Vous êtes sur la page 1sur 14

MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Metropolitan Park, Pasay City

NURSING PROCESS

Hypertension
Clinical Instructor

Mr. Enriquez Mina RN, MAN

Group 35

Martinez, Marty Nathaniel

Galizdo, Christafei E.
Fabula, Jean Bernadette B.

BSN IV - A9

I. ASSESSMENT

A. General Data

Patient’s Initial: M. T. Q. Informant: M. T. Q. (Primary)


Address: Las Piñas City Date of Admission: N/A
Age: 75 years old Order of Admission: N/A
Sex: Female No. of days in the hospital: N/A
Date of Birth: August 6, 1935
Civil Status: Widowed
Occupation: Sewer
B. Chief Complaints

“Ang sakit ng batok ko at nahihilo ako.” as verbalized by the patient.

C. History of Present Illness:

2 years ago the client experienced chest pain whenever she drinks coffee and felt
more agitated. She drank aspilet to lessen the pain she felt on her chest. She was
advised by her physician to have her ECG and it was done in Las pinas Hospital and
it was interpreted by the health center physician and was diagnosed by the health
center physician that she has hypertension. She was prescribed with Neoblock but
then she requested her physician to change it too much cheaper drug and Metoprolol
is what they gave her. This was her maintenance drug. She self-medicates herself by
drinking aspirin with metoprolol when she feels pain on pain on her chest.

D. Past History

1. Childhood Illnesses: Mumps, Chicken pox and Measles


2. Adult Illness:
3. Immunization (date): Complete but cannot recall the dates
4. Previous Hospitalization (date): none
5. Operations/s: None
6. Injuries: None
7. Medications taken prior to confinement (6months):
METOPROLOL OD 100 mg
ASPIRIN OD 80 mg
8. Allergies: None

E. Systems Review August 4, 2010 1030H

1. Health Perception – Health Management

She perceived health as important thing in her life. She stated that “ok naman
kalusaugan ko kasi wala naman akong nararamdaman na masakit o kakaiba ngyon. It
Whenever she feels headache she doesn’t drink medicine right away however she put
some leaves of oregano on her head to relieve her from pain and if it doesn’t lessen
the pain she would drink Paracetamol for headache. Also, whenever she or one of her
family member got cough she would boil oregano leaves then she would squeeze the
juice in the leaf then drink at least one tablespoon of it. Then when she has fever she
would do sponge bath and put cotton with alcohol under her arms. She is not fond of
drinking meds unless needed. She go to check up whenever she feels anything
unusual to her. She also self medicate herself by drinking Aspilet whenever she feels
pain on her cheast.

2. Nutritional Metabolic Pattern

The client usually eats vegetables, fish, chicken or sometimes meat at least once a
week. She doesn’t have any allergies. She feels she has weight loss although she
hasn’t checked it yet in the health center. She disciplines herself by not eating fatty
and salty foods. She only eats ½ cup of rice every meal. She stated that “dati 1-2 cups
of rice nakakain ko ngayon ½ cup na lang”. She also avoids eating of sweets. She has
good appetite but she just discipline herself to the foods she know would cause her to
get sick. She drinks about 4-5 glasses a day. Whenever she has wound it get easily
healed and she treat it with agua oxinada and betadine. She wears dentures.

3. Elimination Pattern

The client defecates daily. She described it as semi-formed brown stool. She
doesn’t have any difficulties when she defecates. She urinates 3- 4 times a day
depending on how much water she drinks. She described her urine as yellow. She also
added that she doesn’t have hemorrhoids even if her family has a positive history on
hemorrhoids.

4. Activity and Exercise Pattern

The client does exercise every Saturday morning with her church mates.
Dance or aerobic is the type of exercise she does. When she is at home she usually
watch television, sings, go to church every Wednesday in Baclaran and does
household chores. She has enough energy to do things in her daily life.

5. Cognitive – Perceptual Pattern

sn’t have any problem in her hearing. She has eyeglasses with grade of 450 on
both eyes. Her last check up was year 2009. She has cataract at her left eye. She
hasn’t consulted a doctor for her cataract. The easiest way for her to learn is through
visual. Whenever she has problem she consult God and usually pray. She decides for
her family. She doesn’t have any changes on her memory.

