Section B Presents

Case Study of a Client Diagnosed with Hypertensive Atherosclerotic Cardiovascular Disease (HASCVD)
GRAND CASE PRESENTATION BS NURSING III SECTION B SECOND SEMESTER AY 2009-2010 MARCH 11, 2010: THURSDAY Submitted to: Ms. MARILOU GENODIA, R.N. Ms. GLENDA NAGALLO, R.N. ADVISERS

Hypertensive Atherosclerotic Cardiovascular Disease (HASCVD) is an arterial disease characterized by narrowing of the arteries by atherosclerosis (plaque formation) that obstruct (stenosis) or narrow (sclerosis) necessary blood flow to a specific part of the heart accompanied with increased blood pressure.

HASCVD is a medical way of saying "blocked arteries secondary to cholesterol plaques and in the setting of hypertension." It describes a common clinical syndrome, where the walls of coronary (heart) arteries are lined with cholesterol plaques.

Its the progressive hardening of the arteries due to long standing hypertension. In this case cardiovascular arteries are hardened, compromising blood flow to the heart muscle and tissue. Complications include Angina Pectoris, MI (Heart Attack) and Heart failure.

Patient C.G., female, aged 55, consulted the Medical Center Muntinlupa (MCM) Emergency Room (ER) last November 25, 2009 with chief complaint of numbness on her left arm coincided with chest pain which she described as radiating from her sternum area towards her xyphoid process.

She roughly estimated it lasting about 10-15 minutes. A week prior to admission, she reported experiencing generalized body weakness and occasional radiating chest pain related to stress and fatigue. She was accompanied by her husband.

She stated that approximately 10 years ago (year 2000) she was first diagnosed of hypertension. When asked about medications she is currently taking, she stated that she takes Neobloc, an anti hypertensive drug belonging to the classification of Calcium channel blockers.

With this, she also claimed no familial history of hypertension or any related cardiovascular disease but she stated a link in the genealogy that manifested diabetes on her paternal side.

When asked about her lifestyle, she openly shared that when she was at her peak age (she approximated it between teens to her late twenties) she lived carefree and was engaging in vices like smoking, drinking and eating foods high in fat and sodium.

By the time morning came, she was so exhausted that shed doze off through the day and listen to music. Realization of her sedentary lifestyle only dawned upon her when she started her family.

Upon initial assessment, patient was 57 inches tall and weighed 106.7 lbs. She is not in distress and is conscious and coherent. Initial vital signs T=36C, PR= 120bpm, RR=20 and BP=150/90 clearly shows presence of hypertension. In relation to this, she was confined to rest and given a dose of Nitroglycerin.

She was also ordered to undergo several diagnostic tests such as: 1. Blood Studies, 2. BUN, Creatinine, 3. Troponin T, 4. Urinalysis, 5. CT Scan, 6. FBS and Cholesterol level. Upon analysis of the data stated, patient was diagnosed with Hypertensive Atherosclerostic Cardiovascular Disease (HASCVD).

A. General Objectives
This study aims to convey familiarity and provide effective nursing care to a patient diagnosed with Hypertensive Atherosclerotic Cardiovascular Disease (HASCVD) through understanding the patient history, disease process and management.

B. Specific Objectives
At the end of the session, the students will be able to: 1. Present a thorough assessment regarding HASCVD, through Nursing Health History, Gordons Functional Health Pattern, Physical Assessment, and the interpretation of the laboratory examinations done on the patient.

2. Discuss the anatomy and physiology of the heart, pathophysiology of the patients condition, usual clinical manifestations and possible complications of the condition. 3. Enumerate the necessary medications needed and be familiar to its mode of action.

4. Formulate a workable nursing care plan on the subjective and objective cues gathered through nursepatient interaction to be able to help the patient towards wellness.

A. Biographical Data
Date: November 28, 2009: Saturday Clinical Area: 3rd Floor Left Wing; MCM Private Room
Name Address Date of Birth Age Sex July 24, 1954 55 years old Female Mrs. C. G.

Civil Status Nationality Religious Preferences Place of Birth

Married Filipino Roman Catholic

Educational Attainment College Graduate Occupation Language Spoken Housewife Tagalog and English

Health Care Financing Medocare (Meralco) Date of Admission November 25, 2009

Diagnosis

Hypertensive Atherosclerotic Cardiovascular Disease (HASCVD)

Admitting Physician

Dr. Yason

B. Chief Complaint
Client experienced numbness on her left arm coincided with chest pain which she described as radiating from her sternum area towards her xyphoid process lasting approximately for about 10-15 minutes which prompted consult.

She also stated that a week prior to admission, she experienced generalized body weakness and occasional radiating chest pain related to stress and fatigue. Vital Signs upon admission are as follows: T = 36.2C PR = 120 bpm BP = 170/100 mmHg RR = 20 cpm

A. History of Present Illness

A week prior to admission, client experienced generalized body weakness and occasional radiating chest pain related to stress and fatigue. A day prior to admission she claimed of same symptoms.

B. Past History
Client was diagnosed about 10 years ago (year 2000) of Hypertension. Client has a childhood illness of allergic rhinitis related to dust that is still presently manifested. Client hadnt encountered any form of accident nor serious injuries at the moment.

 Client was previously hospitalized and undergone Bilateral Tubal Ligation approximately 21 years ago. She was about 34 years old. Client takes multivitamins and calcium channel blockers as maintenance drugs.

C. Family History
Client claimed with familial history of hypertension (maternal side) and she stated a link in the genealogy that manifested diabetes on her paternal side.

