Mati Doctors College

City of Mati Davao Oriental

HYPERTENSIVE URGENCY Rule Out Acute Coronary Syndrome;

CARDIOVASCULAR DISEASE; HYPERTENSION II

A Group Case Study

In

NCM 109
(Related Learning Literature)

Submitted to:

Ms. Rodelyn Ocliasa Palma R.N.

Submitted by:

Second Year:

Aquino, Camile Kate C.

Guillano, Cristabelle B.
Pagaura, Cheryl B.
Ruelo, Vanessa Jean G.

January 15, 2022

1
 ACKNOWLEDGEMENT

In fulfilling our tasks as student nurses, especially in accomplishing our case study,
we have received a lot of opportunity to be enlightened and fully understand our first ever
case presentation we had encountered. The completion of this undertaking could not have
been possible without the cooperation and assistance of everybody. Cheers to every person
in this group for the job well done!

A deeper gratitude is also owed to Ms. Rodelyn O. Palma RN, RM., for giving us this
challenge with her utmost guidance and support that contributed a lot for the completion
of this case study.

We would also like to commend our family for their never ending support and
understanding to us.

Above all, to the Great Almighty, the author of knowledge and wisdom, for his
countless love and guidance, for without him, we are nothing.

From the bottom of our heart, we thank you.

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 TABLE OF CONTENTS

Tittle Page

Tittle Page 1

Acknowledgement 2

Table of Contents 3-4

I. Objectives 5
- General
- Specific
II. Introduction 6-7
III. Scope and Delimitation 8
IV. Patient’s Profile 9
V. Patient’s Health History 10-11
- Chief Complain
- Family Health History
- Present Health History
- Lifestyle
- Effects and Expectations of Self and family
Towards the condition
VI. Genogram 12
VII. Physical Assessment 13-18
- General Survey
- Vital Signs
VIII. Definition of Complete Diagnosis 19
IX. Anatomy & Physiology 20-27
X. Pathophysiology 28-36
- Etiology
- Symptomatology

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 - Narrative Pathophysiology
- Schematic Diagram
XI. Physician’s Order 37-43
XII. Laboratory Result 44-52
XIII. Drug Study 53-75
XIV. Nursing Care Plan 76-85
- Actual (3)
- Potential (2)
XV. Nursing Management 86-89
- Actual Care Given
- Problem Encounter During the Implementation
- Restorative Measures used
- Evaluation
- Patient Teaching
- Recommendation
- Outcome
XVI. Prognosis 91-93

Appendix 94-103

Glossary 104-106

Bibliography 107

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 I. OBJECTIVES

General:

This case study aims to impart informative research to the readers seeking
broad understanding about Hypertensive Urgency ruling out Acute Coronary
Syndrome; Hypertensive Cardiovascular Disease; Hypertension II, and the
comprehensive care management necessary for these diseases.

Specific:

 Define and explain Hypertensive Cardiovascular Disease.

 To discuss the health history of the patient.
 To discuss the family’s history of diseases (Genogram)
 To discuss and explain the complete physical assessment of the patient.
 Explain the anatomy and physiology of the systems involved such as Excretory
System & Cardiovascular System.
 To explain the pathophysiology of the disease.
 To discuss the drugs prescribed to the patient.
 To discuss the implications and justifications of every order given by the physician
as well as the laboratory results.
 To impart to the readers the appropriate treatment and care for the patient.
 To discuss the Nursing Care plan and Nursing Management implemented to patient.
 To discuss the Prognosis of the patient.

5
 II. INTRODUCTION

A “Silent killer” because people who have it are often symptom-free it is also known as
high blood pressure (HBP) a long-term medical condition in which the blood pressure in
the arteries is persistently elevated. Blood pressure is a measure of how hard the blood
pushes against the walls of your arteries as it moves through your body. Blood pressure
readings consist of an upper number and a lower number (such as 120 over 90 or 120/90).
High blood pressure is 140/90 or higher. When blood pressure is high, it starts to damage
the blood vessels, heart, and kidneys. This can lead to heart attack, stroke, and other
problems. Cardiovascular disease (CVD) is a general term for conditions affecting
the heart or blood vessels. It's usually associated with a build-up of fatty deposits inside the
arteries (atherosclerosis) and an increased risk of blood clots. Other factors that can raise
the risk of having essential hypertension include obesity, diabetes, stress, insufficient
intake of potassium, calcium & magnesium, lack of physical activity & chronic alcohol
consumption. It can be managed with lifestyle changes and medicines

An estimated 1.13 billion people worldwide have hypertension, most (two-thirds) living
in low- and middle-income countries. In 2015, 1 in 4 men and 1 in 5 women had
hypertension. Fewer than 1 in 5 people with hypertension have the problem under
control. Hypertension is a major cause of premature death worldwide.
According to the MMM website, high blood pressure is the No. 1 contributing factor for
global death, causing strokes, heart attacks, and other cardiovascular complications with
10 million people dying each year from conditions related to hypertension.

Based on the national survey released by the Department of Health in 2017, the total
number of hypertensive Filipinos is now more than 12 million, with more than half of them
are unaware of their condition. Roughly, that is one out of four to five Filipinos in general.

“Many Filipinos are still smoking, we eat a lot of processed foods including junk
foods, we don’t exercise enough and we live a stressful life. High BP and other heart
diseases result from the interaction of genetics and environmental or lifestyle factors,”
Both male and female are equally prone to high BP, males are more prone before
menopause of women; after menopause, they’re just about the same.” quoted by medical
doctor Rafael Castillo, member of Executive Council of the International Society of
Hypertension (ISH) based in United Kingdom and Chairman, Communications Committee.

He advised proper diet, regular exercise and intake of medicines to control and prevent
high blood pressure.

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 III. PATIENT’S PROFILE

Patient’s Name: L.C.K.

Age: 74 years old

Gender: Female

Civil Status: Widowed

Address: Phase 8 Martinez, Dahican, Mati City

Date of Birth: September 19, 1945

Place of Birth: Manay, Davao Oriental

Nationality: Filipino

Religion: Roman Catholic

Father’s Name: Jose Cudada Sr. (deceased)

Mother’s Name: Cristita Cudada (deceased)

Spouse’s Name: Jose Kiay Jr

Philhealth Member: Indigent Member

Date of Admission: January 8, 2020

Time of Admission: From ER to Ward per Wheel Chair

Admitting Diagnosis: HYPERTENSIVE URGENCY Rule Out Acute Coronary

Syndrome; CARDIOVASCULAR DISEASE; HYPERTENSION

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 IV. PATIENT’S HEALTH HISTORY

Chief Complain:

Our patient arrived at the emergency room with a chief complain of epigastric pain
with a blood pressure of 200/110mmhg.

Family Background:

Hypertension is the disease that runs in their family. Her mother died due to natural
death by aged while his father died of cardiac arrest both at the age of late 70s. There is no
known history of Kidney Disease. She has a brother who is hypertensive & a sister who has
Diabetes Mellitus. The patients’ husband was asthmatic & died as a smoker.

Past Health History:

This admission was our patient’s third hospitalization following her recent
admission in the same hospital due to hypertension. Her first admission last 2000 was
related to an accident that led her to a fractured bone at the pelvic area. She is maintaining
an antihypertensive drug for 8 years now. When she reached the age of 47 years old, she
stopped menstruating. She had herself vaccinated with flu and pneumo vaccine last 2000 in
Davao Oriental Provincial Medical Center. She does not have any allergies to any foods and
medicines.

8
Present Health History:

Presence of signs and symptoms started last Monday, January 6, 2020. The patient
had onset dizziness & nape pain. The patient asked for consultation & was advised to be
admitted but refuses to. The symptoms worsen and the patient became really weak. She
was referred to St. Camillus Hospital and was admitted at 7 in the evening with an
admitting diagnosis of Hypertensive urgency rule out Acute Coronary Syndrome,
Hypertensive Cardiovascular Disease; Hypertension II. The patient was generally
complaining about epigastric pain with blood pressure of 200/110 mmhg.

Lifestyle:

According to the patient before the onset of her illness she ates everything and was
not particular on her diet she even drinks Malurka, coconut wine & soda as much as she
could. She does not have work and only stays at home but she do the dishes, clean the lawn
& go to market every now & then for her grandchildren. She carries sack of corn in her
younger years until she accidentally slipped & got injured. She usually go to the market &
exchange goods there in her younger years.

Effects and Expectations of self and family towards the condition:

According to her son, this hospitalization affects primarily their financial status, she
may be admitted to private hospital but only due to government PhilHealth membership.
They expect that she become good (if not better) since they have been accepted that their
mother is too old already and that this is normally a part of being old. They want to go
home as soon as the patient regains her energy. The patient also verbalized eagerness to go
home.

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 V. GENOGRAM

Mother’s Side Father’s Side

A.G.C M.G.K
M.D.C B.E.K

M
D.D.C A.D.C M.D.C F.D.C L.E.K T.E.K C.E.K E.E.K R.E.K
.E.K

R.C.K J.C.K L.C.K R.C.K

L.C.K B.C.K M.C.K

Legends:
Impression:
Male
This genogram shows an evidence of connection
Female to the disease, her mother died naturally & her
Heart Problem /HPN father died in cardiac arrest. There are several
family members who died in Hypertension & still
Asthma
fighting through it.These diseases are genetically
Natural Death acquired or hereditary. Hypertension has many
Diabetes complications if not treated such as kidney
Unknown Death/Dead problems and cardiovascular diseases and may
result to a more serious complications..

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 VI. PHYSICAL ASSESSMENT

 General Survey:

January 10, 2020 at 8:00 in the morning, we received patient at bed in supine
position, conscious, coherent, oriented and is weak. Appropriately in a duster dressed. With
IVF PNSS at 80mL at 20qtts/minute on her left side at dorsal vein and noted inflammation
and redness on the site. IV is patent and is accurately regulated. Comode was present on
her bedside.

 Vital Signs:

Date Time Temp BP PR RR

January 10, 2020 140/90mmHg
8:00 A.M 36.6 C 78 bpm 25 cpm
130/80 mmHg
12:00 P.M 35.7C 72 bpm 26 cpm

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 DAY 1
BODY PARTS NORMAL WAY OF
EXAMINAT FINDINGS JUSTIFICATION
ION

SKIN
Color In white skin: Inspection
Light to dark Palpation Light brown, Pigmentation is normal in aging
pink presence of macules process.
In dark skin: in the periphery.
Light to dark Countable papules
brown in the forearms

Texture Smooth, even, Thin, wrinkled & Wrinkles are a natural part of the
soft leathery aging process. As people get older,
their skin gets thinner, drier and
less elastic.

