lOMoARcPSD|4994919
Mike Kelly HTN - case study
Child & Women's Health Clinic (Florida SouthWestern State College)
StuDocu is not sponsored or endorsed by any college or university
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Hypertension
Mike Kelly, 51 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1.
2.
3.
4.
5.
6.
Glucose Regulation
Pain
Clinical Judgment
Patient Education
Communication
Collaboration
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
UNFOLDING Reasoning Case Study: STUDENT
Hypertension
History of Present Problem:
Mike Kelly is a 51-year-old Caucasian male who is 6 feet tall and weighs 275 pounds (BMI 37.3) with an abnormal
distribution of weight around his abdomen. He does not regularly exercise, does not like to cook, and eats fast food three
to five times during the week. He has smoked one pack per day since the age of 20 (31 pack years). He has a history of
hyperlipidemia, but is unable to afford his medication (atorvastatin), and has not taken since he was diagnosed 5 years
ago. He has no current diagnosed medical problems. He became concerned and came to the emergency department
because he is more easily fatigued and has had a headache the past three days that has not improved.
Personal/Social History:
Mike is self-employed and owns his own auto mechanic business. He has no health insurance. His father had hypertension
and died of a myocardial infarction (MI) at the age of 50. Angelina, his wife, came with him to urgent care. She shares
that he is usually stoic about health problems, so this must really bother him or he is afraid. He took Excedrin and Motrin
f
a a d d d he .
What data from the histories is RELEVANT and has clinical significance for the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
1. Patient BMI iss 37.31
2. Abnormal distribution of weight around abdomen
3. Does not regularly exercise
4. Eats fast food 3 - 5 times per week
5. Smokes 1 pack cigarett per day
6. Hyperlipidemia
7. Unable to afford medication (Atorvastatin)
8. Easily fatigued
9. Headace for the past 3 days that has not improved
1. A BMI between 30 and 39.9 is in the obese range. Obesity increases the risk for many health condition such as
diabetes, hypertension and cardiovascular disease.
2. This puts the patient at risk for insulin resistance which can lead to diabetes and other chronic health problems.
3. This may be one of the reason the patient is obese, a sendentary life style increases the risk of developing
chronic health problems, such as hypertension, diabetes, hyperlipidemia and stroke.
4. Eating unhealthy and high caloric meals can increase body weight and cause health problems.
5. Smoking cause many problems such as cancer, heart diseas, diabetes and hypertension.
6. Increases the risk for cardiovascular disease
7. Untrolled hyperlipidemia will cause cardivascular disease and stroke.
8. Sign of uderlying health conditions
9. May be related to being fatigued or other underlying health coditions.
RELEVANT Data from Social History:
Clinical Significance:
1.Self employed
2. No health insurance
3. Family history of hypertension and MI
4. Took excedrin and Motrin for pain
1. Finances may be affected if he is unable to work
2. This will help determine other resources that are available to cover medical expenses
3. At greater risk for developing hypertension and MI due to genetics
4. Excedrin is a combination of aspirin, acetaminophen and caffeine. Excedrin is a
vasoconstrictor which may elevate blood pressure. Motrin is a NSAID, can treat mild to
moderate pain. This is a cause for concern, these two drugs can interact if they were
taken together.
Patient Care Begins:
Current VS:
T: 98.9 F/37.2 C (oral)
P: 88 (regular)
R: 20
BP: 220/118
O2 sat: 95% room air
P-Q-R-S-T Pain Assessment (5th VS):
Provoking/Palliative: Nothing/Nothing
Ache
Quality:
Global head ache (HA)
Region/Radiation:
8/10
Severity:
Continuous
Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
This patient BP is significantly high, this can lead to a hypertension crisis which may
damage the blood vessels and result in a stroke, loss of consciouness, memory
2. Severe headache - loss, heart, damage to the eyes and kidneys, loss of kidney function and pulmonarry
edema.
8/10
2. This is a sign that that intercranial pressure is buidling up from elevated BP and
causing a severe headache.
1. BP: 220/118
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Appears uncomfortable, body tense with occasional grimacing
Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
Pink, warm and dry, no edema, heart sounds regular S1S2, pulses bounding, equal with
palpation at radial/pedal/post-tibial landmarks
Alert and oriented to person, place, time, and situation (x4)
Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
Voiding without difficulty, urine clear/yellow
Skin integrity intact, skin turgor elastic with no tenting
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
1. General apperance
uncomfortable, body tense with
occasional grimacing
This is a sign the patient is experiencing severe pain.
12 Lead EKG:
Interpretation:
Heart rate is normal, 60. Normal sinus rhythm. P waves are present, No Q waves or ST waves
elevation but there moderate cardiomegaly due to the abnormally large wave forms.
