Hypertension - htn case study PDF

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Keith RN LRCC Nursing II Clinical 2.9.2017

RAPID Reasoning Case Study-STUDENT

I. Data Collection History of Present Problem: Mike Kelly is a 51 year old Caucasian male. He is 6 feet tall and weighs 275 pounds (BMI 37.3) with an abnormal distribution of weight around his abdomen. He does not regularly exercise, does not like to cook, and eats fast food 3-5x during the week. He has smoked 1 pack per day since the age of 20 (31 pack years). He has no current diagnosed medical problems. He becomes concerned and came to the urgent care facility today because he is more easily fatigued and has a headache for the past 3 days that has not improved. He didn’t go to work today and that is not typical for Mike. Personal/Social History: Mike is self-employed and owns his own auto mechanic business. He currently has no health insurance. His father had hypertension and died of a myocardial infarction (MI) at the age of 50. Angelina, his wife, came with him to urgent care and shares that he is usually stoic with health problems so this must really bother him or he is afraid. He took Excedrin and Motrin for pain and it didn’t help that she gave him a dose of Castor oil since she is from Puerto Rico and that is the first thing they do for any illness in her country of origin.

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: -more easily fatigued Etiology of essential hypertension (Ignatavicius 710) -headache for past 3 days Includes: -BMI of 37.3 -smoking -fast food eaten 3-5x per week -excessive intake of sodium -smoker for the past 31 years -obesity -does not regularly exercise -physical inactivity -self employed -high stress

RELEVANT Data from Social History: -father has medical history of hypertension and MI -took Excedrin, Motrin, and castor oil before coming in

Clinical Significance: -family history puts him at a greater risk for a heart attack - Excedrin is a combo of Tylenol, aspirin, and caffeine (Caffeine can create tachycardia) -Castor oil relieves pain and promotes healing used culturally, more useful for open wounds -Motrin is a NSAID as well that thins the blood (Prescription)

II. Patient Care Begins: Current VS: T: 98.9 (oral)

WILDA Pain Scale (5th VS) Words: Ache 1

Keith RN LRCC Nursing II Clinical 2.9.2017 P: 88 (regular) R: 20 BP: 220/118 O2 sat: 95% RA

Intensity: Location: Duration: Aggravate: Alleviate:

8/10 Global head ache Continuous Nothing Nothing

What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: -BP over 140/90 is suggestive of hypertension for ages under 60 -BP 220/118 Pain: Ache, 8/10 (Swearingin 179) Headache -the headache pain can be an indicator of a hypertensive urgency or crisis (Ignatavicius 718) Continuous

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN:

Appears uncomfortable Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses bounding, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants Voiding without difficulty, urine clear/yellow Skin integrity intact

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: -uncomfortable -being uncomfortable isn’t normal and indicates a possible -bounding pulse problem - increase in blood pressure may create a bounding pulse suggesting inadequate perfusion (Ignatavicius)

III. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Hypertension is the most likely problem that my patient is presenting with.

2. What is the underlying cause/pathophysiology of this problem? 2

Keith RN LRCC Nursing II Clinical 2.9.2017 It is a combination of bad lifestyle choices and a paternal history of hypertension and MI. Bad lifestyle choices include: bad diet, poor physical activity, smoker for 31 years, and an obese BMI.

3. What nursing priority(s) will guide your plan of care?(if more than one-list in order of PRIORITY) First I would start an IV for potential antihypertensive medication I would conduct and electrocardiogram I would monitor the BP every 5-15 minutes I would then observe for neuro/cardiac complications such as chest pain, dysrhythmias, numbness/weakness and tingling of extremities. 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: 1. Start an IV(Ignatavicius 713) 2. ECG 3. Monitor BP 4. Observe for complications

(Ignatavicius 713)

1. An IV would give access for any antihypertensive therapy that may be infused 2. ECG would monitor the patient for signs of MI 3. Monitoring the BP would give us an idea of how the BP is trending 4. Observing for further complications can prevent future problems such as MI

Expected Outcome: 1. BP would go down 2. Normal sinus rythmn 3. The BP would steadily go down after pharmological intervention 4. No other complications would result

5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Cardiac, and neuro to watch for further complications.

