CASE STUDY

ON
HYPERTENSION

SUBMITTED TO: SUBMITTED BY:

MRS. RAMA DANAPURE MS. PUNAM SOLANKE

LECTURER M.SC NURSING 1 ST

YEAR

KNC SEWAGRAM KNC SEWAGRAM

INTRODUCTION:

HYPERTENTION (high bp) is a disease of vascular regulation in which the mechanisms that
control atrial pressure within the normal range are altered. The predominant mechanisms of
blood pressure control are the central nervus system (CNS). the renin angiotensin-aldosterone
system and extracellular fluids volume why these mechanisms feel is not known.

Aims of objectives:

1. To study the case of hypertension in the community

2. To study the management to be taken during home visit in community health nursing.

3. To find out the modified and non-modified risk factor

4. To brings awareness about the hypertension among the client and family member.
INTRODUCTION:

My client is a nuclear family and consist of wife, her husband and two daughter. I met them
and establish good rapport with the family members. I provided day care for the family. They
are very co-operative with me.

PATIENT IDENTIFICATION:

Name :Mrs.Indubai Ganesh Chaudhari

Age : 46 year

Sex : Female

Address : Ward no.3 Mothi Anji

Occupation : House Wife

Marital status : Married

Religion : Hindu

Income : 10,000/-

Diagnosis : Hypertension

Chief complaint: Mrs. Indubai Ganesh Chaudhari

Have chief complaints about

1. Difficulty in walking
2. Leg swelling

PRESENT MEDICAL HISTORY

Mrs. Indubai Ganesh Chaudhari have hypertension since last 10 year ago they visit in
Primary health centre and monitoring continues blood pressure and doctor diagnosis as
hypertension and Dr prescribed as medicine.

PAST MEDICAL HISTORY:

Mrs. Indubai Ganesh Chaudhari have no any past medical history.

PRESENT SURGICAL HISTORY:

Mrs. Indubai Ganesh Chaudhari does not have any surgical history

PAST SURGICAL HISTORY:

Mrs. Indubai Ganesh Chaudhari undergone the family planning surgery.

FAMILY HISTORY:

Mrs. Indubai Ganesh Chaudhari has a nuclear family and they have four members in his
family

FAMILY COMPOSITION:

Sr.no. Family Age Education Relation Occupation Health

members status
1 Mrs. Indubai 45 9th pass Client Housewife Unhealthy
Ganesh years
Chaudhari
2 Mr. Ramesh 50 9th pass Husband Farmer healthy
chaudhari years

3. Ms.Kajal 22 10th Daughter - healthy

pass
chaudhari years

4. 20 Daughter healthy
2nd year -
Ms. Tanuja year
chaudhari
FAMILY TREE:

Ramesh chaudhari(50yrs)
Indubai Ganesh Chaudhari
Husband

Ms. Kajal Ms. Tanuja chaudhari

chaudhari
(20 yrs) Daughter
(22.yrs)
Daughter

KEYS

MALE –

FEMALE –

PATIENT –
ECONOMICAL HISTORY:

Mrs. Indubai Ganesh Chaudhari belongs to middle class family having monthly income
10,000/- have a house on rent and proper ventilation, good sanitation condition, good water
supply.

NUTRITION HISTOR

Mrs. Indubai Ganesh Chaudhari is conscious and well oriented with place he is belongs to
middle class family with consumed vegetarian and non-vegetarian food they consumed
mixed diet.

