a care study hypertension
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I. INTRODUCTION
Hypertension, or commonly known as high blood pressure, is a medical
condition wherein the blood pressure of an individual is recurrently elevated.
Hypertension is an important contributor to morbidity and mortality from
cardiovascular disease. It is a an independent risk factor for stroke, myocardial
infarction, renal failure, congestive heart failure, progressive atherosclerosis,
dementia, coronary artery disease and peripheral vascular disease. Hypertension
affects approximately 50 million individuals in the United States and
approximately 1 billion individuals worldwide. As the population ages, the
prevalence of hypertension will increase even further broad and effective
preventive measures are implemented (1). In the Philippines, 9.6M are
hypertensive and 15.4M are predisposed to be hypertensive among adults, 20
years and over (2). Unfortunately, half of those who has hypertension are not
aware that they have the condition, only 13.1% of them has been treated and 19.3
% has been controlled (3). Since hypertension may be present in an individual in
years without noticeable symptoms, it is otherwise known as “The Silent Assasin”
(4) In the Philippines, for over 5 years, hypertension ranks as the fifth leading
cause of morbidity (5). This implies that hypertension is a chronic problem or
condition of the country and perhaps not much has been done on its control and
prevention. Prolonged and uncontrolled hypertension is very dangerous.
Unhealthy lifestyles which include cigarette smoking, unmanaged stress, salty
food consumption, physical inactivity, or being overweight are the common
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modifiable risk factors to having hypertension. Non modifiable factors include
genetic predisposition to hypertension and other disease condition like diabetes,
heart and kidney disease, high cholesterol level, or stroke and an increasing age.
Hypertension in its earlier stage is manageable. The simplest way of controlling
high blood pressure is through lifestyle modification by having healthy diet and
regular exercise. Discontinuation of smoking and alcohol consumption are also
advised to individuals with hypertension. However, medication is prescribed to
hypertensive individuals to control persistent rise in blood pressure.
Hypertensive urgency is defined as a severe elevation of BP, without evidence of
progressive target organ dysfunction. These patients require BP control over
several days to weeks. The most common hypertensive urgency is a rapid
unexplained rise in BP in a patient with chronic essential HTN.Other causes are
Renal parenchymal disease – Chronic pyelonephritis, primary glomerulonephritis,
tubulointerstitial nephritis (accounts for 80% of all secondary causes) Systemic
disorders with renal involvement – Systemic lupus erythematosus, systemic
sclerosis, vasculitides Renovascular disease – Atherosclerotic disease,
fibromuscular dysplasia, polyarteritis nodosa Endocrine – Pheochromocytoma,
Cushing syndrome, primary hyperaldosteronism Drugs – Cocaine, amphetamines,
cyclosporin, clonidine withdrawal, phencyclidine, diet pills, oral contraceptive
pills Drug interactions – Monoamine oxidase inhibitors with tricyclic
antidepressants, antihistamines, or tyramine-containing food CNS – CNS trauma
or spinal cord disorders, such as Guillain-Barré syndrome Coarctation of the aorta
Preeclampsia/eclampsia Postoperative hypertension.
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II. GENERAL DATA
Name : Mrs. S A E M
Age : 47 years old
Address : Magsaysay Hills Toledo City Cebu
Sex : Female
Civil status: Married
Occupation: Teacher
Citizenship: Filipino
Religion: Roman Catholic
Hospital: Chung Hua Hospital
Room/bed number: C-322
Hospital number: 1P0000237751
Date of Admission: July 25, 2010
Date of Discharge: July 28, 2010
Time of admission: 10:28 pm
Attending Physician: Dr. Noval, Lerma Reston (Cardiologist)
Final Diagnosis: Hypertensive Urgency
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III .HISTORY OF PRECENT ILLNESS
A few hours prior to admission patient complain of chest discomfort with note of
elevated blood pressure of 150/80 mmHg. Patient self medicated with her maintenance
medication Atenolol 25 mg and was brought to Toledo Hospital and was referred to
Chung Hua Hospital for further management.
IV. PAST HEALTH HISTORY
The patient has no known allergies but according to her she was diagnosed last year
with heart enlargement due to her inherited condition to her father side which is
hypertension.
V. CLIENT CLINICAL COURSE OF THE UNIT
July 26, 2010
On the first day of care. Patient received lying on bed conscious coherent and awake,
with ongoing IVF # 1 PNSS 1L @ 40 cc/hr hooked at left arm infusing well. Patient
complains of chest discomfort upon rising up to her bed. Patient is anxious as evidenced
by verbalization of her concern upon her current condition. Patient also reported fatigue.
Upon assessing her she stated that she feels like her body was too heavy to carry, she feel
so weak and helpless. Vital signs were monitored as ordered by the physician. Report if
blood pressure is elevated.
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July 27, 2010
On the second day of care. Patient received lying on bed conscious awake and coherent
with ongoing IVF PNSS # 2 1L @ 40 cc/hr infusing well. Patient vital signs were still
monitored as ordered. Patient verbalized that sometimes during walking around the room
she can feel her heart beating so fast. Patient was advice to avoid activities that exerts too
much effort to avoid the risk of injuries. Blood pressure were taken every 2 hours and
reported for any elevation. Patient’s only concern at this time was her heart palpitations
during activities.
July 28, 2010
On the third day of care. Patient received conscious awake and coherent. Patient is
watching television with no IVF attached and was ready to be discharged. Patient state
that she feels well now. Vital signs were still monitored and all were on at the normal
range. Health teaching was provided. Patient was encouraged to low salt and low fat diet
and to avoid activities that exert too much effort. Before the shift, patient was discharged
via wheel chair. Patient verbalized that she will comply with the health teaching that was
being instructed to her.
