Hypertension - Nursing Case Study

Pathophysiology

• Primary mechanism: Hypertension primarily occurs due to an increase in systemic vascular resistance. This resistance is often due to narrowing of the arteries, caused by factors such as atherosclerosis (hardening or thickening of the arteries).

• Secondary mechanism: Another significant mechanism is an increase in blood volume, often due to high sodium intake, leading to water retention. The kidneys play a crucial role here, as they control the balance of salt and water in the body.

• Key complication: If untreated, hypertension can lead to heart failure. High blood pressure means the heart has to work harder to pump blood, which over time can cause it to weaken and result in heart failure. It can also lead to kidney disease, stroke and vision loss.

Patient Profile

Demographics:

56, Female, Office Worker

History:

• Key past medical history: Pre-diabetes, High Cholesterol

• Current medications: Metformin, Statins

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Occasional headaches and fatigue

• Key symptoms: Mild headache, tiredness, no chest pain, no shortness of breath

• Vital signs: Blood pressure 142/92 mmHg, heart rate 78 beats/min, temperature 98.2°F, respiratory rate 16 breaths/min, oxygen saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon physical examination, the patient appeared comfortable and in no acute distress. She was alert, oriented and able to walk unassisted. However, she reported feeling generally unwell and mentioned experiencing sleep disturbances, which could be a contributory factor for her fatigue. The patient's skin was warm and dry, with no visible signs of edema or cyanosis. On auscultation, her lungs were clear and heart sounds were normal with no murmurs or gallops.

New Diagnostic Results:

The patient's lab results came back, revealing a slightly elevated level of serum creatinine at 1.2 mg/dL (normal range: 0.6-1.1 mg/dL), indicating a possible early sign of kidney dysfunction, which can be a complication of untreated hypertension. Her fasting blood glucose was 106 mg/dL, consistent with her history of pre-diabetes. The cholesterol profile showed a total cholesterol of 210 mg/dL (desirable level: less than 200 mg/dL), LDL cholesterol 130 mg/dL (optimal level: less than 100 mg/dL) and HDL cholesterol 40 mg/dL (low HDL level). These results suggest that her current statin therapy may need to be reevaluated and adjusted. The patient was advised to continue her current medications and a follow-up appointment was scheduled to discuss the results and possible treatment modifications.

Section 2

Change in Patient Status:

Two weeks later, the patient returned for her follow-up appointment. She reported ongoing sleep disturbances and a persistent feeling of fatigue. Additionally, she mentioned experiencing occasional headaches and mild episodes of dizziness. She denied any chest pain, shortness of breath, or visual disturbances. Her blood pressure was checked and found to be 138/88 mmHg, which is a slight increase from her previous reading of 130/80 mmHg.

Upon evaluation, her BMI was calculated to be 28, which is classified as overweight for her height. She admitted to having been less active recently due to her fatigue and confessed to indulging in high sodium and high cholesterol foods more frequently than she should. The patient was encouraged to stick to a low sodium, low cholesterol diet and to incorporate moderate physical activity into her daily routine. These lifestyle modifications, along with her current medication regime, are critical for managing her hypertension and preventing further complications. A follow-up appointment was scheduled in a month to assess her progress.

Section 3

At her one-month follow-up, the patient reported some improvement in her sleep quality and a decrease in the frequency of her headaches. However, she still experienced occasional bouts of dizziness. Her blood pressure was checked and found to be 136/86 mmHg, a minimal decrease from the previous reading. She admitted struggling to adhere to the recommended dietary changes, often resorting to convenience foods due to her busy schedule.

To better understand her lack of substantial progress, a detailed dietary assessment was conducted. It revealed an over-reliance on processed and fast foods which are typically high in sodium and cholesterol. Physical activity was also assessed, with the patient admitting to only sporadic exercise due to feeling tired. These findings underline the importance of lifestyle modifications in managing hypertension. A plan was initiated to provide the patient with dietary counselling and a more structured, achievable exercise regimen. The patient was also advised to monitor her blood pressure at home and maintain a BP log. A follow-up appointment in two weeks was scheduled to assess her progress and check her adherence to the new plan.

Section 4

At the two-week follow-up, the patient reported a noticeable improvement in her overall well-being. She had begun incorporating more fruits, vegetables, and lean proteins into her diet, significantly cutting down on processed and fast foods. Her home blood pressure readings had shown a downtrend, averaging around 130/82 mmHg. She had also started a regular exercise routine, walking briskly for 30 minutes a day, five days a week.

However, she expressed difficulty in maintaining the dietary changes, especially, when she was on a tight schedule or when she was out with friends. The nurse suggested ways to plan ahead by preparing healthy meals in advance and choosing healthier options when eating out. The patient was also encouraged to gradually increase the intensity and duration of her exercise routine. A follow-up appointment was scheduled in a month to monitor her blood pressure and assess her adherence to the lifestyle changes. Furthermore, she was reminded to continue maintaining the BP log and bring it to every appointment for review.

Section 5

At the one-month follow-up, the patient reported greater success in maintaining the dietary changes. She had started meal prepping on weekends, which made it easier for her to eat healthier during the week. When dining out with friends, she made a conscious effort to choose options with more vegetables and lean proteins.

However, she reported experiencing occasional bouts of dizziness, especially when getting up suddenly from a sitting or lying position. On assessment, her blood pressure read 112/70 mmHg, which was significantly lower than her usual readings. Her pulse was regular, but slightly elevated at 92 beats per minute. The nurse recognized these as potential signs of orthostatic hypotension. She advised the patient to rise slowly from sitting or lying down, and to stay hydrated. The patient was instructed to continue recording her blood pressure at home, making a special note of any episodes of dizziness. The nurse also scheduled a follow-up appointment for the following week to closely monitor the patient's condition.