CHRONIC HYPERTENSIVE

VASCULAR DISEASE

A Case Study
submitted to
Center for Health Development IV A

as part of the requirements of

Registered Nurses for Health Enhancement and Local Services

Landicho, Lea Lyn A., RN

RNheals

Deployed in
Rural Health Unit – Santa Maria (RHU-Santa Maria)
 I. INTRODUCTION

High blood pressure or hypertension is a medical condition in which the blood

pressure is chronically elevated. Hypertension is the most important modifiable risk
factor for coronary heart disease, stroke, congestive heart failure, end-stage renal
disease and peripheral vascular disease.

Worldwide, hypertension is seen in about 1 billion people and the prevalence has
been estimated to increase by more than 29% by the year 2025.This condition is
associated with increased obesity and aging population. Due to the associated
morbidity, mortality and economic burden to the society, hypertension remains as a
significant public health challenge.

As hypertension rarely causes specific symptoms, it is undetected until an

individual’s blood pressure is measured by a physician or until it had caused
complications such as stroke or heart attack. The primary goal of treatment is to lower
the blood pressure to a normal level through appropriate combination of drugs that
achieves this goal.

II. BACKGROUND OF THE STUDY

The researcher, as trainee under the RNHeals program, has many times dispensed
maintenance medications to the subject client. Aside from knowing the client personally,
the researcher observed that the client have been consistent during follow- ups.

III. GOAL OF CARE

A.1 GENERAL OBJECTIVES

After providing care to the client and conducting a careful and thorough study of
the client’s condition, the researcher will be able to gain knowledge, develop skills and
enhance attitude in rendering quality nursing care in actual situation to the client with
the diagnosis of Chronic Hypertensive Vascular Disease.

A.2 SPECIFIC OBJECTIVES

The nurse researcher is expected to:

1. Define what Chronic Hypertensive Vascular Disease is.
2. Identify its clinical manifestation.
3. Trace the pathophysiology of the disease
4. Establish a good and therapeutic nurse-patient interaction.
5. Determine the status of the client through:
a. Demographic data
b. Past medical history
c. Present history of the illness
d. Socio- economic Background
e. Physical examination
6. Analyze laboratory results and correlate it with client’s present condition.
7. Familiarize self with diagnostic procedures done to client.
8. Identify and understand the importance of medicine in relation to client’s
 present condition.
9. Render nursing care through implementation of Nursing Care Plan.
10.Evaluate the effectiveness of nursing care plan and medical management.

IV. DEMOGRAPHIC DATA

A. Client’s Name: I.B.

B. Address: Brgy. Cabuoan, Santa Maria, Laguna
C. Age: 61 years old
D. Birthdate: May 5, 1952
E. Birthplace: Brgy. Cabuoan, Santa Maria, Laguna
F. Gender: Female
G. Civil Status: Married
H. Religion: Roman Catholic
I. Educational Attainment: Secondary Education, first year high school
J. Usual Source of Medical Care: Rural Health Unit, Hospital of choice
K. Date of Admission: February 5, 2013
L. Time of Admission: 9:00 am
M. Hospital: not applicable
N. Date of Interview: November 08, 2013
O. Primary Informant: the client
P. Secondary Informant: none
Q. Other Data Source: facility records
Occupation: farmer
Monthly Income: 15,000 Php (seasonal)

V. REASONS FOR SEEKING HEALTH CARE

The client believes that her family history of hypertension and Diabetes
mellitus have contributed to her condition. That is why when she had episodes of
headache, she seek medical attention.

VI. HISTORY OF PRESENT ILLNESS

The client visited the Rural Health Unit because she had episodes of
headache. Knowing that she had a family history of hypertension, she agreed to
have her blood pressure monitored. She also knew she have Diabetes mellitus
type II which she believes is connected to her hypertension. Her fasting blood
sugar was also monitored monthly along with other Diabetic clients.

VII. PAST MEDICAL HISTORY

The client had been hospitalized for two days at General Cailles District
Hospital due to epigastric pains. Also, recently she was confined for two days at
Pagsanjan General Hospital last August 8, 2013 because of a hypertensive
episode.
VIII. SOCIO-ECONOMIC

The client and her husband are farmers. Their monthly income is around
15,000 pesos but it is only seasonal depending on which crop was harvested.
She can afford for her simple medical expenses.