ACTIVITIES OF DAILY LIVING (based on Gordon s Functional Health Pattern)

Functional Health Pattern Health Perception Health Management Pattern Prior to Hospitalization She engages in simple exercises such as brisk walking and jogging. She also follows medication regimen. During Hospitalization She was more inclined to bed rest due to easy fatigability but engages in ROM exercises. She eats hospital meals and fruits. She closely listens to the doctors and nurses health advices. She manages her health well since her realization. She now takes a higher regard of health and has become more ware of lifestyle changes significances. Interpretation

Functional Health Pattern Nutritional Metabolic Pattern a. number of meals per day b. appetite c. glass of water per day d. body built e. height and weight y y y y y

Prior to Hospitalization

During Hospitalization

Interpretation

There were no 4 small frequent meals a day (usually s lot of fatty foods)with good appetite 6 - 8 glasses of water a day Pear shaped (BMI=23.15) Height: 57 in Weight: 106.7 lbs. y y y y y 4 small frequent meals a day (meal regulated low sodium and low fat) with good appetite 6 - 8 glasses of water a day Pear shaped (BMI=23.15) Height: 57 in Weight: 106.7 lbs. significant changes in except for a restriction of low sodium and low fat diet.

Functional Health Pattern Elimination Pattern a. frequency of urination b. amount of urine per day c. frequency of bowel movement d. consistency of the feces e. amount defecated per day y y y y y

Prior to Hospitalization

During Hospitalization

Interpretation

There were no 3-5 times per day y Moderate Once a day Formed Moderate y y y y 3-4 times per day significant changes Moderate Once a day Formed Moderate in except for a stricter implementation of low sodium and low fat diet.

Functional Health Pattern

Prior to Hospitalization

During Hospitalization

Interpretation

Activity Exercise Pattern a. exercise b. fatigability c. ADL

y y y

Client is easily Walking Get tired easily Light housekeeping chores

y y y

ROM exercises

fatigued due to

Easy to get tired present disease None condition.

Functional Health Pattern

Prior to Hospitalization

During Hospitalization

Interpretation

Sleep Rest Pattern

Client reported alteration in sleep pattern characterized by insomia episodes

Client still reports alteration in sleep pattern characterized by insomia episodes

Sleep pattern is altered due to present disease condition.

once in while. She once in while. also reported discomfort upon waking up. Though she reported decrease in discomfort upon waking up.

Functional Health Pattern

Prior to Hospitalization

During Hospitalization

Interpretation

Cognitive

No significant

y Oriented to Perceptual Pattern changes. time, place and y Oriented to person a. orientation time, place and y Responds person b. responsiveness appropriately to y Responds verbal and appropriately to physical stimuli verbal and physical stimuli

Functional Health Pattern

Prior to Hospitalization

During Hospitalization

Interpretation

Self-Perception Self-Concept Pattern

Client has high

Client still has high

No significant

regard of self worth. regard of self worth changes. despite of disease process.

Functional Health Pattern Role Relationship Pattern a. as a sister b. as a wife c. a mother and grandmother y y

Prior to Hospitalization With good y relationship with her siblings and provided support whenever needed y With good relationship with husband; performs duties as housewife y With good relationship with sons and daughters as well as with in-laws and grandchildren

During Hospitalization

Interpretation

No significant Still with good changes relationship with her siblings and provided support whenever needed Still with good relationship with husband; performs duties as housewife With good relationship with sons and daughters as well as with in-laws and grandchildren

Functional Health Pattern

Prior to Hospitalization

During Hospitalization

Interpretation

Sexuality Reproductive

Client was gifted with four children and was ligated approximately 21 years ago when she was 34 years old. Due to age, she confessed that sexual contact is rarely done.

Changes were brought about by three main factors:

y y y

Ligation Age Menopause

Functional Health Pattern

Prior to Hospitalization

During Hospitalization

Interpretation

Coping Stress Tolerance Pattern

In spite of challenges, she is enthusiastic This helps in a of overcoming them. She is a strong willed person and her support system (family and friends) has strong foundation. better prognosis of her disease condition.

Value Belief Pattern

She is a devout Catholic and believes that having faith in God will help us get through challenges. She also believes that One should not abuse his/her body

Moral belief have developed and are applied which helps in better prognosis

for it will be ourselves who would reap its of her disease effects later on.. She bases it on her experience. condition.

Date: November 28, 2009: 9:00am Clinical Area: Medical Center Muntinlupa Initial vital signs: T = 36 C CR = 120bpm RR = 20cpm BP = 150/90mmHg

General Appearance
The patient is conscious, coherent and is not in distress. She looks according to age and is calm and engaging. One can see that she is well nourished and practices good hygiene.

Anthropometric Measurements:
Height: 57 inches Weight: 106.7 lbs Chest Circumference: 38 inches Abdominal Circumference: 32 inches

Body Part Assessed Skin

Technique Used Inspection Palpation

Actual Finding

Interpretation

Skin color is fair and even

Normal

Skin is smooth with fair skin Normal turgor

Body Part Assessed

HEENT

Technique Used
Head Inspection

Actual Finding

Interpretation

Normocephalic Normal Evenly distributed hair, no dandruff, Normal lesions nor infection Sinuses non-tender Normal

Palpation

Eyes Inspection

Symmetrical eyelids Pinkish conjuctiva Anicteric sclera Cornea and lens slighty cloudy PERRLA

Normal Normal Normal Signs of Aging Normal

Body Part Assessed

HEENT

Technique Used
Nose Inspection Palpation PERRLA Normoset No discharge Non tender

Actual Finding

Interpretation

Normal Normal Normal Normal Normal

No presence of mass or nodules Symmetrical nasal folds Nasal septum at midline Mucosa is moist, pinkish, intact and no discharge Airways patent on both nares Non tender sinuses

Body Part Assessed

Technique Used
Ears Inspection Palpation

Actual Finding

Interpretation

Normoset No discharge Non tender No presence of mass or nodules

Normal Normal Normal Normal

Nose Inspection

Symmetrical nasal folds Nasal septum at midline Mucosa is moist, pinkish, intact and no discharge Airways patent on both nares

