Case Analysis Format

Profile of the Client:

Name Saud Edris
Age 55 years old
Age group classification middle age
Sex female
Education no education
Occupation house wife
Income medium
Chief complaints- with duration dull pain in the upper left quadrant of the abdomen that Radiate
to the chest for one week.
Diagnosis:
Hypertension.
History collection:
1. Family History
 Family Composition

S. No. Name of Family Age Gender Relationship Health Status

Members
1 Mohammed 60 Male Husband Good
2 Ali 23 Male Son Colon
3 Fatimah 20 Female Daughter Sickle-cell
anemia
4 Ahmed 18 Male Son Sickle-cell
anemia
 Family Tree

2. Social History/Personal History the patient is is an Egyptian married house wife with
three children living in Saudi Arabia
3. Diet History Regular diet
4. Past Health History. Heart surgery 2 years ago + hysterectomy 4 years ago+ hypertension
5. Present Health History
For Children Additional History- Developmental History & Immunization History
For Mothers (antenatal, natal, postnatal)- Menstrual History, Marital History, Past &
Present obstetrical History
No menstrual period because of the hysterectomy operation four years ago.
She has pain in her left leg with swelling and hypertension

Physical Examination:

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021

 1. Head to Foot Assessment
Head; The patient verbalized having headaches frontal Head region, and dizziness at
night. On inspection, the head is symmetric, with normal hair distribution.
Face; symmetric, with no pigmentation or wrinkles around the eyes. No lesions or scars.
Eyes; equal in size, symmetric, eyelid also symmetrical no lesions. The patient verbalized
feeling pain in her eyes and around the ocular area
Nose; symmetric nostrils no lesions, no complaining of discharge or congestion. No
difficulty breathing
Ears; symmetric ears no lesions, adequate hearing no complaints of hearing loss no
previous ear infection.
Mouth; the lips are normally symmetrical, slightly pink in color, and there is no cyanosis
or discoloration the patient said she follows proper mouth hygiene, no complaints of
bleeding gums or tooth pain, though she does not visit the dentist regularly.
Neck; on inspection, there are no lumps or scars, nodal enlargement, a trachea in the
middle no deviation, and the patient has no difficulty swallowing. There are no lymph
nodes enlarged.
Chest; dull pain in the upper left quadrant of the abdomen that radiates to the chest for
one week. Previous open heart surgery 2 years ago as a treatment for coronary artery
disease.
Abdomen; dull pain in the upper abdomen for one week. And last week the pain radiates
to the left quadrant of the abdomen and lower chest region. The pain is severe 6/10
increases in the morning. And when performing any effort. The pain then started to affect
her daily functioning as it was getting hard to raise from the bed, dressing, and walking
worsen the pain.
At first, she thought it was stomach pain and took antisecretory propranolol 5 mg, but she
didn’t feel relieved.
Extremities;
The patient complains of right legs, no asymmetry or skin changes, decreased hair
distribution in the legs, and leg pitting edema +1. The patient complained of cold feet at
night coolness, and no pigmentation or ulcers.

2. Vital Signs
Temperature 36.5; Pulse 74; Respiration 18; Blood Pressure 158/78; O2 saturation98%
3. Anthropometric Measurement
For adults  Weight 107 Kg; Height in167 M;
4. BMI/ Degree of Malnutrition Calculation
For adults  BMI= 38.4
Disease Condition:
 Definition: Blood pressure is the force of circulating blood against the walls of the body’s
arteries, the major blood vessels in the body. Hypertension is when the force of the blood
pressure is excessive.

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021

 Risk Factors:
- Salt consumption.
- Low intake of fruits and vegetables.
- Saturated fat and trans fats.
- Being overweight or obese.
- Harmful use of alcohol.
- Lack of physical activity.
- Tobacco use.
 Prevalence: 1 in 4 men and 1 in 5 women – over a billion people – having the condition.
Hypertension prevalence by WHO region, globally 22%. Africa 27%, Eastern
Mediterranean 26%, South East Asia 25%, Europe 23%, Western pacific 19%, Americas
18%.
 Clinical Manifestations:
- Most people with hypertension are unaware of the problem because it may have no
warning signs or symptoms. When it’s occur, they can include early morning headaches,
nosebleeds, irregular heart rhythms, vision changes, and buzzing in the ears. Severe
hypertension can cause fatigue, nausea, vomiting, confusion, anxiety, chest pain, and
muscle tremors.

Book Picture Client Picture

 Investigations: The only way to detect hypertension is to have a health professional

measure blood pressure.