6. What is the worst possible/most likely complication to anticipate? Heart disease, heart attack, stroke

7. What nursing assessments will you need to initiate to identify this complication if it develops? Monitor the blood pressure, assess the pulse, ECG, assess face symmetry, assess speech, and assess grip strength. (Ignatavicius 713)

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Keith RN LRCC Nursing II Clinical 2.9.2017 8. What will be the consequences of uncontrolled hypertension to the rest of Mike’s body if it remains out of control? List body systems and potential permanent injury. Body System: Cardiac Neuro Urinary Endocrine (Ignatavicius 709)

Potential permanent injury: Heart disease, leading to coma or death Stroke leading to permanent disability or death Renal Failure Diabetes

Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders:

Rationale: To identify contributing factors

Expected Outcome: All within normal range

To look for infection

No signs of infection

To look at how hard the heart has been working

It would be elevated due to such high blood pressure

To see if they are elevated because it would signify plaque in the arteries

With a blood pressure, so high I would expect an elevated lipid panel

To check for kidney abnormalities

Signs of kidney dysfunction

12 lead EKG Chest x-ray

To check for signs of MI

Labetalol (Trandate) 10-20 mg IV push every 15 “. Goal BP: 160/100

To actually look at the heart

Basic metabolic panel (BMP) Complete cell count (CBC) BNP (B-natriuretic Peptide) Lipid profile Urine analysis (UA)

Possible signs of MI, but hopefully normal sinus rhythm Signs that the heart has been working harder than normal

To lower blood pressure Blood pressure would steadily decline with each push

12 Lead EKG:

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Keith RN LRCC Nursing II Clinical 2.9.2017

Nursing II: Reading an EKG strip is done by someone who has had advanced cardiac life support (ACLS) training. For the purpose of the scenario the results have been provided for you as being Normal Sinus Rhythm. Interpretation: Normal Sinus Rhythm Clinical Significance: He is not in early signs of MI, but he is at high risk

Medication Dosage Calculation: Medication/Dose:

Mechanism of Action:

Labetolol (Trandate) 20 mg IV push 5mg/mL vial 4mL Normal Range:

Produces decrease in BP without reflex tachycardia or significant reduction in heart rate. (Skidmore 672)

(high/low/avg?)

Volume/time frame to Safely Administer: Loading dose (672) IV Push: Volume every 15 seconds? IV 20mg/2minutes Q 10minutes would be safe

Nursing Assessment/Considerations :

Assess BP, and pulse (Skidmore 674) Assess for therapeutic response or a radical decrease in blood pressure Watch for orthostatic hypotension

Radiology Reports: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nruse? RELEVANT Results: Clinical Significance:

Chest x-ray: The cardiac size is enlarged. There are no focal infiltrates or consolidations or pleural

Cardiomegaly is a sign of heart disease. (Ignatavicius 707)

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Keith RN LRCC Nursing II Clinical 2.9.2017

effusions. IMPRESSION: 1. No acute disease in the chest. 2. Moderate to severe cardiomegaly.

Complete Blood Count (CBC) Current High/Low/WNL? WBC (4.5-11.0 mm 3) 10.5 WNL Hgb (12-16 g/dL) 15.3 WNL Platelets(150-450x 103/µl) 422 WNL Neutrophil % (42-72) 68 WNL Band forms (3-5%) 1 LOW What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: Basic Metabolic Panel (BMP) Current High/Low/WNL? Sodium (135-145 mEq/L) 136 WNL Band forms (1) infection if high Potassium (3.5-5.0 mEq/L) 4.0 WNL Chloride (95-105 mEq/L) 98 WNL CO2 (Bicarb) 21-31 mmol/L) 29 WNL Anion Gap (AG) (7-16 mEq/l) 14 WNL Glucose (70-110 mg/dL) 188 HIGH Calcium (8.4-10.2 mg/dL) 8.8 WNL BUN (7-25 mg/dl) 32 HIGH Creatinine (0.6-1.2 mg/dL) 1.5 HIGH What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Glucose (188) Cardiac Labs:

Clinical Significance: Could signify diabetes, A1C should be Current: High/Low/WNL Most Recent: ? BNPCreatinine (B-ntriuretic Peptide) (...