Clinical Reasoning Questions

1. What risk factors for hypertension does the client have? What other clinical data is relevant? (Using clinical reasoning give and explain your rational for your answer.)

(a) Age BP rises progressively with increasing age. Elevated BP is present in approximately 5o% of people over 65 years of age, with 90% of the remainder developing hypertension during their lifespan.

Since the client is 45 years old male, he is still young to have elevated BP, but his father died of stroke at the age of 60. Therefore, it was possible that his father also had hypertension at an earlier age, and could be the reason for his stroke and eventual death. (b) Alcohol Excessive alcohol intake is strongly associated with hypertension. Clients with hypertension should limit their daily intake to 30 ml of alcohol/day.

As far as this particular client is concerned there is no clinical data present that he takes alcohol or not. Therefore it should be verified before we can make any reasoning. If he does intake alcohol, we should also get the facts about his daily intake. Since, excessive alcohol plays a major role in developing hypertension; it is very important to get it verified with the client or his immediate family member.

(c) Cigarette smoking Smoking greatly increases the risk of cardiovascular disease. People with hypertension who smoke are at even greater risk for cardiovascular disease.

Our client being a heavy smoker (1 packet /day), he is at risk of developing cardiovascular disease. In addition to his smoking, he already has hypertension, which makes him even more vulnerable for cardiovascular related problems. The diagnostic study on ECG reveals left ventricular hypertrophy.

(d) Diabetes mellitus Hypertension is more common in diabetes. When hypertension and diabetes coexist, complications are more severe.

Our client has been diagnosed 5 years ago with type 2 diabetes which he most likely get it from her mother who also has type 2 diabetes. From the data gathered, it is revealed that he is not compliant with the diabetic treatment plan, which makes him more susceptible in developing hypertension. In addition to that, other serious and life threatening complications can arise by having both diabetes and hypertension together.

(e) Elevated serum lipids Elevated levels of cholesterol and triglycerides are primary risk factors in atherosclerosis. Hyperlipidema is more common in people with hypertension.

As far as our client is concerned, the diagnostic studies do not have any data regarding his cholesterol or triglyceride levels. Since high cholesterol is more common in people with hypertension, it is very relevant information and had to be done soon.

(f) Excess dietary sodium High sodium intake can contribute to hypertension in some clients and can decrease the efficiency of certain anti-hypertensive medications. For prevention of hypertension, a dietary sodium intake of 2300mg /day is recommended. In hypertensive clients, dietary sodium intake should be limited to 1495 - 2300mg / day.

From the diagnostic studies done on the client, he has been recommended for a low sodium diet.

(g). SexHypertension is more prevalent in men in young adulthood and early middle age. After age 55, hypertension is more prevalent in women.

Where our client is concerned, he is 45 years old and therefore coming under the age range for men who are more susceptible to have hypertension.

(h). Family history Level of BP is strongly familial. Risk of hypertension increases for those with a close relative having hypertension.

The subjective data gathered on the client, does not show any indications of his parents have/had hypertension. Since his father died of stroke already, there was a strong possibility that he could have had hypertension too. Although, his mother has type 2 diabetes, there is no data that indicate her having hypertension as well.

(i). Obesity Weight gain is associated with increased frequency of hypertension. The risk is greatest with central abdominal obesity. Waist circumference recommendation for men is 102 cm and for women, 88 cm. Maintenance of a healthy weight and body mass index (BMI) of 18.5- 24.9 kg/m2 is recommended.

Physical examination done on the client reveals that he is moderately obese. Therefore, the weight might have been playing a role in increasing hypertension in our client.

(j). Ethnicity Incidence of hypertension is twice as high in Blacks as in whites. Blacks and Aboriginals in Canada have a higher incidence of hypertension than whites.

As our client is an Aboriginal, the possibility of having hypertension is very high.

(k). Sedentary lifestyle Regular physical activity can help control weight and reduce cardiovascular risk. Physical activity may decrease BP. Daily accumulation of 30-60 minutes of moderate -intensity dynamic exercise (walking, jogging, cycling, or swimming) 4- 7 days / week is recommended. Higher intensities of exercise are no more effective.

Our client admits, that he does not do exercise. Therefore, he is at greater risk of having cardiovascular diseases.

(l). Socioeconomic status Hypertension is more prevalent in lower socioeconomic groups and among the less educated.

Since, he is an Aboriginal; there is a possibility that his education is limited. Many of the Aboriginals are restricted to certain way of life, compare to outside their communities. But, to be certain, we need to find out about his educational qualification or the kind of profession he is in.

(j). Stress

People exposed to repeated stress may develop hypertension more frequently than others. People who become hypertensive may respond differently to stress than those who do not become hypertensive.

There is no indication about his profession or what kind of day to day life this particular client leads. Therefore, this information is relevant and has to be obtained from him or his immediate family member. Even though, the client claimed he is not a hyper person, we have to make certain, that his personal life or work place pose any stressful situation.

2. What misconceptions about hypertension should be corrected? (Using clinical reasoning give and explain your rational for your answer.)

(a). He states that he feels fine and is not a "hyper" person. Hypertension is usually asymptomatic, and he feels fine therefore is not always his true health condition. A person who has hyper personality does not necessarily have hypertension. Likewise, Everyone who have hypertension are not always have hyper personality. (b). He has been told that some medications interfere with sexual relationships. This misconception, may be the main reason, he has not been compliant with the treatment plan for his type 2 diabetes. We have to explain that his medical condition not the medications interfere with his sexual relationships. To overcome that he has to strictly follow the recommendations as well as the treatment plans that is prescribed to him. Most of the times, immediate results couldnt be noticed, but long term benefits are certainly there.