IX. DEVELOPMENTAL HISTORY

Erik Erikson’s Psychosocial Theory

The client belongs to the adulthood stage in which the developmental task is
Generativity vs stagnation. The client wanted to be productive and active in personal
growth. She assumes parental and societal responsibilities. Her expression of
satisfaction with this stage was observed because of her responsiveness in seeking
medical attention.

X. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs
Temperature: 36.5 oC
Pulse Rate: 76 beats per minute
Respiratory Rate: 20 breaths per minute
Blood Pressure: 140/90 mmHg

B. Anthropometric Data
Height: 140 cm
Weight: 78 kg

C. General Assessment
Physical Assessment

Body Part Review of Clinical

Actual Finding Normal Finding
Examined System Significance
Integument The integument
Skin is the natural - brown in - brown in Normal
covering of complexion, good complexion, good Findings
man that skin turgor skin turgor
Hair protects the - Evenly - Evenly Normal
body from distributed, white distributed, color Findings
various and black hair, varies, no
damages such no infestation infestation
as loss of water noted
Nail and abrasions - Short, clean - Short, clean Normal
nails, capillary nails, capillary Findings
refill time of 1 to 2 refill time of 1 to 2
seconds seconds
Head Cephalic part
Eyes and of the body pinkish pinkish Normal
Vision comprises the conjunctiva, conjunctiva, Findings
brain, eyes, whitish sclera, whitish sclera,
ears, nose and PERRLA PERRLA
Ears and mouth No discharges No discharges, no Normal
Hearing noted, no hearing hearing Findings
impairments impairments
noted
Nose and No discharges No discharges Normal
Sinuses noted Findings
Mouth and Pinkish lips, no Pinkish, moist Normal
Oropharynx oral lesions lips, no oral Findings
noted, no lesions, no
bleeding gums bleeding gums,
noted, no dental no dental caries,
caries noted, palate intact,
tonsils were not tonsils not
swollen swollen
Neck Part of the No skin No skin Normal
- Neck body that discoloration discoloration, with Findings
Muscles distinguishes noted, with active active ROM, no
- Lymph the head from ROM, no palpable palpable nodules,
Nodes the torso nodules noted, thyroid not
- Trachea thyroid not enlarged
- Thyroid enlarged
Gland
THORAX Part between Breaths Breaths Normal
and LUNGS neck and diaphragmatically, diaphragmatically, Findings
- Posterior abdomen that RR=2obpm, RR=16-20bpm,
Thorax is partially symmetrical chest symmetrical chest
- Anterior enclosed by expansion, no expansion, no
Thorax ribs containing lesions noted, no lesions, no
the heart and masses noted, masses, clear
lungs clear breath breath sounds
sounds heart heart upon
upon auscultation auscultation
Breast and muscles that No discoloration No discoloration, Normal
Axillae overlies the noted, no no palpable Findings
pectoralis palpable nodules nodules, breast
extending to noted, breast not not enlarged, no
the underarm enlarged, no unusual
unusual pigmentation on
pigmentation on axilla, non-tender
axilla noted, non- nodules
tender nodules
noted,
Abdomen Comprising of No generalized No generalized Normal
abdominal skin discoloration, skin discoloration, Findings
muscles no ecchymosis no ecchymosis,
encasing the noted, no lesions no lesions,
 gastrointestinal noted, symmetrical flat
system, symmetrical abdomen, no
kidneys, flabby abdomen, tenderness upon
ureters and no tenderness palpation
bladder noted upon
palpation

XI. ANATOMY AND PHYSIOLOGY

Anatomy

The blood vessels are the part of the circulatory system that transports blood
throughout the body. There are three major types of blood vessels: the arteries, which
carry the blood away from the heart; the capillaries, which enable the actual exchange
of water and chemicals between the blood and the tissues; and the veins, which carry
blood from the capillaries back toward the heart.