PSYCHOLOGICAL HISTORY:

Mrs. Indubai Ganesh Chaudhari is conscious and well oriented with person family members
and neighbors and they maintained interpersonal relationship to each other his behavior is
good towards the everyone.
PHYSICAL EXAMINATION

Name – Mrs. Indubai Ganesh Chaudhari

Age/sex - 45 yr. / Female

VITAL SIGN

Temperature - 37 degree Celsius

Pulse - 72 beat/min

Respiration - 20 breath /min

Blood pressure - 130 /80 mmhg

GENERAL APPEARANCE

Nourishment - Moderate Nourished

Body built - Moderate

Health - Unhealthy

Activity - Active

MENTAL STATUS

Consciousness - Conscious

Look - Slightly anxious

POSTURE

Body curve - Moderate

Height - 145 cm

Weight - 56 kg
SKIN CONDITION

Colour - Dark

Texture - No dryness

Temperature - Clam

Lesion - No any lesion

HEAD AND FACE

Scalp - No dandruff

Hair - Hair is black and white in colour

EYES

Eyebrows - Normal

Eyelashes - No infection

Eyelids - Present, no stie present

Vision - Normal

Conjunctiva - Normal

Sclera - Redness

EAR

External ear - No discharge

Tympanic membrane - No perforation

Hearing activity - Clear and normal rang

NOSE

External nose - No discharge

Nostrils - No infection, normal

MOUTH AND PHARYNX

Lip - No swelling, no redness, no ulceration.

Odours - No foul odor ( halitosis)

Teeth - All teeth are present

Mucus membranes - No ulcer, no gingivitis

Tongue - Slightly dry

Throat and pharynx - No enlarge tonsils

NECK

Lymph node - Palpable

Thyroid gland - No enlargement

Range of motion - Flexion, extension and rotation

CHEST

Thorax - Symmetric shape is present

Breath sound - Wheezing

Heart - No cardiac murmur

Respiration rate - 20beats /min

Pulse rate - 74breath/ min

Lungs - Chest clear

ABDOMEN

Inspection - No lesion present, no skin rashes, no any scar.

Palpation - No enlargement of organ. Slightly tenderness.

Percussion - No fluid present

Auscultation - No bowl sound is present

EXTREMITIES

Movement of joint - Regular

Tremor - Absent

EQUILIBRIUM TEST

Neurological - Test for sensation

Co-ordination - Test for reflexes

 DISEASE CONDITION:

Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater and/or

diastolic BP of 90 mmHg or greater. The National Health and Morbidity Survey (NHMS)
2011 has shown that the prevalence of hypertension in Malaysia for adults ≥18 years has
increased from 32.2% in 2006 to 32.7%in 2011. For those >30 years old, the prevalence has
increased from 42.6% to 43.5%. About 60.6% of total hypertensive where “undiagnosed”
Hence BP should be measured at every opportunity. No significant difference between
gender was observed. In terms of the main ethnic groups, the Bumiputra from Sabah &
Sarawak have the highest prevalence at 36.4%, followed by the Malays at 34.0%, Chinese at
32.3% and lastly the Indians at 30.6%.

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.

Blood pressure is determined both by the amount of blood your heart pumps and the amount
of resistance to blood flow in your arteries. The more blood your heart pumps and the
narrower your arteries, the higher your blood pressure. A blood pressure reading is given in
millimeters of mercury (mm Hg). It has two numbers.

Top number (systolic pressure). The first, or upper, number measures the pressure in your
arteries when your heart beats.

Bottom number (diastolic pressure). The second, or lower, number measures the pressure in
your arteries between beats.

DEFINITION:

Hypertension, also known as high or raised blood pressure, is a condition in which the blood
vessels have persistently raised pressure. Blood is carried from the heart to all parts of the
body in the vessels. Each time the heart beats, it pumps blood into the vessels.

Or

Hypertensions the medical term for high blood pressure, hypertension is actually a condition
where there is elevated blood pressure in the body.
TYPES:

There are two types

1. Primary hypertension
2. Secondary hypertension

1. Primary hypertension

Primary HTN AALSO KNOWN AS essential hypertension, idiopathic hypertension is most

common and complex types of hypertensions and is found in more 90% of the hypertensive
population by definition it has no direct causes but is a result of secondary lifestyle.

Genes: Some people are genetically predisposed to hypertension. This may be from gene
mutations or genetic abnormalities inherited from your parents.