Temperature/Moisture Warm Increase in skin Increased skin temperature

temperature (cool) indicates an increase in blood flow
and Dry depending on the amount of blood
circulating through the dermis.

Turgor Pinch up skinfold When pinched it The skin loses its elasticity with
returns goes back slowly age, but fluid balance can also
immediately to affect skin turgor.
normal position

Edema No swelling or No Swelling or (NORMAL) Edema refers to visible

pitting edema Pitting edema swelling caused by a a build-up of
fluid within tissues.

HAIR

Color Varies Inspection Gray hair (with NORMAL due to aging process the
black dye) hair turned gray & decreasing
distribution of melanin.

Amount & Distribution Varies Evenly distributed, Evenly distributed

Presence of parasites None None None

SCALP

Smooth, intact, Inspection Smooth & moves Normal

moves freely Palpation freely
over skull

HEAD

Head Round; Palpation Round; Round; normocephalic;

normocephalic; Inspection normocephalic; symmetrical
symmetrical symmetrical

Skull Hard and smooth Normal Normal

Face Nose and brows Symmetrical facial Symmetrical facial movement,

prominent movement, equals in equal in size, small counts of
size, small counts of freckles due to age

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 freckles due to age

EYES AND VISION

Eye lashes Evenly Normal Normal

distributed with
an outward
curve

Eyelids No sclera visible No sclera visible No signs of visible sclera between

between upper between upper lid & upper lid & iris due to normal
lid and iris iris. (Normal) findings.
Upper and lower
lids completely
approximated
when closed

Conjunctiva Clear, pale Inspection Numerous small Normal

glistening pink visible blood vessels
conjunctiva,
numerous small
visible blood
vessels common

Sclera White Normal Normal

Cornea transparent; Normal Normal

smooth; shiny;
details of iris are
visible; blink
when touched

Pupils Round, regular Round, equal in both Round, equal in both eyes
equal in both eyes
eyes

Peripheral visual field Client can see Blurry vision Blurry vision
objects in the
periphery when
looking straight
ahead

EARS

Placement Top of pinna Inspection Normal Normal

level with outer Palpation
corner of the eye

Appearance Skin intact, Normal Normal

similar in color
to face, smooth,
uniform

NOSE

Inspection Nasal flaring The patient is experiencing hard

External Nose Symmetric Palpation time in breathing

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 MOUTH

Lips Smooth, pink, Palpation smooth, intact & Normal findings

moist, intact, free Inspection free of lesions
of lesions

Gums Pink, moist, Normal Normal

intact, clearly
defined margin

Teeth 32 pearly white Missing or loss of Missing or loss of teeth, cavities,

and shiny, stable, teeth, cavities, dark dark brown discoloration due to
smooth edges, brown aging.
clean and free of discoloration.
debris

Tongue Pink, moist, Whitish Whitish

intact, smooth
movement,
papillae on
dorsal aspect,
absence of
furrow.

Palates Pale, moist, Pale, moist, intact, Pale, moist, intact, bony ridge down
intact, bony ridge bony ridge down the the center is a normal variation
down the center center is a normal
is a normal variation
variation

NECK

Appearance Symmetrical, Inspection Symmetrical, Symmetrical, coordinated,

coordinated, Palpation coordinated, some controlled movement
controlled uncontrolled
movement movement

Thyroid gland Usually not Not visible, smooth, Usually not visible, smooth,
visible, smooth, symmetrical, and symmetrical, and rubbery on
symmetrical, and rubbery on palpation
rubbery on palpation
palpation

CHEST &LUNGS

Ribs Normal sloping Inspection Normal sloping of Normal sloping of the ribs
of the ribs Auscultatio the ribs
n
Spine Straight, without Percussion Slightly curved, Slightly curved due to previous
lesions or masses Palpation without lesions or accident.
masses

Breathing Regular rate 20-23 cpm; regular 20-23 cpm;

between 16 and rhythm, equivalent regular rhythm, equivalent in
20 cpm; regular in expiration length expiration length
rhythm in which
inspiration is
approximately
equivalent to

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 expiration in
length

Muscle Normal tone, Weak Weak

nontender

Heart

Heart rate and rhythm The average Inspection 70bpm-75bpm 70bpm-75bpm

heart rate for Palpation
adults is between
60 and 100
beats/minute.

Peripheral Inspection
Venous/arterial Palpation
circulation

Blood Pressure Will vary 130/70mmHg- 130/70mmHg- 130/80mmHg

normally among 130/80mmHg
individuals; in
general average
of 120/80

Skin Normal skin Pallor ,brownish Pallor ; brownish discoloration of

discoloration of lower extremities
lower extremities

Pain No calf No calf tenderness No calf tenderness or pain due to

tenderness or or pain normal findings
pain

Sensation The pt. Should be Normal The patient was able to declare the
able to perceive different sensation in the skin
soft, sharp, and
vibratory
sensations

Vessels Veins appear Palpable veins & Normal

bluish, feel appear greenish
elastic, and are
non-tender

Edema No edema No edema No signs of pitting edema

Abdomen Inspection
Auscultation
Percussion
Palpation

Posture Able to sit or lie Move freely but Need assistance to move freely but
comfortably and complaining about can move independently
to move freely her back injury
without pain in
any position

Skin Color consistent Old surgical scars Old surgical scars at the back
with the rest of at the back portion portion

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 the body; skin
smooth,

Musculoskeletal Inspection
Palpation

Posture Ability to stand Inability to stand Inability to stand erect due to past
erect, with head erect accident.
up, face forward,
arms hanging
straight at the
sides, shoulders
and hips parallel,
legs straight with
both knees

Stance Ability to stand Can stand without Can stand without assistance
comfortably assistance
without
assistance or
extrinsic support
and without
swaying or loss
of balance on
both feet or on
one foot at a
time.

Gait Ability to walk Evidence of an Evidence of an unsteady gait,

with equal and unsteady gait,
symmetrical

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 VII. DEFINITION OF COMPLETE DIAGNOSIS

For the purpose of better understanding of the diagnosis, the following terms are
defined conceptually and/or operationally.

 HYPERTENSION – A “Silent killer” because people who have it are often

symptom-free it is also known as high blood pressure (HBP) a long-term medical
condition in which the blood pressure in the arteries is persistently
elevated. High blood pressure is 140/90 or higher.

 CARDIOVASCULAR DISEASE (CVD) – a general term for conditions affecting

the heart or blood vessels. It's usually associated with a build-up of fatty deposits
inside the arteries (atherosclerosis) and an increased risk of blood clots.

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 VIII. ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM

Transport of nutrients, oxygen, and hormones to cells throughout the body

Location & Size

 Heart is approximately the size of a person’s fist, the hollow, cone-shaped heart
weighs less than a pound.
 Enclosed within the inferior mediastinum, the medial cavity of the thorax
 Heart is flanked on each side by the lungs
 APEX- located at the 5th intercostal space, left midclavicular line.
 BASE- broad posterosuperior aspect, from which the great vessels of the body
emerge, points toward the right shoulder & lies beneath the 2nd rib

COVERINGS & WALL

 PERICARDIUM- is enclosed by a double-walled sac

o Fibrous Pericardium- loosely fitting superficial part of this sac. Helps
protect the heart & anchors it to surrounding structures, such as diaphragm
and sternum.
o Serous Pericardium- deep to the fibrous pericardium is the slippery 2 layer
 Parietal layer- the interior of the fibrous pericardium
 Epicardium- the visceral layer which is actually part of the heart wall
 MYOCARDIUM- consists of thick bundles of cardiac muscle twisted and whorled
into ringlike arrangements, producing a slippery lubricating fluid (serous fluid)
 the layer that actually contracts & reinforced internally by a dense,
fibrous connective tissue network called the “skeleton of the heart”
 ENDOCARDIUM- (simple squamous epithelium) is a thin glistening sheet of
endothelium that lines the heart chambers

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CHAMBERS & ASSOCIATED GREAT VESSELS

 CHAMBERS
 Superior Atria- primarily receiving chambers, blood flows into the atria
under low pressure from the veins of the body & then continues on to fill the
ventricles
 Thick-walled ventricles- are the discharging chambers, or actual pumps of
the heart. When they contract, blood is propelled out of the heart and into the
circulation.
 SEPTUM
 Interventricular Septum- the stout wall separating the ventricles
 Interatrial Septum- separates the right and left atria of the heart
 Superior & Inferior Venae Cavae- receives relatively oxygen poor blood from the
veins of the body through & pumps it oout through the pulmonary trunk.
 PULMONARY TRUNK
 Pulmonary arteries- which carry blood to the lungs, where oxygen is
picked up & carbon dioxide is unloaded
 Pulmonary veins- oxygen-rich blood drains from the lungs & is returned the
left side of the heart
 AORTA- runway of blood that pumps out of the heart from which systemic arteries
branch to supply essentially all body tissues

ARTERIAL BRANCHES OF THE AORTIC ARCH

 Brachiocephalic Trunk- is an artery of the mediastinum that supplies blood to the

right arm and the head and neck.
 Common Carotid Artery- is a large elastic artery which provides the main blood
supply to the head and neck.
 Subclavian Artery- Supply our arms with blood, it branch to the vertebral arteries.
These carry oxygenated blood up to the brain from the base of the neck

 VALVES- equipped with 4 valves, which allow blood to flow in only one direction
through the heart chambers
 Atrioventricular valves- are located between the atrial and ventricular
chambers on each side, this valves prevents backflow into the atria
 Bicuspid/ mitral valve- the left AV valve consist of two flaps, or
cusps of endocardium
 Tricuspid valve- the right AV valve has 3 flaps

19
  Chordae Tindinaea- anchor the flaps to the walls of the ventricles
 Semilunar valves- guards the bases of the 2 large arteries leaving the
ventricular chambers
 Aortic Semilunar Valve
 Pulmonary valve

SYSTEMIC CIRCULATION- oxygen-poor blood circulates from the tissues back to the right
atrium via the systemic veins, which finally empty their cargo into either the superior or
inferior vena cava. This second circuit, from the left side of the heart through the body
tissues and back to the right side of the heart.

