Republic

Republic
of the Philippines
of the Philippines
NUEVA
NUEVA ECIJA ECIJAUNIVERSITY
UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
OF SCIENCE
AND
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED

In Partial Fulfilment
of the Requirement for the
Related Learning Experience
for the
Bachelor of Science in Nursing

Submitted By:

Alvarado, Claudine Joy Gamboa, Mayflor M.

Bautista, Tracy Nicole Garcia, Jomari
Cabigas, Alyssa Gayla, Rommel J.
De Belen, Angelica Herrera, Kathleen E.

Ferrer, Jezel Mae

Submitted to:
Kristhine Abegail Gamiao, MAN, RN

September 2021

Paki-ayos yung header and footer.

Remove all red
I’ll send cover page format.
Pakigaya na lang. Replace it with blue
 Republic
Republic
of the Philippines
of the Philippines
NUEVA
NUEVA ECIJA ECIJAUNIVERSITY
UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
OF SCIENCE
AND
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED

CHAPTER I
Diagnosis
Hypertension

All words should be in 12 font

General Objectives:
size
“At the end of the case study, the level III students will be able to
acquire adequate ideas and knowledge that can utilize their skills in providing
Wag gumamit ng acquire since
care to a patient with hypertension.” you are nursing student you
should already have a
Specific Objectives: background knowledge
Student nurses will be able to: regarding the disease. Use
ENHANCE
1. Understand what kind of condition is hypertension;
2. Recognized its clinical signs and symptoms; Enhance your specific
3. Identify causative factors of the disease. objectives
4. Review and understand the anatomy and physiology of the cardiovascular
system as well as the circulatory system. Double spacing
5. Explain and illustrate the pathophysiology of coronary artery disease.
6. Develop a valid and reliable nursing care plan that is applicable Add for
some avalues:
patient with hypertension
Prevalence, mobidity,
7. Provide dependent, independent and collaborative nursing care plan. ;and
and mortality rate
8. Elaborate ideas and facts about drugs that is administered to the patients
with hypertension. Have international and
local sources
Introduction Improve the delivery
High blood pressure (hypertension) is a common condition in which the long-
term force of the blood against your artery walls is high enough that it may
eventually cause health problems, such as heart disease.
Hypertension is quite common. In fact, since the guidelines have recently
changed, it’s expected that nearly half of American adults will now be diagnosed
with this condition.
Hypertension typically develops over the course of several years. Usually,
you don’t notice any symptoms. But even without symptoms, high blood pressure can
cause damage to your blood vessels and organs, especially the brain, heart, eyes,
and kidneys.
You can have high blood pressure for years without any symptoms.
Uncontrolled high blood pressure increases your risk of serious health problems,
including heart attack and stroke. Fortunately, high blood pressure can be easily
detected. And once you know you have high blood pressure, you can work with your
doctor to control it.

Demographic Profile
PRIVACY.
Hospital Number: 09032020-001 USE Patient X
Patient’s Name: Cruz, Juana O.
Address: General Tinio St., Cabanatuan City, Nueva Ecija
Gender: Female
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Birthday: May 25, 1975
Age: 46 years old
Birthplace: Cabanatuan City, Nueva Ecija
Nationality: Filipino
Civil Status: Married
Religion: Roman Catholic
Educational Level: College Graduate
Allergies: None as claimed by the patient.
Admitting Time: 5:00 PM
Admitting Date: 09/10/2021
Admitting Diagnosis: Hypertension Stage?
Admitting Physician: Dr. Woo
Chief Complaint: Severe headache

Family History Refer to the COLDSPA

The Client’s family heath history includes that her father died of myocardial
infraction at the age of 40. Hher Mother has a hypertension at age of 70, his
brother has a hypertension and cardio vascular disease at age of 37 and her
sister has a hypothyroidism at age of 34.

History of Past Illness

The client was admitted in the hospital when she was 5 years old due to
tonsillectomy, she undergone surgery of caesarean section and blood transfusion
for post-cesarean at age of 30.

Admitting History

The Client was admitted to the Medical ward with a severe headache. The client
was brought to the hospital due to elevated blood pressure. The patient appears
with blurred vision and complaining of “Sobrang sakit ng ulo ko” around 5PM in
the afternoon, the client vital signs during the shift taken as follows: PR: 87,
RR 18 T: 37.4˚C BP: 178/110mmHg. The client has given a prescribe medication for
her high blood pressure.