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VI. FAMILY PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY
A. FAMILY HISTORY
Table 1: Patient’s immediate family members:
NAME POSITION IN
THE FAMILY
AGE OCCUPATION
Mr. D E Grand Father Deceased Farmer
Mrs. J E Grand Mother Deceased Tailor
Mrs. M E F Father’s sister 69 years old Teacher
Mr. A E Father 72 years old Businessman
Mr. R E Father’s Brother 65 years old Government employee
Mrs. S A E M Patient 47 years old Teacher
Mr. A E Brother 45 years old Teacher
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FAMILY GENOGRAM:
Legend: = Normal (male)
= Hypertensive
= Normal (female)
= Hypertensive
Grand Mother
Grand Father
Father Father’s Sister
Father’s Brother
PatientPatient’s Brother
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B. PERSONAL AND SOCIAL HISTORY
Mrs. S A E M 47 years old a female and a Filipino. She is a roman catholic and
a pure Cebuano recently residing at Magsaysay Hills Toledo City Cebu. Mrs. S
A E M was a very loving and responsible wife to her husband. She is a very
friendly person. She’s always attending to the needs of her family. She always
sees to it that she can provide the needed things for her family. She wanted to
give her best to her family. If she doesn’t have any chores in the house or
doesn’t have any work, she does gardening on her little garden in their house.
She is also fun on watching television especially noon time shows.
C. ENVIRONMENTAL HEALTH HISTORY
Mrs. S A E M and her family are living in their own house at Magsaysay Hills
Toledo City Cebu and their house is made up of concrete materials. Their house
is just about enough for her family to live in and to protect them from stranger
and for hot and cold environment. They also have a backyard and she made a
little garden in order to help in their family in terms of fresh vegetables as food.
Their house is equipped with electricity. Their water supply is in their deep
wheel for laundry and mineral water is for drinking. Their house has its own
toilet facility; according to her it was well maintained and cleaned always.
Their garbage is dispose through compose pit on their backyard. Their house is
surrounded with trees that are planted by her father’s parents.
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VII. PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEM
Physical assessment was also known as the physical examination is the
evaluation of a body to determine its state of health. This method involves the use of the
five senses of the medical care provider since it uses the technique of inspection,
palpation, percussion, and the last was the auscultation. Physical assessment findings
provide objectives data in determining correct diagnosis and devising for the appropriate
interventions and treatment if the physical assessment is a medical practitioner-based
data, nursing review of system is a patient based data or commonly known as the
subjective data. This is a method of assessing a condition by asking a set of questions to
the patient that pertains to the particular parts or system of the body.
It is usually supported by the results from the physical assessment. Both physical
assessment and nursing review of system are vital in achieving a plan of care to the
patient and assuring a optimal care being rendered.
The table below shows the results and findings from the physical assessment and the
nursing review of system conducted to patient, Mrs. S A E M:
Table 2. PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEM:
NURSING REVIEW OF SYSTEM PHYSICAL ASSESSMENT
HEAD
“wala raman bukol bukol ako ulo dong” as
vervalized by the patient.
Head is proportion to the patient’s body. Some hair
is gray and evenly distributed. No lesions are
visible. Dandruff was noted.
EYES Patient eyes are symmetrical, eyebrows are free
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“ depektado na jud ako panan-aw dong, dili ko ka
klaru og basa kong dili ko mag eyeglass” as
verbalized by the patient.
from scaling, pupils constricted when light is
focused, sclera is white, conjunctiva is clear, and
eye movement and blinking reflex are in good
condition. Teary eyes noted. Patient’s eyeglass
grade is 180.
EARS
“ok raman ako pan dungog” as verbalized by the
patient.
Patient ears are symmetrical, equal in size and same
in appearance. No foul smelly sticky discharged in
both ears. Patient was able to her whispered words.
NOSE
“ ok raman, wala man sad nag ping-ot ako ilong” as
verbalized by the patient.
Nose is located at the midline of the face with no
lesion or redness noted. Client report no tenderness.
Can breathe through the nose clearly. Septums are
not perforated.
MOUTH
“ wala na koy bag-ang sa taas og ubos” as
verbalized by the patient.
Lips are pale without lesions or swelling. Teeth are
incomplete, left and right molars are absent. Gums
and tongue are pale and slightly dry. No lesions and
ulcers noted. Tonsillar pillar are symmetrical,
tonsils are present, vulvula at the midline and gag
reflex are in good condition.
NECK
“ok raman ako pag tulon dong” as verbalized by the
patient.
Patient’s neck is smooth, controlled movement,
cervical lymph nodes are palpable, patients thyroid
are at the midline, smooth, firm, tender and no
lesion noted.
INTEGUMENTARY SYSTEM Skin is fair in complexion, no presence of marks or
scars. Nails are short and with capillary refill time
of 2-3 seconds.
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“Normal raman ako gipamati karon dong” as
verbalized by the patient.
RESPIRATORY SYSTEM
“Usahay maglisod ko og ginhawa” as verbalized by
the patient.
Respiratory rate ranges from 21-22 cycles per
minute, lungs expansion is symmetrical, clear breath
sounds are present.
CARDIOVASCULAR SYSTEM
“ma feel nako nga paspas ang pinitik sa ako kasing-
kasing” as verbalized by the patient.
Heart rate is 78 beats per minute, blood pressure is
130/80 mmHg.
GASTROINTESTINAL SYSYTEM
“wala raman problema dong, makalibang raman ko
kada adlaw” as verbalized by the patient.
Patient reported no abdominal pain. Patient was able
to pass bowel during the shift. Bowel sounds are
normal.
URINARY SYSTEM
“dili man ko mag lisod og pangihi dong” as
verbalized by the patient.
Patients urinary output ranges from 660-750 cc in a
day that’s approximately 20-30 cc/hr. Patient urine
is amber in color.
MUSCULOSKELETAL SYSYTEM
Usahay murag lay-lay ako pamati” as verbalized by
the patient.
Patient can move her legs and other extremities.
Doesn’t need assistance upon walking and
ambulation.
NEUROLOGIC SYSTEM
“ok lng man” as verbalized by the patient.
Patient is conscious, coherent and responsive.
Response with environmental stimuli and interact
with other persons in the room. Answered questions
correctly. Patient is aware of time date and place
when admitted.
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GENETO-URINARY SYSTEM
Patient refuses.
VIII. DEVELOPMENTAL DATA
Developmental history refers to the series or sets of events that an individual
usually undergoes in the specific age and specific time of growth. The purpose of
gathering the developmental history or data is to determine the patient’s physical,
mental, and psychosocial developmental development in order to assess any
developmental delays.
