A patient with a history of hypertension presents with worsening headaches, blurred vision, and mild edema in the lower extremities. Laboratory tests reveal elevated serum creatinine levels and hypokalemia. The nurse anticipates a collaborative plan to adjust the patient's medication regimen. Which of the following medication adjustments is most appropriate for this patient?

B) Add an ACE inhibitor to the current treatment plan.

A) Increase the dose of hydrochlorothiazide.

B) Add an ACE inhibitor to the current treatment plan.

C) Substitute hydrochlorothiazide with a calcium channel blocker.

D) Initiate a beta-blocker therapy.

A patient with long-standing hypertension and recent renal impairment is being evaluated. Which of the following interventions should the nurse prioritize to address the current clinical concerns and improve the patient's long-term outcomes?

A) Initiate an ACE inhibitor to protect renal function and reduce blood pressure.

B) Increase the dosage of hydrochlorothiazide to enhance diuresis and reduce edema.

C) Recommend a high-protein diet to strengthen cardiac muscle function.

D) Discontinue all antihypertensive medications until renal function stabilizes.

A patient with newly diagnosed diastolic heart failure is experiencing occasional chest discomfort and palpitations after exertion. With her current symptoms and medication regimen, which nursing intervention is most appropriate to prevent further cardiac complications?

B) Educate the patient on the importance of daily weight monitoring and reporting sudden gains.

A) Advise the patient to increase fluid intake to maintain hydration.

B) Educate the patient on the importance of daily weight monitoring and reporting sudden gains.

C) Instruct the patient to discontinue the ACE inhibitor if experiencing dizziness.

D) Encourage the patient to engage in high-intensity exercise to strengthen the heart.

A patient with hypertension and newly diagnosed diastolic heart failure presents with chest discomfort and palpitations. The nurse notes an S4 heart sound and mild jugular venous distension. Which of the following nursing actions is most appropriate to address the patient's current symptoms and prevent further complications?

B) Educate the patient on performing daily weight monitoring to assess fluid retention.

A) Advise the patient to reduce fluid intake to prevent fluid overload.

B) Educate the patient on performing daily weight monitoring to assess fluid retention.

C) Recommend the patient to increase physical activity to improve cardiovascular fitness.

D) Suggest the patient to decrease dietary sodium intake to manage blood pressure.

During a follow-up visit, a patient with a history of hypertension and recent initiation of a beta-blocker reports increased fatigue and occasional dizziness upon standing. Her serum creatinine is 1.8 mg/dL, indicating a decline in renal function. Which nursing intervention is most appropriate to address the patient's risk of orthostatic hypotension and renal function decline?

B) Advise the patient to change positions slowly and ensure adequate hydration.

A) Encourage the patient to increase salt intake to improve blood pressure.

B) Advise the patient to change positions slowly and ensure adequate hydration.

C) Suggest the patient reduce fluid intake to prevent fluid overload.

D) Recommend the patient discontinue the beta-blocker immediately.

A patient with a history of hypertension and recent introduction of a beta-blocker reports increased fatigue and dizziness upon standing quickly. Her blood pressure is 140/88 mmHg, and recent labs show a rise in serum creatinine to 1.8 mg/dL and mild anemia. Which nursing intervention is the most appropriate to address the patient's current symptoms and prevent further complications?

B) Educate the patient on the importance of rising slowly from sitting or lying positions to prevent dizziness.

A) Advise the patient to increase daily physical activity to improve cardiovascular health.

B) Educate the patient on the importance of rising slowly from sitting or lying positions to prevent dizziness.

C) Recommend reducing fluid intake to manage potential fluid overload and hypertension.

D) Suggest increasing dietary potassium intake to counteract the effects of the beta-blocker.

A patient with a history of heart failure and anemia is experiencing persistent dizziness and fluctuating blood pressure despite medication adjustments. Which nursing action is most appropriate to address these symptoms while considering the patient's overall condition?

B) Instruct the patient to rise slowly from sitting or lying positions to reduce dizziness.

A) Encourage the patient to increase fluid intake to manage dizziness.

B) Instruct the patient to rise slowly from sitting or lying positions to reduce dizziness.

C) Advise the patient to stop taking the ACE inhibitor until dizziness resolves.

D) Suggest the patient increase dietary sodium intake to stabilize blood pressure.

A patient with a history of diastolic dysfunction and anemia reports persistent dizziness and occasional shortness of breath. Recent labs show stabilized serum creatinine and decreased hemoglobin. Physical assessment reveals mild jugular venous distension and S4 heart sound. Which intervention should the nurse prioritize to address the current symptoms and prevent further cardiac decompensation?

B) Educate the patient on sodium restriction to help manage fluid status.

A) Encourage increased oral fluid intake to improve blood volume.

B) Educate the patient on sodium restriction to help manage fluid status.

C) Recommend bed rest to reduce exertion and cardiac workload.

D) Advise the patient to take iron supplements to address anemia.

