HISTORY

Patient’s Initials: Age:56

Sex:
Citizenship
Religion: Roman Catholic
Birth date:
Civil Status:
Educational Attainment:
Race:
Occupation:
History of Present Illness
Chief Complaint: Dizziness
Diagnosis: Hypertensive Urgency

Past History
Allergies: None
(+) Hypertension (2015) UBP 130/90 HBP 150/90

Family Health History

(-) Stroke
(-) DM
(-) MI
TREATMENTS
1/22/19  Admitted to room
 Diet: 1800 kcal/day 60% CHO 25%
Fats 15% CHON <200mg cholesterol
<7% saturated fats <4g Na divided
into 3 meals & 2 sncacks
 Monitor VS q1 & record
 IVF = PNSS 1L @ 120cc/hr
 Diagnostics: 12L-EECG, CBC w/ PH,
Na, K, Crea, BUN, BUA, SGPT, SGOT,
CXR, Lipid Profile, 2D Echo
 Therapeutics: Nicardipine Drip 10mg
in 90cc PNSS to run @20cc/hr, titrate
to 5cc/hr to maintain BP < 140/90
mmHg
 Fall protection at all times
 CBG monitoring TID
1/23  Irbesartan + Amlodipine
150/5mg/tab OD
 Aspirin 80mg/tab OD
 Sitagliptin 100mg/tab OD w/ Lunch
 Rosuvastatin 20mg/tab ODHS
 Metformin 1g/tab 1 tab BID (BF-
Dinner)
 Approvasc 150/5mg/tab BID
 Gliclazide 60mg/tab OD
 Keltican 50mg/cap BID
 Bisoprolol 10mg/tab 1tab OD
 Combivent + Zicanib Q8 PRN
 Pioglitazone + Metformin
15/600mg/tab OD p dinner

1/24  Nicardipine drip 20mg/IV in 8cc

PNSS to run at 20cc
 Metformin 1gm/tab OD
1/25/  VS noted
130/100
 Stop Nicardipine
LABS
1/21
High Fasting Plasma Glucose = 195.70
Cholesterol (high) = 280.60
LDL – Direct (high) = 216.60

1/22
CBC = hgb – 154
hct – 0.47
platelet – 305
RBC – 5.76
WBC – 10.50
SGPT-ALT (high) – 35.80
Ionized Calcium (high) – 1.34
HbA1c (high) – 10.73
 CXR – cardiac size magnified w/ allowance for position
- Aorta is tortuous
- Lung fields clear
ECG – Sinus Rhythm
Atrial Rate: 100/min QTA: 0.40 secs Ventricular Rate: 100/min QRS arise: -5o
Dx: Sinus Rhythm w/ isolated ventricular premature complex; Prolonged QTC
1/23 CBG monitoring – 6am = 234 mg/dL
11am = 202mg/dL
6pm = 212mg/dL
10pm= 178mg/dL
1/24 6am= 167mg/dL
10am=171mg/dL
6pm = 180mg/dL
9pm = 167mg/dL
1/25 6am = 134mg/dL
PATHOPHYSIOLOGY
Risk Factors:
-(+) Hypertension (2015) UBP 130/90
HBP 150/90
 NCP
CUES/CLUES NURSING DIAGNOSIS SCIENTIFIC RATIONALE GOALS & OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective Tissue Perfusion Increased cardiac output that After 4 hours of nursing 1. Monitored blood pressure 1. To have a baseline of data  After 8 hours of
 Verbalized “Nahihilo related to high blood injures the endothelial cells of interventions, the patient will every hour. and closely monitor for abrupt nursing interventions,
agad ako at pressure the arteries and the action of be able to: changes or stability in the the patient’s blood
nahihirapan maglakad prostaglandins.  Maintain stability of blood pressure. pressure was reduced
ng walang alalay Vasoconstriction occurs and blood pressure to 130/90
kapag tumatayo o blood pressure increases. without any further 1. Instructed to have enough 1. To provide comfort to the
papunta sa CR.” rise. rest on semi-fowlers patient as well as reduce
 Objective: Source: Brunner & Suddarth’s position. possibilities in difficulty of
- BP 140/90 textbook of medical – surgical After 8 hours of nursing breathing.
- PR: 94 Nursing 11th edition by interventions, the patient will
- RR: 23 smeltzer, Bare, Hinkle, be able to: 1. Instructed to eat low fat
cheever  Manifest lower blood and low salt diet. 1. Aids in reducing high blood
pressure from pressure and prevents
140/100 to 120/80 collection of fluid in
extremities.
1. Administered anti-
hypertensive drugs as 1. To have active physiologic
ordered. control of blood pressure.