General Objective

At the end of the case presentation, the presenters together with the audience will enhance their understanding on the disease process of hypertensive cardiovascular disease.

Specific Objectives
After the case presentation, we will be able to:

Knowledge
Define the terms Hypertensive Cardiovascular Disease, Ischemia, Infarction, and the concept of collateral blood flow. determine the risk factors and warning signs of Hypertensive cardiovascular disease and the basic mechanisms by which it occurs.

Skills
Define

and discuss Hypertensive cardiovascular disease and interpret data gathered through theoretical analysis of nursing history, physical assessment, laboratory results, pathophysiology, and medications taken by the client, its action, side effects and nursing responsibilities. Explain the anatomy and physiology of cardiovascular system Create effective and efficient Nursing Care plan

Attitude Develop communication skills of the gathered information for the case presentation.

Basic Information
Name: T.L. Address: Leon, Iloilo City Age: 61 years old Gender: male Civil Status: Married Date and Time admitted: February 14, 2012 12:30 P.M. Attending Physician: Dr. S. Chief Complaint: Left Sided Numbness Diagnosis: Hypertensive Cardiovascular Disease

Clinical Assessment Nursing History History of Present Illness

Last February 14, 2012, at around 12:30 P.M., 61 years of age, the patient was rushed into the hospital due to numbness of the left part of his body and dizziness. He felt the numbness for almost 2 days already so his wife decided to bring him to the hospital. Prior to that, his wife verbalized that he smoked and get drunk a lot the past days.

History of past Illness/ Family history

At a very young age,17 years old, the patient started smoking and drinking. He could consume at least a pack of cigarette in a day and could drink almost 6-8 bottles of beer in a day. His vices continued until his first hospitalization last 2007, where he had a mild stroke. Their was a clotting of blood in his left brain, causing his right body to feel numb. Then last July 2011, he was again hospitalized with the same condition, the difference is that this time, it was his left body thats affected. Hypertension is present at his father side.

Patient Expectation:
Regarding Hospitalization: ginapanumdum ko gid nga maatipanan gid nila ko mayo atipanon man ko mayo sang mga nurses

Regarding Nursing Care:

Brief Social, Cultural, & religious Background

Educational background: Occupational: Religious Practice: Person/s Significant: Social Role:

Elementary Graduate Former Fish Vendor Seldom goes to church Wife None

Patterns of Functioning

PRIOR TO HOSPITALIZATION DURING HOSPITALIZATIO

*BREATHING PATTERN Respiratory Problems Usual Remedy Manners of Breathing None None Regular and quiet breathing. None

None
Regular and quiet respiration (19cpm)

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION

* CIRCULATION Usual Blood Pressure Any history of chest pain,palpitation, etc. Coldness of extremities, etc. 170/110 mmHg wala 120/80 mmHg wala man

None

None

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION

*SLEEPING PATTERN

Usual Bedtime
Bedtime Rituals

10:00 PM
gahigda, kis-a nagakatulogan sa tubing sang TV wala

kung ano lang oras

gahigda

Problems regarding sleep

wala

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION

* EATING PATTERNS Breakfast Lunch Dinner Snack 8 A.M. kan-on kag kung ano ang sud-an 11 A.M. Kan-on kag utan gid 6 P.M. Kan-on kag kung ano nabilin na sud-an 3 P.M. Kape kag tinapay 6 A.M. Kung ano nahatag sang Hospital 11 A.M. kung ano nahatag sang hospital 5 P.M. kung ano man na hatag sang hospital tubig o wala man

PRIOR TO HOSPITALIZATION DURING HOSPITALIZATIO

Food Likes Food dislikes Total amount of fluid intake per day

Wala ko pili

Wala pili

Wala man
5-8 ka baso

wala
mga lima ka baso

Kinds of fluid usually taken

juice/water/beer/coffee tubig lang

PRIOR TO HOSPITALIZATION DURING HOSPITALIZATIO

*BOWEL MOVEMENT Frequency Problems or difficulties Usual remedy kada aga gd daw wala man wala kis-a lang indi ka bowel inom lang tubig