Clinical Significance:
This EKG shows that there is no imminent cardiovascular threat, and no past heart attack. The
patient's heart is enlarged, so interventions need to be done to reduce the size of his heart.
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Radiology Reports: Chest x-ray
What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Results: Clinical Significance:
The cardiac size is
enlarged. There are no
focal infiltrates or
consolidations or pleural
effusions.
IMPRESSION:
1. No acute disease in the
chest.
2. Moderate to severe
cardiomegaly
A enlarged heart is not a disease but the heart is bigger than normal, this
increases the risk of hear failure.
Lab Results:
Complete Blood Count (CBC:)
WBC (4.5 11.0 mm 3)
Hgb (12 16 g/dL)
Platelets(150 450x 103/µl)
Neutrophil % (42 72)
Current:
10.5
15.3
422
68
High/Low/WNL?
WNL
WNL
WNL
WNL
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
All labs WNL
General health is good
Basic Metabolic Panel (BMP:)
Sodium (135 145 mEq/L)
Potassium (3.5 5.0 mEq/L)
Glucose (70 110 mg/dL)
BUN (7 25 mg/dl)
Creatinine (0.6 1.2 mg/dL)
Current:
136
4.0
188
32
1.5
High/Low/WNL?
WNL
WNL
High
High
High
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
1. Glucose - 188
2. BUN - 32
3. Creatine - 1.5
1. This is a sign of an infection or diabetes, high glucose level and high blood pressure can lead to
kidney failure.
2. Elevated BUN is a sign that the patient has poor diet with abundant protein or kidney disease.
3. Elevated creatine is a sign of kidney failure or heart failure.
Cardiac Labs:
BNP (B-natriuretic Peptide) (<100 ng/L)
Current:
758
High/Low/WNL?
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
BNP - 758
This indicates the patient has a severely high amount of BNP in his blood, this
is a sign of heart failure.
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Lipid Panel:
Low density lipoprotein LDL (<130 mg/dL)
High density lipoprotein HDL (>40 mg/dL)
Total cholesterol (<200 mg/dL)
Triglycerides (30 149 mg/dL)
Current:
260
28
290
484
High/Low/WNL?
High
Low
High
High
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
1)Low Density Llipoprotein
(LDL) 260
2)High Denesity Lipoprotein
(HDL) 28
1)High amount of LDL can lead to health problems including coronary artery disease and related problems:
2)Low levels of HDL cholesterol are associated with a higher isk of heart disease.
3)Total amount of cholesterol in your blood. It includes both LDL and HDL)cholesterol. LDL , The higher the cholesterol
buildup and blockage in the arteries.
4) High triglycerides are often a sign of other conditions that increase the risk of heart disease and stroke. A saturated
amount of fat around the waist, high blood pressure, high triglycerides, high blood sugar and abnormal cholesterol levels.
3)Total cholesterol 290
4)Triglycerides 484
Urine Analysis (UA:)
Color (yellow)
Clarity (clear)
Specific Gravity (1.015 1.030)
Protein (neg)
Glucose (neg)
Ketones (neg)
Bilirubin (neg)
Blood (neg)
Nitrite (neg)
LET (Leukocyte Esterase) (neg)
MICRO:
RBC (<5)
WBC (<5)
Bacteria (neg)
Epithelial (neg)
Current:
Yellow
Clear
1.018
Moderate
Moderate
Negative
Negative
Positive
Negative
Negative
High/Low/WNL?
3
2
Negative
Negative
WNL
WNL
WNL
High
High
WNL
WNL
High
WNL
WNL
WNL
WNL
WNL
WNL
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
1) Protein
2) Glucose
3) Blood
1) One major signs of kidney disease is when proteins such as albumin may
leak from your blood into your pee. High amounts can mean kidney dysfunction.
2) High amount of glucose can indicate diabetes mellitus.
3) High amount of blood in the urine can indicate reneal disease or trauma.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab:
Normal Value:
BNP
High levels of B-natriuretic
Critical Value: Peptide indicates heart
failure/complication.
(B-natriuretic
Peptide)
Why Relevant?
Value:
758
Nursing Assessments/Interventions
Required:
Auscultation of heart and ECG
monitoring. There may be damage to
the heart and assessment by a
physician should be recommended.
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Clinical Rea oning Begin
1. What is the primary problem that your patient is most likely presenting with?
Acute Myocardial Infarction
2. What is the underlying cause/pathophysiology of this primary problem?
Severe hypertension, hyperlipidemia, atherosclerosis.
Collaborative Care: Medical Management
Care Provider Orders:
Basic metabolic panel
(BMP)
Complete cell count (CBC)
Rationale:
1)BMP can identified any electrolyte imbalances that may be occuring that may be
causing hypertension as well as possible kidney complication.
2) CBC can help discover if possible infection could be contributing to the hypertension.