Psychosocial Developmental Theory
Stage and age Central task Indications of
positive
resolutions
Patient’s
resolution
INFANCY
Birth to 1 year
Oral- sensory
Trust
vs.
Mistrust
-Infants develop trust
in self, others, and in
the environment when
caregiver is responsive
to basic needs and
provides comfort.
-Consistency of care
must be given from
same care provider.
-Patient related that
she have any clear
memory during those
times, but she said
that her mother told
her that she loved to
be cuddled and eager
to have her feeding.
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-IF NOT MET, infants
become uncooperative
and aggressive and
show decreased
interest to
environment.
TODDLER
1-3 years old
Muscular-anal
Autonomy
Vs.
Shame/Doubt
-Toddlers learn to
control while
mastering skills such
as toileting, feeding
and dressing when
caregivers provide
reassurance.
-IF NOT MET,
toddlers feel ashamed
and doubt own
abilities, which leads
to lack of self
confidence.
The patient claimed
that the she cries
when she can’t have
those things that she
wants.
PRESCHOOL
3-6 years old
Locomotors
Initiative
Vs.
Guilt
-Child begins to
initiates activities in
place of just imitating
activities; uses
imagination to play;
learns what is allowed
and what is not
-Patient loved to go to
school because she
wanted to learn new
things and meet
classmates and friends
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allowed to develop
self conscience.
-Caregivers must
allow child to be
responsible while
providing assurance.
-IF NOT MET, child
feels guilty and
hesitant.
SCHOOL AGE
6-12 years old
Industry
Vs.
Inferiority
-Childs becomes
productive by
mastering learning
success; child learns to
deal with academics,
group activities, and
friends.
-IF NOT MET, child
develops sense of
inferiority and
incompetence.
-Patient engaged in
some school activities
like volleyball and
participated in other
academics matters.
ADOLESCENCE
12-18 years old
Identity
vs.
Role Confusion
-Adolescents reach for
self-identity by
making choices about
occupation, sexual
orientation, lifestyle
-Patient is really sure
that she is a true girl.
She starts to engaged
in a relationship at
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and adult role; relies
on peer group for
support and
reassurance to create
self-image separate
from parents.
-IF NOT MET,
Adolescent
experiences role
confusion and loss of
self-belief.
this time.
YOUNG
ADULTHOOD
19-25 years old
Intimacy
vs.
Isolation
-Young adults learn to
make a personal
commitment to others
and share life events
with others.
-IF NOT MET, adults
may fear relationship
and isolates self from
others.
- Patient states that at
this time she started to
build relationship to
opposite sex.
MIDDLE – AGE
ADULT
Generativity vs. -middle age adults
prioritize in
-patient state that she
is more concern about
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25-40 years old Stagnation establishing needs for
self and others.
-IF NOT MET,
persons might be more
concern of one-self in
spite of the needs of
others.
herself and her
family.
OLDER –ADULTS
40-60 years old
Integrity
Vs.
despair
-Older adults uses past
experience to assist
others. At this time
they already accept
their limitation in life.
-IF NOT MET, Older
adults might not
accept changes in life;
they will be
demanding
unnecessary assistance
and attention to others.
- Patient state that she
always makes sure
that her children will
grow up as a
respective person, she
always reminds her
about their future.
IX. ANATOMY, PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY
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A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED
“THE HEART”
Human heart is a muscular pump, which is located between the lungs, but
slightly to the left side. The heart of an adult weighs between 250 to 300 grams in
females, and 300 to 350 grams in males. The length of a human heart is around
six inches, and the width is roughly four inches. An average human heart beats
approximately 72 times per minute, and pumps 4-5 liters of blood (per minute) at
rest.
Human Heart – Location
The human heart is located in the middle of the chest - anterior to the spine
and posterior to the sternum or breastbone (long flat bone in the center of the
chest). The heart lies slightly to the left, from the center of the thorax (region
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between head and abdomen). Hence, the left lung is smaller compared to the right
lung.
Parts of the Human Heart
The heart is divided into two cavities (left cavity and right cavity) by a
wall of muscle called septum. The two cavities consist of two chambers each.
Upper chambers are called atrium and the lower ones are called ventricles. The
right cavity receives de-oxygenated blood from various parts of the body (except
the lungs) and pumps it to the lungs, whereas the left cavity receives oxygenated
blood from the lungs, which is pumped throughout the body. Let us discuss the
anatomy of this amazing organ in detail.
Outer Covering - Pericardium: The heart and the roots of its major blood vessels
are surrounded and enclosed by a sac-like structure called pericardium. It
comprises of two parts - the outer fibrous pericardium, made of dense fibrous
connective tissue and an inner double-layered membrane (parietal and visceral
pericardium). The fibrous pericardium is attached to the spinal column,
diaphragm and other parts of the body, by ligaments. The double-layered
membrane consists of an inner layer called visceral pericardium, outer layer called
parietal pericardium (fused to fibrous pericardium) and a pericardial cavity
(between the two layers), which contains serous fluid - pericardial fluid. This fluid
helps in reducing the friction caused by the contractions of the heart.
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Heart Wall: The wall of the heart is made up of three layers of tissues - outer
epicardium, middle myocardium and the inner endocardium. The outer
epicardium functions as a protective outer layer, which includes blood capillaries,
lymph capillaries and nerve fibers. It is similar to the visceral pericardium, and
consists of connective tissues covered by epithelium (membranous tissue covering
internal organs and other internal surfaces of the body). The inner layer called
myocardium, which forms the major part of the heart wall, consists of cardiac
muscle tissues. These tissues are responsible for the contractions of the heart,
which facilitates the pumping of blood. Here, the muscle fibers are separated with
connective tissues that are richly supplied with blood capillaries and nerve fibers.
The inner layer called endocardium, is formed of epithelial and connective tissue
that contains many elastic and collagenous fibers (collagen is the main protein of
connective tissues). These connective tissues contain blood vessels and
specialized cardiac muscle fibers called Purkinje fibers. This layer lines the
chambers of the heart and covers heart valves. It is similar to the inner lining of
blood vessels called endothelium.
