Introduction
This care study is based on a 75-year-old male patient diagnosed with hypertension whom I met at the placement ward. For the purposes of confidentiality, the patient will be referred to as the patient, and the ward will be referred to as the ward. In such a manner, no specific details will be disclosed to protect the organization and the involved individuals from the breach of privacy. The purpose of the case study is to analyze the episode of nursing care that occurred within the first twelve hours after admission to the ward. The completion of this project is anticipated to contribute to my scope of expertise as a nursing practitioner, expand my practical skills of nursing care, and increase my experience of communicating with patients. The paper’s structure will consist of the assessment process overview, planning for care, implementation, and evaluation. The overall work with the client, their diagnosis, nursing care interventions, pharmacology, and education will be discussed and then evaluated as per success and possible improvements. The paper will be concluded by summarizing the main points and reflecting on the learning opportunities obtained as the result of the project undertaking.
Assessment
When conducting an assessment of the patient’s condition, it is essential to incorporate several aspects of the issue at hand. These elements should include the context of care, psychological and social factors affecting the situation, and the assessment information related to vital signs and symptoms obtained via the application of nursing tools and protocols. According to Carvalho, Oliveira-Kumakura, and Morais (2017), it is “the nurse’s responsibility to accurately interpret the human responses, in order to select appropriate interventions and evaluate the outcomes achieved” (p. 662). Moreover, when conducting the initial assessment of the patient’s condition for diagnosis, the nurse should utilize evidence-based practice principles to validate the most appropriate and objective measures for care delivery (Lo et al., 2018). Thus, the assessment of the patient within the framework of this care study was undertaken using evidence-based practice principles and assessment tools.
The patient is a 75-year-old male who resides with his wife in an easily accessible home. The care to the patient was delivered in the context of the acute medical ward admission. The patient was assessed within the first twelve hours after admission to the acute care ward, where he was admitted with the symptoms of severe hypertension. The patient was at home with his wife and started gradually feeling more and more severe headaches, shortness of breath, and difficulty breathing. The patient experienced an episode of a fall, after which he was admitted to the ward. His condition post-fall was characterized by more severe pains, confusion, and anxiety. Following the episode, the wife admitted the patient to the ward for immediate care delivery. At the ward, the patient was interviewed by the nurse according to the protocol.
It is necessary to note that the application of effective communication strategies during the assessment is key in the accuracy of diagnosis, patient well-being during admission, and the overall outcomes of care delivery. As stated by Sibiya (2018), “communication is a core component of sound relationships, collaboration, and co-operation, which in turn are essential aspects of professional practice” (p. 20). Therefore, in the process of interacting with the patient, the nurse utilized appropriate therapeutic communication techniques and skills to collect necessary data on the patient’s psychological state, social status, current health condition, and medical history.
In particular, the nurse used the technique of active listening to elicit subjective information from the patient. Moreover, the techniques of clarification requesting and recognition giving were used to encourage the patient to engage in communication as well as obtain objective information about the patient’s health history (Abdolrahimi et al., 2017). The nurse used effective relationship-forming approaches to ensure that the patient feels safe and comfortable, as well as confident in the quality of care delivered. In addition, the nurse made sure that all the questions of the patient were answered in a timely, informative, and polite manner. Overall, the patient was interviewed effectively, concisely, and in a comforting atmosphere, which allowed for calming him and obtaining the necessary information.
The patient was assessed using relevant history-taking techniques. In particular, as introduced by Toney-Butler and Unison-Pace (2018), the SAMPLE technique is an effective tool in obtaining health history information from a patient in an efficient manner. The SAMPLE technique includes such elements as “S: Signs and symptoms, A: Allergies, M: Medications, P: Past medical history, L: Last meal or oral intake, E: Events before the acute situation” (Toney-Butler and Unison-Pace, 2018, para. 12). The results of using this approach allowed for identifying that the patient had no allergies, was not taking any medications and had a past history of hypertension. His last meal intake was within ten or eight hours before admission. The events prior to the acute situation were associated with unusual physical activity and nervousness.