Book Picture Client Picture

 Management:
- Follow medical advice and adhere to lifestyle changes.
- Take medication as prescribed.
- Regularly check blood pressure.
- Reduce and manage stress.
- Treating high blood pressure.
- Managing other medical conditions.
 Nursing Care:
- Encourage restriction of sodium and fat
- Emphasize increased intake of fruits and vegetables.
- Implement regular physical activity
- Advise patient to limit alcohol consumption and avoidance of tobacco.
- Assist the patient to develop and adhere to an appropriate exercise regimen

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021

- Encourage the patient to consult a dietitian to help develop a plan for improving nutrient
intake or for weight loss.
 Complications: It increases the risk of:
- Heart attack
- Stroke
- Kidney failure
- Blindness
- Chest pain (angina)
- Irregular heartbeat.

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021

 Needs and Problems Identified:
Nursing Process:
(Minimum 3 process)
Assessment Nursing Planning Implementatio Rationale Evaluatio
Diagnosis/ n n
Goals
Subjective data: Pain related The patient 1.Provide 1.To promote Goal is
The patient to increased will report comfort nonpharmacological pain partially
verbalized “I have cerebrovasc pain is measures (e.g., man- agement. met
dull pain in the ular relieved/contr touch, 2.To maintain
upper left quadrant pressure, olled repositioning, “acceptable” level of pain.
of the abdomen evidenced use of heat/cold Notify physician if
that radiate to the by verbal packs, nurse’s regimen is inadequate to
chest for one reports presence), quiet meet pain control goal.
week.” environment, 3.Observations may/may
and calm not be congruent with
Objective data: activities verbal reports or may be
Temperature 36.5; 2.Administer only indica- tor present
Pulse 74; analgesics, as when client is unable to
Respiration 18; indicated, to verbalize
Blood Pressure maximum
158/78; O2 dosage, as
saturation98% needed
Weight 107 kg; 3.Observe
Height 167 cm nonverbal
cues/pain
behaviors

Subjective data: Deficient The patient 1. Determine 1. Individual may not be Goal is
knowledge will client’s physically, emotionally, or met
The patient [Learning Participate in ability/readiness mentally capable at this
verbalized “I don’t Need] learning and barriers to time.
have much regarding process. learning 2. Can encourage
information about condition, 2. Provide continuation of efforts
hypertension" therapeutic positive 3. to facilitate
regimen, reinforcement learning/recall.
and 3. Determine
potential client’s method
complicatio of accessing
ns related to information
lack of (visual,
information auditory,
as kinesthetic,

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021

 evidenced
by patient’s gustatory/olfact
verbalizatio ory) and include
n in teaching plan

Subjective data: risk for The Patient 1. Note 1. Feelings of frustration Goal is
“I. don’t move decreased will emotional/behav and powerlessness may partially
during the day; I Cardiac participate in ioral responses impede attainment of met
like to sit on the Output activities that to problems goals.
sofa and use my related to reduce associated with 2. Concerns of SO(s)
phone” condition BP/cardiac self- or regarding threats to
requiring workload condition- personal health/longevity,
Objective data: change in imposed or acceptance by teen
sedentary lifestyle lifestyle as sedentary peers may be sufficient to
evidenced lifestyle. cause client to initiate
by 2. Discuss change; however, client
sedentary motivation for must want to change for
lifestyle change himself or herself in order
3. Review to sustain change.
necessity 3. Research confirms that
for/benefits of exercise has benefits for
regular exercise the whole body (e.g., can
boost energy, enhance
coordination, reduce
muscle deterioration,
improve circulation, lower
blood pressure, produce
healthier skin and a toned
body, prolong youthful
appearance.

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021

Health Education:
 Disease condition:
- Follow medical advice and adhere to lifestyle changes
- Take medicines as prescribed.
- Regularly check blood pressure.
- Reduce and manage stress
 Hygiene:
- Moisturizing the mouth permanently to avoid dehydration by the effect of medicines.
Avoid tobacco use. Brush two times a day.
 Diet:
- Reduce salt to less than 5g daily.
- Eat fruits and vegetables regularly.
- Avoid saturated fats and trans fats.
- Reduce alcohol.
 Exercise:
- Being physically active every day can help lower your blood pressure and make your
heart stronger.
 Follow up:
- Regularly check blood pressure. Emphasize strict compliance of follow-up check.

Conclusion
 (In one paragraph)

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021

 References

Exercise Tips for Those With High Blood Pressure. (2004, November 4). WebMD. Retrieved

September 22, 2022, from

https://www.webmd.com/hypertension-high-blood-pressure/safe-exercise-tips

Hypertension. (2019, June 20). Retrieved September 22, 2022, from https://www.who.int/health-

topics/hypertension#tab=tab_1

Vera, M. B. (2022, June 6). 6 Hypertension Nursing Care Plans. Nurseslabs. Retrieved

September 22, 2022, from https://nurseslabs.com/hypertension-nursing-care-plans/

Case Analysis_Provider of Care 4: Community and Public Health Nursing 2020-2021