Cardiac Circulation:

 Coronary Arteries- blood supply that oxygenates & nourishes the heart is
provided by the right & left coronary arteries, branch from the base of the aorta and
encircle the heart in the coronary sulcus ( at the junction of the atria and ventricles)
 Anterior interventricular & Circumflex arteries ( on the left)
 Posterior interventricular & Marginal arteries (on the right)
 Coronary Sinus- where myocardium is drained by several cardiac veins, which
empty into an enlarged vessel on the posterior of the heart. In turn, empties into the
right atrium.

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Physiology of the Heart

As the heart beats or contracts, the blood makes continuous round trips- into & out
of the heart, through the rest of the body, and then back to the heart – only to be sent put
again. In one day it pushes the body’s supply of 6 Liters through the blood vessels over
1000 times, meaning that it actually pumps about 6000 quarts of blood in a single day.

Intrinsic/Nodal Conduction System of the Heart: Setting the Basic Rhythm

That is built into the heart tissue and sets its basic rhythm. It enforces a
contraction rate of approximately 75 BPM on the heart; thus, the heart beats as
coordinated unit.

 Sinoatrial Node- “pacemaker” one of the most important parts of the intrinsic
conduction system is a crescent- shaped node of tissue, located in the atrium.
Other components:
 Atrioventricular (AV) node- at the junction of the atria & ventricles, picks up
stimulus from SA nodes
 Atrioventricular (AV) bundle (BUNDLE of HIS)- connected to the AV node,
takes stimulus from AV node to ventricles
 Purkinje fibers- which spread within the muscle of the ventricle walls. It
takes stimulus from AV bundle out to cardiac muscle fibers of ventricles
causing ventricle to contract.

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 EXCRETORY SYSTEM

KIDNEY

 Small, dark red organs with a kidney bean shape lie against the dorsal body wall in
the retroperineal position in the superior lumbar region.
 Extend from the T12- L3 vertebra, this they receive some protection from the lower
part of the rib cage
 The right kidney is positioned slightly lower than the left because of the crowded
liver
 Adult kidney is about 12cm (5 inches) long & 6cm( 2.5inches) wide & 3cm (1inch)
thick

FUNCTIONS
 Maintaining overall fluid balance regulating, & filtering minerals from blood filtering
waste materials from food, medications & toxic substances.
 Excreting nitrogenous waste
 Maintaining PH
 Maintaining water
 Electrolyte balance of the blood

 NEPHRONS -the basic structural & functional unit of kidneys
 Filtration, tubular reabsorption, tubular secretion

22
  Renal corpuscles- are glomerulus & glomerular or Bowman’s capsule
 Calyces form cup-shaped areas that enclose the tips of the pyramids.
 Collect urine which continuously drains from the tips of the pyramids into
the renal pelvis
 Urine then flows from the pelvis to the ureter, which transports it to the
bladder for temporary storage.

3 Distinct Regions:

 RENAL CORTEX- the outer region

 RENAL MEDULLA- deep to the cortex is a darker reddish brown area, has many
basically triangular regions
 RENAL PELVIS- medial to the hilum is a flat , basinlike cavity

Blood Supply

 Kidneys continuously cleanse the blood and adjust its composition.

Physiology:

AORTA → RENAL ARTERY→ SEGMENTAL ARTERY → INTERLOBAR ARTERY →ARCUATE

ARTERY → INTERLOBULAR ARTERY→ AFFERENT ARTERIOLE→ GLOMERULUS(
capillaries) EFFERENT ARTERIOLE→ PERITUBALAR CAPILLARIES INTERLOBULAR
VEINS→ ARCUATE VEIN INTERLOBAR VEIN→ RENAL VEIN→ INFERIOR VENA CAVA

23
URINE FORMATION:

Reabsorption: NaCl, H2O

FILTRATION:

H20, NaCl, K, HCO3, Glucose, Amino

Secretion: K, H
acids.

Waste Products: Creatinine, Urea DISTAL CONVULATED TUBULE

Glomerulus

Proximal Convoluted Tubule Collecting Duct

Reabsorption: K, NaCl, H2O,
Amino acids, Glucose
E
Secretion: Uric acid, Organic
Acids X

DILUTING SEGMENT E

Reabsorption: H20 & .NaCl T

N
H20,NaCl, K,HCo3,
Creatinine, Urea

24
 IX. PATHOPHYSIOLOGY

Etiology:

Patient L.C.K.experienced hypertensive urgency which defines severely elevated BP

(systolic 220mmHg & diastolic of 120 mmHg) with no evidence of target organ damage.
Arterial Chronic Hypertension is one of the established cardiovascular risk factors for
development of atherosclerosis and an increased incidence of peripheral vascular disease,
cerebrovascular disease, chronic renal disease, and coronary artery disease. It is the risk
factor for heart failure, myocardial infarction, stroke, and cardiovascular death.

Symptomatology

Hypertension occurs when the body’s small vessel narrow, causing blood to exert
pressure. Symptoms stated below occur as a sign increase of blood pressure and we gather
this information during our history taking. The signs and symptoms of hypertension:

SYMPTOMS PRESENT ABSENT JUSTIFICATION

Chest pain  Chest pain or
discomfort caused
when your heart
muscle doesn’t get
enough oxygen – rich
blood.

25
Headache  Hypertension can
accompanied & result in excess
blurred vision pressure on the brain,
which can cause blood
leak from the blood
vessels in this organ.

Nausea and  Due to discomfort

vomiting radiating to the back,
jaw, and throat.
Fullness ingestion or
choking feeling (may
feel like heartburn).

Shortness of  When high blood

breath pressure causes the
heart muscle thicken
space for the oxygen-
rich blood to flow from
the lungs into the
chamber or ventricle
that pumps it to the
rest of the body.
Epigastric pain  pain increases blood
pressure by increasing
sympathetic activity

Nape pain Nervous signals from the

neck ensure g that
adequate blood supply is
maintained. If signal fails
person will suffer
problems w/ balance an
increase blood pressure

26
 Narrative Pathophysiology

No precise cause can be identified for most cases of hypertension & it is understood

that hypertension is a sign of multifactorial condition. High blood pressure can be viewed

in three ways: as a sign, risk factor for atherosclerotic cardiovascular disease, or a disease.

Elevated pressure may indicate an excessive dose of vasoconstrictive medication or other

problems. Hypertension is a major contributor to death from cardiac, renal, and peripheral

vascular disease. Prolonged blood pressure elevation eventually damages blood vessels

throughout the body, particularly in target organs such as the heart, kidneys, brain, eyes.

Consequences of prolonged, uncontrolled hypertension are myocardial infarction, heart

failure, renal failure, strokes and impaired vision. Hypertension is a multifactorial

condition. Because hypertension is a sign, it is most likely to have many causes, just as fever

has many causes.

For hypertension to occur there must be a change in one or more factors affecting

cardiac output. The first contributor is Stress which is a regulator of other unhealthy

activities such as frequent drinking of alcohol. Alcohol is a depressant that has a short life

span in the body. When you consume alcohol, it first enters the digestive system. 20% of

alcohol from a single drink moves directly to the blood vessels.

Increased renal absorption of sodium, chloride and water related to a genetic

variation in the pathways by which kidney handle sodium; Increased activity of the renin-

angiotensin-aldosterone system, resulting in expansion of extracellular fluid volume and

27
increased systemic vascular resistance; Decreased vasodilation of the arterioles related to

dysfunction of vascular endothelium.

Pathogenesis of essential hypertension is multifactorial and highly complex. The

kidney is both the contributing and the target organ of hypertensive processes the disease

involves the interaction of multiple organ system and numerous mechanisms of

independent or interdependent pathways. Factors that play important role in the

pathogenesis of hypertension include genetics, activation of neuron hormonal system such

as the sympathetic nervous system and renin-angiotensin-aldosterone system obesity and

increased dietary salt intake. Hypertension usually has no symptoms and may affected

individuals do not know they have the condition. However, hypertension is a major risk

factor for heart disease, stroke, and kidney failure and eye problem. When blood pressure

is elevated, the heart and arteries hardens or damages artery walls. As a result, flow of

blood and oxygen to the heart and other organ is redirect damage to the heart caused by

extra and lack of oxygen cause heart disease. Family members shares genes, behavior,

lifestyle and environment that can influence the health and their risk for disease. High

blood pressure can run in a family and your risk for high blood pressure can increase based

on your age and race or ethnicity. When member of a family pass traits from one

generation to another through genes, that process called heredity. Genetic factor likely play

some role in high blood pressure, heart disease and other related conditions. However, it is

also like that people with a family history of high blood pressure share common

environments and other potential factors that increase their risk. Risk for high blood

pressure can increase even more heredity combines with healthy lifestyle choices. Such as

28
the cigarettes and eating unhealthy fool. Salt is sodium a mineral that occurs naturally in

foods. Sodium is the substance that may cause your blood pressure to increase. Other forms

of sodium are also present in food.

Progression of mild stroke or Transient Ischemic attack and atherosclerosis will

result to blockage of the blood vessels and lack of oxygen and nutrients supply to the brain

causing a decrease in cerebral perfusion. Formation of cytotoxic edema and possible

rupture may happen (aneurism) that will result to ischemic stroke, prolong brain tissue

damaged and death.

29
 Schematic Diagram:

STRESS
Predisposing Factors: Precipitating Factors:

 Diabetes Mellitus  Age

Excessive Alcohol  Renal disease  Race/ Genetic
Consumption  Stroke  Family History
 Family History  Life events (Diet)

Cerebral blood flow

Changes in Arterioles bed

Systemic Vascular Resistance

H2o Intake
Afterload

Sodium
Polyuria
Frequent Activity of Heart
Renal Sodium Retention

Chest ECF dehydration

CARDIOMEGALY pain Decreased Filtration surface

Blood Viscosity
Vasoconstriction Juxtaglomerular will
Function

Resistance of Arterioles
BLOOD PRESSURE Sluggish Circulation 30

Blood flow to organ

 O₂ glucose supply to the brain

Cell membrane destruction

If Treated:
Breakdown of cell membrane and proteins from free radicals
 There will be a controlled Blood Pressure & no more
risks for Chronic Diseases.
 If time permits the patient will be able to improve
her healthy lifestyle to its optimum level. NEUROLOGICAL DYSFUNCTIONAL
 Prompt management of Hypertension.