Normal Normal Normal Normal

Palpation Non tender sinuses Normal

Body Part

Technique

Actual Finding

Interpretation

Assessed Used Mouth, Mouth Pharynx and Inspection Neck

Lips pinkish and dry Tongue at midline Gums and mucosa pink Presence of dentures

Normal Normal Normal Aging (decalcification) Normal Normal Normal Normal Normal Normal

Pharynx Inspection Neck Inspection Palpation

Uvula at midline Tonsils not inflamed

Neck symmetrical with full ROM Trachea at midline Lymph nodes non tender Thyroid gland non palpable

Body Part Assessed

Pulmonary

Technique Used
Inspection Palpation Percussion Auscultation

Actual Finding
Symmetric AP:L ratio = 1:2 Symmetrical lung expansion Symmetrical tactile fremitus Resonant Clear lung sounds No adventitious breath sounds

Interpretation
Normal Normal Normal Normal Normal Normal Normal

Body Part

Technique

Actual Finding
Apical pulse at 5th ICS MCL Presence of palpitation

Interpretation
Normal Due to cardiac compensation Normal Normal Normal Normal Normal Normal

Assessed Used Cardiovascular Auscultation

Abdomen

Inspection

Auscultation Percussion

Flat and symmetrical No lesions Normoactive burbogorhythmic sounds (26 on 4 quadrants in 1 full min) Tympanic over LLQ Dull at RUQ, LUQ and RLQ No tenderness

Palpation

Body Part Assessed Extremities

Technique Used Inspection

Actual Finding
Skin smooth Skin intact Nails convex curved Pink nail beds Normal capillary refill Skin cool to touch Bounding pulses Muscles with slight atrophy Fair muscle strength Full active ROM

Interpretation
Normal Normal Normal Normal <3 sec. Decreased perfusion Cardiac compensation Aging process Normal Normal Normal Normal

Palpation

Motor Sensory

Inspection

100% intact 12 cranial nerves responsive

Hypertensive Arteriosclerotic Cardiovascular disease

Atherosclerosis (also known as Arteriosclerotic Vascular Disease or ASVD) is the condition in which an artery wall thickens as the result of a build-up of fatty materials such as cholesterol.

It is a syndrome affecting arterial blood vessels, a chronic inflammatory response in the walls of arteries, in large part due to the accumulation of macrophage white blood cells and promoted by Low density lipoproteins (plasma proteins that carry cholesterol and triglycerides) without adequate removal of fats and cholesterol from the macrophages by functional high density lipoproteins (HDL), (see apoA-1 Milano).

It is commonly referred to as a hardening or furring of the arteries. It is caused by the formation of multiple plaques within the arteries.

CAUSES
Atherosclerosis develops from low-density lipoprotein molecules (LDL) becoming oxidized (ldl-ox) by free radicals, particularly oxygen free (ROS). When oxidized LDL comes in contact with an artery wall, a series of reactions occur to repair the damage to the artery wall caused by oxidized LDL.

The LDL molecule is globular shaped with a hollow care to carry cholesterol throughout the body to generate brain tissues, vitamin D, and soon cholesterol can move in the bloodstream only by being transported by lipoprotein. The body's immune system responds to the damage to the artery wall caused by oxidized LDL by sending specialized white blood cells (macrophages and T-lymphocytes) to absorb the oxidizedLDL forming specialized foam cells.

Atherosclerosis typically begins in early adolescence, and is usually found in most major arteries, yet is asymptomatic and not detected by most diagnostic methods during early stages of life.

PHYSIOLOGIC FACTORS THAT INCREASE RISK

Various anatomic, physiological & behavioral risk factors for atherosclerosis are known. These can be divided into various categories: congenital vs acquired, modifiable or not, classical or non-classical. The points labeled '+' in the following list form the core components of "metabolic syndrome".

Treatment
Some symptoms such as angina pectoris can be treated. Nonpharmaceutical means are usually the first method of treatment, such as cessation of smoking and practicing regular exercise.

If these methods do not work, medicines are usually the next step in treating cardiovascular diseases, and, with improvements, have increasingly become the most effective method over the long term. However, medicines are criticized for their expense, patented control and occasional undesired effects.

HEMATOLOGY (NOVEMBER 25, 2009)

NORMAL VALUE Hemoglobin Erythrocytes vol fr (HCT) (F) Leukocytes Erythrocyte Segmenters Eosinophil Basophil Lymphocyte Monocyte Platelet count Mean corpuscular vol Mean corpuscular hemoglobin Mean corpuscular hemoglobin conc 11.0 15.0 g/L 37 47 vol% 5,000 10,000 3.7 5.0 u/L 50 70 05 01 20 40 07

RESULT 14.9 g/L 46.0 vol% 10,300 5.16 u/L 47 3 1 43 6

INTERPRETATION Leukocyte and Lymphocyte count are slightly elevate due to inflammation process in the arterial lumen. May also indicate infectious problems occurring in other systems. Erythrocyte count is slightly high due to bodys compensation towards hypoxemia.

150, 000 400,000 Adequate 80 90 fL 26 32 mg 32 36% 89 fL 28.8 mg 32.3%

CHEMISTRY (NOVEMBER 25, 2009)

NORMAL VALUE Blood Urea Nitrogen (BUN) Creatinine Sodium (NA) Potassium (K) Hemoglucose (HGT) 3.5 5.3 mmol 80 120 6.0 20.0 mg/dL 0.5 1.7 mg/dL 135 145 mmol

RESULT INTERPRETATION

14.6 mg/dL 1.2 mg/dL 137.8 mmol 4.17 mmol 190

Serum Glucose is high due to ineffective lysis glucose into energy which is indicative of diabetes.

TROPONIN T (NOVEMBER 25, 2009)

NORMAL VALUE

RESULT INTERPRETATION Though having an episode of chest pain, patient has no myocardial infarction.

