OVERVIEW OF THE DISEASE

 INTRODUCTION

A hypertensive emergency is severe hypertension (high blood pressure ) with acute

impairment of organ system 9 especially the central nervous system , cardiovascular system
and/or renal system ) and the possibility of irreversible organ damage. In case of hypertensive
emergency, the blood pressure should be lowered aggressively over minutes to hours with a
hypertensive agent. Several classes of hypertensive agents are recommended and the choice of
hypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated
blood pressure and the patient’s usual blood pressure before the hypertensive crisis. In most
cases, the administration of an intravenous Sodium Nitroprusside injection which has an almost
immediate anti hypertensive effect is suitable but in many cases, oral agents are given like
Captopril, Clonidine, Labetalol, Prazosin, which all have a delayed onset of action by several
minutes compared to Sodium Nitroprusside, can also be used.

 DEFINITION

Generally, the terminology describing hypertensive emergencies can be confusing. Terms such as
hypertensive crisis, malignant hypertension, hypertensive urgency, accelerated hypertension and
severe hypertensions are all used to=in the literature and often overlap.

As a specific term hypertensive emergency is primarily used as a crisis with a diastolic pressure
of 120 mm hg and above plus end organ damage (Brain, Cardiovascular, renal) as described
above in contrast to hypertensive urgency where as yet no end organ damage has developed.
The former requires immediate lowering of blood pressure as with Sodium Nitroprusside
infusions.

 SIGNS AND SYMPTOMS

 Headache
 High blood pressure usually 140/100 and above
 Shortness of breath
 Convulsion
 Changes in vision
 Nausea
 Vomiting
 Heart palpitations

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 DIAGNOSTIC EXAM
 Blood pressure monitoring using sphygmomanometer
 Electrocardiogram (ECG)
 Complete Blood Count(CBC)
 Physical Examination
 LDL-HDL Ratio

 TREATMENT

The usual treatment is to reduce blood pressure using anti –hypertensive drugs, it includes:

ACE inhibitors;

ARBs;

Diuretics;

Beta-blockers;

Calcium- blockers

Diuretics are usually recommended as the first line of therapy for most people who have high blood
pressure. If one drug doesn’t work or is disagreeable, other types of diuretics are available.

 NURSING INTERVENTION

The primary responsibility of the nurse is to assess the condition of the patient during the treatment.
It includes the following but are not limited to;

 Vital signs monitoring specifically blood pressure,

 Assessment for possible and sudden drop of blood pressure,
 Monitoring of adverse reactions to drugs,
 Tabulation of Input and Output when ordered and carrying out doctor’s order.

A. Client’s profile:

2
Name: Mr. AM
Address: Abbay Maddela Quirino
Age: 26 years old
Sex : Male
Civil status : Married
Nationality : Filipino
Religion : Born Again
BirthDate : November 5,1983
Occupation : BaKer
Date of admission: May 4, 2010
Time of admission: 2:45PM
Chief Complaint: body weakness and pale looking
Diet : DAT
Diagnosis: Anemia to consider Blood Dyscrasia
Physician: Dr.X

MEDICAL HISTORY:
• Present health history of illness:
- Two weeks prior to admission the patient suffered body weakness
associated with pale looking. According to the patient he also felt
dizziness and severe headache; he take paracetamol to relieve the pain
but then he was not relieve that’s why they decided to have his check up
at QPH and his Physician advised him for confinement with a diagnosis
of Anemia. Admitted last May 4, 2010 @ 2:45pm

• Past medical history:

- He is not fully immunized that’s why he occasionally experienced Childhood
diseases like; cough,colds and fever. His last confinement was on October
2009 at Dundayong Hospital at part of Maddela Quirino. Also Last December
28, 2009 at QPH with an admitting diagnosis of Idiopathic thrombocytopenia
Purpura . Last April 16-22, 2010 he was confined at SIGH and was diagnosed
with Anemia.
• Family health history:

Father Possible hereditary Mother

+ HPN +
- Asthma -
- Cancer -
- DM -
II GORDONS HEALTH FUNCTIONAL PATTERN

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

3
 BEFORE HOSPITALIZATION: the Pt. verbalized that he is healthy.
He can actually maintain his body healthy
without any problems.