Social History
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client is a full-time nurse in local hospital she has a
sedentary lifestyle. She drinks alcohol occasionally, non-smoker and drinks a lot
of caffeinated beverages.

Status of Present Illness Wag niyo gawing normal hehe.

The client’s condition is making a good progress which is evident to the

latest vital signs taken to the client, and those vital signs are as
follows: BP- 120/100 mmHg. PR-77 bpm, RR-17bpm, T-36.7 °C. These was taken
Add your findings even if it is normal
at 4:30 PM.
FORMAT:

Body Parts – Normal Findings –Actual

Physical Assessment Finding- Result
The table below shows the cephalocaudal physical assessment of the client.
BODY PARTS NORMAL FINDINGS
Proportional to the size of the
body, round, with prominences in the
Skull Normal
frontal area and occipital area, No
tenderness

No lesions should be noted, No

Scalp Normal
tenderness or masses

Evenly distributed covers the whole

Normal
scalp, no evidence of Alopecia,
Hair
maybe thick or thin, coarse or
smooth, neither brittle nor dry.

Moist skin and pinkish conjunctiva,

pupil equally round reactive to
Eyes Blurred vision
light and accommodation with equally
distributed eye lid and eye lashes

Symmetrical in appearance and in

Face Normal
movement

Symmetrical, no presence of
discharge or redness can react to Normal voices tones not
Ears and Hearing
sound and there is a little presence audible.
of cerumen

No nasal discharge, no redness and

inflammation and no nasal deviation
Nose and Sinuses Normal

Moist and pinkish mucus membrane,

can able to move the tongue in all
Normal
direction and uvula is ay the
Mouth and Throat
midline. No tenderness when
palpating for the soft and hard
palate and with intact gag reflex
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Swollen
The neck is straight, no visible neck veins, pain on the
mass or lumps, symmetrical, no nape
Neck
jugular venous distension
(suggestive of cardiac congestion).

Yellow discoloration in
Nail surface is slightly curved and
Nails both fingernails and
no clubbed finger
toenails, flat nail beds.

Uniform in color, except in the

Skin areas exposed to the sun, no edema, Dry skin
moist skin, and no other lesions,

There should be no lift or heaves,

Quiet, rhythmic respiration, normal
breathing rate, Loud pulmonic valve sound,
Chest
irregular heartbeat
Your client should have
lesion since she undergo
CS
Abnormal sound of blood
vessel in the abdomen,
No abdominal distention with no abnormal buildup of fluid
Abdomen
signs of tenderness or masses (edema)

Grade pitting edema?

Abnormal sound of blood
Convex curvature, smooth texture, no flow (bruit) in the blood
Lower and Upper
presence of petechiae in upper and vessels, abnormal buildup
Extremities
lower extremities of fluid (edema) in lower
extremities.
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CHAPTER II

Definition of Case Definition of Case

Hypertension, also known as high or Anatomyblood

raised pressure, is a
Pathophysiology
condition in which the blood vessels have persistently (include yourBlood
raised pressure. signs is
carried from the heart to all parts of the body in and
thesymptoms)
vessels. Each time the
heart beats, it pumps blood into the vessels. BloodMedical management
pressure is created by the
force of blood pushing against the walls of blood Nursing
vessels (arteries) as it is
Management
pumped by the heart. The higher the pressure, the harder the heart has to pump. 

MEDICAL MANAGEMENT:

 Stabilize blood pressure into normal range (120/80) through

administration of antihypertensive medication and changing your
lifestyle by eating healthy diet (low salt), staying physically
active, maintain healthy weight, etc.
This is nursing management.

Medical Management is more on

pharmacologic management
 Diuretics.

Administer thiazide (chlorthalidone) 25mg OD PO

Implication: Help the kidneys get rid of excess water and salt
(sodium). This reduces the volume of blood that needs to pass through
the blood vessels.

 Angiotensin-converting enzyme (ACE) inhibitors.

Administer benazepril (Lotensin) 20-40mg OD PO
Implication: Relax blood vessels by blocking the formation of a
natural chemical that narrows blood vessels.