-Trouble
speaking
Hypoxia -Trouble seeing
-UNKNOWN
pain
Altered cerebral metabolism -Dizziness
If Not Treated

Cerebral perfusion

Aneurysm rupture Ischemic stroke Brain tissue neurosis

Local acidosis

Cytotoxic edema DEATH

31
 Nursing Intervention:
Medical Intervention:
 Monitor vital signs and refer
unusualities  Physical Examination
 Frequent assessment of neurological  Blood tests
assessment  Computerized Tomography (CT
 Fall prevention measures Scan)
 Prevent aspirations, keep HOB  Magnetic Resonance Imaging (MRI)
degrees during oral intake and keep  Antiplatelet drugs
patient upright after a meal  Antihypertensive drugs
 Promote rest  Electrolytes
 Prevent further progression of  Proton Pump Inhibitor
edema  Therapeutic Lipid Lowering
 Promote complete bladder emptying
 Promote cerebral tissue perfusion
 Promote adequate nutrition
 Prevent skin breakdown; turn side
to side every two hours, keep linen
clean and dry
 Monitor intake and output, quantify
and refer unusualities
 Ensures that the patient took the
medicine
 Facilitate communication, promote
family coping and communication

32
 x. PHYSICIAN’S ORDER

DATE ORDER IMPLICATION JUSTIFICATION

AND
TIME
January  Please admit patient under Please admit patient For further
8,2020 Dr. Jaylo under Dr. Jaylo observation and
8:00Pm thorough
monitoring of
the patient.
Under the
specific and
specialized
physician that
will help in a
faster recovery
of the patient.
 Secure consent to care, to room To practice the Serve as
of choice rights of the patient evidence that
in receiving services the patient
and treatment. agreed in all the
treatment and
procedures to
be done to her
patient.
 Low salt, low fat Diet To control sodium & This will
fats monitor the
sodium intake
of the patient
during hospital
stay.
 IVF PNSS 1L at 100cc/hr To keep the vein It was necessary
open for because the
medications and for patient is having
fluid and excessive
electrolytes balance vomiting thus
avoid
dehydration
 Monitor Input & Output every To help evaluate a Closed
shift patient's fluid and monitoring of
electrolyte intake & output

33
 imbalance, to measurements
suggest various for fluid
diagnoses and allow imbalances & if
prompt intervention the patient is at
to correct any risk for
imbalances. dehydration by
calculating.
 Vital signs Monitoring every To determine Monitoring of
4hours changes in vital vital signs is
signs. necessary; it
may change
from time to
time that may
indicate
complication.
 IVFTF: PNSS 1L @ SFSR x 2 This helps to replace
loss fluid in the
body.

 For laboratory Test:

- CBC
-Urinalysis
-CBG
-ECG 12L
-Trop I
-FBS
-Lipid profile
-Creatinine
-SGPT, SVA
-Chest X ray –PA
-Electrolytes

 Medicine:
-Clonidine 75mg 1TAB sl Anti-hypertensive Patient is
-ISDN 5mg 1TAB sl hypertensive
-Omeprazol 40mg
-Losartan 100g 1TAB –stock -treat

 Will inform Attending

Physician
 Refer unusualities
January  For laboratory Test: This is to rule in or To look for
9, 2020 - CBC rule out a diagnoses, changes in
6:00 AM -Urinalysis monitor & screening patients’ health

34
 -CBG purposes. & monitor
-FBS baseline.
-Lipid profile
-Creatinine
-SGB, SVA
-Chest X ray –PA

 Medicines:
- Cefuroxime 1.5 qm
every 8 hours IVTT
- 6PM, 2AM, 10AM
- Telmisartan x Hct
(Nicardus plus) 5mg
1TAB OD
6PM  Medicines:
-Valsartan+ amlodepine 1tab
OD
-Nebivolol 5mg 1tab OD
-Clopidrogel

9PM  Medicine:
-Astorvastatin 20mg 1TAB OD
January  Please start Kalum Durule 1 Use to treat
10,2020 TAB OD hypokalemia
6AM
 Regulate IVF PNSS 1L at To keep vein open
100cc/hr

 Continue Medicine

 Refer any unusualities For further For monitoring

management & vital signs
continuous
medication
 O2 at 2L/min via NC To monitor level of Patient
oxygen experiencing
chest pain

35
 X. LABORATORY RESULT

 Capillary Blood Glucose (CBG)

1/9/20 @11:38am

Types of Result Normal value Implication Justification

examination
Capillary Blood 110mg/dL 70-130mg/dL Normal
Glucose (CBG)

 Urinalysis
1/8/20

RESULT NORMAL IMPLICATIONS JUSTIFICATIONS

Color Yellow Yellow Normal The urine sample is visually
examined for color, with
“yellow”, “straw” or “nearly
colorless” area normal values.
Abnormal color possible:
orange can be a side effect of a
prescribed medication, brown
and pink may indicate the
presence of blood, and dark
yellow can mean dehydration;
it was done for detection of
infection and diseases.
Character Hazy Clear Abnormal Possible indication of urinary
tract infection
Reaction 6.0 5-8- 6.4 Normal It is a test that analyzes the
acidity or alkalinity of a urine
sample, too low or too high
result may indicate the
likelihood kidney problems

36
 and other conditions.
Specific 1.015 1.005-1.025 Normal Urine specific gravity result
Gravity will fall between 1.002-1.030
kidney are functioning
normally.
Albumin (-) Normal There is no signs of Kidney
dysfunction
Sugar (-) Normal No signs of glycosuria
RBC 0-3/hpf 4 Normal .
Pus cells 15-19/ 0-2/hpf Above normal Pyuria is a condition that
hpf occur when excess WBC are
present in the urine due to
urinary tract infection
Epith cells + Abnormal

 Chemistry
1/09/20 @ 6:34 AM

Types of Result Normal value Implication Justification

examination
FBS 5.28 3.8-5.8mmol/L Normal There is no signs
Normal fasting blood of high content
glucose is a test to sugar in the blood
determine how much
glucose (sugar) is in a
blood sample after an
overnight fast
commonly used to
detect diabetes
mellitus
Cholesterol 2.87 < 5.2𝑚𝑚𝑜𝑙/𝐿 Normal High cholesterol is
It is a type of fats found the one at risk.
in the blood
Triglycerides 1.17 <1.7mmol/L Above Normal High triglycerides
might raise high
risk of heart
disease and may
be a sign of

37
 metabolic
syndrome is a
combination of
high blood sugar.
HDL 1.30 < 51𝑚𝑚𝑜𝑙/𝐿 Above Normal HDL usually high
cholesterol High density in patients with
lipoprotein cholesterol hypertension and
may protect the body diabetes.
against narrowing
blood vessels.

LDL 0.98 < 3.6𝑚𝑚𝑜𝑙/𝐿 Normal Low density

Cholesterol lipoprotein

 HEMATOLOGY
1/8/20 @ 11:37

Type of Result Normal value Implication Justification

Examination
Hemoglobin 117 F(120-140)g/l Below Normal To determine the
M(135-160)g/l patient’s level of
protein in her red
blood cells that
carries oxygen.
RBC 4.11 F(3.70-4.20) Normal During the
M(4.05-4.20) To determine development of
volume of red hypertension
blood cells in peripheral
the patient’s vascular resistance
body. is increase.
WBC 7.1 5-10 Above Normal Patient’s has
To determine urinary tract
the number of infection as
WBC in the evidence by
body. WBC increase pus cells
helps fight of 15-19.
infections,
viruses and

38
 bacteria that
invades the
body.
Hematocrit 0.38 F (37- 0.45) Normal It is necessary to
To determine measure the
the percentage proportion of RBC
of red blood in the blood
cells in the because it helps
plasma. the doctor to make
a diagnosis or
monitor the
response of the
patient to the
treatment.
Segmenters 0.75 0.50- 0.70 Above Normal High segmenters
To determine due to infection
the level of WBC and inflammation.
in the blood that
responds to
bacterial
infections.
Lymphocytes 0.25 0.25-0.40 Normal These essential
WBC fight cells circulate in
illness and blood and lymph
disease. fluid.
Lymphocytopemia
occur when edema
is present.

 SEROLOGY
January 10, 2020 @ 6:35 am

TYPES OF RESULT NORMAL IMPLICATION JUSTIFICATION

EXAMINATION VALUE
Sodium 136.1 135- Normal Sodium is an
Substance 145mmo/L electrolyte and it
helps regulate the
amount of water that
is around the cells.
Chloride S. 112.5 98-107mmo/L Above Normal Hyperchloremia have
Chloride in the body too much chloride in
maintains fluid balance the bloodstream due

39
 and maintain proper to changes in the
blood volume pressure. body fluid level or a
presence of pitting
edema and increase
blood pressure of the
patient.
Alt/SGPT 49 < 31𝑢/𝑙 Above Normal Our body uses ALT to
Alanine Aminotransferase break down food into
or ALT used to be called energy. Normal ALT
serum glutamic pyruvic level in the blood is
transaminase or SGPT is low. If liver is damage
an enzyme made in the it will release more
liver. It is release into the ALT into the blood.
blood when tissues are
damage or liver tests.
Creatinine 110 53-97 Above Normal These are used to
screen, diagnose, and
monitor
kidney(renal)
disorders, including
chronic kidney
disease and acute
renal failure.
Uric Acid 460.3 150-350 Above Normal these are used to
Increased concentration in screen, diagnose and
the patients with monitor kidney or(
neurodegenerative renal) disorders
disease must be balance including chronic
with its possible adverse kidney disease and
effects which include bp, acute renal failure.
renal disease coronary
disease, and stroke.
Capillary 110 70-130mg/dl Normal Decreased CBG occur
Blood Glucose when taking insulin
or certain other
medication.
Potassium 3.49 3.5-4.5mmo/L Normal Due to patient clinical
Potassium is one of the manifestation
most important mineral in transient ischemic
the body help regulate attack can affect low
fluid balance muscle level of potassium
coronation and nerve due to inflammation
signals. of the skin body
weakness, numbness

40
and slowly damage
nerve.