Chambers of the Heart: As discussed earlier, the human heart has four chambers,
the upper chambers known as the left and right atria, and the lower chambers
called left and right ventricle. Two blood vessels called the superior vena cava
and the inferior vena cava, brings deoxygenated blood to the right atrium from the
upper half and the lower half of the body, respectively. The right atrium pumps
this blood to the right ventricle through tricuspid valve. Right ventricle pumps this
blood through pulmonary valve to the pulmonary artery, which carries it to the
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lungs (to get re-oxygenated). The left atrium receives oxygenated blood from the
lungs through the pulmonary veins, and pumps it to the left ventricle through the
bicuspid or mitral valve. The left ventricle pumps this blood through the aortic
valve to various parts of the body via aorta, which is the largest blood vessel in
the body. The heart muscles are also supplied with oxygenated blood through
coronary arteries. The atria are thin-walled, as compared to the ventricles. The left
ventricle is the largest of the four chambers of the heart, and its walls have a
thickness of half inch.
Valves of the Heart: Basically the valves in the heart can be classified into two
types – antrioventricular or cuspid valves and semilunar valves. The former are
the valves between the atria and ventricles, whereas the latter are located at the
base of the ventricles. Tricuspid and bicuspid (mitral) valves are antrioventricular
valves, and pulmonary and aortic valve are semilunar valves.
These valves allow the blood to flow only in one direction and prevent reverse
flow. The human heart pumps around five liters of blood per minute
The Cardiovascular System
Your heart and circulatory system make up your cardiovascular system. Your
heart works as a pump that pushes blood to the organs, tissues, and cells of your
body. Blood delivers oxygen and nutrients to every cell and removes the carbon
dioxide and waste products made by those cells. Blood is carried from your heart
to the rest of your body through a complex network of arteries, arterioles, and
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capillaries. Blood is returned to your heart through venules and veins. If all the
vessels of this network in your body were laid end-to-end, they would extend for
about 60,000 miles (more than 96,500 kilometers), which is far enough to circle
the earth more than twice!
The one-way circulatory system carries blood to all parts of your body. This
process of blood flow within your body is called circulation. Arteries carry
oxygen-rich blood away from your heart, and veins carry oxygen-poor blood back
to your heart.
In pulmonary circulation, though, the roles are switched. It is the pulmonary
artery that brings oxygen-poor blood into your lungs and the pulmonary vein that
brings oxygen-rich blood back to your heart.
In the diagram, the vessels that carry oxygen-rich blood are colored red, and the
vessels that carry oxygen-poor blood are colored blue.
Twenty major arteries make a path through your tissues, where they branch into
smaller vessels called arterioles. Arterioles further branch into capillaries, the true
deliverers of oxygen and nutrients to your cells. Most capillaries are thinner than a
hair. In fact, many are so tiny, only one blood cell can move through them at a
time. Once the capillaries deliver oxygen and nutrients and pick up carbon
dioxide and other waste, they move the blood back through wider vessels called
venules. Venules eventually join to form veins, which deliver the blood back to
your heart to pick up oxygen.
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“THE KIDNEY”
Structure of the kidney:
On sectioning, the kidney has a pale outer region- the cortex- and a
darker inner region- the medulla.The medulla is divided into 8-18 conical
regions, called the renal pyramids; the base of each pyramid starts at the
corticomedullary border, and the apex ends in the renal papilla which merges to
form the renal pelvis and then on to form the ureter. In humans, the renal pelvis
is divided into two or three spaces -the major calyces- which in turn divide into
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further minor calyces. The walls of the calyces, pelvis and ureters are lined with
smooth muscle that can contract to force urine towards the bladder by
peristalisis.
The cortex and the medulla are made up of nephrons; these are the functional
units of the kidney, and each kidney contains about 1.3 million of them
The nephron is the unit of the kidney responsible for ultrafiltration of the blood
and reabsorption or excretion of products in the subsequent filtrate. Each
nephron is made up of:
A filtering unit- the glomerulus. 125ml/min of filtrate is formed by the kidneys as
blood is filtered through this sieve-like structure. This filtration is uncontrolled.
The proximal convoluted tubule. Controlled absorption of glucose, sodium, and
other solutes goes on in this region.
The loop of Henle. This region is responsible for concentration and dilution of
urine by utilising a counter-current multiplying mechanism- basically, it is water-
impermeable but can pump sodium out, which in turn affects the osmolarity of the
surrounding tissues and will affect the subsequent movement of water in or out of
the water-permeable collecting duct.
The distal convoluted tubule. This region is responsible, along with the collecting
duct that it joins, for absorbing water back into the body- simple maths will tell
you that the kidney doesn't produce 125ml of urine every minute. 99% of the
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water is normally reabsorbed, leaving highly concentrated urine to flow into the
collecting duct and then into the renal pelvis.
B. PATHOPHYSIOLOGY CONCEPTUAL FRAMEWORK
Risk factors;
-Family history
-Age
-High salt intake
-Low potassium intake
-Obesity
-Alcohol consumption
-Smoking
-Stress
AGENT;
No etiologic factor
HOST;
-family history
-stress
-Age
ENVIRONMENT;
Not related
Affects arteriolar bed
Arteriolar bed constriction
Increase systemic vascular resistance
Increase after load of the heart
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Decreased Blood flow towards the organ
Adrenal cortex secretes aldosterone
Angiotensin I
Angiotensin II
AngiotensinogenJuxtaglomerular cells secretes renin
Increase reabsortion of water and sodium
Increased Blood pressure
Increase aldosterone
Increased phireperal resistance
Arteriolar vasoconstriction
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C. DISCUSSION OF PATHOPHYSIOLOGY
Patient condition was an inherited one from her father side which is
hypertension. Patient has a past health history of heart enlargement due to his
current disease. Her blood pressure increases was also due to a related factor
which is stress, stress could cause constriction of the arteriolar bed. If there will
be constriction of the arteriolar bed there will be increase systemic vascular
resistance. It will affect the heart because the left ventricle in the heart will try to
compensate first for the altered systemic circulation. After load of the heart will
increase so there will be a decreased blood flow towards the organs of the body
because of increased resistance in the arteries. Decreased blood flow will enter to
the kidneys, the juxtaglomerular cells in the kidney will try to compensate for the
decreasing blood that enters to the kidney by secreting renin into the blood
stream. Renin travels towards the liver in a form of angiotensinogen in order to be
converted as angiotensin I, through an angiotensin converting enzyme.