< 0.03 mg/ml = (-) low risk < 0.03 0.03 0.99 mg/ml = borderline 0.1 2.0 mg/ml = (+) high risk > 2.0 mg/ml = massive myocardial damage mg/ml

URINALYSIS (NOVEMBER 25, 2009)

NORMAL VALUE RESULT PHYSICAL Color Reaction Transparency Specific gravity CHEMICAL Albumin Sugar Amorphous urates Bacteria MICROSCOPIC CELLS Pus RBC Epithelial Light yellow 4.8 6.2 Transparent 1.010 1.025 Trace Negative (-) None to Few None to Few 1. 5/hpf 0-2/hpf Light yellow 6.0 Hazy 1.020 Trace Negative (-) Few Few 10 15/hpf 1/hpf

INTERPRETATION Hazy urine may indicate dehydration or fluid conservation. As a compensatory mechanism for decreased cardiac perfusion, body may retain fluid in attempt to increase circulating blood volume. Presence of pus in the urine is an indication on possible Urinary Tract Infection (UTI).

Few to moderate Moderate

PLAIN CRANIAL COMPUTED TOMOG RAPHY (CT) SCAN (NOVEMBER 25, 2009)

RESULT 1. Hypodense foci are seen in the anterior limb of the right internal capsule, anterior limb of the left external capsule and left periventricular white mater. 2. No midline shift or mass effect. 3. Sulci, sicterns, ventricles are not prominent. 4. Posterior fossa structures are unreachable. 5. The left vertebral artery is sclerotic.

INTERPRETATION The scan reveals that the left vertebral artery has begun narrowing maybe due to plaque formation and inflammatory response. Consequently, blood supply to the brain is compromised that if continued to persist may eventually lead to Cerebrovascular Accident (CVA) or stroke.

TROPONIN T (NOVEMBER 26, 2009)

NORMAL VALUE

RESULT

INTERPRETATION Patient reported no chest pain. Test was ordered to validate first finding. Patient has no myocardial

< 0.03 mg/ml = (-) low risk < 0.03 mg/ml 0.03 0.99 mg/ml = borderline 0.1 2.0 mg/ml = (+) high risk > 2.0 mg/ml = massive myocardial damage

infarction.

CHEMISTRY (NOVEMBER 26, 2009)

NORMAL VALUE Magnesium (Mg) Fasting Blood Sugar (FBS) Blood Urea Nitrogen (BUN) Cholesterol Triglyceride High density lipoproteins (HDL) Low density lipoproteins (LDL) SGPT (ALT) 1.6 3.0 mg/dL 74 109 mg/dL

RESULT

INTERPRETATION

2.0 mg/dL 151.9 mg/dL 8.4 mg/dL

Serum fasting blood sugar is high which confirms the first finding of a possibility of diabetes. Increased Blood Urea Nitrogen (BUN) indicates

207.5 mg/dL 2.4 5.7 mg/dL 185 mg/dL

decreased perfusion on kidneys.

0 220 mg/dL 43.3 mg/dL 40 190 mg/dL 30 75 mg/dL < 130 mg/dL 0 47 u/L. 127.2 mg/dL 24 u/L

CARDIAC DIAGNOSTIC TEST ELECTROCARDIOGRAM (ECG) RESULT (NOVEMBER 25, 2009)

DIMENSION

NORMAL VALUE

RESULT

FUNCTION

NORMAL VALUE

RESULT

(ed) (es) RV (ed) LA (es) RA (es) Aorta PA IVS (ed) IIS (es) LVPW (ed) LVPW (es) MV ANNU

4.5 5.0 2.2 3.5 3.0 3.5 3.5 3.5 3 (0.8 1.1) (0.8 1.1)

4.2 3.0 3.1 3.1 3.1 2.9

LVEPV LVESV Stroke Volume (SV) Cardiac Output (CO) (< OOD) EF% 1 1.7 FS% (55 77%) (28 92% 0 (0.8 1.1) (< 195) 44 ml 2 L/min 55% 28%

2.5 1.1 VSF 1.3 EPSS 1.1 Wall Stress 1.3 Wall Stress LVWMSI LVTD

ELECTROCAR RESULT DIOGRAM Rate Rhythm Axis P Wave T wave QRS Complex ST Segment Others 60s Sinus 0.04 0.20 0.12

INTERPRETATION

Electrocardiogram results show that values are within the normal limits though there are changes in the Q, T and ST segment. This indicates dysrhythmia and is significant in determining ventricular enlargement (Left Ventricular Hypertrophy). It is also indicative of a conduction abnormality, may be mechanical, which explains S3 sound upon auscultation or chemical, electrolyte abnormalities (none). No drug toxicity has been detected.

IMPRESSION: SINUS TACHYCARDIA

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Glimipiride (Amaryl)

Anti diabetes Glucagon

2mg OD

PO

Lowers blood glucose level. Stimulates release of insulin from functioning pancreatic beta cells and lead to increased sensitivity of peripheral tissues to insulin.

Adjunct to 1. Advise diet and patient to take it with exercise to first main lower meal of glucose the day. level (DM 2. Teach type 2) patient to whose carry hyperglyce candy or mia cant be simple managed sugars to by diet and treat mild exercise episodes alone. of low sugar level.

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Clopidogrel Bisulfate (Plavix)

Antiplatelet drug

75mg/tab OD

PO

Inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor, impending ADPmediated activation.

Reduce thrombotic events in patients with atheroscler osis.

1. Inform patient that drug may be taken without regard to meals. 2. Instruct patient to notify physician if unusual bleeding or bruising occurs

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Lactulose (Duphalac)

Laxative

30cc OD Hs

PO

Produces an osmotic effect in colon; Promote peristalsis, decrease ammonia as a result of bacterial degradation which lowers the pH of the colon contents.

Constipatio n; prevent stimulation of the vagal nerve

1. Inform patient about adverse effect and to notify physician once it occurs

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Simvastatin (Synvinolin)

Anti lipemics

40g/tab OD

PO

Inhibits HMG-COA reductase, an early and rate limiting step in cholesterol biosynthesis.