PRIOR TO HOSPITALIZATION DURING HOSPITALIZATIO

* URINATION Frequency indi ko maisip wala None mga 8x a day wala None

Problems
Usual remedy *EXERCISE PHYSICAL ACTIVITY

Exercise/physica gapamial kahoy, gasag-ob l activity tubig

panaw-panaw

PRIOR TO HOSPITALIZATION DURING HOSPITALIZATIO

PERSONAL HYGIENE
*

Type Frequency Frequency of brushing the teeth

paligo sang lawas

panibin lang ka duwa ka duwa None

isa ka beses sa isa ka adlaw, kung maramig wala ko kis-a gapaligo

3x a day
None

Care of dentures

PRIOR TO HOSPITALIZATION DURING HOSPITALIZATIO

*SHAVING Frequency *USE OF COSMETICS Use of cosmetics *RECREATION Recreation *HEALTH SUPERVISION Health Supervision kadto sa centro lantaw TV, lantaw basket ka mga bata kung san-o lang may kadtuan wala wala wala

istorya sa mga upod ko

doctor kag nurse

PHYSICAL ASSESSMENT VITAL SIGNS

Date Taken: February 16, 2012 Time Taken: 12 P.M. Temperature : 35.7 C Pulse Rate : 71 bpm Cardiac Rate : 74 bpm Respiratory rate: 19 cpm Blood Pressure: L-120/80mmHg Height: 53 Weight: 62kg

General Appearance: Physical Appearance Ambulatory; medium built body with limited movement in his left extremities; slow gait; Psychological Appearance Well-groomed with good personal hygiene; speech is understandable and has moderate pace with clear tone; positive response to pain stimuli; hyperactive

Skull -rounded (normocephalic & symmetrical with frontal, parietal, 7 occipital prominences), smooth skull contour, absence of nodules and masses, Scalp -lighter in color than the complexion; no scars noted; free from lice and dandruff; no lesions noted, tenderness nor masses on palpation Hair -Thick, short hair; black in color; equally distributed with oily texture; straight hair type

Skin

-Brown in complexion; generally uniform except to areas usually exposed to the sun; no edema; dry in moisture; warm in temperature; a bit rough in texture due to sagging of the skin; free from rashes and lacerations; no signs of blisters
Nails -Convex curvature; pinkish nail color; good capillary refill (returns within 2-3 seconds); smooth; Eyes -both eyes coordinated; black in color; uses glasses; no signs of cataract; good visual acuity

Eyebrows -thick eyebrows; hair evenly distributed; symmetrically aligned; equal movement; grayish in color; skin intact Eyelashes -black in color; equally distributed; curled, slightly outward Eyelids -no discharges, no discoloration; lids close symmetrically, approximately 13 involuntary blinks/minute; bilateral blinking when lids open;

Conjunctiva -pinkish in color; shiny and smooth Cornea -No irregularities; transparent in color; shiny and smooth Pupils -size is 3mm in diameter and both pupil are equal in size; equally round; pupils dilate when looking at distant objects; pupils constrict when looking at nearer object; positive response to light and accommodation to both eyes;

Ears -same color as of the facial skin; no swelling or tenderness observed; auricles has a firm cartilage on palpitation; no pain or tenderness on palpitation of the auricles and mastoid process; no discharges or lesions noted at the ear canal; has good hearing acuity Nose -symmetric and straight; dry and pinkish nasal mucosa; nasal septum is intact and in midline; air moves freely in both nares; no discharges or flaring Mouth -brownish in color; soft, moist, smooth and soft; able to purse lips; presence of cavities on lower portion of the teeth; positive gag reflex; 32 adult teeth present;

Tongue -Central position; dark in color; moist, slightly rough, with this whitish coating noted, no lesion raised papillae; moves freely; no tenderness
Neck -Muscles equal in size; head centered; coordinated; normal movement of the neck; no visible mass or lumps noted; wrinkles noted; no swelling of lymph nodes Anterior Chest -areola is rounded; brown in color; same in size and equal in color; no obvious mass noted; no discharges from the nipples; symmetric; ribs structure not visible; crackles breath sounds noted;

Posterior chest -Symmetrical chest; spine vertically aligned; spinal column is straight; consistent skin color; warm temperature; skin intact; no lesions noted; no masses; crackles sound also noted Breast -Skin uniform in color (same color as of the abdomen or back); areola round and bilaterally the same; nipples round; breast not enlarged; both nipples point in the same direction; no discharges in the nipple Axilla -No tenderness, masses or nodules noted. Abdomen -Uniform in color; no scar noted; umbilicus is at midline; no evidence of enlargement of liver, or spleen; firm, flat in shape; relaxed abdomen with smooth, consistent tension.

Upper Extremities -equal in size; warm temperature with IVF attached to left basilica vein; no lesions noted; sagging muscle tone; cant perform complete motion due to numbness of his left extremities; Lower extremities -equal in size; no swelling noted; warm temperature; limited range of movement in his left extremities; capillary refill is good; slow gait; varicose vein noted in his right leg; Genito-Anal Area -Patient refused to be assessed but claimed no abnormalities; able to void and defecate;

TEXT DISCUSSION HYPERTENSION Occurs due to complication of high blood pressure. In this condition the workload of the eart is increased manifold and with time this causes the heart muscles to thicken. The heart continues pumping blood against this increased pressure and over period of time the left ventricle of the heart enlarges.

