A patient with long-standing hypertension presents with persistent high blood pressure, lower extremity edema, and signs of left ventricular hypertrophy. Despite adherence to her medication regimen, her blood pressure remains at 160/100 mmHg. Which nursing intervention is most appropriate in managing this patient's condition?

A) Educate the patient about reducing sodium intake to less than 1500 mg per day.

B) Advise the patient to increase fluid intake to promote renal function.

C) Suggest the patient discontinue current medications and monitor blood pressure daily.

D) Recommend the patient avoid physical activity to prevent exacerbation of symptoms.

A patient on an adjusted hypertension regimen, including a calcium channel blocker and a low-dose diuretic, reports a persistent dry cough and bilateral pitting edema. The nurse notes an increase in serum creatinine to 1.4 mg/dL. Which intervention should the nurse anticipate as most appropriate to address the underlying causes of these symptoms?

B) Discontinue the ACE inhibitor and consider an ARB (Angiotensin II Receptor Blocker).

A) Increase the dose of the diuretic to manage the edema.

B) Discontinue the ACE inhibitor and consider an ARB (Angiotensin II Receptor Blocker).

C) Initiate a beta-blocker for better blood pressure control.

D) Advise dietary sodium restriction to reduce fluid retention.

A patient with hypertension and recent medication adjustments reports a persistent dry cough and bilateral pitting edema rated as +2. The healthcare team is considering further diagnostic testing for secondary causes of hypertension. Which of the following nursing interventions is most appropriate to prioritize at this time?

B) Monitor the patient's serum potassium and creatinine levels regularly.

A) Educate the patient about lifestyle modifications to manage hypertension.

B) Monitor the patient's serum potassium and creatinine levels regularly.

C) Instruct the patient to maintain a daily log of blood pressure readings.

D) Schedule the patient for follow-up appointments with a nephrologist and cardiologist.

A patient with confirmed renal artery stenosis and uncontrolled hypertension is undergoing changes in her management plan. Which of the following nursing interventions is most appropriate to prioritize in this scenario?

B) Monitor the patient's blood pressure closely and adjust medications as prescribed.

A) Educate the patient on the importance of regular exercise to enhance cardiovascular health.

B) Monitor the patient's blood pressure closely and adjust medications as prescribed.

C) Encourage the patient to completely eliminate sodium from her diet to reduce edema.

D) Advise the patient to increase fluid intake to prevent dehydration from diuretic use.

A patient with a history of hypertension and newly diagnosed renal artery stenosis is being managed with an angiotensin II receptor blocker (ARB) to replace the ACE inhibitor due to a persistent dry cough. The nurse should prioritize which of the following assessments to ensure safe administration of the ARB?

A) Monitor the patient's potassium levels regularly.

B) Assess the patient for signs of angioedema.

C) Evaluate the patient's liver function tests.

D) Check the patient's white blood cell count.

A patient with a history of hypertension and renal artery stenosis is on an angiotensin receptor blocker (ARB) and diuretics. During a follow-up visit, the nurse notes mild pitting edema in the lower extremities and a potassium level of 5.0 mEq/L. What is the most appropriate nursing action to address the patient's condition?

B) Educate the patient on reducing dietary potassium intake.

A) Increase the diuretic dosage to manage the edema.

B) Educate the patient on reducing dietary potassium intake.

C) Recommend a low-sodium diet to the patient.

D) Advise stopping the ARB medication immediately.

A patient undergoing treatment for hypertension presents with mild pitting edema and a serum potassium level at the upper limit of normal. The nurse understands that which of the following actions is the priority to prevent complications associated with this patient's current condition?

C) Monitor the patient for signs of hyperkalemia, such as muscle weakness or palpitations.

A) Increase dietary sodium intake to counteract the potassium level.

B) Educate the patient on the importance of adhering to a sodium-restricted diet.

C) Monitor the patient for signs of hyperkalemia, such as muscle weakness or palpitations.

D) Suggest the healthcare provider reduce the dose of the angiotensin receptor blocker (ARB).

A patient with hypertension and pitting edema is experiencing dizziness and fatigue. Her laboratory results indicate a serum creatinine of 1.4 mg/dL and a potassium level of 5.3 mEq/L. Which nursing intervention should be prioritized to address the patient's current clinical condition?

B) Educate the patient on a potassium-restricted diet.

A) Increase the dose of her current diuretic to reduce edema.

B) Educate the patient on a potassium-restricted diet.

C) Advise the patient to increase fluid intake to manage dizziness.

D) Recommend discontinuing antihypertensive medication until symptoms resolve.

A patient with a history of hypertension and edema is experiencing increased pitting edema, dizziness, and fatigue. Laboratory tests reveal a serum creatinine level of 1.4 mg/dL and a potassium level of 5.3 mEq/L. Which nursing intervention is most appropriate to address the patient's current condition?