DURING HOSPITALIZATION: when he was admitted at QPH he

still thinks that he is okay because he feel
good still but easily feel tiredness.

2. NUTRITIONAL-METABOLIC PATTERN

BEFORE HOSPITALIZATION: Pt.AM prefers vegetables than meat.

He rarely eats meat because he thinks those
are the reason that’s why he is suffering
anemia.

DURING HOSPITALIZATION: the doctor ordered DAT diet. And the

hospital usually serves meat as their vian.

3. ELIMINATION PATTERN

BEFORE HOSPITALIIZATION: PTA, the pt. urinates 7-8x a day with

colorless - light yellow urine with no foul
odor.

DURING HOSPITALIZATION: when he was admitted, he urinates 6-

7x a day. And perspires at all times bec.of
warm environment in the hospital.

4. ACTIVITY-EXERCISE PATTERN

BEFORE HOSPITALIZATION: The pt. is fun of playing basketball and

this serve as his exercise.

DURING HOSPITALIZATION: He can’t play basketball because of his

condition .

5. SLEEP-REST PATTERN

BEFORE HOSPITALIZATION: Sometimes his number of sleep

ranges from 6-7 hours a day. But mostly he

4
 has hard time on getting his sleep with
unknown cause.

DURING OSPITALIZATION: he mentioned that, since his

confinement here in QPH, he felt as though
he was refreshed than that as compared with
before because he had enough time to sleep
without any interruptions. he had no more
worries about his routine activities.

6. COGNITIVE PERCEPTUAL PATTERN

Pt. AM is only a high school undergraduate but

he can read and write. He can easily
understood and respond to our questions
directly.

7. SELF PERCEPTION/ SELF CONCEPT PATTERN

BEFORE HOSPITALIZATION: He sees himself as a very busy

person and responsible father on his
two child.

DURING HOSPITALIZATION: Because of her stay at QPH, his

anxiety about his daily
routines/activities at home is
temporarily relieved.

8. ROLE RELATIONSHIP PATTERN

BEFORE HOSPITALIZATION: He is a responsible father and

husband. He is a baker on a small
bakery at Zamora.

DURING HOSPITALIZATION: he can’t work anymore because of

his condition.

9. SEXUALITY-REPRODUCTIVE PATTERN

He was 7 years old when he was circumcised by what they call “de
pok-pok”before.

5
10. COPING STRESS MANAGEMENT

BEFORE HOSPITALIZATION: Due to his routine Activities, he was

not aware that he was under stress.
he had been encountering it every
day which may trigger the disease.

DURING HOSPITALIZATION: he now understand that having

enough rest when he is tired and
stressed is very indispensable to
overcome his condition. He also
recognizes though our health
teachings are the essence of taking of
multivitamins rich in iron to
strengthen his immune system.

11. VALUE BELIFE PATTERN

BEFORE HOSPITALIZATION: He was a devoted Born again. He

sometimes attends mass together
with his wife and children at their
nearby church.

DURING HOSPITALIZATION: Now that he is confined, he can’t

attend mass anymore but still prays
all the time.
PHYSICAL ASSESSMENT

Date: May 06,2010@10:00am

General Appearance: conscious

BODY PARTS TECHNIQUE FINDIN INTERPRETATIO

GS N
HEAD
 Hair Inspection Black in Normal
color
No lice
 Scalp Inspection No Normal
Palpation presen Normal
ce of
dandr
uff