Physical changes: If something in your body changes, you may begin experiencing issues
throughout your body. High blood pressure may be one of those issues. For example, it’s
thought that changes in your kidney function due to aging may upset the body’s natural
balance of salts and fluid. This change may cause your body’s blood pressure to increase.

Environment: Over time, unhealthy lifestyle choices like lack of physical activity and poor
diet can take their toll on your body. Lifestyle choices can lead to weight problems. Being
overweight or obese can increase your risk for hypertension.

2.Secondary hypertension:

By the definition is a result of identifiable couses. It is very important to detect secondary

hypertention as the treatment for secondary hypertenstion is associated treating te couse.
Secondary hypertention results from the interplay of several pathophysiological
mechanismsregarding plasma volume, peripheral vascular resistance and cardiac output, all
of which may be increased.

several conditions that may cause secondary hypertension include:

kidney disease

obstructive sleep apnea

congenital heart defects

problems with your thyroid

side effects of medications

use of illegal drugs

alcohol abuse or chronic use

adrenal gland problems

certain endocrine tumors

Other classification:

 Malignant hypertension
 Paroxysmal hypertension
 Portal hypertension
 Pulmonary hypertension
 Renovascular hypertension

ETIOLOGY:

Smoking

Being overweight or obese

Lack of physical activity

Too much salt in the diet

Too much alcohol consumption

Stress

Older age

Genetics

Family history of high blood pressure

Chronic kidney disease

Adrenal and thyroid disorder

Sleep apnea

RISK FACTORS:
Non-modifiable risk factors:

Ageing

Getting old is one of the biggest risk factor which cannot be dealt with. As we age, risk of
cardiac diseases increases manifold.

Family History

A family history of cardiovascular disease makes you prone towards it.

Gender

Men are at greater risk of heart disease than a pre-menopausal woman. Post menopause, the
risk for both becomes similar

Ethnicity

African and Asians are at higher risks of developing cardiac disease than other racial groups.

Modifiable risk factors:

Overweight and Obesity

Carrying around extra weight is not just about fitting into a smaller pair of jeans. Extra body
fat can be a health concern, raising risk for many conditions, including hypertension.
Achieving a so-called “normal-weight” may be far-fetched, but that is okay. Losing any
amount of extra weight can lower risk for hypertension. Even preventing weight gain as time
passes helps prevent hypertension risk from rising further.

Salt intake:

There is an increasing body of evidenced to the effects that a high salt intake.( i.e. 7-8 gm per
day )increses blood pressure proportionally low sodium intake has been found to lower the
blood pressure.

Potassium intake: potassium antagonizes the biological effect of sodium.potassium

suppliments lower the bp of mild to moderate hypertensive’s.

Saturated fats: the evidences suggest that saturated fat raise blood pressure as well as serum
cholesterol.
Alcohol: high alcohol intake is associated with an increased risk of high blood pressure.it
appers that alcohol consumption raises systolic pressure more than the diastolic.

Dietary Risk Factors

What you eat clearly matters, and the Dietary Approaches to Stop Hypertension (DASH) diet
can lower high blood pressure within weeks. The guidelines include eating more fruits and
vegetables, whole grains, and reduced-fat calcium products compared to the typical
American. In addition, DASH has only a limited amount of sweets and red meat.

Too much sodium, usually from salt, is another risk factor for hypertension. It is usually
highest in prepared, pickled, canned.

Smoking:

Nicotine stimulates adrenergic drive raising blood pressure. It raises blood pressure
temporarily.

Lack of Exercise

Physical activity may help with weight loss, improve mood, and make you look better, but
those are only side effects. The biggest benefits of exercise may be its health effects,
including lower risk for hypertension.

Inadequate Sleep

Almost every choice you make all day and into the night can affect your blood pressure.
Routinely stay up doing social media instead of getting the sleep you need, and your risk for
hypertension increases. Set aside enough time for sleep every night and establish a bedtime
routine to help fall asleep faster, and hypertension risk decreases.