3) BNP indicates possible myocardium muscle damage from strokes, myocardial
Infarction.
BNP (B-natriuretic Peptide)
4)Lipid profile serves as an initial screening tool for abnormalities in lipids, such as
cholesterol and triglycerides that can contribute to pt. Myocardial infarction
Lipid profile
Urine analysis (UA)
5) Urine analysis helps determine if kidney complication may be presented such as high
amount of protein, glucose or blood in the urine can help contribute to pt. Hypertension
or metabolic disorder.
6)12 Lead EKG help read and diagnose heart irregularities.
12 lead EKG
Chest X-ray
Labetalol 20 mg IV push
every 10". Maximum 300
mg dose.
Goal-BP: 160/100
7) Chest X-ray help see the organ around the heart and the heart itself for any
abnormalities.
8) Labetalol: Helps decrease blood pressure.
9) The Goal of 160/100 is high but a short term goal to help reduce organ damage or
failure caused by hypertension.
Collaborative Care: Nursing
3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
4. What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
1)Monitor response to medications to control
blood pressure.
1)Monitoring pt reaction to medication for effectiveness of the
medication as well as any negative reaction such as hypotension
and allergic reactions.
2)Maintain activity restrictions (bedrest or chair
rest); schedule periods of uninterrupted rest;
assist patient with self-care activities as needed.
2)Lessens physical stress and tension that affect blood pressure
and the course of hypertension.
3) Auscultate heart tones and breath sounds.
3) Development of S3 indicates ventricular hypertrophy and
impaired functioning. Presence of crackles, wheezes may indicate
pulmonary congestion secondary to developing or chronic heart
failure.
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
Expected Outcome:
1) Pt will show no signs of allergic
reaction or hypotension complications.
2) By maintaining a tranquil
environment. The patient will show no
signs of stress and avoid increase in BP
3) Pt will have no crackles, wheezing or
pulmonary congestions. If abnormal
sounds are heard, proper steps would
be taken.
lOMoARcPSD|4994919
5.
What body system(s) will you most thoroughly assess based on the primary/priority concern?
The heart and the lung will be primarily assessed for concerns.
6. What is the worst possible/most likely complication to anticipate?
Cardiac arrest due to myocardial ischemia
7. What nursing assessments will identify this complication EARLY if it develops?
Changes in EKG will help diagnosed as well as auscultation of the heart and lungs.
8. What nursing interventions will you initiate if this complication develops?
Calling a code and initiating CPR until help arrives.
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Mike has no health insurance and is out of work since his self employee. Consulation with
a social worker can help
10. How can the nurse address these psychosocial needs?
A social worker can help Mr Mike and his wife find financial help and community support
for people in his situation.
Medication Dosage Calculation:
Medication/Dose:
Mechanism of Action:
Labetalol
Blocks stimulation of beta1
and beta2. Contains
alpha1-adrenergic blocking
activity, which
may result in more
orthostatic hypotension
20 mg IV push
5 mg/mL vial
Volume/time frame to
Safely Administer:
4 mL
IV Push:
Volume every 15
sec?
Nursing
Assessment/Considerations:
Monitor BP and pulse frequently during dose adjustment and
periodically during therapy. Assess for orthostatic
hypotension when assisting patient up from supine position.
Monitor intake and output ratios and daily weight. Assess
patient routinely for evidence of fluid overload (peripheral
edema, dyspnea, rales/
crackles, fatigue, weight gain, jugular venous distention).
Monitor patients receiving beta blockers for signs of
overdose
Evaluation:
Evaluate your patient response to nursing and medical interventions during your shift. All physician orders listed under
medical management have been implemented..
T o ho
la e
Mike has received a third dose of labetalol 20 mg IV push and you obtain the following clinical
data when he is re-assessed:
Current VS:
Most Recent:
T: 98.6 (oral)
P: 82 (regular)
R: 16
BP: 176/104
O2 sat: 96% RA
T: 98.9 (oral)
P: 78 (regular)
R: 20
BP: 188/102
O2 sat: 95% (RA)
Current PQRST:
Provoking/Palliative: Nothing/Nothing
Quality: Ache
Region/Radiation: global HA
Severity: 3/10
Timing: Continuous
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
Previous:
Nothing/Nothing
Ache
Global HA
8/10
Continuous
lOMoARcPSD|4994919
Current
Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Resting comfortably, appears relaxed and in no acute distress
Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
Alert and oriented to person, place, time, and situation (x4)
Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
Voiding without difficulty, urine clear/yellow
Skin integrity intact
1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data:
Clinical Significance:
Blood pressure has decreased
from 220/118 to 176/104
Blood pressure is decreasing, which indicates labetalol is
working.
RELEVANT Assessment Data:
Clinical Significance:
Cardiac
Blood pressure is beginning to lower, and the patient's pulse has
become regular.