6
 No
masse
s
No
tender
ness
 Ears Inspection With Normal
norma
l
hearin
g
 Earlobes Inspection Bean- Normal
shape
d
 Ear Canacl Inspection No Normal
abnor
mal
discha
rges
 Eyes Inspection PERRLA Normal
(Conjunctiva) With pale Due to lack of red
conju blood cell
nctiva
 Lips Inspection Pale in Due to lack of red
color blood cell
(white)
 Teeth Inspection With Due to poor
presen hygiene
ce of
dental
carrie
s
 Gums Inspection Pinkish in Normal
color
 Tongue Inspection Moist Normal
FACE Inspection Pale in Due to lack of red
Palpation color blood cell
No
masse Normal
s
NECK Inspection Symmetri Normal
cal
and Due to present
pale condition
in
color

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UPPER Inspection No lesion Due to present
EXTREMITIES Palpation and condition
pale
in
color
Symmetri Normal
cal,
no
bones
disloc
ated

 Fingernails Inspection Clean and Normal

prope
Palpation rly Due to lack of red
cut blood cell
Slightly
poor
capill
ary
refill

 Shoulder Inspection symmetri Normal

cal
and Due to present
pale condition
in
color.

 Heart Auscultation 115 bpm Normal

 Thorax and Palpation No Normal

lungs tender
Auscultation ness Normal
No
wheez
ing
sound

8
  Abdomen Inspection Flat, Due to present
Sym condition
metric
al
Auscultation slightl
y pale Normal
Palpation in
color Normal
Normoact
ive Normal
sound
No
Percussion tender
ness
Resonant
LOWER Inspection Symmetri Normal
EXTREMITIES cal
Pale in Due to lack of red
Palpation color blood cell

 Legs Inspection Hairy and Due to lack of red

slightl blood cell
y
pale. Due to basketball
And accident.
with
compl
ain of
pain
on the
left
leg.

II. ANATOMY & PHYSIOLOGY

9
 The heart pumps oxygenated blood to the body and
deoxygenated to the lungs. In the human heart there is one
atrium and one ventricle for its circulation, and with both a
systemic and pulmonary circulation there are four chambers in
total; left atrium, left ventricle, right atrium and right ventricle.
The right atrium is the upper chamber of the right side of the
heart. The blood that is returned to the right atrium is
deoxygenated (poor in oxygen) and passed in to the right
ventricle to be pumped through the pulmonary artery to the
lungs for re-oxygenation and removal of carbon dioxide. The left
atrium receives newly oxygenated blood from the lugs as well as
the pulmonary vein which is passed into the strong ventricle to
be pumped through the aorta to the different organs of the
body.

III. PATHOPHYSIOLOGY

HYPERTENSIVE EMERGENCY

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ETIOLOGIC FACTOR: RISK FACTORS:

 Obesity
Increased BP
 Age
 Stress

Stressor initiated

Reni is released by the kidney

Angiotensin is produced

Angiotensin I is converted
to Angiotensin II

IV. COURSE IN THE WARD

DOCTOR’S ORDER RATIONALE

5/4/10
2:45 pm
>pls. admit to male medicare Ward >To treat underlying condition
> Record TPR > for baseline data
>DAT > applicable diet to the patient
>CBC > to check any abnormalities
>BT > to replace components of blood loss
>PNSS1L- 25 gtts/min > for electrolytes and fluid balance
>Secure 4 units of FWB type O+ & transfused >to check for compatibility of blood
after crossmatching

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 > refer accordingly  to evaluate the condition

5/5/10
10:10 am
>TF: PNSS1L at KVO  for electrolytes and fluid balance
> For Peripheral blood smear  to check abnormalities of blood
> for referral to Hematologist  for further evaluation and management
> continue for BT  To replace components of blood loss
> refer  To evaluate condition

5/6/10
9:30am
 Continue BT  To replace components of blood loss

5/7/10
 Still for BT  To replace components of blood loss
 Continue IVF PNSS1L x 24hrs

5/7/10
3:00pm
 For referral to Hematologist  For further evaluation and management
 D5NM1L x 25 gtts/min  For electrolytes and fluid balance
 Multivit. + Iron 1 capsule TID  To boost immune system
 refer  For further evaluation

V. LABORATORY RESULTS

Name: Mr AM

Result Normal
values
WBC 3.5

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13
 URINALYSIS

Date: 11- 30- 09

Chemical Examination

Color: yellow

Clarity: clear

MICROSCOPIC EXAMINATIONS:

Pus cells: 0-2/hpf

Red cells: 5-7/hpf

Epithelial cells: moderate/hpf

Amorphous urates: few/hpf

Mucus threads: +/hpf

Bacteria: +/hpf

Dr. Nathanael B. Vidad, MD, FPSP

Photologist ( 59251)

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 CHEMISTRY

Date: Nov. 30, 2009

TEST REFERENCE VALUE

Fasting blood sugar: 5.97 mmol/L 3.89-5.83 mmol/L

Cholesterol: 7.33 mmol/L 3.87-6.71 mmol/L

Triglycerides: 1.35 mmol/L up to 1.7 mmol/L

Blood urea Nitrogen: 5.78 mmol/L 2.5-6.5 mmol/L

Creatinine: 87.9 mmol/L 150-357 mmol/L

Dr. Nathanael B. Vidad, MD, FPSP

Photologist ( 59251)

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 SERUM ELECTROLYTES

Date: Nov. 30, 2009

Test Reference Value

Sodium: 133.7 mmol/L 135.0-155.0 mmol/L

Potassium: 2.89 mmol/L 3.60-5.50 mmol/L

Dr. Nathanael B. Vidad, MD, FPSP

Photologist ( 59251)

HEMATOLOGY

DATE: Nov. 29, 2009 Reference Value

WBC: 7.6 3.5-10

RBC: 5.14 3.80-5.80

HGB: 152 110-165

HCT: .470 .350-.500

PLT: 289 150-390

PCT: .198 .100-.500

WBC FLAGS: G3 Reference Value

LYM- 23-8% 17.0-48.0%

MON- 7.0-% 4.0-10.0%

GRA- 69.2% 43.0-76.0%

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XII. VITAL SIGNS

Admitted: November 29, 2009

Initial vital sign bp- 220/140

November 29, 2009

8am-4pm
• 9:25 am bp-160/ 100 PR-90bpm
• 10:30 am bp-160/100 PR-86bpm
• 11:40 am bp-160/100 PR-86bpm
• 12:50pm bp-130/90 PR-86bpm
• 2:00pm bp-160/100 PR-88bpm
• 3:45pm bp-170/100 PR-98bpm
•
November 29, 2009
4pm-12am
• 5:00pm bp-190/110 PR-96bpm
• 6:30pm bp-200/130 PR-102bpm
• 8:15pm bp-200/120 PR-98bpm
• 9:50pm bp-180/120 PR-100bpm
• 11:00pm bp-210/130 PR-98bpm
•
November 30, 2009
12am-8am
• 1:00 bp-190/120 PR-96bpm
• 2:00 bp-220/110 PR-98bpm
• 3:00 bp-200/110 PR-84bpm
• 5:30 bp-180/120 PR88bpm
• 7:30 bp-190/120 PR-80bpm
•
November 30, 2009
8am-4pm
• 9:30am bp-190/120 PR-72bpm
• 12:00pm bp-190/130 PR-84bpm
• 1:00pm bp-200/120 PR-89bpm
• 2:30pm bp-180/130 PR-83bpm
• 3:30pm bp-190/120 PR-68bpm

November 30, 2009

4pm-12am
• 6:00pm bp-150/100 PR-58bpm
• 8:30pm bp-170/100 PR-64bpm

17
• 9:40pm bp-140/100 PR-60bpm
• 10:40pm bp-140/100 PR-57bpm
• 11:30pm bp-160/100 PR-60bpm
•
December 1, 2009
12am-8am
• 1:30am bp-170/110 PR-62bpm
• 2:30am bp-160/110 PR-64bpm
• 3:30am bp-180/120 PR-57bpm
• 4:30am bp-170/100 PR-58bpm
• 5:30am bp-170/110 PR-62bpm