41
 XI. DRUG STUDY

DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATION

Adjunctive  Contraindicated in: CNS: dizziness,  Obtain a dietary history,
Drug Name: management of Hypersensitivity; headache, insomnia, especially with regard to fat
Inhibit an
Atorvastatin primary active liver disease weakness. consumption.
enzyme, 3-
Classification: hydroxy-3- hypocholesteremia or unexplained CV: chest pain,  Lab test considerations:
methylglutary
Therapeutic: and mixed persistent ↑ in AST peripheral edema. Evaluate serum cholesterol
lcoenzyme A
Lipid-lowering (HMG-CoA) dyslipidemias. or ALT; OB, EENT: rhinitis; and triglyceride levels
reductase,
agents  Primary Lactation: lovastatin―blurred before initiating, after
which is
Pharmacologic: responsible prevention of Pregnancy or vision. 4―6wk of therapy, and
for catalyzing
HMG-CoA cardiovascular lactation (potential RESP: bronchitis. periodically thereafter.
an early step
reductase in in the disease (↓ risk of for fetal anomalies); GI: abdominal cramps,  Monitor liver function tests,
synthesis of
inhibitors MI or stroke) in Concurrent use of constipation, diarrhea, including AST, before, at 12
cholesterol.
Dosage: patients with gemfibrozil or azole flatus, heartburn, altered wk after initiation of
10 mg multiple risk antifungals ; taste, drug induced therapy or after dose
Frequency: factors for Concurrent use of hepatitis, dyspepsia, elevation, and then q 6 mo.
Once a day coronary heart nelfinavir or elevated liver enzymes, If AST levels ↑ to 3 times
Route: disease CHD or ritonavir (with nausea, pancreatitis. normal, HMG-CoA
Oral type 2 diabetes lovastatin or GU: erectile dysfunction. reductase inhibitor therapy
mellitus (also ↓ simvastatin) DERM: rashes, pruritus. should be reduced or

42
risk for of angina  History of liver MS: discontinued. May also
or disease; alcoholism; RHENABDOMYOLYSIS, cause ↑ alkaline
revascsularizatio rosuvastatin only― arthralgia, arthritis, phosphatase and bilirubin
n procedures in patients with Asian myalgia, myositis. levels.
patients with ancentry (may have MISC: hypersensitivity  If patient develops muscle
multiple risk ↑ blood levels and ↑ reactions. tenderness during therapy,
factors for (CHD) risk of monitor CK levels. If CK
rhabdomyolysis); levels are > 10 times the
Altorvastatin, upper limit of normal or
lovastatin, myopathy occurs, therapy
rosuvastatin, and should be discontinued.
simvastatin  Do not confuse Pravachol
only―concurrent (pravastatin) with Prevacid
use of gemfibrozil, (lansoprazole)
azole antifungals,  PO: administer lovastatin
macrolides, with food. Administration
protease inhibitors, on empty stomach
niacin, cyclosporine, decreases absorption by
amiodarone or approximately 30%. Initial
verapamil (↑ risk of once-daily dose is
myopathy/rhabdom administered with the
yolysis); Renal evening meal.

43
impairment;  Administer extended-
OB: Women of release tablets should be
childbearing age; swallowed whole, do not
PEDI: Children<8yr crush, break, or chew.
(safety not  Atorvastatin can be taken
established; some any time of day. May be
products approved administered without
for use in older regard to food.
children only)  Avoid large amount of
grapefruit juice during
therapy: may ↑ risk of
toxicity.
 Instruct patient to take
medication as directed and
not to skip doses or double
up on missed doses.
 Advise patient that this
medication should be used
in conjunction with diet
restrictions (fats,
cholesterol, carbohydrates,

44
 alcohol), exercise, and
cessation of smoking.
 Advise patient to avoid
taking Rx, OTC, or herbal
products without
consulting with ahealth
care professional.

45
DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATION
Kalium Durule Principal Prevention and correction Contraindicated with GI: nausea, vomiting,  Monitor I&O
intracellular of potassium deficiency; allergy to tartrazine, diarrhea  Administer oral drug
Classification caution of most when associated with aspirin; therapy with after meals or with
: Electrolytes body tissues, alkalosis, use potassium potassium-sparing food and a full glass
participates in a chloride diuretics or of water to decrease
number of aldosterone inhibiting GI upset
Dosage: physiologic agents; sever renal  Caution patient not to
1 tab processes impairment with chew or crush
maintaining oliguria, anuria, tablets; have patient
Frequency: intracellular azotemia; swallow tablet whole.
TID 3x a days tonicity, hyperkalemia; acute
transmission of dehydration heat
nurse impulses; cramps
Route: contraction of
Oral cardiac,
skeletal, and
smooth muscle;
maintenance of
normal renal
function; also

46
plays a role in
carbohydrate
metabolism and
various
enzymatic
reaction

47
Generic Name Action Indication Contraindication Adverse Effect Nursing Considerations
DrugName: Inhibits Adults: Inititally, - Contraindicated in CNS: Dizziness,  Drug can be used alone
vasoconstrictive or with other
Losartan 50mg P.O. daily. patients asthenia, fatigue,
and aldosterine antihypertensives.
secreting action Maximum daily hypersensitive to headache,  If antihytensive effect is
of angiotensin II inadequate using once-
Classification: dose is 100mg in drug. Breast-feeding insomnia
by blocking daily doses, a twice-daily
Antihypertensives angiotensin II one or two isn’t recommended CV: Edema, chest regimen using the same
receptor on the or increased total daily
divided doses during losartan pain
surface of dose may give a more
Dosage: vascular smooth Children age 6 therapy. EENT: Nasal satisfactory response.
muscle and and older: 0.7  Monitor patient’s BP
1 tab - Use cautiously in congestion,
other tissue mg/kg (up to closely to evaluate
patients with
cells. 50mg) P.O. daily, sinusitis, effectiveness of therapy.
impaired renal or
adjusted as When used alone , drug
Frequency: hepatic function. pharyngitis, sinus
needed up to 1.4 has less of an effect on
mg/kg (maximum disorder BP in bask patients than
100mg). in patients of other
GI: Abdominal
races.
Route: pain, nausea,  Monitor patients who
are also talking diuretics
Oral diarrhea,
for symptomatic
dyspepsia hypotension.
 Regularly assess the
RESP: Cough,
patient’s renal function
upper respiratory
(via creatinine and Bun
tract infection
levels).
 Patients with severe
heart failure whose
renal function depends
on the angiotensin
aldosterone system may

48
 develop acute renal
failure during therapy.
Closely monitor patient’s
BP, renal function, and
potassium levels,
especially during first
few weeks of therapy
and after dosage
adjustments.
Look alike-sound alike: Don’t
confuse Cozaar with Zocor
or Colace.

49
Generic Name Action Indication Contraindication Adverse Effect Nursing Considerations
Drug Name: Inhibit platelet Reduction of In hypersensitivity, CNS: depression,  Asses patient sign of
aggregation by atherosclerotic pathologic bleeding stroke, peripheral
Clopidrogel dizziness, fatigue,
irreversibly event (mI, stroke, (peptic ulcer, vascular disease or ml
inhibiting the vascular death) in intracranial headache periodically during
binding of ATP to patient at risk for hemorrhage therapy
Classification: RESP: cough,
platelet receptor such events lactation)  Monitor patient for sign
Antiplatelet including recent dyspnea of thrombolytic purpura
mI, acute coronary  Lab test: monitor
agents CV: chestpain,
syndrome, stroke, bleeding time during
or peripheral edema, hypertension therapy
vascular disease.  Prolonged bleeding time
Dosage: EENT: epistaxis
which is time-and-dose
70 mg GI: abdominal pain, dependent, is expected.
diarrhea, deppepsia,  Monitor CBC with
gastritis differential and platelet
Frequency: count periodically
during therapy
Once a day
 Instruct patient to take
medication exactly as
directed
Route:
 Advice patient to notify
health care professional
promptly if fever, chills,
sore throat, or unusual
bleeding or bruising
occurs
 Avoid over the counter
medication

50
Generic Name Action Indication Contraindication Adverse Effect Nursing Considerations
Selectively blocks Adults: Initially, 5mg - Patients CNS: Asthenia,  Check patient’s BP
Drug Name:
beta1-adrenergic P.O. once daily. hypersensitive to dizziness, fatigue, and heart rate often.
Nebivolol receptors, Increase at 2-week drug and those with headache, insomnia,  Monitor LFT’s and
reducing heart intervals to a decompensated paresthesia. renal function test
Classification: rate, myocardial maximum dose of heart failure, severe GI: Abdominal, results.
Antihypertensive contractility, and 40mg, if needed. bradycardia, second- diarrhea, nausea  If nebivolol must be
sympathetic tone. Adjust-a-dose: For or third-degree AV CV: Bradycardia, stopped, do so
Dosage: Reduces BP by patients with severe block, sick sinus chest pain, gradually over 1 to 2
5mg suppressing renin renal impairment or syndrome, peripheral edema weeks.
1 tab activity and moderate hepatic cardiogenic shock, METABOLIC:  Observe a diabetic
decreasing impairment, start bronchial asthma or Hypercholesterole patient closely
Frequency: peripheral with 2.5mg P.O. once related mia, hyperuricemia because drug may
Once a day vascular daily. Increase dose bronchospastic RESP: Dyspnea mask evidence of
resistance cautiously, if needed. conditions, or severe SKIN: Rash hypoglycemia.
Route: hepatic impairment  If patient has heart
Oral failure, watch for
worsening symptoms,
renal dysfunction, or
fluid retention. His
diuretic dosage may
need to be increased.
 Store drug at room
temperature in a
light-resistant
container.

51
Generic Name Action Indication Contraindication Adverse Effect Nursing Considerations
Blocks Adults: 40mg -Patients CNS: Dizziness, pain,  Monitor patient for
Drug Name:
vasoconstrictions P.O. daily. BP hypersensitive to fatigue, headache hypotension after
Telmisartan and aldosterone response is drug or its GI: Nausea, abdominal starting drug, place
secreting effects dose-related components. pain, diarrhea, dyspepsia patient supine if
Classification: of angiotensin II over a range of Use cautiously in CV: Chest pain, hypotension occurs,
by preventing 20 to 80mg patients wuth biliary hypertension, peripheral and give I.V. NSS, if
Antihypertensi angiotensin II daily. obstruction disorders edema needed
ves from binding to or renal and hepatic MUSCULO: Back pain,  Most of the
the angiotensin I insufficiency and in myalgia antihypertensive
Dosage: receptor. those with an RESP: Cough, upper effect occurs within 2
activated renin- respiratory tract infection weeks. Maximal BP
40/12.5mg angiotensin system, OTHER: Flulike symptoms reduction is usually
1 tab such as volume or reached after 4 weeks.
sodium-depleted Diuretic may be added
Frequency: patients if BP isn’t controlled
by drug alone.
Once daily  Drug isn’t removed by
hemodialysis. Patients
Route: undergoing dialysis
may develop
orthostatic
hypotension. Closely
monitor BP.
 Monitor patients with
impaired hepatic
function or biliary
obstruction carefully.
Start telmisartan at
low dose and nitrate
slowly.