The arteries and veins have three layers, but the middle layer is thicker in the
arteries than it is in the veins:
 Tunica intima (the thinnest layer);
 Tunica media (the thickest layer in arteries) which is rich in vascular smooth
muscle, which controls the caliber of the vessel;
 Tunica adventitia: (the thickest layer in veins) Capillaries consist of little more
than a layer of endothelium and occasional connective tissue.

There is a layer of muscle surrounding the arteries and the veins which help contract
and expand the vessels. This creates enough pressure for blood to be pumped around
the body. Blood vessels are one of the three main organs of the circulatory system. The
others include the hearts and the blood.

Physiology

Blood vessels do not actively engage in the transport of blood (they have no
appreciable peristalsis), but arteries—and veins to a degree—can regulate their inner
diameter by contraction of the muscular layer. This changes the blood flow to
downstream organs, and is determined by the autonomic nervous system. Vasodilation
and vasoconstriction are also used antagonistically as methods of thermoregulation.

Oxygen (bound to hemoglobin in red blood cells) is the most critical nutrient
carried by the blood. In all arteries apart from the pulmonary artery, hemoglobin is highly
saturated (95-100%) with oxygen. In all veins apart from the pulmonary vein, the
hemoglobin is desaturated at about 75%. (The values are reversed in the pulmonary
circulation.)

Vasoconstriction is the constriction of blood vessels (narrowing, becoming

smaller in cross-sectional area) by contracting the vascular smooth muscle in the vessel
walls. It is regulated by vasoconstrictors (agents that cause vasoconstriction). These
include paracrine factors (e.g. prostaglandins), a number of hormones (e.g. vasopressin
and angiotensin) and neurotransmitters (e.g. epinephrine) from the nervous system.
Vasodilation is a similar process mediated by antagonistically acting mediators. The
most prominent vasodilator is nitric oxide (termed endothelium-derived relaxing factor
for this reason).

Vascular disease

Blood vessels play a huge role in virtually every medical condition. Cancer, for
example, cannot progress unless the tumor causes angiogenesis (formation of new
blood vessels) to supply the malignant cells' metabolic demand. Atherosclerosis, the
formation of lipid lumps (atheromas) in the blood vessel wall, is the most common
cardiovascular disease, the main cause of death in the Western world.

Blood vessel permeability is increased in inflammation. Damage, due to trauma or

spontaneously, may lead to hemorrhage due to mechanical damage to the vessel
endothelium. In contrast, occlusion of the blood vessel by atherosclerotic plaque, by an
embolised blood clot or a foreign body leads to downstream ischemia (insufficient blood
supply) and possibly necrosis. Vessel occlusion tends to be a positive feedback system;
an occluded vessel creates eddies in the normally laminar flow or plug flow blood
currents. These eddies create abnormal fluid velocity gradients which push blood
elements such as cholesterol or chylomicron bodies to the endothelium. These deposit
onto the arterial walls which are already partially occluded and build upon the blockage.
XII. PATHOPHYSIOLOGY

Risk Factors Predisposing factors

 Obese  Age: 61 yo
 Eating habits  Gender: Female
 Diabetes mellitus II  Family history of
Diabetes mellitus and
hypertension

Deposition of fat on endothelial lining of blood vessel

Narrowing of the lumen

Cholesterol=
Increased
Decreased blood flow 107 umol/L
viscosity
of the blood
Hypoperfusion of the organs

Brain Heart Kidney

Increased risk for stoke increased cardiac rate activation of the RAAS
(Renin-Angiotensin I-
increased CSF production Increased BP= 150/90mmHg Angiotensin II System)

Increased ICP Aldosterone production

Headache increased Na reabsorption

Increased water retention

Increased BP= 150/90mmHg

Decreased kidney function

Increased creatinine increased risk for renal failure

5.6 mg/L
XIII. MEDICAL TESTS

Name: I.B. Hospital Number: not applicable

Age: 60 Date of Test: July 5, 2013
Birthdate: May 5, 1952 Physician: Cynthia S. Tamares, MD

REFERENCE
TEST RESULT CLINICAL SIGNIFICANCE
RANGE
Creatinine= 107 umol/L 46- 92 umol/L Elevated; sign of loss of kidney
Blood
function
chemistry
Cholesterol= 5.6 mol/L <5.2 mol/L Elevated; Hypercholesterolemia

