Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
A case analysis on nursing care for a patient with hypertensive urgency and anxiety. It includes the patient's profile, nursing health history, health assessment, physical examination, nursing care plans, drug studies, and bibliography. The health assessment section uses Gordon's Functional Health Patterns to evaluate the patient's health before and during hospitalization. The nursing care plans section includes three plans related to decreased cardiac output, anxiety, and risk for falls. scientific basis, planning, interventions, and rationales for each plan.
Typology: Study Guides, Projects, Research
1 / 24
This page cannot be seen from the preview
Don't miss anything!
Salinas Drive, Lahug, Cebu City
Submitted by: Mary En P. Cena Clinical Instructor Mark Paul M. Balbuena, RN March 2023
ii TABLE OF CONTENTS i. Title Page i ii. Table of Contents ii A. Patient’s Profile 1 B. Pertinent Nursing Health History 2 C. Health Assessment 3 D. Physical Examination 6 E. Nursing Care Plans 8 F. Drug Studies 17 G. Bibliography 22 LIST OF TABLES Table Number Name of Table Page Number 1 Health Assessment Gordon’s Functional Health Patterns
2 Physical Examination 6 3 4 5 Nursing Care Plans NCP # 1 NCP # 2 NCP # 3
Drug Studies Rosuvastatin Fenofibrate Losartan
Patient had been diagnosed with hypertension years prior to admission. Hypertension had been managed with antihypertensive agents as prescribed. Blood pressure had been maintained around 130/80 to 150/90 mmHg. Days prior to present admission, patient reported to have had misunderstanding with son at home. The argument lasted for as long as 30 minutes. Patient suddenly complained of dizziness mid argument. Blood pressure was checked and was at 160/100 mmHg. Patient was then rushed to the hospital. FAMILY HEALTH ILLNESS Father and grandfather of patient had a history of hypertension. Patient’s mother had a history of type 2 diabetes mellitus ENVIRONMENTAL HISTORY Patient lives in a two-storey concrete house with wife and son. Patient occupies one room with wife. House is spacious with good airflow and ventilation. There is a backyard at the back with fence surrounding the entire house. There is a school, wet market, park, and mall located proximally within the area. There is consistent and clean water supply. Drinking water is obtained from nearby commercial water source.
Table 1. Gordon’s Functional Health Patterns Functional Health Pattern Before Hospitalization During Hospitalization Health Perception and Health maintenance Patient verbalized that he had not been very watchful of his health throughout the years. He admitted that he had been negligent with his maintenance before diagnosis and even after it. Patient verbalized that he had made changes with his health perception in a way that he had viewed a healthy diet and regular exercise as necesaary for health maintenance. Nutritional - Metabolic The patient stated that he eats his meals 3x a day with snacks in between. He reported to scarcely drink water. Patient claimed to have a good appetite. Patient verbalized that he eats high sodium and high caloric foods. Since patient had been on restricted diet, he had started to consume meals less in sodium and glucose, focusing diets high with fiber and vitamins. Elimination The patient voids about 8-12 times a day with light yellow urine, estimated around 1,200 mL and defecates at least once a day with brown, well-formed stool. The patient has voided with light yellow urine with clear consistency. Patient defecated at least once every other day. Activity and Exercises Patient admitted that he had not been engaging in physical exercices throughout the years. He admitted to have been quiet living a sedentary lifestyle, and had been very limited with his physical movements. Patient’s movements were very limited due to pain that is exacerbated upon sudden and strenous movements. Patient was assisted with passive range of motion exercises.