 Angiotensin II receptor blockers (ARBs).

Administer losartan (Cozaar) 50mg OD PO
Implication: Relax blood vessels by blocking the action of a natural
chemical that narrows blood vessels.

 Calcium channel blockers. 

Administer amlodipine (Norvasc) 5mg OD PO
Implication: Relax the muscles of your blood vessels.
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NURSING MANAGEMENT: Please specify

(e.g., ...)
 Monitor blood pressure frequently

 Administer antihypertensive medications as prescribed by the

physician.

 Educate the patient on the importance of taking antihypertensive

medications

 Educate patient on a low salt diet, exercise, and healthy eating

 Emphasize increase intake of fruits and vegetables.

 Assist the patient to develop and adhere to an appropriate exercise
regimen. 
 Emphasize importance of regular and long-term medical follow-up
appointments.

Anatomy of Circulatory System

The circulatory system is made up of blood vessels that carry blood
away from and towards the heart. Arteries carry blood away from the heart
and veins carry blood back to the heart. The circulatory system carries
oxygen, nutrients, and hormones to cells, and removes waste products, like
carbon dioxide.
Improve your Anatomy

Physiology of Circulatory System

The circulatory system is the continuous system of tubes through which
the blood is pumped around the body. It supplies the tissues with their
nutritional requirements and removes waste products. The pulmonary
circulatory system circulates deoxygenated blood from the heart to the
lungs via the pulmonary artery and returns it to the heart via the
pulmonary vein. The systemic circulatory system circulates oxygenated blood
from the heart around the body into the tissues before returning
deoxygenated blood to the heart.
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PATHOPHYSIOLOGY OF HYPERTENSION

Don’t just copy paste it. Make

sure that you can explain. Create a
diagram.

And specify what age.

Add gender as a risk factor

Please, make this a client-based

pathophysiology
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CHAPTER III Indent every paragraph

Review your symptoms on your

CLINICAL MANIFESTATION
entire manuscript. Dapat
magkakatugma
Hypertension is usually a silent illness. Many people will not show any
signs or symptoms. It may take years, if not decades, for the disease to
progress to the point where symptoms are visible. Even yet, these symptoms
might be due to anything else.
Severe hypertension can cause the following symptoms headaches, shortness
of breath, nosebleeds, flushing, dizziness, chest pain, visual changes and
blood in the urine.
These signs and symptoms necessitate medical intervention right once. They
don't happen to everyone who has hypertension, but waiting for a symptom to
emerge might be fatal.
LABORATORY RESULTS Separate each laboratory

LABORATORY TEST RESULTS

Add interpretation and its significance
Blood Chemistries:
BUN 26 mg/dL
Creatinine 1.48 mg/dL
Sodium 134 mg/dL
Potassium 4.0 mg/dL
Glucose 166 mg/dL
Fasting Lipid Profile:
Total cholesterol 245 mg/dL
LDL 188 mg/dL
HDL 29 mg/dL
Triglycerides 344 mg/dL
UA:
Color yellow
Clarity clear
Sp. Gravity 1.015
pH 5.5
urobilinogen normal
glucose moderate
protein moderate
ketone negative
blood negative
nitrite negative
leukocyte esterase negative
RBC 20
WBC none
Bacteria occasional
Creatinine 1.48
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CHAPTER IV
Nursing Care Plan
ASSESSMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION RATIONALE EVALUATIO
IDENTIFI N
CATION Gawin niyong landscape.
Subjective: After 8
Acute  Rep After 8  Page layout
Determi • – Breaks
To –hours
Next page
of–
“Madalasnasumak pain ort hours of ne assess
orientation
and – landscapenursing
itanguloko” as related a nursing documen etiology interven
verbalized the red interven t Your client has
precipita Edema, jaundice, and
tions,
to
patient. uct tions, dry
presenc ting
skin. Maraming the
problema
increased the
ion e of contribut
according patient
to your assessment
Objective: cerebrova in patient possibl ory was able
scular pai will e factors.
Your objective to
wasn’t mentioned on
 Restlessne pressure n verbaliz pathoph
your assessment neither verbaliz
on your
ss as per ed ysiolog
admitting history. ed
 Irritabili evidence cep relief ical relief
ty tio from and Where is your pain from
scale? Pain scale
by
n. pain. psychol • To pain.
 Sleep reluctant should be included also on your
 Rep ogical evaluate
disturbanc to move chapter 1. Kindly do a thorough
ort cause clients Goal was
e assessment
head and tha of response met.
 Self- Where is to pain.
verbal t pain. Long
focused
report. the your term
pai long  Note What is• the exact
To chief complaint of
 VS as promote
Nasan to n term? the your client? You’ve mentioned chest
follows: non-
sa has client’
pain onpharmacol
your signs and symptoms
com s
 BP objective
ple attitud ogical
-178/110mm niyo? tel e pain
Hg y managemendependent and
Add independent,
toward
dis t.
pain collaborative interventions
 RR – 18 sip and use
bpm ate a pain • To
d. medicat prevent
 T – ion. Pleasefatigue.
improve your interventions
37.4˚C  Your
outcom  Monitor
 PR – 87 e, skin .
bpm planni color
ng and and
evalua vital
tion sign.
should
be Instruct and
SMART. encourage
use of
relaxation
technique
and
encourage
adequate
rest period.