Name: I.B. Hospital Number: not applicable

Age: 60 Date of Test: June 07, 2013
Birthdate: May 5, 1952 Physician: Cynthia S. Tamares, MD

REFERENCE
TEST RESULT CLINICAL SIGNIFICANCE
RANGE
Fasting 126 mg/dL 70- 110 mg/dL Increased; hyperglycemia
blood sugar

XIV. PHARMACOLOGY

Drug Name Nursing

Mechanism Contraindicati
/ Specific Indication/s Side Effect/s Responsibili
of Action on/s
Action ties
METOPROL  HPN Combines  Bronchospas  Heart  Monitor VS,
OL 50mg 1  Chronic reversibly m or asthma failure EF, CBC,
tab BID mgmt. of mainly with  Hx of  Heart block liver/renal
angina beta 1- obstructive  Bronchosp function
 Beta- pectoris adrenergic airway dse. asm studies,
adrenergi  Tx of receptors to  Metabolic  Loss of ECG,
c stable block the acidosis hearing echocardio
blocking symptoma response to  Sinus  Fatigue gram.
drug tic heart sympathetic bradycardia  Coldness  Take at the
failure of nerve  Partial heart of same time
ischemic, impulses, block extremities at each
hypertensi circulating  CHF  Bradycardi day, do not
ve or catecholami a CHF stop
cardiomyo nes, or pneumoniti suddenly.
pathic adrenergic s  Avoid
origin drugs.
 Depression activities
 Hallucinatio that require
n mental
alertness
before drug
effects are
realized.
  Continue
with diet,
regular
exercise,
and wt. loss
in the
overall plan
to control
BP.
 Report any
symptoms
of fluid
overload
such as
sudden
weight gain,
SOB or
swelling of
extremities.
 Dress
appropriatel
y; may
cause an
increased
sensitivity
to cold. Do
not smoke.

Drug Name / Mechanis Nursing

Indication/ Contraindi Side
Specific m of Responsibilit
s cation/s Effect/s
Action Action ies
METFORMIN Decreases To improve  Renal  Hypoglyce  Take with
500mg 1 tab hepatic glycemic dse. or mia food to
BID glucose control in dysfuncti  Diarrhea minimize GI
production, clients with on  N&V upset.
 Antidiabeti decreases type II DM  CHF  Asthenia  May cause
c, oral; intestinal  Pt.  Flatulence a metallic
biguanide absorption undergoi  Headache taste; should
of glucose, ng  Abdl. pain subside.
and radiologic or  Regular
increases studies discomfort exercise,
peripheral using decreased
uptake and iodinated caloric
utilization of contrast intake and
glucose. media wt. loss are
 Acute or required to
chronic reduce bld.
metabolic glucose
 acidosis levels.
 Inadequate
caloric
intake or
strenuous
exercise
without
caloric
replacement
may
precipitate
hypoglycemi
a.
 Avoid
alcohol and
other
situations
that may
precipitate
dehydration.
 Consume
plenty of
fluids.
 Stop drug
immediately
and report
any
symptoms of
DOB, severe
weakness,
muscle pain,
increased
sleepiness
and sudden
increased
abdominal
distress.

Mechanis Side Nursing

Drug Name / Contraindicatio
Indication/s m of Effect/ Responsibiliti
Specific Action n/s
Action s es
SIMVASTATIN 20 hyperlpidem   
mg 1 tab ODHS ia
 antihyperlipidemi
c

Drug Name /
Mechanism Side Nursing
Specific Indication/s Contraindication/s
of Action Effect/s Responsibilities
Action
Vitamin B   
Complex 1 tab
OD


XV. MEDICAL MANAGEMENT

PROCEDURES INDICATION NURSING

RESPONSIBILITIES
Maintenance medication To maintain a lower blood - Assess client for any
management pressure, sugar and hypersensitivity to any of
cholesterol level the drugs
- observe the 10 rights in
giving medication
- dispense medications and
record it appropriately
-assess vital signs
especially BP
- discuss the side effects of
the drugs and advise client
to report any adverse
reactions felt after taking up
the medication
- Instruct client on proper
intake of medication
- Advise client to follow up
every month