Reduce risk of death from cardiovascul ar disease and cardiovascul ar events in patients at high risk for coronary events; Reduce total LDL cholesterol

1.

2.

Instruct patient to take drug with evening meals because taking this enhances absorption and increase cholesterol biosynthesis. Instruct patient to inform physician if adverse reactions occur particularly muscle pains

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Clonidine Hydrochloride (Catapres)

Anti hypertensive

75mcg/tab PRN for BP> 150/90 mmHg

SL

Stimulates alpha receptors and inhibits the central vasomotor centers, decreasing sympathetic outflow to the heart, kidneys and peripheral vasculature and lowering peripheral vascular resistance, blood pressure and heart rate.

Hypertension greater than 150/90mmH g

1. Tell patient to take the last dose immediately before at bedtime. 2. Inform patient that dizziness upon standing (orthostatic hypotension) can be minimized by rising slowly from a sitting position or lying position and avoiding sudden position changes.

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Nitroglycerin

Vasodilator, Antianginal

5mg. Patch OACW q 8 NFI

Decreases oxygen demand by decreasing preload and afterload

To prevent or minimize anginal attacks before stressful events

1. Closely monitor V/S esp. BP 2. Applied to any nonhairy parts of the skin except distal parts of the arms and legs

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Humulin R (Regular, crystalline Zinc Insulin)

Anti diabetic Glucagon

4u Sliding scale

SQ

Increase glucose transport across muscle and fat cell membranes to reduce glucose level.

Prevent moderate to severe Hyperosmol ar Hyperglyce mia state as well as hyperkalemi a.

1. Take with first main meal of the day.

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Levofloxacin (Levaquin)

Anti infective

1 tablet TID

PO

Inhibits bacterial DNA gyrase and prevents DNA replication, transcriptions, repair and recombination in

Acute bacterial infections caused by susceptible strains of streptococcus

1. Tell patient to take medication 1 hr before or 2 hrs after eating for increased absorption.

DOSAGE NAME OF CLASSIFICATION /FREQUENCY DRUG (GENERIC AND BRAND NAME)

ROUTE

MECHANISM OF ACTION

INDICATION

NURSING RESPONSIBILITY

Isosobide Anti angina Mononitrate (Indur)

60g/1/2 tab SL OD

Reduces cardiac oxygen demand by decreasing preload and afterload; Increases blood flow through the collateral coronary vessels.

Prevent acute anginal attacks; Acute anginal attacks

1. Tell patient to take sublingual tablet at first sign of attack. 2. Wet tablet with saliva and place under tongue until absorbed. 3. Take in sitting down and at rest.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective:

Decreased Cardiac Objective: Output BP = 170/90 related to mmHG inotropic Bounding changes in pulses heart from Orthopneic increased dyspnea systemic Cold vascular extremities resistance ECG changes and in T and Q decreased waves as well myocardial as ST contractility. segment

After 8 hours of effective nursing care and management, client will develop no irreversible complications associated with decreased cardiac output as manifested by:

1. Assess level of cardiac functioning and existing cardiac and other conditions.

1. Changes Goal met. associated with aging may be cause of the cardiac condition. The existence of other factors places an additional burden on the heart.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

No jugular vein distention No episodes of angina /chest pain No respiratory distress

2. Assess BP (150/90 mmHG), pulse rate and rhythm (69 bpm; bounding), apical pulse (69 bpm; with tachycardia intensity), respiratory rate, depth and ease (20 cpm; not in distress).

2. Indicates reduced cardiac output, vasodilation and lower blood volume. Respiratory changes or difficulties that decrease oxygen intake can cause hypoxia.

Assessment

Diagnosis

Planning

Intervention

Rationale Preload depends on venous return of the blood t the heart, afterload on the resistance against which the heart must pump blood and contractility on the ability of the myocardium to adjust the force of contractions.

Evaluation

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

3. Auscultate heart sounds for abnormal sounds; breath sounds for crackles or wheezes (not present).

3. Reveals mechanical or electrical alterations in cardiac function, presence of fluid congestion in heart and/or lungs and cardiac dysfunction. Crackles or wheezes may indicate the presence of, or impending, congestive failure and fluid overload.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

4. Monitor for existence of dysrhythmias, cardiac conduction and rhythm (ECG changes).

4. The heart conduction system controls the rhythmic contractions and relaxations of the heart and maintains its pumping efficiency, rate and rhythm which ultimately affect cardiac output. Dysrhythmias and conduction aberrations decrease cardiac output by increasing the workload of the heart and decreasing myocardial

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Dysrhythmias and conduction aberrations decrease cardiac output by increasing the workload of the heart and decreasing myocardial perfusion 5. Assess lower extremities and sacral area for edema, distended neck veins, cold hands and feet (present) or oliguria (not present). 5. Indicates reduced venous return to the heart and low cardiac output.

Assessment

Diagnosis

Planning

Intervention

Rationale Oliguria is the result of decreased venous return caused by fluid retention resulting in reduced urinary output. Distended neck veins may indicate presence of fluid overload, resulting in decreased perfusion to all body systems.

Evaluation

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

6. Administer cardiac glycosides, nitrates, vasodilators, anti hypertensives, diuretics and electrolyte replacement as ordered.

6. Treats vasoconstriction , reduces heart rate and contractility, reduces blood pressure and relaxes venous and arterial vessels, which acts to increase cardiac output and decrease workload of the heart.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

7. Position in semi or high Fowler s position.

7. Prevents pooling of blood in pulmonary vessels and facilitates breathing via increased lung expansion. 8. Weight gain of >1lb/day may indicate fluid retention. Utilization of the same scale facilitates consistent data to ensure correct correlation with fluid status.

8. Weigh on same scale at the same time.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

9. Pace activities, avoiding going past point of tolerance and progress in exercise regimen as able.

9. Prevents undue demands on heart and protects cardiac function by preventing sudden reduction in cardiac output.

10. Avoid Valsalva maneuvers with straining and coughing.

10. Results in sudden reduction in cardiac output by increasing intra abdominal pressure and intra thoracic pressures.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

11. Instruct client in administration of prescribed medications, actins and side effects. Advise client to avid over the counter (OTC) drugs without physician advice.