December 1, 2009
8am-4pm
• 9:00am bp-160/100 PR-80bpm
• 10:00am bp-180/110 PR-86bpm
• 10:15am bp-170/100 PR-83bpm
• 10:30am bp-160/100 PR-86bpm
• 10:45am bp-160/100 PR-85bpm
• 11:00am bp-170/100 PR-80bpm
• 11:15am bp-160/100 PR-66bpm
• 11:30am bp-160/100 PR-64bpm
• 11:45am bp-170/110 PR-63bpm
• 12:30pm bp-160/110 PR-60bpm
• 1:00pm bp-160/110 PR-68bpm
• 1:15pm bp-160/110 PR-67bpm
• 2:00pm bp-160/110 PR-65bpm
• 2:30pm bp-160/110 PR-64bpm
• 3:30pm bp-170/110 PR-66bpm

December 1, 2009
4pm-12am
• 5:00pm bp-170/110 PR-66bpm
• 6:45pm bp-180/110 PR-68bpm
• 9:30pm bp-180/110 PR-61bpm
• 10:00pm bp-140/110 PR-64bpm
• 11:00pm bp-170/110 PR-65bpm

18
 December 2, 2009
12am-8am
• 1:00am bp-180/120 PR-72bpm
• 2:30am bp-180/90 PR-70bpm
• 5:30am bp-160/110 PR-80bpm
• 7:30am bp-160/100 PR-79bpm

December 2, 2009
8am-4pm
• 9:00am bp-160/110 PR-62bpm
• 10:00am bp-150/90 PR-64bpm
• 11:00am bp-160/100 PR-66bpm
• 12:00pm bp-150/100 PR-62bpm
• 2:00pm bp-150/100 PR-63bpm

December 2, 2009
4pm-12am
• 6:30pm bp-170/110 PR-80bpm
• 7:00pm bp-160/110 PR-94bpm
• 9:00pm bp-140/90 PR-87bpm
• 10:00 bp-150/110 PR-92bpm

December 3, 2009

12am-8am

• 1:30am bp-140/100 PR-98bpm

• 5:30am bp-150/110 PR-84bpm
• 7:00am bp-140/100 PR-84bpm

December 3, 2009
8am-4pm
• 9:30am bp-140/100 PR-89bpm
• 10:30am bp-140/100 PR-87bpm
• 11:30am bp-160/100 PR-90bpm
• 12:30pm bp-140/100 PR-93bpm
• 1:30pm bp-140/90 PR-86bpm
• 2:00pm bp-140/90 PR-78bpm
• 2:30pm bp-140/100 PR-68bpm

December 3, 2009
4pm-12am
• 6:00pm bp-140/90 PR-66bpm
• 10:00pm bp-130/90 PR-68bpm

19
 December 4, 2009
12am-8am
• 12:30am bp-160/120 PR-85bpm
• 1:15am bp-150/120 PR-86bpm
• 1:30am bp-140/100 PR-89bpm
• 1:45am bp-140/100 PR-86bpm
• 2:00am bp-140/100 PR-83bpm
• 2:15am bp-140/100 PR-86bpm
• 6:00am bp-140/100 PR-79bpm

December 3, 2009
8am-4pm
• 10:00am bp-140/100 PR-86bpm

20
 VI. NURSING CARE PLAN

Assessment Diagno Planni Interventi Rational Evaluatio

sis ng on e n
SUBJECTIVE: elevated After 1- Independent: Goal met as
• “Lagi blood 4° of -Established -To gain pt trust evidence
sumasakit press nursi rapport and by the pts
ulo ko.” as ure ng cooperation verbalizat
verbalized by inter -Monitored -For baseline ion of
the pt. venti BP and data “hindi na
OBJECTIVE: on PR -To lessen masakit
• Body the anxiety and ulo ko.”
weakness pts -Instructed pt stress
• Irritable head on proper -For pts comfort
• Oily face ache deep
will breathing
be -Positioned
relie the pt on
ved. a
comforta -To relief
ble headache
position -To lessen fat
deposit and
Dependent: retention of
NaCl ions.
-Due meds
given