6. Sleep—Rest Pattern
7.
The client generally rested and has energy to do his work and other things.
She sleeps at 8 PM and wakes up at around 4 in the morning. She gets 8 hours of
sleep a day. She usually lies on her back or on her right side. She does not have
difficulty in sleeping. She always takes nap whenever she is free and usually it is at
the afternoon. She does not use any sleeping aids nor does she have nightmares.

8. Self – Perception

The client feels good about herself and confident in herself she does some part
of the household chores and takes care of her two grandchild and she is an active
member of the church and she does not give up whenever she encounters a problem

9. Role – Relationship

The client had a good relationship with grandchild except to her children
because they never help her in raising her grandchild nor help her in everyday
expenses. She have a good relationship with her neighbors.
10. Sexuality – Reproductive Pattern

The client had menarche at the age of 11 and had menopause at the age of 50
years old and she had a good relationship to the opposite sex

11. Coping/Stress Tolerance

The Client always get angry whenever her grand child goes home late and
whenever she has problems she either talk it with her grand child or to God. She does
not smoke nor drink just to forget her problems

12. Values—Belief Pattern

The client is a roman catholic she is active member in the of the church and
goes to mass every sunday and always shares her problem to God.

F. Family Assessment

Name Relation Age Se Occupation Educational


x Attainment
M.T.Q. Informant 75 years old F Sewer HS graduate
M.S. Granddaughter 21years old F Employee College Graduate
G.T. Granddughter 13 years old F N/A HS level

G. Heredo – Familial Illness


Maternal: Hypertension
Peternal: Hypertension and Diabetes Mellitus
H. Developmental History

THEORIST AGE TASK CLIENT DESCRIPTION

Psychosocial 75 Despair The client stated that her children does not suport
ERIK H. her. And she stated about 1 of her daughter leaves
ERIKSON her grandchild and she is the one that support her
until she graduated.

Psychosexual 75 Genital stage


The client had an inimate relationship with her
SIGMUND
husband before he died and they have 5 childrens
FREUD

Cognitive 75 Formal The client could answer all interview questions. She
Oper
JEAN is aware of the consequences of her decisions. The
ationa
PIAGET l client attended high school. She also has no
difficulty learning new things. The client also says
that she easily makes decisions without any
difficulty

Moral 75 Post-
The Patient was able to reach this stage for she
Conv
LAWRENCE
ention
knows how to follow the rules and regulations of her
KOHBERG al
Level
society but in spite of that there are things that
(Socia
l sometimes she wishes to be changed for she believes
Contr
act that there is more from it that the society really
Reori
entati needs.
on)

Universalizin
Spiritual 75 The patient states that she is Christian and attends
g
JAMES church every Sunday. And always shares her
FOWLER problem to god.
I. Physical Examination

Date: August 04, 2010


Time: 1100H

Height: 5’0 ft Weight: 110 lbs.\


BMI: 21.5 IBW: 100 lbs
Vital Signs:

Temperature: 36.6 C
Pulse Rate: 65 bpm
Respiratory Rate: 18 cpm
Blood Pressure: 140/90 mmHg

Regional Examination:

Appearance and mental status

I: -Height: 5’0 ft
-Weight: 110 lbs.
-Relaxed
-Clean and neat
-No body odor
-Cooperative and alert
-Able to follow instructions
-Understandable

Skin

I: -Skin color varies from light to deep brown


-Generally uniform in skin color
-Skin has wrinkles
-Skin is dry

P: -Warm to touch, uniform temperature


- Decrease in elasticity of skin turgor

Nails

I: -Convex curvature
-Smooth texture
-Pinkish nail beds and intact epidermis.
P: -Blanch test of capillary refill (3 seconds)
-No clubbing.

Head and Face

I: -Hair is thick and dry; black in color but has white hairs too.
-No infestations,
-Evenly distributed hair
-Head is rounded (normocephalic)
-Symmetric facial features and movements.
P: -No presence of nodules or masses.

Eyes

I: -Eyebrows symmetrically aligned


-Equal movement, hair evenly distributed.
-Iris is dark brown.
-Coordinated eye movements.
-Pink conjunctiva
-has cataract on Left eye
-wears eyeglass with grade of 400/450.