11. Promotes desired action and results. Prevents adverse interactions with other drugs.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

12. Instruct patient in program of activities; combination of interchanging active and passive range of motion (ROM) activity. 13. Instruct client in establishing pattern of bowel elimination of soft stool; proper administration of stool softer or laxative if ordered.

12. Promotes circulation by preserving muscle tone and strength. Heat generated by exercises promotes cellular metabolism. 13. Promotes easy elimination without straining.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

14. Instruct client 14. Promotes in elevation of venous blood legs when sitting, return. to avoid standing in one place or for long periods of time. 15. Instruct client in reporting edema, chest pain, changes in vital signs and input and output imbalance.

15. May indicate complications of reduced cardiac output.

16. Instruct client 16. Allows for and significant self-monitoring. other in techniques for taking pulse and blood pressure.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

17. Instruct client regarding dietary restrictions and methods to reduce fat, cholesterol and sodium intake.

17. May assist with reduction in cholesterol levels to control atherosclerosis and its effect on blood flow. Sodium restriction may also improve hypertension and prevent edema.

Nursing care Plan

#2

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Objective: Chest pain Numbness of left arm ECG changes in T and Q waves as well as ST segment Cold extremities Increased BUN 8.4 mg/dL

Ineffective Tissue Perfusion related to decreased cardiac output

After 8 hours of effective nursing care and management, client will show signs of adequate perfusion to all body systems as evidenced by: Warm extremities No paresthesia (numbness) Absence of chest pain/angina

1. Monitor vital signs q2 and prn.

1. Tachypnea, tachycardia and hypertension will most likely occur with hypoperfusion and decreased cardiac output.

2. Monitor ECG for cardiac rhythm, conduction defects and dysrhythmias.

2. Fluid shifting can create electrolyte imbalances and cardiac hypoperfusion that may result in cardiac rhythm irregularities.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

3. Auscultate lung fields and heart tones.

3. Wheezes and crackles may indicate possible pulmonary edema. May indicate impending cardiac failure and cardiac hypoperfusion. 4. Decreasing or absent bowel sounds may indicate presence of ileus, obstruction or hypoperfused state.

4. Auscultate abdomen for presence and character of bowel sounds. Observe for abdominal distention.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

5. Palpate peripheral pulses and observe extremities for color, temperature, capillary refill and sensation.

5. Hypoperfusion causes the body to shunt blood from the periphery to vital organs, leading to cold extremities and change in peripheral pulse intensity. 6. Position, impedes gas exchange, increases pulmonary blood flow and may decrease cerebral perfusion.

6. Avoid Trendelenburg s position.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

7. Assist with ambulation and combination of passive and active range of motion (ROM) exercises. 8. Monitor patient for orientation status. Reorient as needed.

7. Assists to improve peripheral and arterial circulation and prevents venous stasis. 8. Hypoperfusion may result in decreased level of consciousness (LOC). Re orientation helps to maintain sense of well-being and orientation to surroundings to decrease risk of injury.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

9. Instruct client regarding dietary restrictions and methods to reduce fat, cholesterol and sodium intake.

9. May assist with reduction in cholesterol levels to control atherosclerosis and its effect on blood flow. Sodium restriction may also improve hypertension and prevent edema.

Nursing care Plan

#3

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Naninikip and dibdib ko , as verbalized by the patient

Impaired Gas Exchange related to ineffective ventricular function

After 8 hours of effective nursing care and management: client will: Achieve and maintain adequate ventilation, without adventitious breath sounds on auscultation Be able to perform activities without experiencing dyspnea.

1. Assess patient and establish baseline values for vital signs. Assess for coexisting disease processes.

1. Baseline data is crucial to help recognize agerelated changes. Elderly patients usually have a shorter respiration, which decreases their maximum breathing capacity, vital capacity, functional capacity and residual volumes.

After the shift, with effective nursing care and management: client: Achieved and maintained adequate ventilation, without adventitious breath sounds on auscultation Was able to perform activities without experiencing dyspnea.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

2. Auscultate lung fields.

3. Place client in semi or high Fowler s position as tolerated.

2. Wheezes and chackles may indicate presence of pulmonary emboli. 3. Facilitates maximum lung expansion. In elderly patients, the muscles of the larynx and pharynx may deteriorate and these positions may be required to achieve adequate thoracic expansion.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

4. Instruct patient in relaxation techniques and guided imagery. Discuss patient s method of relaxation and adapt them as appropriate.

4. The ability of patient to relax may enhance and facilitate reduction of oxygen demand to the tissues. Using patient s previous experiences with relaxation may enhance ability to decrease oxygen consumption and improve oxygenation.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

5. Instruct patient in positions to use to assist when dyspnea occurs, such as high Fowler s or orthopneic position.

5. Because of anatomic changes n the elderly, compensation with different positions may be required to achieve maximum chest excursion and facilitate oxygenation.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

6. Instruct client to schedule rest periods between activities.

6. Older patients may have decreased exertional capacity and need rest periods to conserve respiratory effort. Their alveoli are usually more fibrous and less elastic and contain fewer functional capillaries in which to achieve oxygenation.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

7. Instruct client and significant others regarding lifestyle changes.

7. Patient may need to have bedroom or living area moved to first floor, be moved close to the bathroom, have smaller meals more frequently and have frequent rest periods during activities in order to reduce exertion and oxygen demand and consumption.

Nursing care Plan

#3

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Ang sakit ng dibdib ko , as stated by the patient. Objective: Chest pain radiating to arm Exertional dyspnea Pain occurring after activity Pain scale of 6-7

Acute Pain related to decreased myocardial perfusion.