B) Educate the patient on the importance of adhering to prescribed dietary restrictions to manage electrolyte balance.

A) Encourage the patient to consume a high-potassium diet to counteract the effects of the diuretic.

B) Educate the patient on the importance of adhering to prescribed dietary restrictions to manage electrolyte balance.

C) Suggest the patient increase fluid intake to help reduce edema.

D) Advise the patient to avoid all physical activity to prevent falls due to dizziness.

Hypertension - Nursing Case Study

Pathophysiology

• Primary mechanism: Increased systemic vascular resistance due to arterial narrowing and stiffening, often from chronic endothelial dysfunction, leads to sustained high blood pressure, placing stress on the cardiovascular system.

• Secondary mechanism: Elevated renin-angiotensin-aldosterone system (RAAS) activity promotes vasoconstriction and sodium retention, increasing blood volume and vascular resistance, further elevating blood pressure.

• Key complication: Persistent hypertension can cause end-organ damage, notably hypertensive heart disease, which includes left ventricular hypertrophy and heart failure, impacting overall cardiac function.

Patient Profile

Demographics:

56-year-old female, office manager

History:

• Key past medical history: Hypertension diagnosed 5 years ago, borderline Type 2 Diabetes

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

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent headache and fatigue

• Key symptoms: Occasional dizziness, blurred vision, chest tightness

• Vital signs: Blood Pressure 160/100 mmHg, Heart Rate 88 bpm, Respiratory Rate 18 breaths per minute, Temperature 98.6°F, BMI 30

Section 1

During the initial assessment, the nurse notes that the patient's blood pressure remains elevated despite adherence to her current medication regimen. The patient's blood pressure is recorded at 160/100 mmHg, indicating a possible need for medication adjustment or the addition of a second antihypertensive agent. On physical examination, the nurse observes mild edema in the patient's lower extremities and elicits a positive response to palpation of the precordial area, suggesting the presence of left ventricular hypertrophy. The patient reports continued episodes of dizziness and blurred vision, which could indicate inadequate cerebral perfusion or possible retinal changes due to chronic hypertension.

The nurse orders a series of diagnostic tests to further investigate the patient's condition. An electrocardiogram (ECG) reveals signs consistent with left ventricular hypertrophy, marked by increased voltage in the QRS complexes. A basic metabolic panel shows a slight increase in serum creatinine at 1.3 mg/dL, indicating potential renal involvement, likely due to long-standing hypertension. A fundoscopic exam reveals hypertensive retinopathy with arteriovenous nicking and a few scattered cotton wool spots, suggesting retinal damage.

These findings prompt the healthcare team to consider more aggressive management of the patient's hypertension to prevent further end-organ damage. The team discusses the possibility of adjusting the patient's current medications, potentially adding a calcium channel blocker or a diuretic to address fluid retention and improve blood pressure control. This adjustment aims to reduce the risk of progression to more severe complications, such as heart failure or chronic kidney disease. The patient is also educated on lifestyle modifications, including dietary changes and increased physical activity, to help manage her hypertension and borderline diabetes. These steps are crucial in preventing further deterioration of her condition and improving her overall quality of life.

Section 2

Following the medication adjustment, the healthcare team introduces a calcium channel blocker to the patient's treatment plan to aid in blood pressure control. Additionally, a low-dose diuretic is prescribed to manage the observed fluid retention. Over the next few weeks, the patient adheres to the revised regimen and reports improved symptoms, including reduced episodes of dizziness. However, during a routine follow-up visit, her blood pressure remains elevated at 150/95 mmHg, suggesting partial but insufficient control of hypertension. Furthermore, the patient continues to experience mild edema in the lower extremities, although it has not worsened.

The nurse conducts a thorough reassessment and notes new findings. The patient complains of a persistent dry cough, which she attributes to her previous medication, an ACE inhibitor, raising concerns about its ongoing suitability. The nurse also observes bilateral pitting edema, now rated as +2, indicating a need for further evaluation of fluid status and heart function. A repeat basic metabolic panel shows that the serum creatinine has increased slightly to 1.4 mg/dL, underscoring the importance of closely monitoring renal function as part of the patient's hypertension management strategy.

Given these developments, the healthcare team considers additional interventions. The persistent elevated blood pressure and renal involvement necessitate a closer look at potential secondary causes of hypertension, such as renovascular disease. The team plans for further diagnostic testing, including renal ultrasound and possibly a renal artery Doppler study, to assess for renal artery stenosis. The patient is also referred to a nephrologist and cardiologist for specialized input on optimizing her treatment plan. These steps are crucial in preventing the progression of cardiac or renal complications and ensuring comprehensive care for the patient’s complex condition.

