Question

Mr. Cowen calls his primary HCP to schedule an appointment. Before the appointment, Mr. Cowen goes to a local laboratory and has a series of blood tests drawn as prescribed by the HCP.  

At his appointment with the HCP, the nurse weighs Mr. Cowen.  He is 5 feet 9 inches tall and weighs 225 pounds.  Mr. Cowen's BP is 166/92 mm Hg with a large cuff in the right arm and 168/96 mm Hg in the left arm.  His heart rate is 84 beats per minute with a  regular rhythm, respiratory rate is 18, and he is afebrile.  His total cholesterol is 260 mg/dL.  During the health history assessment, the HCP learns that Mr. Cowen drinks at least four to six ounces of regular coffee per day and that his father has coronary artery disease and Hypertension.  Mr. Cowen denies feeling stress because of his job, relationship with his wife and family, or other factors. "I am a pretty laid back guy.  I am not worked up or excited about much.  I leave that worrying to my wife."  The HCP notes that Mr. Cowen carries the majority of his weight in his upper body.  He has an increased amount of subcutaneous fat around his waist and his abdomen.

The HCP prescribes Hydrochlorothiazide (HCTZ) daily for the client and askes the nurse to provide Mr. and Mrs. Cowen with instructions regarding the education and lifestyle modifications.  A follow-up appointment is scheduled for one month.

Questions

1. Briefly explain what the systolic and diastolic BP readings indicate?

2. According to the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), what is the definition of prehypertension, stage 1 HTN, and stage 2 HTN? Describe primary and secondary HTN.  Based on Mr. Cowen's clinical manifestations and history, how would you classify his HTN, and does he have primary or secondary HTN?

3. Generate at least 5 questions the nurse should ask the client to assess for the possible symptoms of HTN.

4. Identify Mr. Cowen's risk factors for HTN.  Indicate which of the client's risk factors are nonmodifiable and which are modifiable.

5. Mr. Cowen asks the nurse, "Is my cholesterol that bad? What should my numbers be?" How should the nurse respond?

6.  The HCP prescribes Hydrochlorothiazide for Mr. Cowen. Discuss the benefits of monotherapy with Hydrochlorothiazide to treat the client's HTN.

7. The nurse is providing Mr. Cowen with instructions regarding his newly prescribed HCTZ.  What are the most common adverse effects of HCTZ that Mr. Cowen should monitor and what should Mr. Cowen do if he forgets to take his daily dose of medication as prescribed?

8. The nurse warns Mr. Cowen not to discontinue the medication abruptly. Briefly explain why the nurse offers this precaution?

9. The nurse is providing Mr. and Mrs. Cowen with instructions regarding lifestyle modifications to help reduce the client's HTN.  Identify at least 2 points of discussion the nurse will include in the teaching plan?

10.  In priority order, identify 5 nursing diagnoses the nurse will include in the teaching plan?

11. One month later, Mr. Cowen returns for a follow-up appointment with his HCP.  His BP is 138/82.  The nurse congratulates Mr. Cowen on his success and asks him about his compliance with the DASH diet.  He states, "I don't like it but I am following it as you said. My wife has been keeping a close eye on me and everything that I eat.  She walks with me every night to give me the push I need to exercise."  To confirm his compliance with the DASH diet, the nurse asks him to recall his last 3 meals and any snacks.  Which meal or snack is least compliant with the DASH diet and what alternative(s) can the nurse suggest?

Breakfast: a bowl of whole-grain cereal with  low-fat milk, a banana, and a glass of orange juice

Lunch: roast beef sandwich on white bread with mayonnaise and a soft drink

Dinner: fish, cooked vegetables, brown rice, and a glass of low-fat milk

Snack: a toasted slice of bread with grape jelly

Answer 1

QUESTION: BRIEFLY EXPLAIN WHAT THE SYSTOLIC AND THE DIASTOLIC BP READINGS INDICATE.

• BP READINGS IN THE RIGHT ARM: 166/92 mm Hg; LEFT ARM : 168/96 mm Hg.
• SYSTOLIC BP REFERS TO THE FIRST NUMBER (166 AND 168) WHICH REFLECTS THE ARTERIAL PRESSURE WITH EACH CONTRACTION OF THE HEART MUSCLE.
• DIASTOLIC BP REFERS TO THE SECOND NUMBER (92 AND 96) WHICH REFLECTS THE PRESSURE IN THE HEART MUSCLE IN BETWEEN BEATS.
• THE BLOOD PRESSURE READINGS OF Mr. COWEN INDICATE A CAUSE FOR CONCERN AND REQUIRES ACCURATE MEDICAL ATTENTION AT THE EARLIEST.

QUESTION: According to the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), what is the definition of prehypertension, stage 1 HTN, and stage 2 HTN?Describe primary and secondary HTN.  Based on Mr. Cowen's clinical manifestations and history, how would you classify his HTN, and does he have primary or secondary HTN?

ANSWER: ACCORDING TO JNC 8 :

• PREHYPERTENSION REFERS TO THE BLOOD PRESSURE WHICH HAS 120-139 mm Hg SYSTOLIC BP or 80-89 mm Hg of DIASTOLIC BP.
• STAGE 1 HTN: REFERS TO THE SYSTOLIC BP OF 140-159 mm Hg or DIASTOLIC BP OF 90-99 mm Hg.
• STAGE 2 HTN: REFERS TO THE SYSTOLIC BP OF MORE THAN 160 OR DIASTOLIC BP OF MORE THAN 100 mm Hg.

PRIMARY AND SECONDARY HYPERTENSION:

• PRIMARY HYPERTENSION ALSO KNOWN AS ESSENTIAL HYPERTENSION, THE EXACT ETIOLOGY IS UNKNOWN . MAY HAVE A FAMILY HISTORY.
• SECONDARY HYPERTENSION RESULTS MOSTLY AS A COMPLICATION OF AN UNDERLYING DISEASE LIKE RENAL DISEASES, CONGENITAL HEART ABNORMALITIES, ADRENAL GLAND TUMORS.

Mr. COWEN HAS PRIMARY HYPERTENSION . THE REASONS SUGGESTIVE OF PRIMARY HYPERTENSION IN HIS CASE INCLUDES:

• BLOOD PRESSURE: 166/92 mm Hg AND 168/96 mm Hg. IN THE CASE OF SECONDARY HYPERTENSION BP WOULD BE MORE THAN 180 mmHg SYSTOLIC.
• PRESENCE OF FAMILY HISTORY OF HYPERTENSION: FATHER IS HYPERTENSIVE.
• NO UNDERLYING DISEASE CONDITIONS .
• ABSENCE OF ANY ABNORMALITIES IN THE VITALS .
• HIGH CHOLESTEROL LEVEL AND PRESENCE OF SUBCUTANEOUS FAT IN THE WAIST AND ABDOMEN : ENVIRONMENTAL FACTORS LIKE LIFESTYLE .

-------------------------------------------------------------------------------------------------------------------------------------------------