52
Generic Name Action Indication Contraindication Adverse Effect Nursing Considerations
Unknown. Adults and - Transdermal form is CNS: Drowsiness,  Drug may be given to
Drug Name:
Thought to children age 12 contraindicated in dizziness, sedation, lower BP rapidly in
Clonidine stimulate and older: Initially, patients weakness, fatigue, some hypertensive
alpha2 0.1mg daily on a hypersensitive to any malaise, agitation, emergencies.
Classification: receptors and weekly basis. component of the depression.  Monitor BP and pulse
Antihypertensive inhibit the Usual range is 0.2 adhesive layer of GI: Constipation, dry rate frequently.
central to 0.6mg daily in transdermal system. mouth, nausea, Dosage is usually
Dosage: vasomotor divided doses; - Epidural form is vomiting, anorexia adjusted to patient’s
15g centers, infrequently, contraindicated in CV: Bradycardia, BP and tolerance
1 tab decreasing dosages as high as patients receiving severe rebound  Elderly patients may
sympathetic 2.4mg daily are anticoagulant therapy, hypertension, be more sensitive than
Frequency: outflow to the used. in those with an orthistatic younger ones to
7:30am heart, kidneys, Or, apply injection-site hypotension drug’s hypotensive
and peripheral transdermal patch infection, and in those GU: Urine retention, effects.
Route: vasculature, once every 7days, who are erectile dysfunction  Observe patient for
Oral and lowering starting with 0.1- hemodynamically METABOLIC: Weight tolerance of drug’s
peripheral mg system and unstable or have gain therapeutic effects,
vascular adjusted with severe CV disease. SKIN: Pruritus, which may require
resistance, BP, another 0.1-mg or - Use cautiously in dermatitis with increased dosage
and heart rate. larger system after patients with severe transdermal patch,  Noticeable
1 or 2 weeks if coronary rash antihypertensive
desired BP insufficiency. OTHER: Loss of effects of transdermal
reduction isn’t Conduction libido clonidine may take 2
achieved. disturbances, recent to 3 days. Oral
MI, cerebrovascular antihypertensive
disease, chronic renal therapy may have to
failure, or impaired be continued in the
liver finction. interim

53
Generic Action Indication Contraindication Adverse Effect Nursing Considerations
Name
Thought to be a Short-term Lactation. Use as CNS: headache, dizziness, - Take capsule at least 1hr
Drug Name:
gastric pump treatment of active maintenance Possibly, anxiety disorders, before eating and swallow
Omeprazole inhibitor in that duodenal ulcer; therapy for anxiety, disorders, abnormal whole; do not open, chew, or
it blocks the final First line therapy duodenal ulcer dreams, vertigo crush. Antacids ca be
Classificatio step of acid in treatment of disease. OTC use GI: Diarrhea, N&V, administered with
n: production by heartburn or in those who have abdominal pain/swelling, omeprazole.
Proton pump inhibiting the symptoms of trouble or pain constipation, flatulence, - For those who have difficulty
inhibitor H+/K+ ATPase gastroesophageal swallowing food, anorexia, fecal discoloration, swallowing capsules, add
system at the reflux disease are vomiting esophageal candidiasis, 1tbsp of applesauce to an
Dosage: secretory (GERD). Long- blood, or excreting mucosal atrophy of the empty bowl. Open omeprazole
75mg surface of the term therapy: bloody or blacks tongue, dry mouth, irritable capsule and empty pellets onto
gastric parietal Treatment of stool. colon, gastric fundic gland applesauce. Mix pellets with
Frequency: cell. Both basal pathologic hyper polyps, gastroduodenal the applesauce and swallow
7:30am and stimulated secretory carcinoids. immediately. Do not heat or
acid secretions conditions CV: Angina, chest pain, chew the applesauce and do
Route: are inhibited. (Zollinger- tachycardia, bradycardia, not chew or crush the pellets.
Hab Serum gastric Ellisonsyndrome, palpitation, peripheral Do not store mixture for future
levels are multiple edema, elevated BP. use.
increased during adenomas, DERMATOLOGIC: Rash, - take oral suspension on an
the first 1 or 2 systemic severe generalized skin empty stomach at least 1hr
weeks of therapy mastocytosis). reaction including toxic before a meal. To prepare the
and are epidermal necrolysis, Stevens- oral suspension, empty the
maintained at Johnson syndrome; erythema contents of a packet into a
such levels multiform, skin small cup containing 1 or 2
during the inflammation, urticaria, tbsps. of water. Do not use
course of pruritus, alopecia, dry skin, other liquids or foods. Stir well
therapy. hyperhidrosis. and drink immediately. Refill

54
GU: UTI, acute interstitial
nephritis, urinary frequency,
hematuria, proteinuria,
glycosuria, testicular pain,
microscopic pyuria,
gynecomastia.
HEMATOLOGIC:
Pancytopenia,
thrombocytopenia, anemia,
leukocytosis, neutropenia,
hemolytic anemia,
agranulocytosis.
MUSCULOSKELETAL:
Asthenia, back pain, myalgia,
joint/leg pain, muscle
cramps, muscle weakness.
MISCELLANEOUS: Rash,
angioedema, fever, pain,
gout, fatigue, malaise, weight
gain, tinnitus, alteration in
taste; allergic reactions,
including anaphylaxis (pain),
fever, pain, malaise. When
used with clarithromycin the
following additional side
effects were noted: Tongue
discoloration, rhinitis,
pharyngitis, and flu
syndrome. NOTE: Data are
lacking on the effect of long-
term hypochlorhydria and
hypergastrinemia on the risk
of developing tumors.
cup with water and drink.
- report any changes in urinary
elimination, pain, discomfort
or persistent diarrhea.
- avoid alcohol and OTC agents
as well as foods known to
cause GI upset/irritation.
- avoid activities that require
mental alertness until drug
effects realized; may cause
dizziness.
- do not use OTC product for
more than 14days unless
directed by provider.
- Use reliable contraception;
potential risk to the fetus.
For short-term use only, drug
inhibits total gastric acid
secretion. Side effects of
prolonged therapy and
suppression of acid secretion
alter bacterial colonization and
lead to hypochlorhydia and
hypergastrinemia which may
cause an increased risk for
gastric tumors.
55
Generic Name Action Indication Contraindication Adverse Effect Nursing Considerations
Hydro thiazide - Indicated for Pregnancy and  Headache  Monitor BP
Drug Name:
inhibits sodium treatment of severe hepatic  Dizziness periodically in patients
Valsartan reabsorption in hypertension by impairment, biliary  Fatigue on concurrent
the distal tubules lowering blood cirrhosis and  Abdominal pain antihypertensive
causing increased pressure (BP). cholestasis, anuria,  Cough therapy.
Classification: secretion of - Indicated for the severe renal  Diarrhea  Monitor intake and
Angiotensin II sodium and water treatment of heart impairment,  Nausea output of patient.
Receptor as well as failure to reduce refractory  Hyperkalemia
Blockers potassium and the risk of hypokalemia,  Impotence
hydrogen ions. hospitalization for hyponatremia and  Reduced renal
Dosage: Valsartan acts as heart failure in hypercalcemia. function
1 tab direct antagonist patients. Symptomatic  Allergic reactions
of angiotensin II - Indicated to hyperuricemia.
Frequency: receptors and reduce the risk of
Once a day causes cardiovascular
vasoconstriction, death in clinically
Route: aldosterone stable patients w/
Oral release, arginine left ventricular
vasopressin failure or left
release, water ventricular
intake, and dysfunction.
hyperthopic
responses.

56
Generic Name Action Indication Contraindication Adverse Effect Nursing Considerations
A fungal metabolite - As an adjunct to - Contraindicated CNS: Headache,  Establish baseline
Drug Name:
that inhibits the diet in the w/ allergy to any dizziness, serum lipid levels
Rosuvastatin enzyme(HMG-CoA) treatment of component of the insomnia, and liver function
that catalyzes the elevated total product, active liver hypertonia, test results before
first step in cholesterol and dse. or persistent paresthesia, beginning therapy.
Classification: cholesterol LDL cholesterol elevated serum depression,  Consult dietician
Antihyperlipidemic synthesis pathway, and triglyceride transaminase, anxiety, vertigo, about low
drug resulting in a levels in patients pregnancy, neuralgia cholesterol diets.
HMG-CoA decrease in serum w/ primary lactation. CV: Hypertension,  Administer drugs at
reductase inhibitor cholesterol, serum hypercholesterole - Use cautiously w/ angina pectoris, bedtime (highest
LDL’s and either mia. impaired hepatic vasodilation, rate of cholesterol
Dosage: increase or no - Adjunct to diet to function, palpitation, synthesis occur
1tab change in serum slow alcoholism, renal peripheral edema between midnight
HDL’s. atherosclerosis impairment, GI: Nausea, and 5am).
Frequency: progression in advanced age, dyspepsia,  Monitor patients for
patients with hypothyroidism. diarrhea, closely for signs of
elevated constipation, injury.
Route: cholesterol. gastroentiritis,
Oral - As an adjunct to vomiting,
diet for the flatulence,
treatment of peridontal,
patients with abscess, gastritis,
elevated serum liver failure
triglyceride levels. RESPI:
Pharyngitis,
rhinitis, sinusitis,
cough, dyspnea,
pneumonia

57
Generic Name Action Indication Contraindicati Adverse Effect Nursing Considerations
on
Second It is effective for the Hypersensitivity CNS: Before:
Drug Name:
generation treatment of to GI: Diarrhea,  Determine history of
Cefuroxime cephalosporins penicillinase cephalosporins nausea, antibiotic hypersensitivity reactions
that inhibits producing Neisseria and related associated colitis to cephalosporins,
Classification: cell wall gonorrhea (PPNG). antibiotics; SKIN: Rash, penicillins and history of
Anti-infectives synthesis, Effectively treats bone pregnancy pruritis, urticaria allergies, particularly to
promoting and joint infections, (category B), UROGENITAL: drugs, before therapy is
Dosage: osmotic bronchitis, lactation. Increased serum initiated.
1.5mg instability; meningitis,gonorrhea, creatinine and  Lab tests: Perform culture
1 tab usually otitis media, BUN, decreased and sensitivity tests before
bactericidal. pharyngitis/tonsillitis, creatinine initiation of therapy and
Frequency: sinusutis, lower clearance periodically during therapy
Every 8hrs respiratory tract HERMAT: if indicated. Therapy maybe
infections, and is used Hemolytic anemia instituted pending test
Route: for surgical MISC: results. Monitor
IVTT prophylaxis, reducing Anaphylaxis periodically BUN and
or eliminating creatinine clearance
infection. After:
 Inspect IM and IV injection
sites frequently for signs of
phlebitis.
Monitor for manifestations of
hypersensitivity

