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Stenberg College NURS 201-3 Weekly Case Study and Care Plan
Clinical group Members:___ Cara Mason, Faith Burr, Davina Magarrell, Ashley Grittner,
Courtney Humphrey, Shiena Brar, Marina Bettiol, Loveleen Bhandal
Date:__June 20, 2014____________________
Case Study Critical thinking questions
1.
What risk factors for hypertension does James have?
James has a number of risk factors that could have contributed to his hypertension.
Firstly, James is of Aboriginal descent. According to Bradley (2014), hypertension is far
more prevalent amongst the Aboriginal population than it is in the non-Aboriginal
population. Added to this, hypertension in Aboriginal patients develops at an earlier
age, is more aggressive and results in more severe end-organ damage (p. 867). Secondly,
hypertension tends to run in families and James has a familial history of cardiovascular
disease as his father died of stroke at the age of 60. Thirdly, life style factors that James
engages in are significant contributing risk factors for hypertension. For example, James
smokes one package of cigarettes per day. Smoking is said to be a major risk factor for
cardiovascular disease and the nicotine contained in the cigarettes causes
vasoconstriction and increases blood pressure rates (Bradley, 2014, p. 878). James also
admits to drinking a six pack of beer on Friday and Saturday nights. The consumption of
excessive alcohol is another risk factor for hypertension (p. 878). Finally, James states
that he does not like to exercise. Lack of exercise is also a risk factor and all adults
should strive to engage in at least 30 minutes of moderate-intensity exercise each day
(p. 886). James is currently observed to be moderately obese and being overweight or
obese is a significant risk factor for hypertension as the more a person weighs, the more
blood that is required to supply oxygen and nutrients to the tissues of the body. As the
volume of blood increases, the pressure on the artery walls also increases contributing
to high blood pressure (Mayo Clinic, 2014). James’ current age is also a risk factor. He is
45 years old and the risk of high blood pressure increases as one ages (Mayo Clinic,
2014).
2.
What evidence of target organ damage is present?
According to Bradley (2010), target-organ diseases are the most common complications
of hypertension. As such, target-organ diseases can occur in the heart as hypertensive
heart disease, in the brain as cerebrovascular disease, in the peripheral vasculature as
peripheral vascular disease, in the kidneys as nephrosclerosis and in the eyes as retinal
damage (Bradley, 2010). In the case of this client, James, target organ damage is
evident. The ECG results showed a left ventricular hypertrophy which is evidence of
damage to the heart as
“sustained high blood pressure increases cardiac overload”
(Bradley, 2010, p. 829). If this continues, it can lead to heart failure because the heart
can no longer pump enough blood to meet the body’s needs. Further, there is evidence
of renal/kidney damage as James’s urinalysis indicates protein at a value of 0.3 g/L
which is indicative of proteinuria. James’s serum creatinine level is elevated at a value of
141 mmol/L which is also evidence of chronic kidney disease as it is above 130 mmol/L
(Bradley, 2010). According to Bradley (2010), further organ damage is also evident by
changes in the retina. Hypertension, if not treated and managed can also lead to
cerebrovascular disease in the form of atherosclerosis and stroke. This point to the
importance for James to adhere to treatment, comply with medication and make
lifestyle changes to manage hypertension before there is further organ damage.
3. What misconceptions about hypertension should be corrected?
James seems to think that hyperactive people are more susceptible to hypertension
than people who are more laid back. He can be educated about hypertension and that it
often does not have any noticeable symptoms (Bradley, 2010). It is often referred to as
the “silent killer” (Bradley, 2010). Being and Aboriginal man, James is in a higher risk
group than others (Bradley, 2010). James may have heard from someone that
antihypertensive medication interferes with the libido. Some teaching about
hydrochlorothiazide and enalapril would be in order as these medications do not
generally interfere with sexual function (MedlinePlus, 2014).
4. What areas would you focus on in teaching this client about his illness?
Being that James drinks, smokes and admits to not exercising regularly, lifestyle
modifications needs to be emphasized when teaching this client about hypertension. It
is important to explain to the client that his nutrition is important to the maintenance of
his health and the dietary management for hypertensive individuals includes the
“restriction of sodium, calcium, magnesium intake; and calorie restriction” (Levine,
2006, p. 794). It is crucial to suggest that James should follow the DASH diet as
recommended by the American Heart Association and the Heart and Stroke foundation
of Canada. This diet encourages the client to eat several servings of fish every week,
plenty of fruits and vegetables and increasing fiber and water intake (Levine, 2006).
James is a moderately obese male, therefore exercise regimens should be discussed as
well as weight reduction due to dietary intake and physical activity is recommended for
overweight hypertensive clients. It is suggested that in order to promote cardiovascular
health, adults should be exercising thirty minutes or more on most, and preferably every
day of the week to help weight reduction and maintain physical health (Levine, 2006).