Stress

When a car cuts into the lane in front of you, do you wave your fist and curse, or do you take
a deep breath and continue driving as safely as you can? Taking a deep breath and other
stress management techniques can help keep blood pressure down, while letting stress
overwhelm you can lead to higher blood pressure. Chronic stress from work, worries about
health and money, relationship troubles, and even too much noise outside your home can all
contribute to stress levels and should be managed.
Socioeconomics factors:

In countries with post transitional stage of economy and epidemiological change high BP is
noted in lower socio-economic group while in pre-transitional and transitional higher
prevalence of hypertension is in upper socio-economic group.
PATHOPHYSIOLOGY:

High Sodium Intake Stress Decreased Natriuretic Hormones

Increased sympathetic nervous system activity

Stimulation of the renin angiotensin system activity

Renal efferent arteriole construction

Increased filtration fraction

Increased tubular sodium reabsorption

Increased intravascular volume

HYPERTENTION
CLINICAL MANIFESTATION:

In book In patient

Severe headache No
Fatigue and confusion No
Vision problems Yes
Chest pain No
Difficulty in breathing No
Irregular heart beat No
Blood in the urine No
Pounding in your chest, neck and ears. No

DIAGNOSTIC EVALUTION:

HISTORY TAKING:

Patient come in primary health Centre with present chief complaints of Headache, Fatigue,
Vision problems, Difficulty in breathing. And dr. prescribed medicine of HTN.

PHYSICAL EXAMINATION:

In physical examination, I observed that patient face has painful, inability to take the breath,
and blurred vision.

ECG: to determine the effects of hypertension on the heart or presence of underlying heart
disease.

CHEST X-RAY: may show cardiomegaly or aortic dilation by the presence of a widened
mediastinum.

PROTEINUREA: elevated serum blood urea, nitrogen, and creatinine level – in dicale
kidney disease and creatinine ratio are earlier indicators.
SERUM POTASSIUM – decreases in primary hyper aldosterone elevated in Cushing
syndrome both are cause of secondary hypertension:

1. Renal ultrasound to defects renal vascular disease

2. Renal artery duplex imaging to identity renal artery stenosis

3. Outpatient ambulatory BP measurement

COMPLICATION:

a) Atherosclerosis
b) Heart failure
c) Coronary artery disease
d) Stroke
e) Renal disease
f) Peripheral arterial disease

MANAGEMENT:

Prevention and control:

Primary prevention-

Control of primary hypertension can be successfully achieved by medication. The ultimate

the goal in general is primary prevention.

Population strategy and high-risk strategy:

1. Population strategy: the multifactorial includes –

 Nutrition
 Weight reduction
 Exercise
 Behavioral changes
 Health education
 Self-care
 2. High risk strategy:

This is also a part of primary prevention.

The detection of high-risk subject should be encouraged by the optimum use of clinical
methods since hypertension and ‘tracking’ of blood pressure from child hood may be used to
identify individual at risk.

Secondary prevention –

The goal of secondary prevention is to detect and control high blood pressure in affected
individual. Modern antihypertensive drug to reduced high blood pressure

the control measure comprises-

1. Early case detection

2. Treatments
3. Patient compliance

TREATMENT:

Medical management:

Calcium channel blocker:

1. Amlodipine is a dihydropyridine calcium antagonism (slow calcium channel blocker)

that inhibits the trance membrane in flex of calcium ions vascular smooth muscles and
cardiac muscles. Amlodipine binds to both dihydropyridine and non dihydropyridine
binding site.

Doses Frequency

2.5mg, 5.0mg, 10mg.

Side effects:

Fatigue, Palpation, Blushing, swelling of the ankle or feet, irregular pounding binding or
racing heat beat, feeling of warmth.

Nurses’ responsibility

Give right drug, right patient, dose, route, documentation.