Generic Name Action Indication Contraindicati Adverse Effect Nursing Considerations

on

58
 Relaxes Acute anginal attack; Contraindicate CNS: headache, Before:
Drug Name:
vascular to prevent situation with allergy to vertigo, dizziness,  Monitor blood pressure &
Isosorbide dinitrate smooth muscle that may cause Nitrate, severe faintness, intensity & duration of
with resultant anginal attack anemia, head weakness responds to drug.
Classification: decrease in trauma cerebral GI: nausea,  Advise patient to avoid
Anti-angina venous retun & hemorrhage, vomiting, alcoholic beverages they
Nitrate decrease & hypertrophic abdominal pain, produce increase
Vasodilator arterial BP, cardiomyopathy diarrhea hypotension.
which reduces , narrow-angle Dermatologic:  Warn patient not to
Dosage: left ventricular glaucoma & rash, exfoliative confuse sublingual with
5 mg workload & postural dermatitis, oral form
1 tab decreases hypotension. cutaneous  Store in cool place in tightly
myocardial vasodilation with closed container away from
Frequency: oxygen flushing light
Every 8hrs consumption. CV: tachycardia,
hypotension,
Route: orthostatichostati
Sublingual c hypotension
MISC:
Anaphylaxis

59
 XII. NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: After 8 hours span 1. Identify client 1. Persons w/ impaired After 8 hours
Naglisod ko Ineffective of our care the populations at risk. ciliary function; those w/ span of our care
ug ginhawa Airway patient will be able excessive or abnormal the patient was
ma’am, Clearance to: 2. Assess level of mucus production. able to:
tungod consciousness/cognition
siguro sa 1. Maintain airway and ability to protect 2. This information is 1. Maintaine
plema , gahi patency. own airway. essential for identifying d airway
man gud potential for airway patency
akong ubo. 2. Expectorate 3. Monitor respirations problems, providing
(as /clear secretions and breathe sounds, baseline level of care 2. Expectorated
verbalized by readily. noting rate and sounds. needed, and influencing /cleared
the patient) choice of interventions. secretions
3. Verbalize 4. Evaluate client’s readily
understanding of cough/gag reflex, 3. Indicative of respiratory
Objective: cause(s) and amount and type of distress an/or 3.Verbalized
-difficulty of therapeutic secretions, and accumulation of understanding
breathing management swallowing ability. secretions. of cause(s) and
-productive regimen. therapeutic
cough 4. Demonstrate 5. Position head 4. To determine ability to management
d behaviors to appropriate for age protect own airway. regimen
u improve or maintain and condition. 4. Demonstrated
clear airway. 5. To open or maintain open behaviors to
d 6. Suction nose, mouth, airway in an at-rest or improve or
i 5. Identify potential and trachea prn. compromised individual. maintain clear
complications and airway

60
how to initiate 7. Elevate head f bed, 6. To clear airway when 5. Identified
appropriate encourage early excessive or viscious potentials
preventive or ambulation, or change secretions are blocking complications
corrective actions. client’s position every 2 airway or client is unable and how to
hr. to swallow or cough initiate
effectively. appropriate
8. Encourage deep- preventive or
breathing and coughing 7. To take advantage of corrective
exercises or splint gravity decreasing actions.
chest/incision. pressure on the
9. Evaluate changes in diaphragm and
sleep pattern, noting enhancing drainage
insomnia or daytime of/ventilation to different
somnolence. lung segments.
10. Assess client’s/SO’s 8. To maximize effort
knowledge of 9. Which may be evidence of
contributing causes, nighttime airway
treatment plan, specific incompetence or sleep
medications, and apnea?
therapeutic procedures. 10. To determine
educational and support
needs.

61
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: After 8 hours span 1. Note individual’s age 1. Chances of frailty rise 85. After 8 hours
 Fatigue Risk for frail of our care the and gender. Women are likely than men span of our
 hopeles elderly patient will be able 2. Determine nutritional to be frail because women care the
sness syndrome to: status are more typically start out patient was
r/t age >70 3. Assess the clients w/ less muscular mass than able to:
yrs. & 1. Acknowledge the physical and cognitive men.
Objective: female presence of status 2. Malnutrition’s and factors 1. Acknowled
gender factors affecting 4. Note the clients living contributing to failure to eat. ged the
 impaired well-being. situation 3. Identify tolerance for activity presence
physical 2. Identify 5. Ascertain safety of the and/or self-care of factors
activity corrective/adapt home environment and 4. This helps to identify affecting
 irritability ive measures for persons providing care environmental risk factors well-being.
 lethargy individual 6. Evaluate the client’s such as falls, problem w/ 2. Identified
situation. level of adaptive behavior food shopping or corrective
3. Demonstrate and client ‘caregiver preparation, depression and /adaptive
behaviors/lifesty knowledge and skills so on measures
le changes about health 5. To identify the potential for for
necessary to maintenance, presence of neglectful or individual
enhance environment, and safety. abusive situations and/or situation.
functional status. 7. Encourage the client need referrals 3. Demonstrat
to talk about positive 6. To instruct, intervene, and ed
aspects of life and to keep refer appropriately. behaviors/
as physically active as 7. To reduce the effects of lifestyle
possible dispiritedness. changes
8. Promote socialization 8. To provide additional necessary
within individual 9. stimulation and reduce sense to enhance
limitations of isolation functional
9. Help client to explore 10. This enhances hope and status.
reasons for living sense of control

62
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: After 8 hours span 1. Identify physical 1. That can impact the clients After 8 hours span
 Expres Readiness for of our care the conditions. elimination patterns. of our care the
ses enhance patient will be able 2. Asceratin methods of 2. To identify strengths and patient was able
desire urinary to: self-management. areas of concern in to:
to elimination 3. Encourage fluid elimination management.
enhanc 1. Verbalize intake, including 3. To help maintain renal 1. Verbalized
e understanding water. function and prevent understanding
urinary of condition 4. Determines client’s infection. of condition
elimina that has usual daily fluid 4. Amount and timing of fluid that has
tion potential for intake. intake, as well as beverage potential for
altering 5. Restrict fluid intake 2 choices, are important in altering
elimination. to 3 hrs before managing elimination. elimination.
Objective: 2. Maintain normal bedtime, if indicated. 5. To reduce voiding during 2. Maintained
 Disten or acceptable 6. Observe voiding night. normal or
ded elimination pattern, time, color, 6. To document normalization acceptable
bladde pattern and amount voided. of elimination. elimination
r emptying 7. Regulate liquid intake 7. To promote a predictable pattern
bladder, voiding at prescheduled voiding pattern. emptying
in appropriate times. 8. Limiting caffeine intake bladder,
amounts. 8. Modify or recommend because of its bladder voiding in
3. Alter lifestyle or diet changes. irritant effect. appropriate
environment to 9. Encourage 9. This promotes proactive amounts.
accommodate continuation of problem-solving & supports 3. Altered lifestyle
individual successful toileting self-esteem. and or environment
needs. program and identify normalization of social to
possible alterations interactions and desired accommodate
to meet individual lifestyle activities. individual
needs. needs.

63
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: After 8 hours span 1. Note of presence acute 1. Many factors can cause or After 8 hours span
Activity of our care the or chronic illness, such contribute to fatigue, of our care the
‘’dli na jud na intolerance patient will be able as heart failure, having potential to patient was be
sya ka tindug r/t to: pulmonary disorders, interfere with client’s able to:
kaayu maam generalized hypothyroidism, ability to perform at a
lalo nag walay weakness 1. Identify negative diabetes mellitus, AIDS, desired level of activity. 1. Identified
mo alalay sa factors affecting anemias, cancers, However, the term negative factors
iya’’ as activity tolerance pregnancy-induced “activity intolerance” affecting activity
verbalized by and eliminate or hypertension, and acute implies that the client tolerance and
the patient’s reduce their effects and chronic pain. cannot endure or adapt eliminate or
husband. when possible. 2. Ask client/significant to increased energy or reduce their effects
other (SO) about usual oxygen demands caused when possible.
2. Use identified level of energy. by an acitivity.
techniques to 2. To identify potential 2. Used identified
Objective: enhance activity 3. Evaluate the client’s problems and/or techniques to
tolerance. actual and perceived client’s/SO’s perception enhance activity
Lethargy limitations and severity of client’s energy and tolerance.
Disoriente 3. Participate of deficit in light of usual ability to perform needed
d willingly in status. or desired activities. 3. Participated
weak necessary/desired 3. This provides a willingly in
activities. 4. Note client reports of comparative baseline necessary/desired
weakness, fatigue, pain, and information about activities.
4. Demonstrate a difficulty accomplishing needed education or
decrease in tasks, and/or insomnia. interventions regarding 4. Demonstrated a
physiological signs quality of life. decrease in
of intolerance (e.g., 5. Assess 4. Symptoms may be a result physiological signs
pulse, respirations, cardiopulmonary of or contribute to of intolerance (e.g.,
and blood pressure response to physical intolerance of actiivity pulse, respirations,
remain within activity, including vital 5. Dramatic changes in heart and blood pressure
client’s normal signs, before, during, and rate and rhythm, changes remain within
range). after activity. Note in usual blood pressure, client’s normal

64
 accelerating fatigue. and progressively range).
5. Verbalize worsening fatigue result
understanding of 6. Ascertain the client’s from an imbalance of 5. Verbalized
potential loss of ability to stand and oxygen supply and understanding of
ability in relation to move about and the demand. potential loss of
existing condition. degree of assistance 6. To determine current ability in relation
necessary or use of status and needs to existing
equipment. associated with condition.
participation in
7. Identify activity needs needed/desired
versus desires. activities.
7. To evaluate
8. Assess emotional and appropriateness
psychological factors 8. (e.g., stress and/or
affecting the current depression may be
situation. increasing the effects of
an illness, or depression
9. Note might be the result of
treatment=related forced inactivity).
factors, such as side 9. Which can affect the
effects an interactions of nature and degree of
medications. activity intolerance
10. To prevent overexertion
10. Reduce intensity
level or discontinue
activities that cause
undesired physiological
changes.