ASSESSMENT DIAGNOS OUTCOME PLANNING INTERVENTI RATIONALE EVALUATI

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IDENTIFICATI ON ON
ON
After 8
Subjective: Decrea Exhib After 8 1. Monit 1. Chang hours
“ nahihilo at sed it hours or BP es in of
parangnanlalaboang cardia stabi of every BP nursing
akingpaningin” as lity 1-2 interve
c nursing may
verbalized by the in hours ntion,
patient. output interve . indic the
the
r/t cardi ntion, ate client
Prioritize your malign ac the 2. Sugge chang had no
problem. Nahihilo ant rate client st es in elevati
na nga tapos hypert and will frequ patie on in
nanlalabo pa ension rhyth have no ent nt blood
paningin. Isa isa m. posit pressur
as elevati statu
lang.  Maint ion e above
manife on in chang s normal
ain
sted blood es. requi limits
blood
Objective: by press pressur ring and
decrea ure e above 3. Encou promp will
 Generalized sed withi normal rage t maintai
weakness stroke n an limits patie atten n blood
 Decreased accep nt to pressur
volume and tion.
cardiac table decre e
and will ased within
output /stab 2. It
blurre maintai intak accepta
 Edema le
may
d range n blood e of ble
 Decreased caffe decre limits.
vision . pressur
stroke ine,
and Engage in e ase
volume. cola Goal
increa interventio within perip
 Optic disc and was
papilledema sed n to help accepta heral
choco met.
 Increased blood decreased ble late. venou
blood pressu blood limits s
pressure. re. pressure.an 4. Obser pooli
Dont include dcardia Long ve ng Long
this since Improv load. term? for that term
you have VS compl may
e your
 VS as aints
be Please
assess SMART. Your of
follows: enhance
ment outcome blurr poten
 BP your
and should be ed tiate
-178/110mmHG
diagno your visio d by ncp
Your status
of present sis general n, vasod
illness BP is dapat goal while tinni ilato
normal. tus rs
swak. your
Change it. or
planning and
 RR – 18 confu
should be sion. prolo
 T – 37.4˚C nged
your 5. Obser
 PR - 87 ve sitti
specific
goal skin ng
color and
, stand
tempe
ing.
ratur
e,
capil
lary 3. Caffe
refil ine
l is a
time cardi
and ac
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diaph
oresi stimu
s. lant
6. Instr and
uct may
clien
adver
t and
famil sely
y on affec
fluid t
and cardi
diet ac
requi funct
remen
ts ion.
and
restr 4. May
ictio indic
ns of ate
sodiu cyani
m. de
Instruct
toxic
the
ity
client
from
and
incre
family on
asing
medicatio
intra
n side
crani
effect
al
contraind
press
ications
ure
and signs
to report .
5. Perip
heral
vasoc
onstr
ictio
n may
resul
t
pale,
cool,
clamm
y
skin,
with
prolo
nged
capil
lary
refil
l
time.

6. Restr
ictio
n can
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assis
t
with
decre
ased
in
fluid
reten
tion
and
hyper
tensi
on
there
by
impro
ving
cardi
ac
outpu
t.