In terms of psychological and social factors, one might indicate that he exhibited a high level of anxiety and uncertainty about his condition. He cried and complained about the experienced headache, fatigue, irregular heartbeat, and difficulty breathing. The patient was in a low mood overall during the communication with the nurse. The patient was accompanied by his wife, with whom he resides in an easily accessible house and for whom there was no point of care. As it was informed by the discussion of the selection of communication strategies, the interaction with the patient allowed for eliminating his low mood and informing him about the possible treatment methods for achieving prompt relief of his condition.
In addition, after admission, the patient was interviewed and examined for the collection of the vital signs to assess the patient’s condition. The results of the assessment of the vital signs were indicative of the patient’s diagnosis. In particular, such indicators as blood pressure, temperature, respiratory rate, pulse rate, and nutrition quality were monitored regularly. The results of the vital signs assessment were as follows:
- Blood Pressure – 186/100
- Temperature – 37.0
- Respiratory Rate – 19
- Pulse Rate – 84
Blood pressure monitoring is one of the most important tools for hypertension assessment. In particular, the normal level of blood pressure in a healthy adult is measured as less than 120 for systolic pressure level and less than 80 for diastolic pressure. Therefore, the level of 186/100 is a significantly elevated level of blood pressure. Moreover, the normal respiratory rate for adults is measured around 14 and 16 breaths per minute; the respiratory rate of the patient is elevated since it reaches the level of 19 breaths per minute. Pulse rate and temperature are within their normal range of indicators. As for nutrition, the Waterlow classification tool was utilized to assess the patient’s possible malnutrition category (Sahin, Goktepe, and Ozen, 2017). The patient’s nutrition quality was normal, with no indicators of malnutrition.
Several difficulties in the assessment were faced by the nurse during this stage of care delivery. In particular, the overall state of health of the patient and his low mood obstructed the clarity of communication at first, which might be a factor of bias in some subjective information retrieved during the assessment. Moreover, the patient’s diagnosis of hypertension is characterized by significant risks for other health-related problems. In particular, according to AlWabel et al. (2018), “hypertension is a major risk factor for heart disease, stroke, kidney failure” (p. 1100). Therefore, it is essential to administer proper treatment and ensure adequate patient education to promote a healthy lifestyle and effective hypertension management to minimize these risks for the patient. Overall, the results of the assessment were further used by the nurse to plan, implement and evaluate the care delivery.
Planning
At the stage of care planning, the most important elements of nursing decision-making are the diagnosis identifications and its treatment. For the treatment, the particular medications appropriate for the condition identified and informed by evidence-based practise should be validated. Their pharmacokinetics and pharmacodynamics should be discussed to justify the effect of the chosen medications on the condition and the lack of negative effects on the patient’s health given his concurrent conditions, if any. In such a manner, the planning stage of the care delivery process is covered in this section of the care study with the discussion of the diagnosis, medications, their characteristics, and the summary of the priorities of nursing care.
Pathophysiology of the Diagnosed Condition
After the patient’s admission to the ward, the state of his health was assessed, and the diagnosis of severe hypertension was established. As stated by Xu et al. (2021), “hypertension, a common form of cardiovascular disease (CVD), is a leading risk factor in global disease burden, hence, an important public health problem in the world” (p. 1). The assessment of the patient in relation to this illness required particular attention from the nursing staff, including the accuracy of diagnostics, detection of risk factors, appropriate treatment, and management methods (Himmelfarb, Commodore-Mensah and Hill, 2016). With the diagnosis established, the nurse integrated the evidence-based data on the illness to validate the pathophysiology of the condition and its possible treatment.
Hypertension results from chronically elevated blood pressure levels in a long-term perspective. Increased blood pressure damages the blood vessels and commonly leads to heart failure, stroke, kidney failure, and other comorbidities, as well as premature death (AlWabel et al., 2018). Blood pressure is the product of flow and systemic vascular resistance. Blood pressure is measured in systolic and diastolic blood pressure. Blood pressure is “the ratio of the systolic BP (that is, the pressure that the blood exerts on the arterial walls when the heart contracts) and the diastolic BP (the pressure when the heart relaxes)” (Oparil et al., 2018, p. 2). Overall, the pathogenesis of hypertension is based on the disruption of the renal pressure regulation process. This process involves the reaction of kidneys to high blood pressure by the elimination of water and elevation of sodium level to reduce blood pressure (Harrison, Coffman and Wilcox, 2021; Oparil et al., 2018). The disruption in this function causes constant blood pressure increase and ultimate disruptive effect on the bodily systems.