A patient with heart failure is being managed with a low-dose diuretic and dietary modifications. She presents with mild jugular venous distension, lower extremity edema, crackles at the lung bases, and a serum creatinine level of 1.8 mg/dL. Considering her current symptoms and lab findings, what is the nurse's priority action?

C) Notify the physician about the renal function and suggest reviewing diuretic therapy.

A) Increase the diuretic dosage to address fluid overload.

B) Educate the patient on reducing sodium intake further.

C) Notify the physician about the renal function and suggest reviewing diuretic therapy.

D) Initiate oxygen therapy to manage her shortness of breath.

A patient with heart failure is experiencing mild jugular venous distension and crackles at the lung bases. Her serum creatinine has increased to 1.8 mg/dL after starting a low-dose diuretic. Which nursing intervention is most important to address these findings while considering her renal function?

C) Monitor daily weights and report any significant changes to the healthcare provider.

A) Increase the dose of the diuretic to reduce fluid overload.

B) Encourage the patient to increase fluid intake to improve renal perfusion.

C) Monitor daily weights and report any significant changes to the healthcare provider.

D) Discontinue the diuretic to prevent further renal impairment.

hypertension - Nursing Case Study

Pathophysiology

• Primary mechanism: Increased systemic vascular resistance often results from the narrowing of blood vessels (vasoconstriction) or structural changes in the vessel walls. This elevates arterial pressure as the heart works harder to pump blood through narrowed pathways.

• Secondary mechanism: Overactivation of the renin-angiotensin-aldosterone system (RAAS) leads to increased sodium and water retention, raising blood volume and pressure. Angiotensin II also causes vasoconstriction, further elevating blood pressure.

• Key complication: Left untreated, hypertension can lead to left ventricular hypertrophy due to the heart's increased workload, reducing cardiac efficiency and potentially leading to heart failure.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Hypertension diagnosed 5 years ago, family history of cardiovascular disease

• Current medications: Lisinopril 20 mg daily, Hydrochlorothiazide 25 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent headaches and fatigue

• Key symptoms: Dizziness, blurred vision, occasional shortness of breath

• Vital signs: Blood pressure 160/100 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F

Section 1

As part of the initial assessment, the nurse conducts a thorough evaluation of the patient's current symptoms and their progression. Upon examination, the patient reports that her headaches have intensified over the past two weeks, now occurring almost daily and often accompanied by an aura. She also mentions a recent increase in episodes of blurred vision, causing concern given her role as an office manager, where visual acuity is essential. Palpation reveals mild edema in the lower extremities, and auscultation of the heart uncovers a possible S4 heart sound, indicative of decreased ventricular compliance, which is often associated with long-standing hypertension.

Laboratory tests reveal elevated serum creatinine levels at 1.5 mg/dL, suggesting possible renal impairment, a common complication of poorly controlled hypertension. Her electrolyte panel indicates hypokalemia, likely a side effect of hydrochlorothiazide, which can contribute to fatigue and muscle weakness. A 12-lead ECG shows evidence of left ventricular hypertrophy, correlating with the increased workload on the heart due to persistent high blood pressure. These findings suggest that the patient's hypertension is not adequately controlled, and there is a need to reassess and possibly intensify her treatment regimen.

The nurse, in collaboration with the interdisciplinary team, considers adjusting the patient's medication to better manage her hypertension and address the emerging renal concerns. An ACE inhibitor or angiotensin receptor blocker (ARB) with renal protective properties may be beneficial. Additionally, the nurse educates the patient on lifestyle modifications, such as dietary changes to reduce sodium intake and incorporating regular physical activity, which can help in managing her blood pressure more effectively. These interventions aim to mitigate further complications, such as heart failure or advanced renal disease, and improve the patient's overall quality of life.

Section 2

New Complications:

Two weeks after the implementation of the adjusted treatment plan, the patient returns for a follow-up appointment. During this visit, she reports experiencing occasional episodes of chest discomfort and palpitations, particularly after exertion or during periods of stress at work. Her blood pressure remains elevated at 152/96 mmHg despite adherence to the prescribed medication regimen, which now includes an ACE inhibitor. The nurse notes that while the frequency of headaches has decreased, the patient still experiences blurred vision intermittently. Additionally, there is a slight increase in the edema of her lower extremities, and she now presents with mild jugular venous distension, a potential indicator of worsening cardiac function.

The nurse conducts a focused cardiac assessment, noting a more pronounced S4 heart sound, and orders further diagnostic testing. An echocardiogram reveals left ventricular hypertrophy with reduced diastolic filling, suggesting the onset of diastolic heart failure. Laboratory tests show a slight increase in serum creatinine to 1.6 mg/dL, although potassium levels have stabilized with dietary adjustments. Given the new symptoms and diagnostic findings, there is a heightened concern for the progression toward heart failure, necessitating a more aggressive intervention strategy.