 High blood pressure is among the topmost factors associated with cardiovascular disease. This can result in ischemic heart disease. This is a also contributing factors to the eventual thickening of walls of blood vessels. This increases the possibility of heart attack and stroke. Heredity is an important factor so far as people suffering from hypertension. Other factor includes excessive consumption of salt and excessive stress.

Risk Factors: Alcohol Use Excess dietary sodium Lack of exercise Stress Obesity Age Gender Genetic factors Race

Symptoms:

Arrythmias
Shortness of breath

Weakness and fatigue

swelling in lower extremities

Chest pain
sweating and dizziness

Prevention: Following healthy eating patterns. Reducing sand and sodium in your diet. Maintaining health weight

Being physically active.

Limiting alcohol

Quit smoking

Test: Stethoscope (ECG) Electrocardiogram Chest X-ray CT scan of the chest Echocardiogram Coronary angiogram

Home Remedies Living a healthy lifestyle can lessen the risk of having hypertension. A healthy diet that includes the right kind of vitamins and minerals is a must.

Blood Chemistry
LIPID PROFILE TOTAL CHOLESTEROL TRYGLYCERIDES Laboratory Result 5.9 1.82 NORMAL 5.7m mol/L 1.71m mol/L

Hematology
Labotory Result NORMAL

NEUTROPHILS NUMBER FRACTION

SEGMENTERS LYMPHOCYTE THROMBOCYTE NUMBER FRACTION SERUM SODUIM SERUM POTASSIUM

0.70
0.68 0.16 ADEQUATE 143.00 3.63

60-70:1
60-70:1 18-30:1

m mol/L- 135-148m mol/L m mol/L-5.30m mol/L

Name of Drug Simvastatin Classification Antihyperlipidemic Dosage/Route/Frequency: 20mg 1tablet, orally, once a day at bedtime Mechanism Of Action: Inhibits HMG-CoA reductase, the enzymes that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs, and either an increase or no change in serum HDLs. Indication coronary artery disease hypercholesterolemia Contraindication hypersensitivity to drugs or its components;active hepatic disease or unexplainend persistent serum transaminase elevations;pregnancy and breast feeding

Adverse Reaction: Headache Asthenia Nausea & vomiting Constipation and abdominal cramps Special Precaution Renal impairment server acute infection, hypotension: severe metabolic, endocrine or electrolyte problems; oncontrolled scizures, visual disturbance; myopathy; major surgery, trauma alcoholism. history of hepatic disease concurrent use of amiodarone;clarithromycin,cyclosporine, digoxin,erythromycin,gemfibrozil,and other fibrates, itraconazole,kelaconazole, nefazodene,nicotinic acid, protease inhibitors, verapamil,or warfarin. cross-sensitivity to other drugs that can affect steroid levels Females of child bearing age

Nursing Responsibilities
Advise patient to take with evening meals, but not with large amount of grapefruit juice tell patient drug may take up to 4 weeks to be effective, caution patient to stop taking drug and contact prescriber if she suspects she is pregnant. Teach patient to recognize and report signs and symptoms of myopathy or hepatic disorders instruct patient to avoid alcohol and red yeast rice as appropriate review all other significant and life threatening adverse reactions and interactions especially those related to the drugs, test, foods, herbs, and behaviors mentioned above.

Name of Drugs Carvedilol Classification antihypertensive Dosage/Route/Frequency 25mg 1tablet Once A Day Orally Mechanism Of Action: Competitively blocks alpha-bata, and beta-adrenergenic receptors and has some symothomimetic activity at beta-receptors. Both alpha and beta blocking actions contribute to the BP-lowering effect;beta blockade prevents the reflex tachycardia seen with most alpha blocking drugs and decreases plasma rennin activity: significantly reduces plasma rennin activity. Indication Hypertension heart failure caused by ischemia or cardiomyopathy left venticular dysfuntion following myocardical infarction

Contraindication Hypersensitivity to drugs uncompensated heart failure pulmonary edema bradycardia or heart block severe hepatic impairment bronchial asthma bronchospasm. Adverse Reaction: Dizziness Vertigo Tinnitus Fatigue pulmonary edema hypotension Gastric pain Flatulence constipation

Special Precaution renal or hepatic impairments polmonary disbars, diabetes mellitus, hypoglycemia, thyrotoxicasis,peripheral vascular disease, hypotension respiratory depression elderly patients pregnant or breast feeding patients, children. Nursing Responsibilities instruct patient to take drug with food exactly as prescribed. Caution patient not to stop taking drug abruptly, because serious reactions may result. Advise patient to move slowly when sitting up or standing, to avoid dizziness or light headedness from sudden blood pressure drop Caution patient to avoid driving and other hazardous activities until he shouldnt exceed 70mg regardless of calculated dosage