After 4 hours of effective nursing care and intervention, client will: Be free of pain Be able to identify pain, communicate needs and utilize methods to reduce pain

1. Assess characteristic of pain, precipitating factors, verbal and non-verbal responses, pain onset, location, severity, duration and radiation.

2. Monitor VS during pain episode.

1. Pain from Goal met angina occurs when myocardial need for oxygen exceeds the ability of coronary vessels to supply needed blood flow as the lumen is narrowed by atherosclerosis.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

3. Administer 2. Increases in pulse and BP are vasodilators caused by as ordered.

anxiety and stress may precipitate angina episode. In elderly patients, dyspnea with exertion may be seen more commonly that chest pain because of increasing left ventricular end diastolic pressures as a result of reduced ventricular compliance.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

3. Vasodilators improve blood flow and reduce ischemia and pain. 4. Increases patient s pain threshold. Morphine may be administered to decrease after load and preload and improving contractility.

4. Administer analgesics as ordered, prn.

5. Administer oxygen at 2-4 L/min via nasal cannula as ordered.

5. Relieves heart muscle hypoxia.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

7. Limit activity and maintain bed rest.

7. Decreases myocardial oxygen consumption and strain on the heart. 8. Reduces stimuli that increase oxygen demand. 8. Hypoperfusion may result in decreased level of consciousness (LOC). Re orientation helps to maintain sense of well-being and orientation to surroundings to decrease risk of injury.

8. Maintain quiet, calm environment, provide relaxing backrub, guided imagery.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

9. Instruct client regarding dietary restrictions and methods to reduce fat, cholesterol and sodium intake.

9. May assist with reduction in cholesterol levels to control atherosclerosis and its effect on blood flow. Sodium restriction may also improve hypertension and prevent edema.

Nursing care Plan

#4

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Ang sakit ng dibdib ko , as stated by the patient. Objective: Chest pain radiating to arm Exertional dyspnea Pain occurring after activity Pain scale of 6-7

Acute Pain related to decreased myocardial perfusion.

After 4 hours of effective nursing care and intervention, client will: Be free of pain Be able to identify pain, communicate needs and utilize methods t

1. Assess characteristic of pain, precipitating factors, verbal and non-verbal responses, pain onset, location, severity, duration and radiation.

1. Pain from Goal met angina occurs when myocardial need for oxygen exceeds the ability of coronary vessels to supply needed blood flow as the lumen is narrowed by 2. Monitor VS atherosclerosis.

during pain episode.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

2. Increases in pulse and BP are caused by anxiety and stress may precipitate angina episode. In elderly patients, dyspnea with exertion may be seen more commonly that chest pain because of increasing left ventricular end diastolic pressures as a result of reduced ventricular

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

3. Administer vasodilators as ordered

3. Vasodilators improve blood flow and reduce ischemia and pain. 4. Increases patient s pain threshold. Morphine may be administered to decrease after load and preload and improving contractility. 5. Relieves heart muscle hypoxia.

4. Administer analgesics as ordered, prn.

5. Administer oxygen at 2-4 L/min via nasal cannula as ordered.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

7. Limit activity and maintain bed rest. 8. Maintain quiet, calm environment, provide relaxing backrub, guided imagery. 9. Instruct pain to report pain lasting longer that 5 15 minutes; review effect of medication administration.

7. Decreases myocardial oxygen consumption and strain on the heart. 8. Reduces stimuli that increase oxygen demand. 9. Indicates that medication adjustment needs to be made or cardiac complication is present.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

10. Instruct patient to maintain log of time, duration and location of angina episodes, amount of medication taken and so forth. 11. Instruct patient to avoid activities that precipitate angina episodes such as, sudden exposure to cold, drinking cold fluids,

10. Offers comparisons for physician to review. 11. Reduces frequency of attacks.

Assessment

Diagnosis

Planning

Intervention stressful situations, large meals, straining at stools, cigarette smoking and caffeine containing beverages.

Rationale

Evaluation

Nursing care Plan

#5

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Objective: Dyspnea on exertion Sense of exhaustion Decreased capacity for physical activity

Fatigue related to decreased cardiac output as evidenced by: Dyspnea on exertion Sense of exhaustion Decreased capacity for physical activity

After the shift, with effective nursing care and management, client will: Be able to manage activities and perform tasks with minimal fatigue

1. Assess/ observe patient for signs of activity intolerance, such as dyspnea, extreme fatigue, lethargy or vital sign changes. 2. Provide periods of rest or sleep alternating with periods of activity as patient can tolerate.

1. Provides baseline data so that identification of problem and interventions may be planned. Elevations in vital signs may indicate physiologic intolerance of activity and fatigue. 2. Prevents excess fatigue and increases stamina.

After the shift, with effective nursing care and management, client was: Able to manage activities and performed tasks with minimal fatigue

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

3. Avoid scheduling patient for two or more energydraining procedures on same day, if possible. 4. Schedule patient s daily routine based on specific needs and desires. 5. Encourage foods high in iron and minerals.

3. Conserving energy helps to avoid overexertion and potential for exhaustion. 4. Encourages compliance with treatment regimen and reduces fatigue. 5. Helps to avoid anemia and demineralization that can affect fatigue. Low RBCs affect a patient s oxygenation as oxygen molecules are carried throughout the

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

6. Provide small, Low RBCs affect easily digestible a patient s meals. oxygenation as oxygen 7. Instruct molecules are patient carried regarding effects throughout the of fatigue on body via daily activity and hemoglobin personal molecules. lifestyle. 6. Frequent small meals conserve energy and encourage increased intake of nutritive sustenance.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

7. Helps to increase patient compliance and allows for planning schedule of activity and rest. 8. Instruct patient to schedule rest periods between activities. 8. Helps to decrease fatigue and increase stamina.

9. Adequate 9. Instruct amounts of patient and help sleep each night him to establish will help a regular decrease sleeping pattern. fatigue.