There are several factors that contribute to the development of hypertension, such as age, ethnic background, overweight, and lack of physical exercise. It was reported that hypertension is asymptomatic and not easily diagnosed until it reaches a systolic of over 200 mmHg (William, 2015). The patient’s age (75 years old) and the lack of physical exercise on a regular basis have been the contributing factors for developing chronically elevated blood pressure and severe hypertension as a result.
Arteries are negatively affected by the condition in the long-term perspective. Indeed, according to Hamrahian (2017), arterial hypertension is related to the constant elevation of systemic blood pressure. As a result, a person might experience severe headaches, dizziness, confusion, fatigue, loss of vision, and other symptoms that might lead to stroke or even death if not treated in a timely manner (Chin et al., 2018). The patient has experienced many of these symptoms with the episode of falling that led to his admission to the ward for care delivery by the professional team.
For an accurate diagnosis, the classification of the disease stages is necessary to consider. The National Institute of Health and Care Excellence (2021) classifies hypertension into two categories that are stage 1 and stage 2, which are supported by an evidence-based study by Saxena, Ali, and Saxena (2018). The first stage or Stage 1 hypertension is when clinic blood pressure is 140/90 mmHg to 159/99 mmHg, and the daytime average is between 135/85 mmHg to 149/94 mmHg (National Institute of Health and Care Excellence, 2021; Saxena, Ali, and Saxena, 2018). The second stage or Stage 2 hypertension is when the clinic blood pressure is between 160/100 mmHg or higher, but less than 180/120 mmHg, and the daytime average is 150/95 mmHg or higher (National Institute of Health and Care Excellence, 2021; Saxena, Ali, and Saxena, 2018). Patients with arterial hypertension may have a rise in cardiac output, a rise in systemic vascular resistance, or both (Foëx and Sear, 2004). In the case of the patient treated at the ward, his condition was diagnosed as Stage 2 Hypertension due to the level of blood pressure reaching 186/100.
Hypertension is a disease that requires treatment; if untreated, it may lead to myocardial infarction, stroke, and kidney failure. The main goal of nursing care for a hypertensive patient is to lower and control the blood pressure. Moreover, it is necessary to normalize vital signs, eliminate symptoms, and ensure the improvement of the overall well-being of the patient. The following list of medications have been administered to the patient:
- Hydralazine 25 mg;
- Felodipine 2.5 mg;
- Atorvastatin 40 mg;
- Indapamide 1.5 mg.
The pharmacology of these medications, their pharmacokinetics, and pharmacodynamics are discussed in the following sub-section of the care study.
Pharmacology of the Medications
In order to eliminate the symptoms and urgently normalize the patient’s blood pressure, the medications were administered according to the protocol. Moreover, the administering of these drugs allowed for avoiding complications and other diseases such as stroke and heart failure (NICE, 2019). The antihypertensive drug is introduced due to the persistence of the symptoms and the age of the patient.
Firstly, Felodipine 2.5mg is the drug introduced to the patient. This medication is used to treat hypertension and is used to prevent heart attacks, heart failure, and stroke. Patients are always advised not to take grapefruit and grapefruit drinks when taking Felodipine because it can make the side effects worsen. The pharmacokinetics of the drug implies its stabilization of calcium channels in muscle cells once transmitted through the blood. This medication’s pharmacodynamics implies lowering blood pressure, making it easier for the heart to pump blood around the body. Felodipine can only be administered to adults over 18 years old (NHS, 2021).
There are common side effects to the drug-like headaches, dizziness, flushing (feeling hot), a pounding heartbeat and swollen ankles. These are common and can be discussed with your doctor if the patient has any concerns. Another side effect of the drug that is not common is having symptoms of allergic reactions such as difficulty breathing swelling of your face, throat, tongue, or lips (Multum, 2021). The patient did not experience any of the above-mentioned side effects of the drug; the level of blood pressure lowered after intake.
Secondly, Hydralazine 25 mg was used to treat high blood pressure in the patient. The drug is commonly used for the acute treatment of severe hypertension (Chera‐Aree et al., 2020). Its pharmacokinetics is based on its easy absorption through the gastrointestinal tract with the following arteriolar vasodilation. The pharmacodynamics of the medication unveils by relaxing the blood vessels so that blood can flow more easily through the body (Chera‐Aree et al., 2020). The side effects of the drug include headache, loss of appetite, or vomiting, neither of which were experienced by the patient.