Angiotensin I travel towards the lungs via blood flow in order to be converted into
the lungs as an angiotensine II, then angiotensin II will travel towards the adrenal
glands and stimulate the adrenal ducts to secrete aldosterone. Aldosterone that is
secreted by the adrenal ducts will reabsorb water and sodium in the body in order
to increase the blood pressure.
The RAAS or rennin angiotensine aldosterone system is responsible for the fluid
balance and for the regulation of blood pressure in the body.
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D. SYMPTOMATOLOGY
Symptomatology is a branch of science that deals with the study of different signs
and symptoms of a certain condition or body processes. Its main purposes are to
facilitate the identification of a disease and its process among others.
IDEAL SIGNS AND
SYMPTOMS
ACTUAL SIGNS AND
SYMPTOMS
MANIFESTED BY
PATIENT
SCIENTIFIC BASIS
Nosebleeds Patient stated nose
bleeding prior to
admission.
is the relatively common
occurrence of
hemorrhage from the
nose, usually noticed
when the blood drains
out through the nostrils
Irregular Heartbeat Patient stated that she can
feel her heart beating so
fast.
Abnormal electrical
activity in the heart. The
heart beat may be too fast
or too slow, and may be
regular or irregular.
Blurred Vision Patient stated blurring of Is a type of vision loss, it
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vision prior to admission. is an ocular symptom.
Confusion - Buzzing In
The Ears - Blood In Your
Urine
Not manifested by the
patient.
Confusion may result
from a relatively sudden
brain dysfunction
Lose Weight Not manifested by the
patient.
Is a reduction of the total
body mass, due to a mean
loss of fluid, body fat or
adipose tissue and/or lean
mass, namely bone
mineral deposits, muscle,
tendon and other
connective tissue
chest pain Patient complains of
chest discomfort.
Occurs when blood flow
to the arteries that supply
the heart becomes
blocked. With decreased
blood flow, the muscle of
the heart does not receive
enough oxygen. This can
cause damage.
Headache Patient verbalized
dizziness and headache
Is a pain anywhere in the
region of the head. It is a
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Dizziness during the first contact by
the student nurse.
symptom of several
conditions.
FatiguePatient verbalized body
weakness during her stay
in the hospital.
Is a state of awareness
describing a range of
afflictions, usually
associated with physical
and/or mental weakness,
though varying from a
general state of lethargy
to a specific work-
induced burning
sensation within one's
muscles.
AnxietyPatient is anxious as
observed by the student
nurse during his first
contact by the patient
Anxiety is a
psychological and
physiological state
characterized by
cognitive, somatic,
emotional, and
behavioral components.[2]
These components
combine to create an
30
unpleasant feeling that is
typically associated with
uneasiness,
apprehension, fear, or
worry. Anxiety is a
generalized mood
condition that can often
occur without an
identifiable triggering
stimulus
X. MEDICAL MANAGEMENT
IDEAL ACTUAL
–Hematologic Report
→Complete Blood Count
TEST RESULT NORMAL RANGE
UNIT
RBC 5.51 4.2-5.4 m/uL
Hemoglobin 12.70 12-16 g/dL
Hematocri
48.6
37-48 o/o
Lymphocyte 14 20-40 o/o
MVP 10.6 0-100 F/L
31
–Urinalysis Report
Platelets 161 140-440 K/uL
Neotrophils 77.3 40.70 o/o
Monocyte 5 2-8 o/o
Monocyte RDC
2.1 3.4-9.0 o/o
Monocyte ADC
0.13 0.16-1.00 10^3/uL
PHYSICAL
CHARACTERISTIC
RESULT NORMAL RANGE
UNIT
Color Yellow
Appearance Cloudy
Ph 7.5 5.0-8.0
Specific gravity 1.010 1.003-1.033
CHEMICAL CHARACTERISTIC
Creatinine 1.0 0.6-1.5 Mg/dL
SG-PT-ALT 25 5.0-50.0 u/L
Sodium (serum) 138.0 134-148.0 mmoL/L
Potassium 4.0 3.3-5.3 mmoL/L
B. TREATMENT AND PROCEDURES
IDEAL ACTUAL
32
- Patients should stop smoking (offer help nicotine replacement therapy).
- Weight reduction should be suggested if necessary, to maintain ideal BMI of 20-25 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help e.g. dieting clubs, may be appropriate.
- Reduce their salt, total fat, saturated fat and cholesterol intake, while increasing consumption of polyunsaturated, monosaturated fats and oily fish. Encourage fruit, vegetables, legumes and whole grains; and low fat (or zero-fat) dairy, poultry meat, fish and shellfish products.
- Cut alcohol intake to no more than 21 units (male) or 14 units (female) of alcohol per week.
- Encourage regular dynamic exercise tailored to age and capabilities of patient. This may mean three vigorous training sessions per week for a young adult, or brisk walking for ≥30 minutes most days for the older individuals.
- Do not offer supplements of calcium, magnesium or potassium to reduce BP.
Relaxation therapy can help
As well as the targets above, strive for a happy, well-informed patient. Remember to look for and treat any underlying cause in your initial assessment
-Vital signs taken every 4 hours
-Blood pressure taken every 2 hours
-Intake and output monitoring every shift
-Laboratory test taken
-Medication administration
33
C. MEDICATION
IDEAL ACTUAL
Initial Drug Choices
If patient is young (<55) and non-black start with:
(A) ACE inhibitor or Angiotensin II receptor antagonist (ACE II)
If patient is black or aged ≥55 years use:
(C) Calcium channel blocker or
(D) Diuretic (thiazide)
Second Drug Choices
(A+C) ACE inhibitor or Angiotensin II receptor antagonist with Calcium channel blocker or
(A+D) ACE inhibitor or Angiotensin II receptor antagonist with Diuretic (thiazide)
Third Drug Choices
(A+C+D) ACE inhibitor or Angiotensin II receptor antagonist (ACE II) and Calcium channel blocker and Diuretic (thiazide)
- Paracetamol ( Tylenol) p.o for temperature more 38 oC.