Roles and Relationship Patient verbalized that the moment he had his son, he had committed himself as a full-time father. He wanted to nurture his son into a good adult and he believes that it has now become one of his purposes in life. He liked to look at himself as a a good husband and father. Patient verbalized that he failed his role as a father. His son does not respect him because he has not shown him that he is respectable. He deeply regrets how his relationship with his son had turned out. He sees himself as a failing father. Stress and Tolerance Coping Patient verbalized that his wife had been his rock throughout the years. She is his confidant and he can truly depend on her. Patient verbalized that his emotional stress in life has almost come to a point that he cannot independently handle anymore. His wife is still with him through all the struggles. However, he sees himself as the primary person involved, thus he should be the one solving his problems. Values and Belief Patient verbalized that he believes in the good Lord. He seeks guidance and protection from him. He believes that his God will save his soul. Patient admitted that there were moments when he questioned his God’s existence. He is confused as to why the Almighty had allowed his life to turn out the way it did. Table 1. Gordon’s Functional Healh Patterns (continued)
Table 2. Physical Examination Assessment Data Patient’s Manifestations General Survey Received patient on March 10, 2023 at 6 AM, with ongoing IVF # 2 of PNSS 1 L at 40 cc/hr on right arm. Patient verbalized anxiety on concerns such as his blood pressure, his present condition, and his son left at home. Weakness and profuse sweating noted. Vital signs were as follows: 36. degrees C, 102 bpm, 20 cpm, 140/80 mmHg, 98 %. Skin, Hair, and Nails Skin is warm and moist. There is no presence of dryness or scaling. Patient’s skin is lightly tanned and is smooth and warm to touch. Turgor is good. Hair is black and is evenly distributed. No dandruffs and lice noted. Scalp is smooth and oily and there were no lesions noted. CRT of 3 sec noted. Nails are not trimmed and visible dirt are noted. Head, Neck, and Cervical Lymph Node Head is hard and smooth. Head size is symmetric, round and in midline with no involuntary movements. Trachea is in midline. Carotid pulse is palpated with strong pulse. No blowing or swishing sound in carotid arteries. Mouth, Nose, and Sinus Tonsils are not swollen. No lesions and masses noted on the nose. Nose is symmetrical with the nasal septum at the midline. No lesions and ulcerations noted on the mouth. There is no nasal tenderness noted. Eyes and Ears Iris is black in color. Eyelashes are evenly distributed and curls outward. Cornea is moist. Eyelashes are evenly distributed and curls outward. No lesions noted on the ears and the skin is intact. Size of ears are symmetrical and proportional to the head. Ear canal is brownish in color. No palpable masses noted on the ears. The auricle, tragus and mastoid processes tenderness not noted.
Nursing Diagnosis : Decreased cardiac output related to increased vascular resistance Table 3. NCP # 1 Assessment Scientific Basis Planning Interventions Rationales Evaluation Subjective: “Nakabantay ko na kung musaka akong pressure, maghuot akong dughan ug maglisud ko ug ginahawa”, as verbalized by patient Objective: -BP: 140/ -PR: 102 -CRT: 3 sec -headache -dizziness -weakness -profuse sweating A less elastic, narrowed arteries resulting from increased vascular resistance, prompts the heart to maintain blood volume by attempting to increase it (Magder, 2018). Reference: Murr’s Nurses’Pocket Guide (15th^ Ed.) Short Term: Within 8 hours of nursing interventions, patient will participate in activites that will reduce cardiac workload and blood pressure. Long Term: Within 2 weeks of nursing interventions, patient will regain blood pressure within acceptable range. Safe and Quality Nursing Care A. ) Minotor vital signs, especially blood pressure B. ) Note the presence, and quality of central and peripheral pulses C. ) Auscultate heart tones and breath sounds D. ) Maintain activity restrictions Safe and Quality Nursing Care A. ) To monitor any deviations from baseline data B. ) Pulses in the legs and feet may be diminished, reflecting worsening vascular resistance C. ) The presence of crackles and wheezes may indicate pulmonary congestion secondary to chronic hypertension D. ) To prevent increase in cardiac Short Term: After 8 hours of nursing interventions, patient was able to participate in activites that reduces cardiac workload and blood pressure. Long Term: After 2 weeks of nursing interventions, patient was able to regain blood pressure at manageable levels.