2. Has the status improved or not as expected to this point?
Mike has not met the short term goal of BP: of 160/100 but with time he will.
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
No, the patient needs continuous monitoring of his heart, lungs, blood pressure, and EKG
to adequately diagnosed and monitor the patient's condition.
4. Based on your current evaluation, what are your nursing priorities and plan of care?
The nurse must continue to monitor the heart, lungs and blood pressure.
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
The ED primary care provider decides to admit Mike to the hospital. The admitting primary
care provider assesses Mike and writes the following orders:
Collaborative Care: Medical Management
Care Provider Orders:
Heart echocardiogram in the
morning
Hydrocodone 5
mg/acetaminophen 325 mg
1 2 tabs PO every 4 hours
prn HA
Hydrochlorothiazide 25mg
PO daily
Lisinopril 10 mg PO daily
Simvastatin 20 mg PO daily
Aspirin 81 mg PO daily
Cardiac diet
Rationale:
Expected Outcome:
1)Echocardiogram uses electrodes to check your heart
rhythm and ultrasound technology to see how blood
moves through your heart.
1)The nurse will continue to
assess Mr. Mike heart.
2)Hydrocodone helps treat severe pain.
3)Hydrochlorothiazide helps bring down hypertension
and reduce fluid retention.
4)Lisinopril relaxes vessels so blood flow easier. It also
helps decrease death after a myocardial infarction.
2)Patient pain level will be
reduce which will contribute
to lowering blood pressure.
3)By lowering fluids in the
body the patient
hypertension will be
reduced.
5)Treat high cholesterol and triglyceride levels.
4)Patient blood pressure
will reduce.
6)Aspirin helps blood flow move easier throught the
vessels. It also reduces inflammation.
5)Patient LDL will decrease
and and HDL will increase.
Helping reduce cholesterol.
7)Reducing sodium, fat and cholesterol intake will help
reduce ccholesterol levels.
8) Will help monitor if the the patient has diabities and
how well his managing his diabetes .
Hgb A1c
6)Patient blood pressure
will be reduce and risk of MI
will be reduced.
7)Cholesterol levels will be
reduce and control.
8) Will help identfied if pt is
suffering from diabities.
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care
of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR
report to the nurse who will be caring for this patient who is being admitted on the telemetry floor:
Situation:
Name/age:
BRIEF summary of primary problem:
Day of admission/post-op #:
Background:
Primary problem/diagnosis:
RELEVANT past medical history:
Assessment:
Most recent vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
TREND of any abnormal clinical data (stable-increasing/decreasing):
How have you advanced the plan of care?
Patient response:
INTERPRETATION of current clinical status (stable/unstable/worsening):
Recommendation:
Suggestions to advance plan of care:
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce
with Mike’s medical condition to prevent future readmission with the same
problem?
•
•
•
Lifestyle changes to lower his blood pressure
Knowledge about what causes an increase in blood pleasure
An understanding of what hypertension is and the effects on the body
2. What are some practical ways you as the nurse can assess the effectiveness of
your teaching with this patient?
•
•
•
•
•
Teach back on how to take a blood pressure and knowledge of disease
Lifestyle modifications such as ; weight control, limiting alcohol, regular exercise,
avoiding illegal smoking cessation.
Following A Low-saturated-fat and low-sodium diet
Assessing the understanding of the prescribed medication, including the dosage,
administration, expected results, duration, and possible adverse effects.
Identify the patient's and family's goals, preferences, comprehension, and concerns
about discharge.
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
The patient is most likely feeling, anxious, overwhelmed, scared and enlightened that he must
change his lifestyle habits if he wants to avoid a MI.
2. What can you do to engage yourself with this patient’s experience and show that he
matters to you as a person?
You can show empathy, while providing different support systems and resources he needs to
change. Education and the availability of different programs will make the patient less stressed
and start forming a plan to under these lifestyle modifications. Also providing a therapeutic
touch can help alleviate stress.
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s
response to an intervention in the moment as the events are unfolding to make a correct clinical
judgment.
1. What did I learn from this scenario?
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)
lOMoARcPSD|4994919
Hypertension is truly a silent killer. Years of poor lifestyle practices slowly take a toll on
the body and can cause an array of different ailments. It’s important to catch poor choices
early to avoid them becoming a habit and consequently lifestyle.
2. How can I use what has been learned from this scenario to improve patient care in
the future?
•
•
Being overweight, smoking, eating fast food, lack of exercise and a family history
of HTN/MI all risk factors for HTN. If a patient displays these behaviors warn
them of the risks and consequences of HTN
Empathize, reassure and educate the patient on how to improve their condition
© 2016 Keith Rischer/www.KeithRN.com
Downloaded by Ashley Rodb (ashleynidlebird@gmail.com)