Thirdly, Atorvastatin 40 mg was administered to prevent heart attack and stroke. Overall, this drug is used to lower cholesterol levels. It is also used to prevent heart disease, including heart attacks and strokes (Perrone et al., 2019). The pharmacokinetics of the drug includes its metabolization by the liver; in terms of pharmacodynamics, the drug inhibits the mevalonate catalyzing enzyme, thus lowering cholesterol in the liver (Perrone et al., 2019). Possible side-effects include aches in the back, constipation, sore throat, and symptoms of cold, neither of which were experienced by the patient in care.
Finally, Indapamide 1.5mg was used to treat high blood pressure (hypertension) and prevent heart failure. From the point of view of pharmacokinetics, the drug is absorbed through oral intake by the gastrointestinal tract and eliminated through plasma (Macfarlane et al., 2019). The pharmacodynamics of the drug implies the normalization of kidney function, which ultimately normalizes the level of blood pressure. Neither of the side effects of the medication, including weakness, numbing, and vomiting, were experienced by the treated patient.
Summary of Priorities of Nursing Care
The prioritization of the decisions made for the patient’s treatment was based on the acute hypertension state that required immediate lowering of the blood pressure. Outside initial intervention, the nurse had administered to manage the symptoms, such as educating the patient on lifestyle changes encouraging the patient to take regular physical exercise (NICE, 2019). Overall, the decisions were made collaboratively with the members of the interprofessional team based on the evidence-informed knowledge and with the incorporation of the patient’s particularities.
Implementation
The implementation of the plan was the most important element of the care delivery process. The patient’s treatment implementation was informed by the evidence-based practice guidelines for acute hypertension care. In particular, the most important element of the treatment was to reduce blood pressure to eliminate the risk of stroke due to the patient’s age and the overall symptoms of severe hypertension (Haidar et al., 2021). The patient was hospitalized and not sent home to ensure continuous professional care and assistance in medication intake, positioning of the patient, and the monitoring of vital signs.
The interventions within the implementation phase of the care process primarily included regular monitoring of blood pressure every two hours to ensure its stable lowering with proper patient well-being. In addition, the nurse applied evidence-based practice interventions of repositioning the patient by regular turning to prevent pressure sores. With the aim of controlling the state of the cardiovascular system of the patient, his skin colour, temperature, capillary refill time, and diaphoresis were regularly checked and evaluated as per the normal condition. Moreover, to eliminate the deterioration of the condition, the patient was encouraged to decrease his intake of caffeine, cola, and chocolates. The communication with the patient for educational purposes guide his lifestyle adjustment to eliminate further risks associated with the complications of hypertension (William, 2015). Indeed, among the implemented interventions, the educational ones were of significant importance.
The nurse educated the patient and family members on diet therapy like salt and cholesterol restriction in diet, as well as educated the patient on the importance of timely and consistent medication intake. Evidence-based practice suggests that hypertension leads to severe complications if untreated, which validates the particular attention paid to the patient’s education on the issue (Chin et al., 2018). In addition, the factors causing hypertension and its signs and symptoms were discussed with the patient to increase his awareness of the condition and ensure his wholesome understanding of the condition and its severity. Finally, the patient was informed about the complications of hypertension in the body and daily living to encourage lifestyle, diet, and medication intake changes on a regular basis.
It is essential to address the input of the interprofessional team to the process of care implementation since the ability to work in teams increases the quality and patient-centred nature of health care delivery. In the process of working with the patient, the team worked collaboratively exchanged experience, knowledge, and professional opinions to make informed decisions. On discharge, the general practitioner obtained the notes on the patient’s condition to monitor the state of his health post-admission. Moreover, the dietician provided the directions as per the regulation of nutrition appropriate for the patient’s condition to minimize risks and educate the patient on the importance of a healthy diet for hypertension management. The cardiologist was contacted to monitor the heart condition due to the severity of the patient’s condition. Finally, the community health care worker was contacted to conduct regular observations of the patient to assist in possible complications or uncertainties. Overall, the work of the interprofessional team was characterized by no complications. The involvement of each member was relevant to their expertise level and the needs of care for the patient. The contribution of each member of the team was invaluable for the balanced and timely care delivery that allowed for fast normalization of the patient’s condition and his following recovery.