2. Enalapril

Doses frequency

2.5 mg BD

Normally angiotensin I is converted to angiotensin II by an ACE. Enalaprilat the action

metabolic of Enalapril inhibit ACE. Inhibit of ACE decrease level of Angio tensive Il leading
to less vasoconstrictor and decreased blocker decreased.

Side effects:
Cough loss of taste sensation, loss of appetite, dizziness, drowsiness, insomnia, dry
mouth, nausea, vomiting, and diarrhea.
Nurses’ responsibility
1.Give right drug, right patient, dose, route, documentation.
2.Check for side effects

B-blocker:

1. Labetalol
2. Atenolol
3. Metoprolol

Alpha blockers

1. Doxazocin
2. Prazosin
3. Methyldopa

Thiazide diuretic’s:

1. Frusemide
2. Metolazone
DIETARY MANAGEMENT

One of the steps your doctor may recommend to lower your high blood pressure is to start
using the DASH diet.

DASH stands for Dietary Approaches to Stop Hypertension (high blood pressure). The diet is
simple:

A. Eat more fruits, vegetables, and low-fat dairy foods

B. Cut back on foods that are high in saturated fat, cholesterol, and trans fats
C. Eat more whole-grain foods, fish, poultry, and nuts
D. Limit sodium, sweets, sugary drinks, and red meats
E. In research studies, people who were on the DASH diet lowered their blood pressure
within 2 weeks.

Another diet -- DASH-Sodium -- calls for cutting back sodium to 1,500 milligrams a day
(about 2/3 teaspoon). Studies of people on the DASH-Sodium plan lowered their blood
pressure as well.

DASH DIET TIPS:

1. Add a serving of vegetables at lunch and at dinner.

2. Add a serving of fruit to your meals or as a snack. Canned and dried fruits are easy to
use, but check that they don't have added sugar.
3. Use only half your typical serving of butter, margarine, or salad dressing, and use
low-fat or fat-free condiments.
4. Drink low-fat or skim dairy products any time you would normally use full-fat or
cream.
5. Limit meat to 6 ounces a day. Make some meals vegetarian.
6. Add more vegetables and dry beans to your diet.
7. Instead of snacking on chips or sweets, eat unsalted pretzels or nuts, raisins, low-fat
and fat-free yogurt, frozen yogurt, unsalted plain popcorn with no butter, and raw
vegetables.
 8. Read food labels to choose products that are lower in sodium.

NURSING MANAGEMENT:

1. Assess patient blood pressure level

2. Assess for take proper medication
3. Assess for blood pressure interventions
4. Assess patient risk for impaired other complication

Nursing assessment

Questioning the patient about the following

1. Family history of high bp

2. Previous episode of bp

3. Dietary habits and salt intake

4. Tobacco use

5. Medication that could elevate bp

A) Hormonal contraceptive, corticosteroids

B) NSAIDS

Physical examination

1. Auscultate heart and heart sound for the presence of an indicated stiffening of the
walls of the left ventricles which may occurs in hypertension

2. Palpate the chest wall for shift of the point of maximum impulse to the left which
occurs in heart enlargement.

3. Auscultate for over the aorta renal arteries and peripheral arteries to determine the
presence of atherosclerosis.

4. Determine about mental status by asking about memory, ability to concentrate.

Diet Plan:

Sample diet plan

MEAL MENU

Early morning :- tea

Breakfast :- Dalia, milk/ tea/coffee/vegetable/ pan cake/staffed/chapati/sprouts

chat/ apple / papaya/ pear/ watermelon.

Lunch :- Two chapati whole moong dal/ any dal perfectly whole dal, rice.

Evening :- Tea/coffee biscuit

Night :- Tomato or vegetables soup

1 chapati, dal, rice, salad.

NURSING DIAGNOSIS:

1) Imbalance nutrition pattern less than body requirements related to inadequate intake

of foods as evidenced by weight loss.