Section 3

The healthcare team proceeds with the planned diagnostic tests to investigate the possibility of renovascular disease as a secondary cause of the patient's hypertension. The renal ultrasound reveals asymmetrical kidney sizes, with the right kidney measuring smaller than the left, which is suggestive of possible renal artery stenosis. To further evaluate this finding, a renal artery Doppler study is performed and confirms significant stenosis in the right renal artery. These results highlight a likely contributing factor to the patient's uncontrolled hypertension and necessitate a re-evaluation of her current treatment plan.

In light of these findings, the nephrologist and cardiologist collaborate to refine the patient's management. Given the confirmed renal artery stenosis, the team considers the possibility of interventional procedures such as angioplasty to improve renal blood flow. Meanwhile, the patient's medication regimen is adjusted to include an angiotensin II receptor blocker (ARB) in place of the ACE inhibitor, aiming to mitigate the dry cough and provide renal protection. To address the persistent edema, the dose of the diuretic is carefully titrated, and dietary sodium intake is further restricted. The patient is educated on the importance of adherence to her modified treatment regimen and the need to monitor for any new symptoms.

As the patient implements these changes, she reports feeling more energetic and notices a slight reduction in her lower extremity edema. Her blood pressure shows a gradual decrease, now averaging 140/90 mmHg, indicating a positive response to the interventions but acknowledging room for improvement. The healthcare team remains vigilant, scheduling regular follow-ups to monitor the patient's progress, adjust treatment as needed, and prevent potential complications. This ongoing, comprehensive approach aims to stabilize the patient's condition and promote long-term cardiovascular and renal health.

Section 4

Several weeks into the modified treatment plan, the patient presents for a routine follow-up. During this visit, the healthcare team conducts an initial assessment to evaluate her progress and identify any emerging issues. The patient's blood pressure at this appointment is recorded at 135/85 mmHg, demonstrating further improvement. However, the nurse notes mild pitting edema persisting in the lower extremities upon physical examination, suggesting that while the diuretic adjustment has had some effect, it may require further refinement.

Laboratory tests are ordered to assess renal function and electrolyte balance, given the adjustments to her medication regimen. Her renal panel reveals a serum creatinine level of 1.3 mg/dL, which, although slightly elevated, has stabilized compared to previous readings. The patient's potassium level is at the upper limit of normal at 5.0 mEq/L, warranting careful monitoring to prevent hyperkalemia, a known risk with ARB therapy. The team also considers the potential impact of her sodium-restricted diet on these values, emphasizing the importance of balanced nutritional intake.

The nephrologist and cardiologist discuss the possibility of proceeding with a renal angioplasty to address the significant stenosis in the right renal artery, weighing the benefits of improved renal perfusion against procedural risks. Meanwhile, they decide to continue with the current pharmacological strategy, carefully titrating the diuretic dose and monitoring fluid status. The patient is advised to report any new symptoms, such as muscle weakness or palpitations, which could be indicative of electrolyte imbalances. The healthcare team remains proactive, planning the next steps based on the patient's evolving clinical picture, aiming to optimize blood pressure control and mitigate any potential complications.

Section 5

A few weeks after the previous appointment, the patient returns for another follow-up visit. During this visit, the nurse conducts a comprehensive assessment, noting that the patient's blood pressure remains stable at 132/84 mmHg. However, there is a noticeable increase in the severity of the pitting edema in her lower extremities, now rated as moderate on the edema scale. The patient also reports experiencing occasional episodes of dizziness and fatigue, symptoms that were not present during the last visit. These new clinical findings prompt the healthcare team to delve deeper into the possible underlying causes.

Subsequent laboratory tests are ordered to reassess her renal function and electrolyte balance. The results show a slight increase in serum creatinine to 1.4 mg/dL, indicating a potential decline in renal function that could be related to the ongoing hypertension or the diuretic therapy. More concerning is the potassium level, which has increased to 5.3 mEq/L, surpassing the normal range and signaling the onset of hyperkalemia. This electrolyte imbalance could be contributing to the patient's symptoms of dizziness and fatigue, necessitating immediate attention and adjustment of her medication regimen.

The healthcare team discusses the situation extensively, recognizing the need to address the hyperkalemia while continuing to manage the patient's blood pressure and edema. They decide to modify her diuretic therapy, opting for a potassium-sparing alternative and consider adding a low-dose calcium channel blocker to aid in blood pressure control without exacerbating the electrolyte imbalance. The patient is educated on the importance of monitoring her symptoms and maintaining adherence to her prescribed dietary restrictions. The team schedules closer follow-up appointments to closely monitor her progress and ensure that these interventions are effectively addressing the evolving complications.