James admits to being a moderate drinker on Friday and Saturday nights, therefore
indicating to the nurse that alcohol consumption should be discussed. Drinking more
than three alcoholic beverages daily is a risk factor for heart disease and stroke, as
alcohol intake is heavily associated with hypertension. With this in mind, hypertensive
clients should be advised to limit their alcohol intake to 1 oz., per day, or in James’s
case, 24 oz., of beer daily (Levine, 2006). James is also a heavy smoker who admits to
smoking a pack of cigarettes a day. The nicotine in tobacco products causes
vasoconstriction and increases blood pressure in hypertensive people, and leads to a
high risk for cardiovascular disease (Levine, 2006). Smoking cessation and the impact
tobacco has on his health should be discussed with James. Stress management can also
be taught to the client, as moments of stress can elevate blood pressure. The patient
can be taught relaxation techniques such as deep breathing, guided imagery and
biofeedback to help maintain blood pressure during stress (Levine, 2006).
James should also be taught about his medication regime and the importance of
compliance. Being that James’s father died of a stroke, and he suffers from type 2
diabetes in which he is noncompliant to the treatment, it is crucial to educate the
patient on the severity hypertension can have on his health, especially in correlation
with an unhealthy lifestyle, underlying disease and non-compliance to treatment. James
is in a high risk group of hypertension, and the importance of his treatment cannot be
understated. Informing the client about side effects of the medication may increase the
chance of compliance, but because James believes that he is fine and is concerned with
the sexual dysfunction that may be associated with his medication, therefore teaching
the necessity of compliance may pose as difficult. Therefore expressing the concern and
high risk the client is at for the development of cardiovascular disease or stroke is
crucial. In addition to lifestyle modifications and medication compliance teaching, James
needs to be taught how to monitor his own blood pressure in order to know when his
blood pressure rises and when it maintains an adequate rate in order to evaluate the
efficacy of his treatment and the concern related to noncompliance (Levine, 2006).
Based on the assessment data presented, write 3 appropriate nursing diagnoses. Are
there any collaborative problems? How will they affect James’ treatment?
3 related NANDA diagnoses:
1. Risk for decreased cardiac output related to increased afterload,
vasoconstriction, myocardial ischemia, ventricular hypertrophy.
2. Knowledge deficit related to lack of information about the disease process and
self-care.
3. Non-compliance (may lead to ineffective or partially ineffective outcomes, if
patient’s behaviour is fully or partially non-adherent to their therapeutic plan.)
Collaborative problems:



Diabetes – and non-compliant with treatment
o Insulin resistance is a risk factor for the development of hypertension in
cardiovascular disease. High insulin concentration elevates CNS activity,
which in turn impairs nitric oxide-mediated vasodilation.
Smokes a pack of cigarettes a day
o Nicotine contained in tobacco creates vasoconstriction and increases BP.
Additionally, smoking is a major risk factor for cardiovascular disease.
Within 1 year of quitting smoking, health benefits are seen. Smoking
cessation aids can help, as they do not typically raise BP.
Drinks a six-pack of beer both Fri and Sat nights
o Consumption of 3 or more drinks daily can be a risk factor for heart
disease and stroke. Intake needs to be limited to 30mL’s per day.




Does not like to exercise
o To promote cardiovascular health, adults need 30 minutes of moderate
intensity of physical activity on most days of the week. If James does not
like to exercise, perhaps there are different forms of cardio exercise that
he could explore (ie. team sports vs. individual pursuits, bike riding
instead of walking, etc.)
Potential for medication non-compliance due to the possibility of sexual
complications
o Adherence is a key point of collaborative care, because the best outcome
is with lifestyle changes and drug therapy combined.
Family history of stroke
o High blood pressure contributes to higher chances of a stroke, and then if
James has a family history, then James might find himself at a higher risk
for a stroke.
Moderately obese
o Weight gain is associated with hypertension, and specifically the appleshaped person (carrying the weight around the vital organs).
As James is sitting at a moderate cardiovascular risk, and that is what the management
plan is based on, there need to be some lifestyle modifications. Medication can work in
collaboration with lifestyle changes, but the medication regime needs to be adhered to.
List in order of priority, three nursing diagnosis (NANDA based).
Give the rationale for the priorities you have selected.
Nursing Focus of Care / Nursing Diagnosis
Rationale for Priority
Anxiety related to management of disease, any
complications and lifestyle changes due to disease
Client may feel overwhelmed with difficulty of
managing the illness
Ineffective therapeutic regimen management related
to unpleasant side effects of medication
Many medications cause adverse side effects that can
result in non-adherence to medication.
