Question

1. Joan Smith, 55 years of age, is a female patient who presents to the intensive care unit with the diagnosis of intracranial hemorrhage. The patient stopped taking her antihypertensives suddenly because of the cost of the medications and she recently lost her job to outsourcing. The patient is slightly drowsy and complains of a headache and blurred vision. The patient’s blood pressure is 220/130 mm Hg upon presentation.

1. According to the definitions set by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), which type of hypertensive crisis is the patient currently experiencing?

2. Describe the treatment goals for handling the hypertensive crisis and apply the goals to the case study. Determine the current mean arterial pressure (MAP) and the goals for treatment.

The physician orders nicardipine hydrochloride (Cardene) 25 mg/250 mL, NS for peripheral IV starting at 2.5 mg/hr, and titrate by 2.5 mg/hr every 15 minutes to reach the goal for the first hour, which is to achieve 25% reduction of the initial MAP.

• Call the physician if the dosing range of 15 mg/hr has been reached and the MAP is still not at target goal for the first hour of treatment, or up to four dose increases.

• Lower the BP within 6 hours to 160/100 mm Hg.

• Adjust the IV rate so that the IV fluids plus the nicardipine IV drip are equal to 100 mL/hr, in total. Call the physician if the IV fluids must go above 100 mL/hr to provide the nicardipine.

c. Explain what rate to set initially for both the nicardipine drip and the NS maintenance fluids.

d. Explain the process of titrating the nicardipine drip for the first hour to achieve the final MAP goal of 25% reduction of the original MAP.

Answer 1

Q. No. a. Answer :

According to seventh report of the joint national committee on prevention, detection and evaluation, treatment of high blood pressure, the patient is currently experiencing " stage II hypertension " because according to JNC 7 classification the blood pressure more than or equal to 160 systolic pressure and more than or equal to 100 diastolic blood pressure we can consider as second stage hypertension.

Q. No. b. Answer :

Treatment goals for handling the hypertensive crisis :

* main goal is to reduce the mean arterial blood pressure to 20 - 25% with in few minutes to hours.

* current mean arterial blood pressure is calculated formula is

Systolic blood pressure plus diastolic blood pressure multiplied with 2 and devided by 3.

Here 220 is systolic pressure and

130 mm of hg. Is diastolic blood pressure.

So MAP is 220 + 2×130 / 3

220 + 260 / 3

480 / 3 = 160

So current MAP is 160 mm of hg.

Normally the mean arterial blood pressure inbetween 65 - 110 mm of hg.

Goals for treatment :

* to reduce MAP by medications administration with in the minutes to two hours that is 25 %.

* to maintain normal mean arterial blood pressure.

Q. No. c. Answer :

IV fluids 100 ml per hour means we need to set drip, 10 mg of nicardipine, because nicardipine is 25 mg per 250 ml.

So that 10 mg = 100 ml.

So we need to start 100 ml per hour that means 10 mg nicardipine, after that the dose can be treate up to coming of 15 mg,

Then call for physician.

Q. No. d. Answer :

From 10 ml we need to titrate 2.5 mg per hour means, 40 ml per hour we need to titrate by combination of intravenous fluids and nicardipine drug to reduce or achieve final goal of 25 % original MAP.