- Plasil 10 mg, 1 ampule, IVTT route, STAT.
- Losartan K ( lifezartan ) 50 mg tablet, once daily.
- Rusovastatin ( crestor ) 20 mg tablet, 1 tablet once a daily at bed time.
- Clopidogrel ( plavix ) 75 mg tablet, one talet orally once daily.
D. DIET : Low salt low cholesterol diet
XI. NURSING MANAGEMENT
34
IDEAL ACTUAL
35
1. Vital signs should be checked 2 hourly
with emphasis on Blood pressure and pulse
rate. Monitor patient's weight daily and
keep proper record. This is to help detect
edema or weight loss. Check for side
effects of drugs e.g. orthostatic
hypotension.
2. Rest: Patient should be advised to avoid
stress and tension. He should therefore
have physical and mental rest in order to
conserve energy. Encourage moderate
exercise e.g. walking if there is no dyspnea.
Mild tranquilizers may be given to enable
patient sleep. Should there be dizziness
patient should be protected from falls and
injury.
3. Diet: Restrict sodium intake to about
4grams daily. Give light, easily digestible
diet. Fatty food and excessive carbohydrate
that can increase weight and cholesterol
should be avoided. Coffee, tea, kola nuts,
alcohol should be avoided or minimized.
4. Physical care: Assist patient with
-Monitoring patient’s vital
signs.
-Bedside care was included.
- Changing of linens.
- Monitoring patient’s intake
and output.
- Monitoring of patient’s IVF.
- Low salt and low cholesterol
diet was instructed.
- Health teaching was given.
36
physical care if patient is very weak. Where
there is blurred vision patient may require
the use of medicated eye glasses. If there is
bleeding from the nose (epistaxis) apply ice
pack to the bridge of the nose and back of
the neck. When the ice pack cannot control
bleeding the nose may be packed. The pack
should however be removed within few
days. Make sure patient does not lie on one
side of his body for several days in bed. If
he is to be admitted for days, his position
should be changed every 2-4 hours to
prevent pressure sore from developing.
5. Elimination: Constipation should be
avoided because it makes the patient strain
at defecation thereby further elevating the
blood pressure. Food rich in fiber should be
given to prevent constipation.
B. PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION
OF NURSING CARE
37
There were no major problems encountered during the implementation of nursing
care. The patient was very cooperative and was aware of her health care needs. My only
problem is that I’m still a student and still on the process of learning and acquiring more
knowledge.
C. RESTORATIVE MEASURES USE
I was able to build rapport to the patient and her family members, I was able to
maintain calm and a relaxing environment, assisted patient and encourages her for
verbalization of her concerns about her condition. Patient was able to gain enough rest
and sleep hours. A low salt and low cholesterol diet were given. Medication was given
at exact time and route.
D. EVALUATION
The patient was very appreciative of the care extended to her. She was grateful for
the time and effort given to help in her condition. She was attentive to what is needed for
her health and verbalize that she will practice what are being thought to her during her
stay in the hospital. She verbalized that she will refrain from activities that will exert too
much effort; she will continue the diet that was recommended to her and to take her
medication at exact time.
E. PATIENT TEACHING
38
The patient was encouraged to avoid activities that will exert to much efforts,
avoid food that are high in sodium and cholesterol, avoid being stress because stress can
trigger in increasing the blood pressure. Patient was also instructed to have enough hours
of rest and sleep and to take medication as prescribed by her physician and emphasizes to
the patient the importance of medication as much as lots of client went to stroke.
XII. CONCLUSION AND RECOMMENDATION
A. CONCLUSION
In this study knowledge is basically the important factors to provide proper
provision of health care. The knowledge towards this condition can promote early
detection and can aid in early treatment and proper intervention towards the
progressing illness.
B. RECOMMENDATION
Nurses working with adults with hypertension must have the appropriate
knowledge and skills acquired through basic nursing education curriculum,
ongoing professional development opportunities and orientation to new
work places. Blood pressure should be measured in both arms.
XIII. IMPLICATION OF THE STUDY TO:
39
A. NURSING EDUCATION
This care study emphasizes the importance of theory in rendering
optimal care. This study shows information of the basic insight in Medical
Surgical Nursing. As a student Nurse, it is very important to our
profession that we consolidate both knowledge we gained and skills we
acquired because in real life situation, we might experience on the spot
decisions.
B. NURSING PRACTICE
Nursing practice is an ever increasing variety of ways and settings.
The focused of all nursing practice is the client, who may be individual, a
family or a community. This care study made me knowledgeable in
dealing with my patient and more confident in rendering my nursing care
and service. Aside from that this care study enhances my skills and
knowledge. It also adds to my own significant experiences.
C. NURSING RESEARCH
Nursing research revealed that the care of a hypertensive client has
gradually improved. But we should not end here. We should encourage
ourselves and other individuals to learn more about this condition by
attending seminars and medical missions for this could aid and help in
improving the care for our client.
40
August 20, 2010
Dr. Carmine P. Villarante
Dean College of Nursing
University of Cebu Lupu-Lapu & Mandaue
Dear Ma’am,
I, Jeffrey R. pescadero, would like to ask permission from your good office to allow me to take the case of Mrs. Sonia Asuncion Espadilla Madrid , 47 years old, Female admitted at Chung Hua Hospital as my subject to my care study. This is in partially fulfillment of the requirement of Medical Surgical Nursing NCM 103.
Diagnosis of Mrs. Sonia Asuncion Espadilla Madrid is Hypertensive Urgency.
I am hoping for your kind and consideration and approval regarding this matter
Thank you.