E.) Provide comfort measures such as back massage and head elevation Safe Environment A. ) Provide calm, restful surroundings, and minimize environmental activity and noise. B.) Limit the number of visitors and length of stay. Health Education A.) Instruct in relaxation techniques, guided imagery, and distractions Teamwork and Collaboration A. ) Administer antihypertensive medications as workload E.) Decreases discomfort and may reduce sympathetic stimulation. Safe Environement A. ) To avoid increase in cardiac workload B.) To avoid increase in cardiac workload Health Education A. ) Can reduce stressful stimuli, and produce a calming effect, thereby reducing BP Teamwork and Collaboration A. ) To manage blood pressure elevation Table 3. NCP # 1 (continued)
Nursing Diagnosis : Ineffective tissue perfusion related to decreased cardiac output Table 4. NCP # 2 Assessment Scientific Basis Planning Interventions Rationales Evaluation Subjective: “Usahay kay mamoypoy akong bukton ug mga legs, especially kung ma stress na kaayo ko”, as verbalized by patient Objective: -BP: 140/ -PR: 102 -CRT: 3 sec
flexion, head flat, or bearing down E. ) Provide rest periods between care activities and prevent the duration of procedures F. ) Assist with position changes G.) Promote active/passive ROM exercises Teamwork and Collaboration A. ) Review laboratory findings, especially the ABG E.) Constant activity can further increase ICP by creating a cumulative stimulant effect E. ) Gently repositioning a patient from a supine to sitting/standing position can reduce the risk for orthostatic BP changes G.) Exercise prevents venous stasis and further circulatory compromise Teamwork and Collaboration A. ) To review if there is a clotting factor that may impede tissue Table 4. NCP # 2 (continued)
Nursing Diagnosis : Anxiety related to emotional stressors Table 5. NCP # 3 Assessment Scientific Basis Planning Interventions Rationale Evaluation Subjective: “Sobra akong kaguol sa akong anak. Di nako madawat na nahimong in ani ang among relasyon”, as verbalized by patient. Objective: -BP: 140/ -PR: 102 -headache -dizziness -weakness -expression of concerns In events of long bouts of stress, there is an increase in cortisol and corticotropin present in the body that lasts for long periods of time, resulting to clinical anxiety and mood disorders (Sambunaris, 2020). Reference: Murr’s Nurses’Pocket Guide (15th^ Ed.) Short Term: Within 4 hours of nursing interventions, the patient will verbalize awareness of feelings and ways on how to manage them. Long Term: Within 2 days of nursing interventions, the patient will appear relaxed and report that anxiety is reduced to manageable levels. Safe and Quality Nursing Care A. ) Assess the patient’s level of anxiety B. ) Assess physical reactions to anxiety C. ) Observe how the client uses coping techniques and defense mechanisms to cope with anxiety D. ) Recognize awareness of the client’s anxiety Safe and Quality Nursing Care A. ) To obtain baseline data B. ) Anxiety may have physical symptoms C. ) Asking questions requiring informative answers helps identify the effectiveness of coping strategies currently used by the client D. ) Acknowledgment of the client’s feelings validates the feelings and communicates Short Term: After 4 hours of nursing interventions, the patient was able to verbalize awareness of feelings and ways on how to manage them. Long Term: After 2 days of nursing interventions, the patient was able to appear relaxed and report that anxiety is reduced to manageable levels.
E.) Provide massage and backrubs for the client to reduce anxiety Effective Communication A. ) Validate observations by asking the client, “Are you feeling anxious now?” B.) Interact with the client in a peaceful manner Safe Environment A. ) Familiarize the client with the environment and new experiences or people as needed acceptance of those feelings E.) This aids in the reduction of anxiety Effective Communication A. ) Anxiety is a highly individualized, normal physical and psychological response to internal or external life events B.) The client’s feeling of stability increases in a calm and non-threatening environment Safe Environment A. ) Awareness of the environment promotes comfort and may decrease the anxiety Table 5. NCP # 3 (continued)
Table 6. Rosuvastatin Name of Drug Classification Mechanism of Action Indications Contraindications Adverse Reactions Nursing Responsibilities Generic: Rosuvastatin Trade: Crestor Dose: 250 g/tab 1tab OD Route: PO Max Dose: 400 g Min Dose: 50 g General: HMG-CoA Reductace Inhibitor Functional: Antihyperlipidemic A fungal metabolite that inhibits the enzyme GMG-CoA that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol. -adjunct to diet in elevated LDL -adjunct to diet to slow atheroscleorsis -treatment of primary dysbetaliprotenemia Patient’s Indication: To reduce LDL -allergy to any component of the drug -active liver disease -persistent elevated serum transaminases -impaired hepatic function -alcoholism -renal impairment -hypothyroidism -headache -dizziness -insomia -hypertonia -paresthesia -depression -anxiety -neuralgia -hypertension -angina pectoris Before:
Assess for cautions and contraindications Obtain baseline values Review hepatic and renal function Assess for allergy to drug components During: Administer drug at bedtime After: Monitor patient closely for signs of muscle injury, especially at higher doses, in Asian patients, and when used with other medications
Provide comfort measures to deal
with headache, muscle cramps, and nausea
Institute appropriate diet and exercise changes that need to be made Instruct to report severe GI upset, unusual bleeding or brusiing, drak urine or light- colored stools, unexplained muscle pain, tenderness, or weakness Table 6. Rosuvastatin (continued)
