hypertension - Nursing Case Study

Pathophysiology

• Primary mechanism: Increased systemic vascular resistance - This is often the result of constriction of small arteries and arterioles, which can be due to various factors such as overactivity of the sympathetic nervous system, dysfunction of the endothelium, or hormonal imbalances. This increased resistance forces the heart to pump harder, leading to higher blood pressure.

• Secondary mechanism: Increased blood volume - This can be due to kidney problems or hormonal changes that cause the body to retain more sodium and water. The increased volume of blood in the circulatory system adds to the pressure on artery walls, contributing to hypertension.

• Key complication: End organ damage - Chronic hypertension can cause damage to vital organs such as the heart, kidneys, and brain. This can lead to complications such as heart failure, renal failure, and stroke, making effective management of hypertension crucial.

Patient Profile

Demographics:

63-year-old male, retired construction worker

History:

• Key past medical history: Diagnosed with hypertension 10 years ago, Type 2 Diabetes Mellitus diagnosed 3 years ago

• Current medications: Lisinopril 20mg daily, Metformin 500mg twice daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent headaches, blurred vision

• Key symptoms: Dizziness, chest discomfort, frequent urination, increased thirst

• Vital signs: Blood pressure 155/95 mmHg, pulse 87 per minute, SpO2 96%, body temperature 37.1°C, respiratory rate 18 per minute.

Section 1

Change in Patient Status:

Over the next 24 hours, the patient's condition begins to deteriorate. His blood pressure remains elevated at 160/100 mmHg despite taking Lisinopril. He reports increased frequency of headaches and episodes of confusion, which are concerning for possible hypertensive encephalopathy. He also complains of increasing chest discomfort, which raises the suspicion of possible cardiac ischemia related to his uncontrolled hypertension.

New Diagnostic Results:

An electrocardiogram (EKG) is ordered, which shows ST-segment depression in leads II, III, and aVF, suggesting possible inferior wall ischemia. His serum creatinine has also increased from 1.2 to 2.1 mg/dL over the past day, indicating possible acute kidney injury. His Hemoglobin A1c (HbA1c) level is 8.4%, which is above the target range for patients with Type 2 Diabetes Mellitus, indicating poor glycemic control. A brain CT scan is also ordered to rule out stroke or other neurological complications from his hypertension.

These findings necessitate immediate therapeutic interventions to manage the patient's hypertension and prevent further end-organ damage. The case also requires the nurse to critically consider the connection between the patient's poorly controlled diabetes, hypertension, and their impact on his kidney function and potential heart disease. The nurse would need to collaborate with the healthcare team to review the patient's medication regimen, evaluate the need for possible changes, and plan for lifestyle modifications to achieve better hypertension and diabetes control.

Section 2

Response to Interventions:

Despite the administration of additional antihypertensive medications, the patient's blood pressure continues to remain elevated at 165/105 mmHg. His headache has intensified, and he has experienced two more episodes of confusion in the past 12 hours. The patient’s persistent chest discomfort warranted the administration of sublingual nitroglycerin, which provided only temporary relief. His serum creatinine has continued to rise to 2.3 mg/dL, suggesting ongoing acute kidney injury.

This development necessitates reevaluation of the current treatment approach. The nurse must ascertain whether the patient is adhering to his medication regimen and if he is experiencing any adverse effects that might affect compliance. The nurse would also need to consider other factors such as underlying secondary causes of hypertension, the need for more aggressive blood pressure control, and the potential requirement for renal protective strategies. Additionally, the nurse would need to collaborate with the healthcare team to manage the patient's chest pain, which could indicate a progression to unstable angina or myocardial infarction. Specific attention should be given to monitoring the patient's cardiac biomarkers and EKG changes. This situation demands swift clinical reasoning from the nurse, emphasizing the interplay of hypertension, diabetes, and cardiovascular and renal complications.

Section 3

New Diagnostic Results:

The patient's EKG results come back showing nonspecific T-wave abnormalities, indicating the possibility of myocardial ischemia. His troponin levels have increased to 1.0 ng/mL, further suggesting cardiac damage. The patient’s urine sample also demonstrates the presence of proteinuria, a potential sign of renal damage due to uncontrolled hypertension and diabetes. This new information heightens the clinical complexity of the case, mandating immediate medical intervention.

The nurse must now consider the potential for a hypertensive emergency with end-organ damage. The combination of persistent chest pain, elevated troponin levels, and abnormal EKG results could signify an acute coronary syndrome. Concurrently, the presence of proteinuria and escalating creatinine levels may represent the progression of renal dysfunction. The nurse must swiftly integrate these findings, correlating the patient's symptoms, diagnostic results, and medical history to provide effective care. This situation calls for the nurse to utilize clinical reasoning to prioritize interventions, focusing on stabilizing the patient and preventing further deterioration. The nurse must also prepare to coordinate with the healthcare team to modify the patient's treatment plan, possibly including the initiation of renal protective strategies and cardiac catheterization.

Section 4

Change in Patient Status:

Over the next few hours, the patient's condition deteriorates further, with new symptoms emerging. The patient complains of worsening chest pain, rated 8/10 on the pain scale, and shortness of breath. His blood pressure readings continue to escalate, with the latest recording at 190/110 mmHg. His pulse rate has increased to 110 beats per minute, and his oxygen saturation has dropped to 89% on room air. Additionally, the patient's urine output has decreased to less than 30 mL/hour, and his latest blood glucose reading is 250 mg/dL.

These new developments underscore a worsening hypertensive crisis, exacerbated by ischemic heart disease and potential renal failure. The patient's escalating blood pressure, elevated pulse rate, and low oxygen saturation levels could signify a compensatory response to myocardial damage. The decreasing urine output and high blood glucose level may also suggest deteriorating renal function and poorly controlled diabetes. This change in patient status warrants immediate intervention and reevaluation of the care plan by the healthcare team. The nurse can anticipate the need to administer antihypertensive medications, possibly including nitroglycerin for chest pain relief and insulin for blood glucose control. Additionally, the nurse should prepare to initiate measures to increase the patient's oxygen saturation, such as oxygen therapy.

Section 5

New Diagnostic Results:

Lab results from the patient’s blood work return, indicating a troponin level of 0.5 ng/mL, a creatinine level of 1.8 mg/dL, and a potassium level of 5.6 mEq/L. His BUN (blood urea nitrogen) is also elevated at 28 mg/dL. The EKG report shows ST-segment elevation in leads II, III, and aVF, with reciprocal changes in the anterior leads.

The elevated troponin level, coupled with the EKG findings, strongly suggest the patient has suffered an ST-elevation myocardial infarction (STEMI), necessitating immediate cardiac intervention. The elevated creatinine and BUN levels, along with the decreased urine output, indicate potential acute kidney injury (AKI), likely secondary to the decreased cardiac output and thus decreased renal perfusion. The elevated potassium level is also concerning as it may lead to life-threatening cardiac arrhythmias.

Based on these new diagnostic results, the nurse should anticipate and prepare for urgent cardiac catheterization, while also closely monitoring the patient's cardiac rhythm. In addition, the nurse should anticipate the need for renal function support and possibly diabetic management if the AKI does not resolve and the blood glucose levels remain uncontrolled.