XVI. NURSING CARE PLAN

Problem: Decreased Cardiac Output

Community Resources
Nursing Objectives Health Evalua
Manpo

Cues Rationale
Money
Materi

Diagnosis of Care Nursing tion

wer

als

Intervention
O>BP=150/90 Decreased At the end >Assessed >to give nurse >BP=110
mmHg cardiac of nursing general proper and / 70
>PR=76 bpm output intervention condition interventions the mmHg
> RBS= 126 vasoconstri s, the >determined >to client >records
mg/dl ction of patient, will BP and PR determine show
>Cholesterol= peripheral be able to and that she
5.6 mmol/L blood demonstrat prevent is going
vessels e ways and complications to her
and techniques >advised to >positioning follow-up
increased on how to rest in semi- to decrease schedule
viscosity of lower BP fowler’s BP
the blood position at
as home
evidenced > Encouraged >stress
by to do causes
increased relaxation vasoconstricti
 BP techniques on
secondary >dispensed > for effective
to disease maintenance and safe
condition medications pharmacologi
as ordered c control of
>instructed on BP
proper
frequency of
taking
medicatons
>advised to >salty and
take low salt fatty foods
and low fat will increase
food blood
pressure

Problem: Risk for Injury

Resource
Community s
Nursing Objectives Health Evaluat

Manpower
Cues Rationale

Materials
Diagnosis of Care Nursing ion

Money
Intervention

S>“masakit Risk for At the end >Assessed for >these nurse >BP=110
ang ulo ko at injury of the contributing factors and / 70
nahihilo” as related to nursing factors to risk should be the mmHg
verbalized episodes of intervention for injuries determined to client >records
O : >BP dizziness ,the patient such as eliminate show her
=150/90 and will positioning them and to adheranc
mmHg headache understand > Monitored apply proper e to
secondary ways on BP interventions treatment
to increase how to >increased regimen
in BP prevent BP will is a
injury >advised to cause of
rest in semi- dizziness
fowler’s >positioning
position at to decrease
home BP
>Instructed to
decrease >to lessen
mobility during dizziness and
episodes risks for falls
> Encouraged
SO to avoid >Salty and
giving salty fatty foods
and fatty foods increase BP
>administered
drugs for
hypertension >for
pharmacologi
>advised to c control of
take adequate BP
rest and sleep >to prevent
episodes of
headache
XVII. PROGRESS NOTES

Date Progress Note

February 25, 2013  Visited the RHU with the complain of headache
 BP= 150/90 mmHg
 Received maintenance medications like Metoprolol,
Simvastatin and Metformin
March 25, 2013  Follow- up check- up; BP= 130/80 mmHg
 Received maintenance medications
April 23, 2013  Follow- up check- up; BP= 140/100 mmHg
 Received maintenance medications
June 7, 2013  Follow- up check- up; BP= 140/90mmHg
 Complained numbness of extremities
 FBS=126 mg/dL
 Received maintenance medications and Vit. B complex
July 23, 2013  Follow- up check- up; BP= 110/70 mmHg
 Consulted about blood chemistry result
 FBS= 5.3 mmol/L
 Creatinine= 107 ummol/L; Cholesterol= 5.6 mmol/L
 Received maintenance medications
September 6, 2013  Follow- up check- up; BP= 140/100 mmHg;
 FBS=106 mg/dL
 Received maintenance medications and Vit. B Complex
October 4, 2013  Follow- up check- up; BP= 100/60 mmHg
 Received maintenance medications
November 8, 2013  Follow- up check- up; BP= 130/70 mmHg
 FBS= 123 mg/dL
 Received maintenance medications
December 6, 2013  Follow- up check- up; BP= 140/100 mmHg
 FBS=120 mg/dL
 Received maintenance medications

XVIII. BIBLIOGRAPHY

Balita, Carl E., Ultimate Learning Guide to Nursing Review, pages 128-130
Lippincott, Nursing Drug Handbook, Antihypertensives
Medical surgical Nursing Vol. I and II, 2004
www.google.com
www.yahoo.com