Question

Hypertensive Emergency

You are the nurse working in the Emergency Department, assigned to triage. A 67 year old patient comes to see you and c/o a severe headache. Patient’s initial BP was 220/105. Patient has a longstanding history of hypertension and was recently seen in outpatient internal medicine clinic for workup for secondary causes of hypertension.

Past Medical History:

1. IDDM
2. Hyperlipidemia
3. GERD
4. Peripheral Vascular Disease
5. CHF with EF of 50%
6. Asthma
7. HTN

Social History:

Lives with sister, took early retirement, spends most of the day outdoors

gardening and chores around the house. Never been married, no kids.

Medications:

• Humulin R- Sliding scale
• Lispro 30u BID
• Digoxin 0.25mg PO daily
• Lipitor 40mg PO daily
• Pantoloc 40mg BID
• HCTZ 25mg PO daily
• Norvasc 5mg PO daily
• Ventolin 2 puffs PRN (with asthma symptoms)
• Coumadin 2mg PO daily

Initial Parameters:

Patient: Responsive, awake, alert, but complaining of a severe headache

Vitals: BP 240/120, HR 95, RR 18, O2 sat 96% on RA, Temp 36.8 C

Eyes: Open, pupils reactive

Lungs: Clear on inspiration, expiratory wheezes

Heart Sounds: Normal

Heart Rhythm: 1^st Degree AV block

Abdomen: Flat, soft, non-tender

Labs: Bloodwork (K-2.9, Fasting Glucose- 6.2, INR 2.1)

CXR: Normal

ECG: 1st Degree AV block

questions to be answered:

1.Provide the Pathophysiology of the Diagnosis as it pertain in case study?

2.Review the "past medical History" ,give a brief overview of what other risk factors could have significance to the current critical situation presented?

3.Is the client in homeostasis? if not explain why?

4.Identyify which medications client is on that are important for cardiac health?

5.Facilitate at least 4 questions that would be pertinent to ask this patient right now?

6.What are nursing considerations?(consider both current event and previous medical history)?

7.Based on case study and finding.Provide client 5 health teaching tips that could change their health for better?

i gave all the information.. its a case scenario for patient.. and atvthe bottom is question what i need answer for.. that is 1..2...3sonon.

Answer 1

1.   First degree AV block

It is the dysfunction of the AV node resulting from varying degrees of heart block ranging from simple prolongation of the PR interval

  

Electrophysiological studies have shown that PR interval prolongation could be due to conduction delay located at the atrioventricular node, right atrium, or the His Purkinje system. However, the most commonly affected place is the AV node. Morphology and size of the QRS complex reflect that the His Purkinje system is the site of conduction delay. The presence of first-degree AV block on ECG represents prolonged conduction in the AV node, commonly due to increased vagal tone in younger patients and fibrosis of the conduction system in older patients.[7]

Even though conduction slows, every impulse originated from the atrium is passed to the ventricles. The conduction delay may also be due to dysfunction in the atria, at the bundle of His, or in the Purkinje system. Delayed conduction in these areas is more often due to underlying heart disease and more frequently progresses to higher degree AV blockade. Patients with conduction abnormalities originating in the His or Purkinje systems are more likely to have prolonged QRS intervals as well as the prolonged PR interval of first-degree AV block. Prolonged conduction is well-tolerated, especially when the PR interval remains shorter than 0.30 seconds. As the PR interval extends beyond 0.30 seconds, synchrony of atrial and ventricular systole worsens, potentially resulting in poor ventricular preload and symptoms of the “pacemaker syndrome,” further characterized below.[8] Poor ventricular filling due to prolonged PR intervals may also result in mitral regurgitation, which exacerbates conditions such as heart failure.

2. By reviewing the past medical history folllowing risk factors may present

* Congestive heart failure is evident as the prolongation of AV node over a consistent period of time may cause further cardiac complications

* Hyperlipidemia may progresses to fatal complications like Atherosclrosis,Myocardial Infartion,Stroke and Peripheral artery disease

* IDDM causes Diabetic Nephropathy also a serious condition in Type 1 Diabetics

*Secondary Hypertension occurs as a result causes Coarctation of Aorta, Obesity etc,.

3. The client is not in Homeostasis as because basicallly he`s been affected by hypertension.Hupertensive patients tends to be not in homeostasis as their blood pressure and osmotic gradients are altered and aslo they may be edmatous due to alterations in the pressure gradient.

4. Prophylactic antiarrhythmic drug therapy is recommended.

  Digoxin is most importantly required for client`s cardiac health.

5. Have you been taken your medications properly?

What`s your diet and physical activity regimen be like?

were you rushing to get here or physically active right before this appointment?

6. Following were the nursing considerations

• Increasing Age. The majority of people who die of coronary heart disease are 65 or older. ...
• Male gender. ...
• Heredity (including race) ...
• Tobacco smoke. ...
• High blood cholesterol. ...
• High blood pressure. ...
• Physical inactivity. ...
• Obesity and being overweight.

7. Eat Right

Healthy food habits can help you reduce three of the major risk factors for heart attack: high cholesterol, high blood pressure and excess body weight. The best way to help lower your blood cholesterol level is to eat less saturated fat, avoid cholesterol and control your weight. Here are some other nutrition tips:

• Eat a variety of fruits, vegetables and grain products, especially whole grains.
• Consume fat-free and low-fat dairy products, fish, beans, skinless poultry and lean meats.
• Limit foods high in saturated fat, trans fat and cholesterol.
• Eat less than 6 grams of salt a day.
• Have no more than one alcoholic drink (no more than 1/2 ounce of pure alcohol) per day if you're a woman and no more than two drinks if you're a man.

Be right

Physical activity is good for your entire body, especially your heart. While getting into a regular exercise routine is great, there are a number of quick ways to easily add more physical activity into your days:

• Take the stairs Get in the habit of taking the stairs instead of the elevator. If you are going to a high floor, take the elevator part of the way – either walk up a few flights and then catch the elevator, or get off early and walk the rest of the way.
• Go for a walk Even a short walk around the block or through your office can help get your heart rate up and invigorate your body.
• Clean the house Vacuuming, dusting and even doing laundry gets you up and moving around.
• Garden Raking leaves, mowing the lawn and pruning plants all get you outside and active.
• Shop When running errands or going to the mall, park farther away and walk the extra distance. Wear your walking shoes and take an extra lap or two around the mall.
• Talk on the phone Stand up while talking on the phone or, better yet, walk around when using a cordless or cellular phone.
• Play Play and recreation are important for good health. Look for opportunities to be active and have fun at the same time.