Evaluation
As with any working process, the presented plan of care implementation is characterized by positive outcomes, as well as might benefit from several improvements. The patient’s state was characterized by severe hypertension that caused his discomfort, weakness, pain, and low mood, which needed immediate action on the side of the professional team. The complications in the communication were evident at the initial stages of admission and interviewing. However, the nurse managed to incorporate the evidence-based knowledge and professional therapeutic communication skills to calm the patient and exchange vital information to identify the problem and decide on the treatment methods. Overall, the evidence used by the professionals for their decision-making was sufficient but might be improved by the implementation of additional diagnostic tools.
On the one hand, at the stage of assessment, the work with the patient was conducted professionally and constructively, following the protocols and with efficient use of time. Since the patient was in a difficult condition, the delivery of urgent care was essential. In this regard, the assessment and decision-making within the initial steps of care delivery were undertaken swiftly and correctly. The assessment was conducted gradually with all the information obtained from the patient for proper diagnosis. The vital signs indicators were obtained on admission and allowed for concluding on the patient’s condition. In this regard, there might have been an improvement for a more precise diagnosis of the condition with the utilization of specialized diagnostic tools. For example, as informed by Frost et al. (2019), electrocardiography is a reliable method of diagnosis for the identification of pulmonary arterial hypertension. However, additional diagnostic tools such as chest computed tomography would be informative as per the state of the patient’s condition (Frost et al., 2019). However, the conducted diagnostic procedures allowed the team to make relevant and fast decisions that allowed for quick care delivery and relief for the patient.
The patient’s preferences were included sufficiently, given the limited number of particularities on the patient’s side. Overall, his stress level related to the condition required professional attitude and collaborative work of the team to ensure that the care was delivered in a comfortable manner. Moreover, the patient’s inquiries about his state, the restrictions, and medications were addressed fully and in a timely manner. However, this element of care might have been improved by a more in-depth investigation of the patient’s concerns through communication with his wife. The overall quality of care was high, with the patient’s needs addressed fully. The patient was capable of verbalizing the disease process, causes, risks, and treatment methods. He comprehended the regimen of drug intake with the validation of the effects expected from each of the prescribed medications and their possible side effects. The patient’s heart rate and cardiac rhythm normalized, which indicates the positive outcome of the care process implementation.
The study was an informative and experience-enriching practice of working with a patient with severe hypertension. This experience helped me consolidate my theoretical knowledge and practical skills of therapeutic communication, diagnosis, and treatment administering under the circumstances of urgent care delivery. I was capable of working with the interprofessional team that collaboratively made proper decisions relevant to the patient’s condition and particularities. The contribution of each member was invaluable and reinforced the evidence-based practice principles adherence. I managed to improve my stress-coping skills to ensure clarity and consistency of communication with the patient. Moreover, the process of treatment implementation was characterized by complex work aimed at addressing the multifaceted nature of the condition at hand. However, it might be recommended to develop more engaging communication strategies and more diverse diagnostic tools to ensure accuracy of diagnosis and relevance of the chosen treatment. In such a manner, the care study was a significant contribution to my professional development.
Conclusion
In summation, the conducted case study has displayed the case of delivering nursing care to a patient with a severe stage of hypertension. The case allowed for assessing the patient’s condition using relevant tools of assessment and obtaining his health history, psychological and social factors, and vital signs. The diagnostic procedures allowed for identifying severe hypertension with the risk of stroke, the elimination of which was prioritized alongside the lowering of blood pressure. To treat the condition, Hydralazine 25 mg, Felodipine 2.5 mg, Atorvastatin 40 mg, and Indapamide 1.5 mg were administered. The patient was educated about the disease, its risks, preconditions, treatment, and diet. For the long-term treatment, consultations with the members of the interprofessional team were encouraged. In particular, a cardiologist, dietician, general practitioner, and community social worker were involved in long-term care. Overall, the study is a significant contribution to my nursing practice, which will help me improve my therapeutic communication skills, treatment implementation, and diagnostic tool use. The integration of the proposed improvements, including the diversification of diagnostic tools and integration of more patient-centered communication strategies will improve my professionalism in the long run.