Ears

I: -Auricles are level with each other


-Ears are aligned with the outer eye canthus
-Uniform in color
-No discharge
P: -Ears are firm and no tenderness.
-Pinna recoils after it is folded.

Nose

I: -Nose is symmetric and straight


-No discharge or flaring
-Uniform in color, no lesions.

Mouth and Pharynx

I: -soft pinkish lips, uniform in color


-Symmetric lips
-Has Dentures
-Pink gums and moist
-Tongue is in central position, pink in color, no lesions and moist.
-Moves freely
-Uvula is positioned in midline of soft palate
-Gag reflex is present

Neck

I: -Able to move head without pain or discomfort


-Muscles equal in size; head centered

Spine

I: -Spine is vertically aligned

Thorax and Lungs

I: -Client’s chest is symmetrical


P: -symmetric and full in chest expansion
A: -No presence of bilateral crackle sounds

Cardiovascular/Heart
I: No noticeable pulsations
P: symmetrical pulse

Breast (client described)

I: - Breasts even with the chest wall


-Skin is uniform

Abdomen

I: -Uniform in color

Extremities

I: -loose or flabby muscles


-decreased muscle strength
-Absence of involuntary trembling
-Presence of varicosities in lower extremeties

P: -No tenderness

Genitals Client refused

Rectum and Anus Client refused

Neurological Exam
- Answers logically and coherent
- Understands Filipino
- Oriented to time, place and people

II. PERSONAL / SOCIAL HISTORY

Habits: Watching television, Sewing clothes, cooking, sleeping


Rank in the Family: Head in the family
Vices: None
Lifestyle: Active
Travel: None
Social Affiliation: Senior Citizen Organization and “Apostolada”
Educational Attainment: Highschool Graduate
Client’s usual day like:
o 4:00am - The client wakes up
o 5:00am – Boil water and prepare breakfast
o 6:00am – Pray to God
o 7:00am – Eat breakfast with grand daughters
o 8:00am – wash clothes
o 10:30am –do household chores
o 11:00am – Cook for lunch
o 12:00pm – Eat lunch
o 1:30 pm – Sleep
o 3:30 pm – Watch TV
o 5:00 pm – Eat snack
o 6:00pm – Cook for dinner
o 7:30 pm – Eats dinner
o 8:00 pm - Sleep
III. ENVIRONMENTAL HISTORY

The client lives at Las Piñas City since 1960; they rent the lot for P263/month.
They are the one who built the house.”Ang tagal na nga namin dito e, simula 1960 pa,
Umuupa lang kami dito.”as verbalized by the client. She lives with her two
granddaughters. According to the patient, there is presence of vectors in their house,
but they use insecticides to kill the vectors. “Madaming ipis at daga dito, pero
bumibili naman kami ng pampatay”as verbalized by the client. There are few trees in
their area. “wala masyadong puno ditto, kasi puro bahay” as verbalized by the client.
Their water comes from NAWASA, and their electricity from MERALCO. The
garbage is collected everyday via Garbage truck.When it comes to their
neighborhood, client verfbalize “Mababait naman yung mga kapit bahay naming”.
The client has a lot of friends in their place.

IV. OB/GYNE
Menarch (age): 11 years old LMP: 50 years old
When: Client cannot recall
Amount and Characteristics: On menopausal period
Duration: N/A
Associated symptoms: N/A