-On low fat,

and low
salt diet

21
NURSING CARE PLAN

22
Assessment Diagno Planni Interventi Rational Evaluatio
sis ng on e n
SUBJECTIVE: Knowled After 1- Independent: Goal met as
-Ø ge 2° of -Established -To gain pt evidence
defici nursi rapport trust and by the pts
OBJECTIVE: t r/t ng -Monitored cooperat verbalizat
-guarded self inter v/s ion ion of “
behavior care venti -For gagawin
-diaphoretic on -Instructed baseline ko yung
the pt to have data itinuro
pt adequate -For mo.”
will rest comfort
be periods and
able -Emphasized relaxatio
to the n.
dem importan
onstr ce of -To promote
ate proper cleanlin
all hygiene, ess
incre grooming
asin and
g feeding
inter
est /
parti
cipat
ion
of
self
care.
NURSING CARE PLAN

23
 Assessment Diagno Planni Interventi Rational Evaluatio
sis ng on e n
SUBJECTIVE: Constipat After 1- Independent: Goal met as
“limang araw na ion 3° of -Established -To gain pt trust evidence
akong hindi nursi rapport and by the pts
ngdudume,kaya ng cooperation verbalizat
nanghihina ako” inter -Monitored v/s -For baseline ion of
ask verbalized venti data “”nagdu
by the pt. on -Palpated -To check for mi na
the abdomen presence of ako.
OBJECTIVE: pt. distention.
-facial grimace will -to promote
-minimal be -Instructed to hydration
movement able increased
to fluid intake -To promote
defe -Encouraged pt moist/ soft
cate to eat stool.
and nutritious
regai foods.
n Dependent:
stren administered
gth. Bisacodyl as
ordered.

24
 VII. DRUG STUDY

DRUG NAME CLASSIFICATIO INDICATION/ACTI SIDE EFFECTS NSG. RESPONSIBIL

N ON
Generic name: Non- steroidal Short term  Headache  Correct Hypovo
Ketorolac anti- management  Dyspepsia  Alert: Maximum
inflammatory of moderately  GI pain parenteral and
Brand name: severe, acute  Constipation  When appropri
pain for single  Flatulence injection. Pt ma
Stock: dose site which can
Doctor’s order: treatment bags.

Generic name:  Anaphylaxis

Ranitidine  Headache  Assess pt for ab
Anti ulcer drugs  Blurred vision presence of blo
Gastric irritation gastric aspirate
Brand Name:
 Drug may be ad
Stock: solutions.
Doctor’s order:

Generic Name:  Bradycardia,sup

metoclopramide Anti-emetics ravetricular
Nausea and tachycardia  Monitor bowel
Brand name: vomiting  Neuroleptic  Safety and effecti
plasil malignant established for t
syndrome,seizu weeks.
Stock:10mg/2ml Doctor’s order: res, suicide
1 amp IV now then ideation.
q8° PRN

Generic name:  Vertigo,

Furosemide headache,
Diuretics dizziness.  To prevent noctu

25
 Hypertension  Panceatitis, preparations in t
Brand name: thrombocytope the early afterno
nia.  Watch for signs o
weakness and cr

Stock:
Doctor’s order:
1 amp IV now then
OD
Generic name:  Neutropenia,
Paracetamol leucopenia,
Non opiod pancytopenia  Alert: Many OTC
analgesic and Mild pain and/or and contain acetamin
Brand name: anti pyretics fever hypoglycemia when calculating

Stock:

Doctor’s order:
1 amp IV stat

Generic name: Headache,

Losartan dizziness,
potassium fatigue,
abdominal pain, Drugs can be used a
Anti hypertensives For hypertension nausea, back antihypertensive
Brand name: pain or leg pain,
Monitor patient’s BP
getzar cough and
therapy and mon
respiratory taking diuretics f
infection

Generic name:
Bisacodyl
Give drugs at times t
Diphenyl methane Chronic Dizziness, faintness, scheduled activi
Brand name: derivative constipation muscle Before giving for con
Dulcolax weakness with

26
 excessive use patient has adeq
Abdominal cramps diet.
Electrolyte
imbalance

27