The interdisciplinary team convenes to discuss the patient's management plan. It is decided to introduce a beta-blocker to help manage her heart rate and reduce myocardial workload. Additionally, the patient is referred to a cardiologist for further evaluation and management. The nurse emphasizes the importance of monitoring daily weights and recognizing signs of fluid overload at home. The team also reinforces the need for ongoing lifestyle modifications, including stress management techniques, to support the medical treatment and prevent further cardiac and renal complications. These steps are critical in averting the development of more severe conditions and maintaining the patient's functional capacity and quality of life.

Section 3

Two weeks following the introduction of the beta-blocker and her referral to a cardiologist, the patient returns for another follow-up appointment. During this visit, she reports a slight improvement in her chest discomfort and palpitations; however, she has noticed increased fatigue and occasional dizziness, especially upon standing quickly. Her blood pressure reading is now 140/88 mmHg, indicating some improvement, but still not at target levels. A repeat cardiac assessment reveals that the S4 heart sound persists, and there is no significant change in her jugular venous distension or lower extremity edema.

The nurse reviews the patient's recent laboratory results, which show that her serum creatinine has risen slightly to 1.8 mg/dL, raising concerns about her renal function. Her potassium levels remain stable, but there is a noted mild anemia with a hemoglobin level of 11.2 g/dL, suggesting potential chronic kidney disease progression. The patient's echocardiogram is re-evaluated, and while there is no significant change in the left ventricular hypertrophy, the diastolic dysfunction appears slightly more pronounced.

Given these findings, the interdisciplinary team revisits the management plan, recognizing that while the beta-blocker has provided some symptomatic relief, the patient's renal function and anemia require further attention. The team discusses the possibility of adjusting the ACE inhibitor dosage or considering an alternative medication to better protect her renal function. Additionally, they emphasize the need for the patient to maintain adequate hydration and monitor her blood pressure closely at home. The nurse educates the patient on recognizing early signs of worsening renal function and the importance of consistent follow-up appointments to prevent further complications. This comprehensive approach aims to stabilize her condition and prevent the escalation of both cardiac and renal issues.

Section 4

As the weeks progress, the patient adheres to the revised management plan, including the adjusted dosage of her ACE inhibitor. During a subsequent follow-up visit, she reports feeling slightly more energetic, but the dizziness episodes continue to persist, especially in the mornings. Blood pressure readings taken at home have shown fluctuating values, ranging from 135/85 mmHg to 150/92 mmHg, suggesting a potential need for further medication adjustment. A repeat blood panel reveals her serum creatinine has stabilized at 1.7 mg/dL, which is a slight improvement, but her hemoglobin level has decreased further to 10.8 g/dL, indicating a progression of her anemia.

The nurse conducts a thorough physical assessment, noting that the S4 heart sound persists, and there is now mild jugular venous distension, though her lower extremity edema remains unchanged. The patient's heart rate is slightly elevated at 92 beats per minute, and she reports experiencing occasional shortness of breath during mild exertion. Given these new findings, the interdisciplinary team considers the possibility of worsening heart failure, likely exacerbated by her persistent diastolic dysfunction and anemia.

The team discusses the introduction of a low-dose diuretic to manage her fluid status and potentially alleviate the symptoms of heart failure, while also considering the risks to her renal function. They further emphasize the importance of dietary modifications, including reduced sodium intake, to support blood pressure management and fluid balance. The nurse reinforces the necessity of monitoring for signs of fluid overload or electrolyte imbalances and encourages the patient to maintain regular communication with her healthcare providers. This proactive approach aims to mitigate the risk of further cardiac decompensation and renal decline, setting the stage for ongoing evaluation and adjustment of her treatment plan.

Section 5

A few weeks after the introduction of a low-dose diuretic and continued dietary modifications, the patient returns for another follow-up visit. She reports some improvement in her shortness of breath, though she still experiences occasional episodes during moderate exertion. Her dizziness has slightly decreased in frequency but still poses a concern, especially in the mornings. During this visit, her blood pressure is measured at 140/88 mmHg, suggesting a slight improvement in control, but her heart rate remains elevated at 95 beats per minute. The nurse notes the persistence of mild jugular venous distension and an unchanged degree of lower extremity edema.

Recent laboratory results provide further insight into her current status. Her serum creatinine has increased slightly to 1.8 mg/dL, raising concerns about renal function in the context of diuretic therapy. Additionally, her hemoglobin level has decreased to 10.5 g/dL, indicating a progression of her anemia, which may contribute to her fatigue and dyspnea. The nurse also observes an S4 heart sound and a new finding of crackles at the lung bases upon auscultation, suggesting possible pulmonary congestion.

The interdisciplinary team meets to discuss these developments, considering the balance between managing her heart failure symptoms and protecting renal function. They deliberate on adjusting her diuretic dosage and explore alternative anemia management strategies, such as iron supplementation or erythropoiesis-stimulating agents. The team emphasizes the need for close monitoring of her renal function and electrolyte levels, as well as continued vigilance for any signs of fluid overload or decompensated heart failure. The patient is encouraged to maintain her dietary modifications and to report any new or worsening symptoms promptly, ensuring vigilant management of her evolving condition.