References
Abdolrahimi, M. et al. (2017) ‘Therapeutic communication in nursing students: a Walker & Avant concept analysis’ Electronic Physician, 9(8), 4968-4977.
AlWabel, A. H. et al. (2018) ‘Assessment of hypertension and its associated risk factors among medical students in Qassim University, Saudi Journal of Kidney Diseases and Transplantation, 29(5), pp. 1100-1108.
Carvalho, E. C. D., Oliveira-Kumakura, A. R. D. S., & Morais, S. C. R. V. (2017) ‘Clinical reasoning in nursing: teaching strategies and assessment tools’, Revista Brasileira de Enfermagem, 70, pp. 662-668.
Chera‐Aree, P. et al. (2020) ‘Clinical experiences of intravenous hydralazine and labetalol for acute treatment of severe hypertension in pregnant Thai women’, The Journal of Clinical Pharmacology, 60(12), pp. 1662-1670.
Chin, K. M. et al. (2018) ‘Psychometric validation of the pulmonary arterial hypertension-symptoms and impact (PAH-SYMPACT) questionnaire: results of the SYMPHONY trial. Chest, 154(4), pp. 848-861.
Foëx, P. and Sear, J. (2004) Hypertension: pathophysiology and treatment. Continuing Education in Anaesthesia Critical Care & Pain, 4(3), pp. 71-75.
Frost, A. et al. (2019) ‘Diagnosis of pulmonary hypertension, European Respiratory Journal, 53(1), pp. 1-12.
Haidar, L. et al. (2021) ‘Evaluation of hypertension treatment in acute ischemic stroke’, Clinical Epidemiology and Global Health, 11, 1-15.
Hamrahian, S. M. (2017) Pathophysiology of hypertension. Web.
Harrison, D. G., Coffman, T. M., and Wilcox, C. S. (2021) ‘Pathophysiology of hypertension: the mosaic theory and beyond’, Circulation Research, 128(7), pp. 847-863.
Himmelfarb, C. R. D., Commodore-Mensah, Y. and Hill, M. N. (2016) ‘Expanding the role of nurses to improve hypertension care and control globally’ Annals of Global Health, 82(2), pp. 243-253.
Lo, K. et al. (2018) ‘Subjective sleep quality, blood pressure, and hypertension: a meta-analysis, The Journal of Clinical Hypertension, 20(3), pp. 592-605.
Macfarlane, T. V. et al. (2019) ‘The effect of indapamide vs. bendroflumethiazide for primary hypertension: a systematic review’, British Journal of Clinical Pharmacology, 85(2), pp. 285-303.
Multum, C. (2021) Felodipine. Web.
National Institute of Health and Care Excellence (2021) Hypertension: What is it?. Web.
NHS, (2021) Felodipine. Web.
NICE (2019) Hypertension in adults: diagnosis and management. Web.
Oparil, S. et al. (2018) Hypertension. Nature Reviews Disease Primers, 4, pp. 1-48
Perrone, V. et al. (2019) ‘Treatment with free triple combination therapy of atorvastatin, perindopril, amlodipine in hypertensive patients: a real-world population study in Italy’, High Blood Pressure & Cardiovascular Prevention, 26(5), pp. 399-404.
Sahin, Y., Goktepe, A. R., and Ozen, E. (2017) ‘Prevalence of malnutrition in a tertiary hospital in Turkey: overlooked subject?’, Archives of Clinical Gastroenterology, 3(2), pp. 41-46.
Saxena, T., Ali, A. O., and Saxena, M. (2018) ‘Pathophysiology of essential hypertension: an update’, Expert Review of Cardiovascular Therapy, 16(12), pp. 879-887.
Sibiya, M. N. (2018) ‘Effective communication in nursing, Nursing, 19, pp. 20-34.
Toney-Butler, T. J. and Unison-Pace, W. J. (2018) Nursing admission assessment and examination. Web.
Xu, L. et al. (2021) ‘Assessment of hypertension association with arsenic exposure from food and drinking water in Bihar, India’, Ecotoxicology and Environmental Safety, 223, pp. 1-10.
William, H. (2015) Hypertension: pathophysiology and diagnosis. Web.