Deliveries: G –5 P -5 Operations: None


OB Score: T- 5 P- 0 A- 0 L- 5

V. PEDIATRIC HISTORY
N/A

VI. PATHOPHYSIOLOGY

.
DRUGS INDICATION ACTION SIDE NURSING PATIENT TEACHING
EFFECTS/ADVERSE CONSIDERATION
REACTION
Date Ordered: Aspirin is indicated to Relieves pain and Dizziness, tinnitus, • identify prior drug • instruct patient not to exceed
Generic Name: prevent heart attacks in reduces inflammation nausea, dyspepsia, heart history; there are recommended dosage,
Aspirin people who have had a by inhibition of burn, increased bleeding, many drug because of the danger of
Brand Name: heart attack in the past or peripheral rashes and anaphylactic interactions acute poisoning
Classification: who have angina prostaglandin shock. • assess for allergic • advise patient of the possible
anti-platelet synthesis. It also reactions: rash, allergic reactions
Dosage: 80mg PO inhibits the synthesis urticaria • tell patient to report tinnitus,
Frequency: 1 tab or action of other • assess for ototoxicity: confusion, diarrhea, sweating
OD mediators of tinnitus, rining, hyperventilation, visual
inflammation. It acts roaring in ears; changes and bleeding
on the hypothalamic audiometric
heat-regulating center evaluation is needed
to relieve fever, by before and after long
promoting sweating term therapy
and vasodilation, • assess for visual
leading to heat loss changes: blurring,
and cooling by halos; corneal, retinal
evaporation. Also damage
decreases platelet
aggregation by
preventing formation
of thromboxane A,
platelet aggregating
substance
DRUGS INDICATION ACTION SIDE NURSING PATIENT TEACHING
EFFECTS/ADVERSE CONSIDERATION
REACTION
Generic It is also Metoprolol Bradycardia, hypotension, • Monitor blood pressure, • Instruct patient to take metoprolol as
Name: indicated for selectively arterial insufficiency, chest ECG and pulse frequently directed at the same time each day, even
metoprolol treatment of inhibits β- pain, CHF, oedema, during dosage adjustment if feeling well; do not skip or double up
Brand Name: hypertension. adrenergic palpitation, syncope, period and periodically on missed doses. Take missed doses as
Classification: receptors but gangrene; dizziness, throughout therapy. soon as possible up to 8 hr before next
Beta-blockers has little or no fatigue, depression, • Monitor intake and output dose. Abrupt withdrawal may cause life-
Dosage: 100 effect on β2- confusion, headache, ratios and daily weights. threatening arrhythmias, hypertension, or
mg PO receptors insomnia, short-term Assess routinely for CHF myocardial ischemia.
Frequency: 1 except in high memory loss, nightmares, (dyspnea, rales/crackles, • Teach patient and family how to check
tab doses. It has somnolence; pruritus, rash, weight gain, peripheral pulse and high blood pressure. Instruct
no membrane- increased psoriasis, edema, jugular venous them to check pulse daily and blood
stabilising nor reversible alopecia; sexual distention). pressure biweekly and to report
intrinsic dysfunction/impotence, • Monitor frequency of significant changes.
sympathomim Peyronie's disease; prescription refills to • May cause drowsiness or dizziness.
etic activity. diarrhoea, constipation, determine adherence. Caution patients to avoid driving or other
flatulence, GI pain, activities that require alertness until
heartburn, nausea, response to drug is known.
xerostomia; • Advise patients to change positions
agranulocytosis (rare); slowly to minimize orthostatic
musculoskeletal pain; hypotension.
blurred vision, dry eyes, • Advise patient to notify health care
tinnitus; dyspnoea, professional if slow pulse, difficulty
bronchospasm, wheezing, breathing, wheezing, cold hands and feet,
rhinitis; cold extremities. dizziness, light-headedness, confusion,
depression, rash, fever, sore throat,
unusual bleeding, or bruising.
VII. LIST OF PRIORITY PROBLEM

1. Acute pain related to elevated blood pressure as evidenced by nape pain


2. Knowledge deficit related to lack of exposure as manifested by inappropriate
behavior, asking of questions lack of information
3. Ineffective family coping related to unable to perceive or to act effectively with
regards to patient’s needs.

VIII. NURSING CARE PLAN

IX. DISCHARGE PLAN

Medication:
Continue to comply with doctor’s order at health center, read and take the prescribed home
medications and daily supplements.

Exercise:
The patient was advised to do simple exercise and was encouraged to rest and do some
relaxation techniques

Treatment:
Inform patient that she must take her medication every day and come to the health center for
BP check up every day

Health education:
The client will be told that exercise program must be accomplished. Her medications must be
taken as directed and on time. She must have an adequate rest and sleep.

OPD follow-up:
the patient to have a follow-up check up after 1-2 weeks at the health center.

Diet:
The client must have diet of low salt low fat.

Signs and symptoms:


Report immediately to the doctor if these signs and symptoms persist:

Vous aimerez peut-être aussi