Nursing care Plan

#6

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Objective: Dyspnea on exertion Fatigue Chest pain during activity

Activity Intolerance related to imbalance between oxygen supply and demand caused by disease process and aging as evidenced by: Dyspnea on exertion Fatigue Chest pain during activity

After the shift, with effective nursing care and management client will: Achieve optimal activity level with increased energy and endurance within imposed restrictions

1. Assess baseline tolerance for activity, ability to adapt to limitations and/or restrictions to lifestyle. 2. Asses pulse, BP, respiration, before, during and after activity. 3. If activity causes pain, administer vasodilators as ordered.

1. Promotes and protects circulatory function and reduces cardiac workload.

After the shift, with effective nursing care and management client will: Achieve optimal activity level with increased energy and endurance within imposed restrictions

2. Pulse increase y more than 20bpm and increases in BP and respirations indicate need for reduction of activity. 3. Controls pain during activity by decreasing oxygen demand and improving perfusion.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

4. Schedule 4. Maintains activities around activity below rest periods. angina threshold. 5. Instruct patient to avoid 5. Conserves extending energy and activities beyond prevents angina. tolerance. 6. Requires 6. Instruct additional patient to avoid oxygen for activities. activity after eating, bathing 7. Availability to or during rest administer when periods. needed. 7. Instruct patient to keep medication nearby when performing activity.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

8. Inform to cease activity when pain occurs and when taking medication, to sit on chair and wait for pain to pass. 9. Suggest cardiac rehabilitation program to establish a daily acceptable exercise plan within determined limits.

8. Prevents falls if feeling dizzy or faint and decreases oxygen requirement. 9. Provides necessary activity without causing increased workload to the heart and improves circulation.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

10. Instruct patient to rest by sitting in chair than lying in bed and to conserve energy during activities.

10. Sitting is the preferred position for resting because it prevents pooling of blood in the pulmonary vessels. Sitting upright also helps to prevent complications associated with immobility and facilitates better chest excursion.

Nursing care Plan

#7

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Objective: Insomia Not feeling rested

Disturbed Sleep Pattern related to internal factors from cardiovascular disease and aging as evidenced by: Insomia Not feeling rested

After the shift, with effective nursing care and management, client will: Be able to sleep without interruption and will express feelings of being rested Be able to perform techniques to promote sleep

1. Assess patient s sleep pattern and changes, naps, amount of activity, awakenings and frequency and patient s complaints of lack of rest. 2. Monitor complaints of pain, dyspnea, discomfort and nocturia.

1. Provides information to alleviate sleep deprivation in relation to agerelated changes and to identify and establish plan of care. 2. Identification of causative factors of frequent awakenings helps facilitate changes in sleep pattern.

After the shift, with effective nursing care and management, client was: Able to sleep without interruption and will express feelings of being rested Able to perform techniques to promote sleep

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

3. Provide calm, quiet environment, closing curtains, adjusting lighting and so forth.

3. Helps to promote conducive atmosphere for restful sleep. External stimulus may interfere with 4. Provide warm going to sleep drinks, extra cover, and warm and increase awakenings in bath prior to bedtime and so the elderly forth. patient because sleep is usually of less intensity.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

5. Instruct patient to avoid stimulants, such as caffeinated drinks, stressful activity and so forth, prior to sleep 6. Instruct patient in relaxation techniques, guided imagery, muscle relaxation, meditation and so forth.

4. Ritualistic procedures may prevent breaks in established routines and promote comfort and relaxation prior to sleep. 5. Over stimulation prevents patient from falling asleep. 6. Relaxation techniques frequently help promote sleep

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

7. Instruct patient to avoid using alcohol at bedtime

7. Although alcohol may initially cause sleepiness, it interrupts sleep later in the night.

Medications:
Advise patient to take the prescribed medications continuously at home Always check the expiration date of the medicine before taking

Environment:
Avoid crowded areas, especially during cold and flu season. Avoid close contact with anyone who is ill. Provide safety measure to promote safe environment and individual safety. Sanitary handling of food and water.

Treatment:
Eating a healthy diet (eating more fruits, vegetables, and low fat dairy products, less saturated and total fat). Reducing the amount of sodium in your diet to 2,300 milligrams (about 1 teaspoon of salt) a day or less.

 Getting regular aerobic exercise (such as brisk walking at least 30 minutes a day, several days a week). In addition to lowering blood pressure, these measures enhance the effectiveness of high blood pressure drugs.

Health Teachings
Teach the patient to use a self-monitoring blood pressure cuff and to record the reading at least twice a week. Tell the patient to take his blood pressure at the same hour each time, with out more than usually activity preceding the measurement. Tell the patient and family to keep a record of drugs used in the past.

 To encourage compliance with antihypertensive therapy, suggest establishing a daily routine for taking medication. Warn the patient that uncontrolled hypertension may cause stroke and heart attack. Tell him to report any adverse reactions to prescribed drugs. Advise him to avoid high-sodium antacids and over-the-counter cold and sinus medications containing harmful vasoconstrictors.

 Help the patient examine and modify his lifestyle behavior. Suggest stress-reduction groups, dietary changes, and an exercise program. Encourage a change in dietary habits. Help the obese patient plan a reducing diet. Tell to the patients to avoid high-sodium foods, table salt, and foods high in cholesterol and saturated fat.

 Encourage a change in dietary habits. Help the obese patient plan a reducing diet. Tell to the patients to avoid high-sodium foods, table salt, and foods high in cholesterol and saturated fat.

Diet
Reduction of sodium intake Moderation of alcohol Weight loss in the obese Possibly increasing potassium and calcium intake Ingestion of a vegetarian diet or fish oil supplements.

BIBLIOGRAPHY Book Smeltzer, Suzanne C., et. al. Brunner & Suddarth s Textbook of Medical-Surgical Nursing. 11th Edition. Volume 1 and 2. Lippincott Williams and Wilkins. 2008. Nurse s Pocket Guide. 11th Edition Davis Drug Guide. 10th Edition