Promotes
knowledge
and
compliance
with drug
regimen.
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CHAPTER V FORMAT

Drug Name
Drug Study
Dosage and Route
Name of Dosage/ Classification Indication Adverse Nursing
Drug Route Mechanism
Reaction of
Responsibiliti
Action es
Generic Adult: •Angiotensin II •Treatment of CNS: Before:
Indication
name: Tablets: receptor hypertension, •headache, •Assess 12
•Losarta •25mg blocker alone or in dizziness, rights
Adverse Effects
n •50mg combination syncope,
Potassiu •100mg •Antihypertensi with other insomnia •Assess the
m ve antihypertensi patients
Pediatri ve drug. CV: Your client ishistory of
Brand c: •Hypotensio
experiencingallergies.
pain
Name: 6yrs and •Reduction of n
•Cozaar older the risk if •Check the
•0.7mg/kg stroke in Dermatologi patients VS
Pregnanc per day c: and health
patient with
y •rash, condition.
Route: hypertension urticaria,
Category
•Oral and left pruritus, During:
C & D ventricular alopecia, •administer
hypertrophy. dry skin the drug
orally and
GI: according to
•Diarrhea, the physicians
abdominal order.
pain,
nausea, •Administer
constipatio the drug 1hr
n, dry before or
mouth. after meal.
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After:
Respiratory •Explain the
: possible
•URI adverse
symptoms, reaction.
cough,
sinus •Advise the
disorders. patient to
stay at bed
Other: for several
•back pain, hours.
fever,
gout, •Instruct the
muscle family or
weakness patient to
report any
other
troublesome
side effect
such as GI
problems.

Name of Dosage/ Classification Indication Adverse Nursing

Drug Route Reaction Responsibiliti
es
Generic Adult: •Antihypertensi •Treatment CV: Before
name: Tablet: ve if •angina •Assess 12
•Benazepril •5mg hypertensi pectoris, rights
Hydrochlori •10mg •ACE inhibitor hypotension
on alone
de •20mg in salt or •check the
•40mg or in volume patients VS
Brand name: combinatio depleted and health
•Lotensin Maintenan n with patients, condition
ce dose: other palpitation
Pregnancy •20-40mg thiazide •Assess the
Category C per day -type Dermatologi patient for
& D c: any medication
diuretics.
Route: •Rash, allergies
Oral pruritus,
diaphoresis •Explain the
medication and
GI: its uses.
•Nausea,
abdominal •Explain the
pain, possible side
vomiting, effect.
constipatio
n During
•Administer
Respiratory the drug
: orally.
•Cough,
asthma, •Administer
bronchitis, the drug 1hr
dyspnea, before or
sinusitis after meals.

Other: After
•Angioedema •monitor
, symptoms of
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risk
impotence, plasma
decreased potassium
libido, level or
asthenia, hyperkalemia,
including
myalgia,
bradycardia,
arthralgia fatigue,
weakness,
numbness and
tingling

•Advice the
patient to
stay in bed
for several
hours after
taking the
drug.

•Instruct the
family and
patient to
report any
other
troublesome
side effect
like GI
problems.
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Evaluation and Findings muna

bago Recommendation
CHAPTER VI
RECOMMENDATIONS Improve your evaluation and
findings

 Exercise regularly. Maintaining a healthy weight or losing weight can

Your recommendation should be
help you avoid of fats in your body.
on METHODS format
 Get plenty of rest. Adequate rest is important to maintain progress
Medication
toward full recovery and to avoid relapse.
 Environment
Diet. In general, eat foods lower in fat, salt, and calories. Use
spices and herbs, vinegar, lemon or fruit juices instead of salt to
Treatment
flavor foods. Use less oil, butter, margarine, shortening, and salad
dressings. Health Teaching
 Observe the given medicines of the patientsOut-patient
if there's signs and
reactions.
Diet
 Keep all the follow- up appointments. Even though the patient feels
better, her blood pressure is in need of monitoring to avoid
Spirituality
complications. It's important to know the progress of patient
condition.

Evaluation and Findings

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After conducting the study, we are able to absorb the idea of
how nursing process works in providing care to our client. The client went
through different laboratory procedures to identify her health problems and
to verify what are the causative factors to it.