Sexual dysfunction related to effects of
antihypertensives medication
It is important to ensure the client is able to continue
normal activities without the disruption of side effects
from medications
Stenberg College 201-3 Weekly Care Plan
Stenberg College RDNP Program
Week 8 Nursing Care Plan: Hypertension
Nursing
Diagnosis
NDX: (Problem)
Desired
Outcomes
Goal (Reversal
of Problem)
Knowledge
deficit related to
lack of
information
about the
disease process
and self-care.
Patient will
verbalize
understanding
of the disease
(hypertension)
and self-care.
R/T: etiology/
factor):
Expected
outcomes:
Misinterpretation
of information
and lack of selfcare.
1. Patient
demonstrates
motivation to
learn.
AEB: (s/sx;
defining
characteristics)
2. Patient
describes
strategies for
managing
hypertension
1. Verbalizes
inaccurate
information
regarding
hypertensionstates he is not a-“hyper” person
and feels fine.
3. Patient
identifies
perceived
learning needs
Interventions
(I)Independent
(C)Collaborative
N1-(C)
Encourage
questions
about
hypertension
and its
prescribed
treatments.
Rational & APA
References
R1- Questions
facilitated open
communication
between the
patient and
health care
providers which
in turn, allows
the verification
of
understanding
of given
information
and the
opportunity to
correct
misconceptions
(Gulanick &
Myers, 2014, p.
339).
Evaluations of
Interventions
E1- From June 20th-27
the patient will ask at
least 10 question
regarding hypertension
and treatment to the
nurse and/or Doctor.
E2- The patient will be
able to correctly
reiterate information
Client will
2. Patient smokes have (list
one pack of
measurable
cigarettes daily.
outcomes;
reverse signs
3. Patient drinks
and
a six-pack of beer symptoms)
on the weekends.
1. Patient will
4. Patient admits verbalize
that he does not accurate
like to exercise.
information
about
5. Inaccurate
hypertension.
follow-through of
diabetic
2. Patient will
treatment plan.
stop smoking.
N2-(C)
Assess the
patient’s
knowledge
about
hypertension
and its
causes.
R2- Assessment regarding hypertension
is a vital
and its causes to the
starting point in nurse by June 27, 2014.
education. The
patient must
understand
that
hypertension is
a chronic,
lifelong disease
and they play a
vital role in the
management of
it (Gulanick &
Myers, 2014, p.
339).
N3-(C)
Provide
rationales and
strategies for
the reduction
of alcohol
intake (no
more than
two drinks a
day).
R3- Research
shows that
increases
alcohol
consumption is
associated with
high blood
pressure
(Gulanick &
Myers, 2014, p.
340).
3. Patient will
limit his
alcohol
consumption
on the
weekends
4. Patient will
follow an
exercise
regime.
5. Patient will
adhere to
treatment plan
instructions.
R4- Weight
reduction from
N4-(C)
exercise has
Provide
been
rationales and consistently
strategies for demonstrated
weight
blood pressure
reduction and lowering
E3- Before discharge,
patient will be able to
reiterate to nurse why a
reduction of alcohol
consumption is
important to their overall
health and the treatment
of hypertension.
E4- Before discharge, the
patient will explain to the
nurse the importance of
daily exercise and weight
reduction in the
treatment of
hypertension.
exercise.
effects
(Gulanick &
Myers, 2014, p.
340).
N5-(C) Assess
for risk factors
that may
negatively
affect
patient’s
adherence to
the treatment
plan.
R5-Knowledge
of causative
factors will help
provide
direction for
subsequent
interventions.
Causative
factors may
include lack of
social support,
lack of financial
resources,
compromised
emotional state
and
values/beliefs
(Gulanick &
Myers, 2014, p.
340).
Compiled for Stenberg College RDPN program
2014
E5-Patient will adhere to
treatment plan for
hypertension, and follow
advice/recommendations
from Doctor.
References
Bradley, E. G. (2014). Nursing management: Hypertension. In Barry, M. A., Goldsworthy,
S. & Goodridge, D. (Eds.), Medical-Surgical nursing in Canada: Assessment and
management of clinical problems (3rd Ed) (pp. 866-890). Toronto, CA: Mosby Elsevier
Gulanick, M., Myers, J. (2014). Nursing Care: Diagnosis, Interventions and Outcomes, 8th
edition .Elsevier, Mosby, Philadelphia, PA.
Levine, B.S. (2006). Nursing management: Hypertension. In Lewis, S., Heitkemper, M.,
Dirksen, S. R., O'Brien, P. G., Barry, M., Goldsworthy, S., & Goodridge, D. (Eds.). Medicalsurgical nursing in Canada. (pp. 787-809). Toronto, ON: Mosby Elsevier
Mayo Clinic (2014). High blood pressure (hypertension). Retrieved from:
http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/riskfactors/con-20019580
MedlinePlus (2014). Enalipril. Retrieved from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a686022.html
MedlinePlus (2014). Hydrochlorothiazide. Retrieved from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682571.html