Respectfully yours,
Jeffrey R. Pescadero
BSN 3-A
Noted by:
Ms. Edna L. Estandarte, RN Clinical Instructor
Ms. Estela R. It-It, RN Level 3 chairperson
Ms. Mary Jane Sabaldica, RNNursing Education Coordination
Dr. Carmenn P. Villarante Dean College of Nursing
NURSING CARE PLAN
Patient’s name: Sonia Asuncion Espadilla Madrid Date of admission: July 25, 2010
Ag e: 47 years old Room No. : C-322
Impression: Hypertensive Urgency Physician : Dr. Lerma Noval
Clinical Portrait Pertinent Data
Assessment:
Received Patient lying on bed conscious awake and coherent with ongoing IVF # 1 PNSS 1L @ 40 cc/hr hooked at left arm infusing well. Vital signs were taken and monitored as ordered. Patient verbalized Body malaise and sudden chest discomfort upon rising up to bed.
Chief Complaint:
Chest Discomfort
History of present Illness:
A few hours prior to admission, patient complain of chest discomfort with note of elevated blood pressure of 150/80 mmHg. Patient self medicated with her maintenance medication atenolol 25 mg and was brought to Toledo Hospital and was referred to Chung Hua Hospital for further management.
Significant Findings
Blood Pressure: 150/80 mmHg
Pulse Rate: 54 Bpm
Vital signs: ( During first contact with the patient )
Blood Pressure: 120/70 mmHg
Temperature: 36.6 oC
Heart Rate: 54 Bpm
Respiratory Rate: 20 Cpm
Past health History:
The patient has no known allergies but according to her she was diagnosed last year with heart enlargement due to hypertension.
Vital signs during admission:
Blood Pressure: 150/80 mmHg
Temperature: 38.1 oC
Heart Rate: 78 Bpm
Respiratory Rate: 26 Cpm
Diagnostics Procedure Done:
Hematology, Urinalysis, Complete Blood Count, Chemical Chemistry Report.
ASSESSMENT NURSING DIAGNOSES
SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA
NURSING INTERVENTIONS
RATIONALE EVALUATION
Subjective:
“Luya jud kayo ko karon” as verbalized by the patient.
Objective:
-PR=54 Bpm
-shortness of breath upon exertion
-Body malaise
-Restlessness
Decreased Cardiac Output related to altered stroke volume
Increased blood pressure could cause vasospasm that lead to increased vascular resistance of the arteries. There will be difficulty of the heart to pump blood so there will be an Increased cardiac workload that could lead to a decreased cardiac output
After 8 hours of nursing interventions the patient will be able to maintain blood pressure/cardiac workload.
Specifically the patient will be able to:
1.Participate an activity that reduces blood pressure.
2.Demonstrate stable cardiac rhythm and rate within the patient normal range.
Independent:
1. Monitor blood pressure in both arms.
2. Provide a calm and restful environment.
3.Provide comfort measures ( eg…back and neck massage, elevation of head.)
4.Instruct in relaxation technique.
-Comparison of blood pressure provides a more complete picture of vascular involvement or scope of the problem.
-Helps reduce sympathetic stimulation, promotes relaxation.
-Decreased discomfort and may reduce sympathetic stimulation.
-Can reduce stressful stimuli; provide calming effect thereby reducing blood pressure.
After 8 hours of nursing intervention
Goals met.
The patient was able to maintain a stable blood pressure 120/70mmHg.
5.Monitor response to medication to control blood pressure.
Dependent:
Administer medication as prescribed by the physician.
Collaborative:
Refer to a dietitian
-To determine the effectiveness of the medication.
-Aids in controlling increase blood pressure.
-provide a healthy diet that could avoid the risk of further complication.
ASSESSMENT NURSING DIAGNOSES
SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA
NURSING INTERVENTIONS
RATIONALE EVALUATION
Subjective:
“nag-guol jud ko sa ako sitwasyun karon” as verbalized by the patient.
Objective:
-Restlessness
-Blank stares or inattention.
Anxiety related to situational crisis as evidenced by express concerned regarding changes in life events.
Anxiety is a feeling of apprehension or fear. The body prepares to deal with a threat: blood pressure and heart rate are increased, sweating is increased, blood flow to the major muscle groups is increased, and immune and digestive system functions are inhibited (the fight or flight response).
After 8 hours of nursing interventions the patient will be able verbalized awareness of feelings of anxiety and healthy way to deal with them.
Specifically the patient will be able to:
1. Report anxiety is reduced to a manageable state.
2. Demonstrate effective coping strategies to reduce anxiety.
Independent:
1.Promote expression of feelings and fears.
2.Proved rest period and uninterrupted sleep.
3. Provide a relaxing and quiet environment.
4.Provide relaxation techniques. (eg.. listening music, massage.)
Dependent:
Administer medication as prescribed by the physician.
-Verbalization of concerns reduces tension.
-Conserved energy and enhance coping mechanism.
-Aids in reducing tension and can promote relaxation to the patient.
-helps in reducing anxiety.
-medication given by the physician can help control the tension.
After 8 hours of nursing intervention
Goals met.
The patient was able to verbalized a reduce of tension that she is feeling.
ASSESSMENT NURSING DIAGNOSES
SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA
NURSING INTERVENTIONS
RATIONALE EVALUATION
Subjective:
“Dali jud kayo ko kutasan dong” as verbalized by the patient.
Objective:
-BP=150/80 mmHg
-PR=54 Bpm
-shortness of breath upon exertion
-Report of dizziness and fatigue.
Activity intolerance related to body weakness.
Muscle cells work by detecting a flow of electrical impulses from the brain which signals them to contract through the release of calcium by the sarcoplasmic reticulum. Fatigue (reduced ability to generate force) may occur due to the nerve, or within the muscle cells themselves. Muscle fatigue is caused by calcium leaking out of the muscle cell. These causes there to be less calcium available for the muscle cell. In addition an enzyme is proposed to be activated by this released calcium which eats away at muscle fibers.
After 8 hours of nursing interventions the patient will be able to report measurable increase in energy and will participate in necessary desired activities.
Specifically the patient will be able to:
1.Participate an activity without shortness of breath.
2.Participate activity without the increase of blood pressure.
3. Report relief of dizziness and fatigue.
Independent:
1. Note client reports of weakness and difficulty in accomplishing task.
2.Assess nutritional status.