2) Risk for decreased cardiac output related to increased afterload vasoconstriction,

myocardial ischemia, ventricular hypertrophy.

3) Risk for prone behavior related to lack of knowledge about the disease as evidenced

by frequently asking question.

4) fear and anxiety related to increased blood pressure as evidenced by verbalization.

5) knowledge deficit related to disease condition as evidenced by verbalization.

ASSESSM DIAGNO GOAL PLANNI RATIO IMPLEMENTA EVALUT
ENT SIS NG NAL TION ION

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nt on n

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data: diet vitamin rich
I observed foods items
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and rich foods diet fruits.
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ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPL

Subjective data: Risk for To maintain Assess the To get baseline Asses
decreased cardiac blood pressure at general condition data condi
output related to normal level. of client
Patient complaint
increased
about discomfort
afterload To provide
Provide calm, Prov
vasoconstriction, restful relaxation and to restfu
myocardial surroundings, decrease surro
Objective data: ischemia, minimize discomfort. minim
ventricular environmental envir
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client face dull
and tiredness noise.

Maintain To feel physical

activity stressless Main
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To control
Monitor
blood pressure Mon
response to
medications to me
HEALTH EDUCATION

Health education is one of the most important for our health maintenance and

promotion of health. Health education comprises education on diet and

medication exercise, personal hygiene, rest and sleep and follow up are included.

Diet

Advised the client to take high caloric and protein rich diet to fulfil the energy requirement in
the body. And fluid restricted consult dietician for meal planning, low sodium diet.

Medication

Medication is one of the most important factor effects on our health, advice to the patient take
daily medicine on right time and right dose. Instruct about the side effects of medication.

Environmental and Personal hygiene

Personal hygiene is one of the most important factors effect on our health advice patient to
maintain surrounding hygiene to reduce the rate of mosquito around and as well as to
maintain self-hygiene and self-care.

Exercise

Exercise is one of the most important factors effect on our health advice to the patient to daily
exercise in the morning such as walking around etc. and exercise decreases the cholesterol,
fat intake and changing other risk factors such as smoking, obesity and stress to reduce the
severe complication.

Rest and sleep

To advice the client to take rest and sleep at least 7 to 8 hours.

Follow up

Follow up is one of the most important, as it has great impact on our health advised client to
come for follow up regularly.
CONCLUSION:

Hypertension is a very important disorder in aged people and is associated with higher risk of
cardiovascular morbidity and mortality. The fact of reducing blood pressure values decreases
the risk for cardiac death as well as neurological, metabolic, and musculoskeletal system
sequelae in aged people. primary prevention of hypertension should be highlighted and it
should get more priority than it is getting Now.

SUMMARY:

I have visited the family of Mrs Indubai Ganesh Chaudhari during rural posting at mothi anji
wardha. I did the family case study on Hypertension and gave all the necessary information
about its causes, pathophysiology, management, diet and prevention and health education.
BIBLIOGRAPHY:

Book:

1. K.park “Textbook of Prevention of Social Medicine” 23rd edition

2. Kamalan “Essential of Community Health Nursing” 1st edition
3. Brunner and suddharth “Ttextbook of Medical Surgical Nursing” 11th eition
4. Ross and Wilson “ Textbook of Anotomy and Physiology” 9th edition
5. Lippincott “Textbook of Medical Surgical Nursing” 9th edition

Internet:

1. https://www.webmd.com/hypertension-high-blood-pressure/guide/dash-diet
2. https://www.slideshare.net/ratheeshkrishnakripa/hypertension Internet:
3. http://www.everydayhealth.com
4. https://www.webmd.com
journal abstract:

Dr. (Mrs.) Monika s. Dharwad, Raipur, Mr. p. Balakrishnan principal, RITEE college of
nursing, Raipur, Chhattisgarh international journals of nursing education and research
volume 5, issue-4, October- December 2017