressure every 2 hours C. Insert a second large bore angiocath if one does not exist. D. Accompany George to the bathroom one last time, so that he can empty his bladder before transfer to the OR. E. Monitor neuro status every 4 hours. *We want to monitor Georges BP, HR to see if there are any irregular rhythms or readings. Having an extra IV site is always a good idea incase the patient needed blood or another medication through and IV. When George returns from radiology where the abdominal CT was performed, the diagnosis of dissecting aortic aneurysm is confirmed. George is informed that he needs immediate surgery. Unfortunately his wife in intubated and unresponsive. Surgical Repair of an Abdominal Aortic Aneurysm The nurse needs to notify George’s children and family, call report to the operating room staff, get surgical consent form signed, and consult a social worker. 19. George is complaining of extreme pain. The HCP prescribes morphine sulfate 8mg IV push. The available form is a 5ml container of morphine sulfate labeled 2mg/ml. How many milliliters should the nurse draw up for one does? _4 mL of morphine sulfate Several things need to be done before surgery Delegation: 20. Which action can be safely delegated to an unlicensed assistive personnel (UAP)? A. Observe George sign the consent form. B. Obtain a full set of vitals plus a neurological check C. Call a report of the client’s condition to the surgery staff D. Document a list of George’s personal belongings *When looking at this list, the UAP is not allowed to assess, or report on the status of George. They are also not allowed to observe George sign a consent form. So the UAP is allowed to document a list of Georges belongings. After all tasks are completed the nurse asks the UAP to obtain a second set of vitals Communication: The first unit Packed Red Blood Cells (PRBCs) is available before George goes to the OR. While the nurse is hanging the first unit of blood, George asks if he is going to die. George is afraid and scared. 21. What is the best response from the nurse? A. “No one knows if you will live or die. Right now focus on being strong for your children when they arrive.” B. “This is a frightening experience. Is there someone with whom you would like to talk to about your fears?” C. “There is a real chance you may die from this. Many people do die from dissecting aneurysm.” D. “Your HCP is the best person to answer your questions about whether you will live through surgery.” *We should acknowledge when our patients are feeling frightened or stressed. I chose this response because it shows that we are paying attention to how George is feeling, and were allowing him an option of talking to someone who can help him feel more at ease. Legal Ethical Issues: George’s children arrive in the ED and spend a few minutes with him before he goes to surgery. After a short period of time, the surgeon reports to the family that the aneurysm repair was unsuccessful and George died during surgery. On of George’s son’s returns to the ED and starts yelling at the nurse. 22. What is the nurse’s best initial response? A. Call security to handle the situation. B. Explain that the nursing staff did everything possible. C. Acknowledge the son’s anger. D. Redirect the son’s hostility. *Everybody grieves in different ways, and one of the stages of grief is anger. We should be able to talk to them about how they are feeling, and to be there when they need it. Acknowledging the anger the son is feeling is best in this case to show him that we understand, and empathize with how he is feeling at the moment. George’s wife is in the ICU. The next day she is becomes alert and responsive. The children tell the ICU nurse that they do not want their mother told of her husband’s death. 