St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

NAME: MARIE KELSEY A. MACARAIG

SECTION: BSN3A

Case Summary: Hypertension

July 23, 2021

1:15 pm
About the px:
Patient’s General Information
Name: P.P.M. Age: 65 Gender: Female
Address: Zone V. Bantay, Ilocos Sur Date of Birth: August 19, 1956
Civil Status: Single Educational Attainment: Highschool Graduate
Religion: Roman Catholic Occupation: Retired teacher
Hospital: St. James’ Hospital

Prior admission:
Patient complains elevated blood pressure of 160/100 mm Hg, episodes of severe headaches,
fatigue, dizziness, and sometimes chest discomforts.
On admission:
July 23, 2021
Interviewed revealed that she does not know why her blood pressure is high however stated
that she have a family history of hypertension from paternal side and her father died from heart
stroke.
Px is always at her home watching TV , smokes half to 1 pack of cigarettes every day and
drinks alcohol during the
She states that she always eat outside or buy foods from fast food chain because she said that
she lives alone.

Doctors order:
CBC, BUN/Crea, Renal function test, Urinalysis, Serum lipid profile, Na K determination.
Intravenous Infusion of PNSS 500 ml to run for 8 hours started.
To administer amlodipine 10mg OD. If SBP >200 start nicardipine drip x 15 gtts/min and titrate
accordingly. Further diagnostic examination of ECG and Cranial CT – Scan was ordered.

Laboratory Findings:
Mild left ventricular hypertrophy
Heat CT – Scan unremarkable plain CT scan of the head.
Elevated sodium levels of 155mmol/L
Total cholesterol 236 mg/dl
Triglycerides 202 mg/dl
HDL – C 61.6 mg/dl
C- LDL 133.6 mg/dl.

Summary of Abnormal Findings:

1. Elevated Blood Pressure of 160/100 mm Hg
2. Heart rate of 114 bpm
3. Respiratory rate of 24 bpm
4. Episodes of severe headaches, dizziness, fatigue, and chest discomfort.
5. Mild left hypertrophy
6. Sodium levels of 155 mmol/L
7. Total cholesterol 236 mg/dl
8. Triglycerides 202 mg/dl
9. HDL -C 61.8 mg/dl
10. C-LDL 133.8 mg/dl
11. Blurring of eyesight
12. Tooth decay
Medical Diagnosis: Primary Hypertension, Stage 2
Nursing Diagnoses:
1. Decreased Cardiac Output related to altered contractility as evidenced by left ventricular
hypertrophy
2. Acute pain related to physical agent [ increased cerebral vascular pressure]
as evidenced by verbal reports of episodes of severe headache, rated pain as 8/10, and
grimace expression.
3. Imbalanced nutrition: more than requirement related to obesity and average daily
physical activity is less than recommended, sedentary behaviors, poor dietary habits as
evidenced by the patient’s body mass index of 26.8 and verbal reports frequent fast food
and restaurant food consumption and poor physical exercise.
4. Ineffective health management related to insufficient knowledge about risk factors and
management of hypertension as evidenced by unhealthy habits and unexpected
acceleration of illness symptoms
5. Risk for activity Intolerance related to generalized weakness as evidenced by verbal
report of fatigue, dizziness weakness, elevated blood pressure of 160/100 mm Hg and
heart rate 114 bpm.

Medications:

Amlodipine 10mg P.O 1 tab OD

Nicardipine 20 mg IVF q8 (If SBP >200)

Atorvastatin 20mg P.O OD

Take home medications:

 Amlodipine (Norvasc) 10 mg P.O OD

o Take 1 tablet orally every morning once a day.
 Nifedipine (Adalat) 20 mg P.O PRN
o Take 1 tablet orally IF BP 200>
 Atorvastatin 20mg P.O OD

July 25, 2021 10:19 a.m.

The patient was discharged