65
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
After 8 hours span 1. Observe the 1. Noting multiple factors that After 8 hours
Subjective: of our care the individual’s general might affect safety, such as span of our care
Luya man Risk for fall r/t patient will be able health status. chronic or debilitating the patient was
akong impaired to: conditions, use of multiple be able to:
paminaw sa balance+ 2. Evaluate the client’s medications, recent trauma
akong tuhod mobility 1. Verbalize current (especially a fall within the 1. Verbalized
ma’am, understanding of disorders/conditions past year), prolonged understanding
medyo individual risk that could enhance risk bedrest/ immobility, of individual
malipong pa factors that potential for falls. unstable balance on risk factors that
pod ko (as contribute to the standing. Or a sedentary contribute to
verbalized by possibility of falls. 3. Note factors lifestyle the possibility
the patient. associated with age, 2. Acute, even short-term, of falls.
Objective: 2. Modify gender, and situations can affect any
environment as developmental level. client, such as sudden 2. Modify
Weak indicated to dizziness, positional blood environment as
Dizziness enhance safety 4. Review the client’s pressure changes, new indicated to
Restlessness medication regimen medication, change in enhance safety
Old age 3. Be free of injury ongoing, noting glasses prescription, recent
Ill number and type of use of alcohol/other drugs, 3. Be free of
drugs that could and so on injury
impact fall potential. 3. Infants, young children,
young adults, and elderly
5. Evaluate use, misuse, are at greatest risk because
or failure to use of developmental issues
assistive aids, when and impaired or lack of
indicated. ability to self-protect
4. Studies have confirmed that
6. Ascertain the use of four or more
client’s/SO’s level of medications

66
knowledge about and (polypharmacy) increases
attendance to safety the risk of falls.
needs. 5. The client may have an
assistive device but is at
7. Consider hazards in use of unfamiliar device but
the care setting and/or is at high risk for falls while
home/other adjusting o altered body
environment. state and use of unfamiliar
device; or the client might
8. Assist in treatments refuse to use devices for
and provide various reasons
information regarding 6. This may reveal a lack of
the client’s understanding, insufficient
disease/condition(s). resources, or simple
disregard for personal
9. Review medication safety
regimen and how it 7. Identifying needs or deficits
affects client. Instruct provides opportunities for
in the monitoring of intervention and/or
effects and side effects. instruction
8. May result in increased risk
10. Recommend or of falls.
implement needed 9. The use of certain
interventions and medications can contribute
safety devices. to weakness, confusion, and
balance and gait
11. Use half side rail disturbances.
instead of full side rails 10. To determine if changes
or upright pole. could reduce the client’s fall
risk.
11. To assist individual in
arising from bed.

67
 XIII. NURSING MANAGEMENT

A. Actual Care Given

On January 10, 2020 at 7-3 shift, we were assigned to patient L.C.K who has been in
the hospital for two days prior to our duty. We first established rapport to the patient,
gained her trust and cooperation. Throughout the course of duty in the hospital,
independent nursing actions were made as a care to the patient. Vital signs were taken and
monitored; fluctuations in BP were noted during the course. Intravenous Fluid was
checked. Bed side care done, made sure that the patient was comfortable and the
environment was clean to promote good ventilation and avoid infection. We did Physical
assessment to her and recorded our findings to our sheet. Oral medications was given and
ensured that the patient took it. Make sure that the patient is safe because she is at risks for
fall. The IVF fluid was maintained and ensures patency and check for possible overload of
fluids. Intake and output is monitored and recorded. Comfort measures are given to relieve
symptoms discomfort and attended all the patient’s needs and concerns to our best ability.

B. Problem Encountered During the Implementation of Nursing Care

Throughout the course, we observed that the patient is cooperative with the
interventions however her watchers are more careful in giving personal information. She is
a submissive type and is very sensitive with the management being given to her. She is
friendly but fragile in action. She is a bit cautious about her health that she is just waiting
for the final say.

C. Restorative Measures Used

As a student’s nurse, we are limited to the prevention of further complications and

promotions of health and wellness by giving dependent nursing interventions to patient.
We monitor the patient’s vital signs and refer to nurse on duty any unusualities for
immediate management. Ensure that the patient took all her medicines properly, at the

68
right time and right dose. We also give her comfort measures to relieve the symptoms
discomfort she experiences. We also monitored her general condition and make sure to
avoid any further complications and progressions of her illness and symptoms by strict
monitoring and proper referrals.

D. Evaluation

By the end of session, it was evident that the patient and significant other has
enough motivation to counter act the situation and bring herself back to normal condition.
They were able to understand her condition and shows readiness to enhance her health
status. The patient will be discharge the next day but she is showing a good progress as
evidenced of diminished symptoms of illness.

E. Patient Teaching

Health advises was given to patient such as:

 Promote clean environment

 Low salt Low fat diet
 Take medications properly and on right time
 Take a rest and complete hours of sleep
 Report immediately if there are any abnormal feelings such as dizziness, nausea and
vomiting, headache and etc.
 Instruct significant others to assist patients in her activities to avoid fall.

F. Recommendations

As we conducted this case study, we have learned a lot about Hypertensive

Cardiovascular Disease. Through-out the study, we realized that monitoring and early
determination of signs and symptoms are important to avoid further complications that
will result to a more severe condition and worst, death.

69

Affecting factors 1- POOR
Onset of illness
Duration of illness  Patient had been
Precipitating illness
Attitude and
Willingness to seek
medication and
treatment
Any depressive features
Level of
awareness(related to
situation management)
Coping mechanism w/
the situation
X. PROGNOSIS
2- FAIR 3- GOOD JUSTIFICATION
 Patient was refusing to
be brought immediately
to hospital when she felt
pain in her epigastric
area and an increase of
BP
experiencing dizziness
and nape pain 2 days
before admission. She
has been staying for 2
days in hospital
 Patient AGE is more
likely experiencing
several conditions. Older
people health are genetic
due to peoples physical
and social environment
 Our patient was
cooperative in every
treatment and
management given to
her medicine. Listening
advises and health
teaching
 Patient did not show any
depression
 Patient was aware of her
surrounding
 Patient coping
mechanism is good, she
is cooperative
70
Computation:

 Poor- 2/21*50+50= 54.76%

 Fair- 2/21*50+50= 54.76%
 Good- 12/21*50+50= 78.58%

Impression:

With these affecting factors, patient shows a score of 54.76% poor prognosis,
54.76% for fair prognosis and 78.58% good prognosis. Seeing the result, patient has
average percentage of prognosis in this manner this helps her recovery and
restoration if it is treated immediately.

71
 APPENDIX

VITAL SIGNS

DATE SHIFT TIME TEMP BP PR RR O2sat

1/08/20 311 7:20pm 36.2˚C 200/110mmHg 89bpm 22cpm 97%

7:30pm 140/100mHg

1/09/20 117 12:00pm 35.0˚C 120/80mmHg 64bpm 20cpm 96%

4:00pm 35.7˚C 110/70mmHg 60bpm 20cpm

1/09/20 73 8:00am 36.0˚C 160/100mmHg 90bpm 20cpm

12:00pm 36.2˚C 120/90mmHg 60bpm 20cpm

1/09/20 311 4:00pm 36.4˚C 130/90mmHg 82bpm 20cpm 98%

8:00pm 36.1˚C 140/90mmHg 73bpm 20cpm

1/09/20 117 12:00pm 36.8˚C 150/90mmHg 85bpm 20cpm 98%

4:00pm 36.6˚C 160/100mmHg 80bpm 20cpm

72
 GLOSSARY

 Anatomy – the science that deals with the structure and composition of the body; it
is largely based on dissection.
 Atherosclerosis- a disease process that causes thickening of arterial wall and loss
of their elasticity.
 Aneurysm- permanent, abnormal, local dilatation or ballooning out of a blood
vessel wall, most commonly in the aorta.
 Cerebrovascular- relating to the blood vessels of the brain, especially to
pathological conditions or changes in these vessels.
 Cerebrum- largest and uppermost part of the brain.
 Diabetes – metabolic disorders marked by the excessive secretions and excretions
of urine and excessive thirst.
 Diuretics- having the effect of increasing the flow of urine.
 Edema- is the abnormal accumulation of fluid in certain tissues within the body.
The accumulation of fluid maybe under the skin – usually in dependent areas such
as the legs (peripheral edema or ankle edema), or it may accumulate in the lungs
(pulmonary edema)
 Genogram- outline of family history in which each member of the group gives his or
her own family history.
 Hematuria – the presence of blood or blood cells in the urine.
 Hemiplegia- paralysis of one side of the body.
 Hyperglycemia- excessive amount of glucose in the circulating blood.
 Hypertension- abnormally high blood pressure and especially arterial blood
pressure; systemic condition accompanying high blood pressure.
 Homeostasis- the states of relative stability or equilibrium of the internal
environment of the body.
 Ischemia- local temporary reduction of blood supply of an area due to obstruction
in the blood vessels supplying the area or due to vasoconstriction.

73
 Lesions- an injured or diseased area or spot or in the body; an abnormal change in
structure of an organ or part due to injury or disease.
 Osmotic pressure- the force in which the fluid apart of a solution is drawn across a
semi permeable membrane that separates two solutions od different concentrations
and that permits the passage of the fluid but not of the solutes.
 Oxidation- the process of converting a substance into an oxide by addition of
oxygen.
 Pathophysiology- the physiology of abnormal states; the functional changes that
accompany a particular syndrome or disease.
 Peripheral- it relating to the main or most important part; relating to, affecting r
being part of the peripheral nervous system; relating to or being the outer part f the
field or vision.
 Permeability- in physiology, the ability of cell membrane to allows salt, glucose,
urea and other soluble substances to pass into and out of the cells from the body
fluids.
 Physiology- a science that deals with the ways that living things or any of their
parts function; a branch of science that deals with the functions and activities of life
or living matter( as organs, tissues, or cells) and of the physical and chemical
phenomena involved.
 Plaque- a small flattened localized about normal area or putch on a body surface or
part.
 Plasma- the liquid fraction of limbs.
 Polydipsia- frequent drinking because of excessive thirst, a characteristic of
diabetes.
 Prognosis- the prospect of recovery as anticipated from the usual course of disease
or peculiarities of the case.
 Renal- relating to the kidney.
 Subcutaneous- being, living occurring or administered under the skin.

74
 Stroke- a sadden sever attack, particularly one resulting from the bursting or
clogging of a blood vessels in brain causing damage to nerves centers.
 Symmetry- the property of being symmetrical; correspondence in shape, size and
relative position of parts on opposite sides of a dividing line or median plane.
 Turgor- the normal state of turgidity and tension in living cells.
 Vesicle- a small abnormal elevation of outer layer of skin enclosing a watery liquid.
 Viscosity- the quality of being glutinous, sticky, viscos.

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