23. How should the nurse respond? A. Honor their wishes, recognizing the children know what is best for their mother. B. Tell the children that legally the nurse must inform their mother. C. Call pastoral care to consult with the family. D. Talk further with the children and explore options with them. *The nurse should assess the situation and talk to the children about their concerns of the current situation. Allowing them to address their concerns also gives the staff a better understanding on how to handle the situation. Case Outcome: George’s children accompanied by their pastor, tell Mrs. Thomas about George’s death. After signing a contract with the Mental Health Counselor stating she will not attempt to commit suicide, Mrs. Thomas is released from the hospital. A funeral service is held for George and Mrs. Thomas continues with outpatient counseling sessions. Classification of Blood Pressure for Adults Age 18 Year Hypertension Common Mistakes in Blood Pressure Assessment Factors Influencing Blood Pressure After completing case study write a practice care map for Ineffective Health Maintenance for a patient like George with Hypertension LEVEL I - CARE MAP STUDENT: McKenzie Goodman CLIENT INITIALS: G. T. DATE: 03/29/2020 MEDICAL DX: Stage 2, Primary/essential Hypertension. NURSING DX/PROBLEM STATEMENT: Ineffective health maintenance related to the state of a person where he is unable to identify, manage, and ask help in maintaining his healthy well- being as evidenced by, BP reading of 189/110, and LDL cholesterol of 200, lots of stress at work, smoking cigarettes daily, and 4-5 cups of coffee daily, goes out to have beers with coworkers, and family history of HTN. ETIOLOGY/PATHOPHYSIOLOGY: Condition of persistent elevation of systemic blood pressure due to unidentified factors. DATA: SUBJECTIVE: Lost wt recently, under lots of stress at work, goes out after work and has several beers, mother has passed away recently making his emotional health go down, thinks mom had HTN, smokes cigarettes, and has 4-5 cups of coffee daily, has tried to quite smoking before using nicotine gum, has been tired lately, having trouble sleeping, , “I know, the doctor told me to quit smoking, change my eating habits, decrease the stress in my life, and stop drinking so much alcohol. There is no way I can make all these changes. There would be nothing left to enjoy in life!” OBJECTIVE: BP reading of 189/110 LDL cholesterol of 200 BP reading of 150/90 (month after first BP) ASSESSMENT RISK FACTORS: Family history of HTN (mother, uncle and grandfather died from aortic aneurysm), smoking, alcohol consumption PHYSICAL: 6 feet tall (182.88cm) and his weight is 190 pounds (86.18 kgs). Pt not being compliant with health regimen. LAB TESTS/RESULTS: LDL Cholesterol of 200 mg/dL. DIAGNOSTIC STUDIES: Abdominal CT. PATIENT CENTERED CARE (r/t NUR DX) MONITORING INTERVENTIONS: Blood pressure, cholesterol, heart rate NURSING CARE/INTERVENTIONS (with rationale): Help the client choose a healthy lifestyle, it will prevent unwanted complications that may arise during the treatment. MEDICATION: Chlorothiazide (Diuril) and Atenolol (Tenormin), Nifedipine (Procardia) INTERPROFESSIONAL CARE: Nutritionist, therapist, Cardiologist CLIENT EDUCATION: Teach him about the adverse effects of his medications, and what to expect while taking them, and signs/symptoms to report back to HCP. As well as food that are healthier for him. I could also teach him different ways to cope with stress, as well as ways to quit smoking. HEALTH PROMOTION SAFETY CONSIDERATIONS: Fall risk. COMPLICATIONS: Heart attack, aneurism, stoke. EVALUATION: ASSESSMENT/EVALUATION of GOAL: MET/PROGRESSING/NOT PLAN OF CARE Outcome criteria: Patient will MET MODIFICATIONS: verbalizes aim to follow prescribed Not met I will allow the patient to regimen on our second meeting have some more time to together, a week after our first read over, and fully meeting. understand regimen we planned out. Allowing the patient more time to ask question as well. Reflection “What could the nurse have done differently in order to prevent the patient's fatal outcome?" -I think including George more in his plan of care would’ve helped him follow his regimen. And putting an end to his smoking would’ve also helped decrease his chances of this outcome from happening. Including George in his plan of care, and finding what options would fit his lifestyle better, would’ve made him more likely to follow his medication regimen. As a nurse we should’ve assessed his lifestyle better and made modifications based on that so it would be more compatible with Georges lifestyle. I also think we could’ve shown George more options to help end his smoking of cigarettes. Although George did cut down his smoking, it would’ve been better for his if he completely quit. We could’ve given him options such as attending a support group, giving him activities that could keep him busy and his mind off of smoking. It is our jobs as nurses to help educate our patients on the importance of following the regimen they are given.