3.Provide a positive atmosphere while acknowledging difficulty of the situation for the client.
4.Monitor response to medication and change in regimen.
- Symptoms may result or contribute to tolerance of activity.
- Adequate energy reserves are requirement for activity.
- Helps minimize frustration and rechanneled energy.
- To monitor the effect of the medication.
DRUG NAME DOSAGE AND
FREQUENCY
MECHANISM OF ACTION
INDICATION CONTRAINDICATION
SIDE EFFECTS NURSING RESPONSIBILITIES
GENERIC NAME:
Paracetamol
BRAND NAME:
Biogesic
CLASSIFICATION:
Antipyretic, Analgesic
PATIENT DOSE:
1 tab PO q4 for temperature more than 38 0C
Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat.
- Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis
- Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and anti-inflammatory effects)
- Contraindicated with allergy to acetaminophen.
- Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.
CNS: Headache
CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr
GI: Hepatic toxicity and failure, jaundice
GU: Acute kidney failure, renal tubular necrosis
Hematologic: Methemoglobinemia—cyanosis; hemolytic anemia—hematuria, anuria; neutropenia, leucopenia, pancytopenia, thrombocytopenia, hypoglycemia
Hypersensitivity: Rash, fever
- Monitor liver function studies; may cause hepatic toxicity at doses >4g/day
- Monitor renal function studies; albumin indicates nephritis
- Monitor blood studies, especially CBC and pro-time if patient is on long-term therapy.
- Check I&O ratio; decreasing output may indicate renal failure.
-Assess for fever and pain
- Assess hepatotoxicity: dark urine, clay-colored stoolsAssess allergic reactions: rash, urticaria
DRUG NAME DOSAGE AND
FREQUENCY
MECHANISM OF ACTION
INDICATION CONTRAINDICATION
SIDE EFFECTS NURSING RESPONSIBILITIES
GENERIC NAME:
Losartan
BRAND NAME:
Lifesar tan
CLASSIFICATION:
angiotensin II receptor (type AT1) antagonist
PATIENT DOSE:
50 mg tablet once daily
It stimulates aldosterone secretion by the adrenal cortex. Losartan and its principal active metabolite block the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor found in many tissues.
Hypertension
Hypertensive Patients with Left Ventricular Hypertrophy
contraindicated in patients who are hypersensitive to any component of this product
pregnancy
- “colds” (upper respiratory infection) - - dizziness
- stuffy nose
- back pain
Take blood blood pressure before giving the medication.
DRUG NAME DOSAGE AND
FREQUENCY
MECHANISM OF ACTION
INDICATION CONTRAINDICATION
SIDE EFFECTS NURSING RESPONSIBILITIES
GENERIC NAME:
Clopedogrel
BRAND NAME:
Plavix
CLASSIFICATION:
coagulant
PATIENT DOSE:
75 mg Tablet
The drug works by irreversibly inhibiting a receptor called P2Y12, an adenosine diphosphate ADP chemoreceptor.
-Prevention of vascular [[ischemic] events in patients with symptomatic atherosclerosis
-Acute coronary syndrome without ST-segment elevation (NSTEMI),
-ST elevation MI (STEMI)
- Hypersensitivity to the drug substance or any component of the product.
- Active pathological bleeding such as peptic ulcer or intracranial hemorrhage
-you are allergic to any ingredient in Clopidogrel
-you have an active bleeding disorder, such as a stomach ulcer or bleeding in the brain
-hemorrhage, severe neutropenia, and Thrombotic thrombocytopenic purpura (TTP).
Advise patient to do not perform other possibly unsafe tasks until you know how you react to it.
Avoid activities that may cause bruising or injury
DRUG NAME DOSAGE AND
FREQUENCY
MECHANISM OF ACTION
INDICATION CONTRAINDICATION
SIDE EFFECTS NURSING RESPONSIBILITIES
GENERIC NAME:
Rusovastatin
BRAND NAME:
Crestor
CLASSIFICATION:
HMG CoA reductase inhibitors, or "statins."
PATIENT DOSE:
20 mg tab once daily
it increases the number of hepatic LDL receptors on the cell-surface to enhance uptake and catabolism of LDL. Second, rosuvastatin inhibits hepatic synthesis of VLDL, which reduces the total number of VLDL and LDL particles
Hyperlipidemia and Mixed Dyslipidemia
Hypertriglyceridemia
Primary Dysbetalipoproteinemia (Type III Hyperlipoproteinemia)
Homozygous Familial Hypercholesterolemia
Slowing of the Progression of Atherosclerosis
you are allergic to any ingredient in Crestor
you have liver problems or unexplained abnormal liver function tests
you are pregnant or breast-feeding
you are taking itraconazole, mibefradil, or telithromycin
headache;
mild muscle
pain;
joint pain;
constipation;
mild nausea; or
stomach pain or indigestion.
Instruct patient to:
- Avoid using antacids without your doctor's advice.
-Do not increase or decrease the amount of grapefruit products in your diet without first talking to your doctor
-Do not perform other possibly unsafe tasks until you know how you react to it.
Follow the diet and exercise program given to you by your health care provider
Do NOT take more than the recommended dose without checking with your doctor
Type of solution
Classification Content Mechanism of action
Indications Contraindications How supplied Dose Nursing responsibilities
PNSS Hypertonic 100mL Hypertonic solutions contain a high concentration of solute relative to another solution ( e.g. the cell’s cytoplasm ) when a cell is placed in a hypertonic solution, the water diffuses out of the cell, causing the cell to shrivel.
(Wikipedia encyclopedia, 5th edition).
For replacement or maintenance of fluid and electrolytes.
Hypersensitivity to any of the components.
Intravenous infusion
Before:1. Use sterile
infusion set.2. Use only if
solution is clear and container is not leaking.
3. Assess patient’s hydration status.
During:1. Perform time
taping.2. Regulate IVF as
prescribed.3. Check from time
to time the positioning of the patient.
After:1. Chart the date and
time the solution was consumed.
2. Discard empty bottles and tubing to their proper container.
3. Dispose the sharps not together with the bottle but to its correct box for sharps.
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