Name Of Drugs Ampicilin & Sulbactam Sodium Classification Anti-Infective Dosage/Route/Frequency 750mg IVT every 8 hours Mechanism Of Action: Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death. Indication Intra-abdominal gynecologic & skin structure infections caused by susceptible vita-lactamase producing strains. Contraindication Hypersintivity to penicillin Cepbalosporin impenem, or other beta-lactamase inhibitors Adverse Reaction: Lethargy, hallucinations, seizures, heart failure, glossitis, stomatitis, gastritis, sore mouth, furry tongue, blackhairy tounge , nausea, vomiting,diarrhea, abdominal pain, bloody diarrhea, enterrocolitis pseudomembranouscolitis, nonspecific hepatitis.

Special Precaution Renal insufficiency, underlying haemostatic disorders major operations of severe hemorrhage abrupt discontinuation in myoclonic patients Nursing Responsibilities Instruct patient to immediately report signs and symptoms of hypersensitivity reaction, such as rash, fever or4 chills Tell patient to report signs and symptoms of infection or other problems at injection site. Advise patient to minimize gi upset by eating small, frequent servings of food and drinking plenty of fluids inform patient that drug lowers resistant to certain infections. Instruct him to report new signs or symptoms of infection, especially in mouth.

Name Of Drugs Salbutamol Classification Bronchodilator, Anti-Asthmatic Dosage/Route/Frequency 1 Nebula every 6 hours Nebulization Mechanism Of Action: It binds therefore to Beta 2 receptors found particularly in the bronchioles of the respiratory system. In binding to these receptors it activates the Gs protein that the receptor is associated with and GDP is exchanged for GTP. Indication To prevent and relieve bronchospasm in patients with reversible obstructive airway disease to prevent exercise induced bronchospasm Contraindication Hypersensitivity to Drugs Adverse Reaction Nausea, dizziness, skin rash w/iritation, increased heart rate restleness chest pain and tremor

Special Precaution Cardiac disease, hypertension, diabetes mellitus, glaucoma, seizure disorder, hyperthyroidism excersize-induced bronchospasm, prostate hypertrophy elderly patients pregnant breastfeeding patients children Nursing Responsibilities monitor serum electrolyte levels teach patient signs and symptoms of hypersensitivity bronchospasm tell him to stop taking the drug immediately and contact prescriber if these occur advise patient to limit the intake of caffeine containing foods and beverages and to avoid herbs unle4ss prescriber approves, advice patient to establish effective bedtime routine and to take drug well before bedtime to minimize insomia.

Name Of Drug Piracetam Classification Neotropics and Neurotonics Dosage/Route/Frequency 1gm IVT every 8 hours Mechanism Of Action: Drug influences neuronal and vascular functions and influences cognitive function without acting as a sedative or stimulant. Indication cerebral circulatory insufficiency and chronic manifestations of cerebro vascular accident or of cerebral atherosclerosis egsquelae of stroke in particular,aphassia, post traumatic syndromes severe mental coolness and vascular coma of a traumatic or toxic origin Contraindication cerebral hemorrhage, end stage renal disease

Adverse Reaction Insomnia lost weight gain hypekinisia and depression diarrhea rashes Special Precaution Renal insufficiency, underlying haemostatic disorders major operation or severe hemorrhage, abrupt discontinuation in myoclonic patients.

Nursing Responsibility
advise patient to take the medicine before meals.

Assessment

Nursing Diagnosis Impaired physical mobility related to left sided numbness as verbalized by the patient Indi ko mahulag ang wala ko nga kamot kag tiil. Nagaparamiring lang and evidenced by limited range of motion, and difficulty in moving his left body parts.

Outcome Criteria At the end of the shift, the patient will be able to: Participate in Activities of Daily Living and desired activities. Maintain or increase strength and function of affected and/or compensator y body part.

Intervention

Rationale

Evaluation

Subjective: Indi ko gawa mahulag ang wala ko nga kamot kag tiil. Nagaparamiring lang. Objective: Limited range of motion Difficulty in moving his left body parts Temp - 35.7 C Pulse - 71 bpm Resp - 19 cpm BP 120/80

Independent: Check vital signs. Support affected body parts using pillows/rolls, foot supports/sho es. Keep side rails up. Collaborative: Consult with physical or occupational therapist.

Goals met. To provide At the end of the baseline shift: data. The patient To maintain was able to position of perform function and physical reduce risk activities. of pressure mahakwat ulcers. ko na ang To provide akon kamot safety kag maalsaalsa ko na ang akon tiil . The patient is planning to see a To develop Physical individual therapist as exercise/mob soon as he is ility program discharged. and identify appropriate mobility devices.