3. What areas would you focus on in teaching this client about his illness? (using clinical reasoning give and explain your rational for your answer.)When presenting information to the client or family, the nurse should do the following: (a). I will provide the numerical value of the client's BP and explain what it means. When presenting numerical value of his BP and explaining the ideal range, he will be more than willing to work towards bringing down his BP level. The more the client and his family know and understand about his health condition, the better he is able to adjust and lead a life style that is more appropriate for him. (b). I will inform the client that hypertension is usually asymptomatic and symptoms do not reliably indicate BP levels. Since, he insisted that he feels fine, he should know that most of the time; hypertension does not reveal any symptoms until it is too late. By that time, targeted organ damage and cardiovascular diseases and stroke can take control of his body(c). I will make him understand that hypertension means elevated blood pressure and does not related to a "hyper" personality. (d). I should explain that long - term follow - up and therapy are necessary to treat hypertension. It is very important for him to follow a strict diet plan, take all prescribed medications without skipping, and do regular exercise that is more appropriate for his condition and make some other lifestyle changes. He has to do regular checkups to find out any changes (improved /elevated BP, diabetes condition, any other new threats that pop ups etc) and adjust his treatment according to it. Therefore, it is very important to make him understand that long term follow-ups are necessary to fight back the condition.(e). I will make understand that therapy will not cure, but should control, hypertension. He has to be told that the treatment for his hypertension and diabetes cannot be cured permanently, but following and sticking to his prescribe treatment and a healthy life style can kept the condition under control.(f). I let the client know that controlled hypertension is usually compatible with an excellent prognosis and a normal lifestyle. We have to explain to the client that hypertension kept under control lets him enjoy his life fully, and make him have good sexual relationship as well.(g). I make him fully understand the potential dangers of uncontrolled hypertension. Uncontrolled hypertension leads to very serious life threatening situations. It is responsible for targeted organ damage, stroke, cardiovascular diseases, kidney failure and much more. The client should know all this.(h). It is very important to tell the client all about his medications. We have to be specific about the names, the action, the dosage, and the side effects of prescribed medications. Being known about the side effects and dosage of the medications, the client can seek medical attention in case of overdose or side effects. (i). Hydrochlorothiazide 12.5 mg /daily Side effects: vertigo, headache, weakness, anorexia, nausea, vomiting, diarrhea, constipation, pancreatitis, sexual problems (impotence and decreased libido), blood dyscrasias and dermatological (photosensitivity, skin rash) effects, decrease glucose tolerance. (ii). Enalapril (Vasotec) 5mg/day Side effects: hypotension, loss of taste, cough, hyperkalemia, acute renal failure, skin rash, angioneurotic edema, same as oral forms.(I). I tell the client to plan regular and convenient times for taking medications. Sticking to the same time every day to take the medications has its benefits. By sticking to the same time for a while, the client will automatically remember to take the medications.10. I tell the client not to discontinue drugs abruptly because withdrawal may cause a severe hypertensive reaction. Discontinuing drugs abruptly has serious repercussions and much more dangerous than never taking medications at all. He has to fully understand the dangers of stopping the treatment abruptly. 11. I explain the client not to double up on doses when a dose is missed rather take the medication as soon as he remembers. But if it is close to the time for the next dose, instead of doubling up take the next dose.12. I inform the client that if BP increases, the client should not take an increased medication dosage before consulting with the health care professional. The client should seek medical attention immediately, instead of taking an increased dosage.13. I strongly advise the client not to take a medication belonging to someone else, even if it is used for the same medical condition. Medications are prescribed by medical practitioners according to individual needs and their health condition. The particular brand of medication and the dosage are prescribed considering a clients other health conditions as well. Therefore, I will advise against taking someone-else medications.14. I inform the client that side effects of medications often diminish with time. I ask him not to stop any medications, just because he has some minor side effects. While certain serious side effects needs medical attention immediately, other minor ones like light headache can go away after a while.15. I recommend the client to consult with the health care professional about changing drugs or dosages if impotence or other sexual problems develop. Always letting the healthcare professional know about his troubles and get advice on lifestyle changes as well as change of treatment plans.16. I recommend the client to supplement diet with food high in potassium (e.g., citrus fruits and green leafy vegetables) if taking potassium - losing diuretics. 17. Tell the client to avoid hot baths, excessive amounts of alcohol, and strenuous exercise within 3 hours of taking medications that promote vasodilation.18. Explain that to decrease orthostatic hypotension, the client should arise slowly from the bed, sit on the side of the bed for a few minutes, stand slowly, not stand still for prolonged period, do leg exercise to increase venous return, sleep with the head of the bed raised or on pillows, and lie or sit down when dizziness occurs. 19. Caution about potentially high risk over - the - counter medications. Such as high - sodium antacids, appetite suppressants, and cold and sinus medications. Advice the client to read warning labels and to consult with pharmacist

4. Based on the assessment data presented what is the priority of care? Are there any collaborative problems? How will they affect his treatment? (Using clinical reasoning give and explain your rational for your answer.)1. Ineffective health maintenance related to lack of knowledge of pathology, complications, and management of hypertension.

Anxiety related to complexity of management regimen, possible complications, and lifestyle changes associated with hypertension Sexual dysfunction related to effects of antihypertensive medicationIneffective therapeutic regimen management related to: - lack of knowledge - unpleasant side effects of medication - return of blood pressure to normal while on medication - high cost of some medications - inconvenient schedule for taking medications - lack of trusting relationship with health care professional - Disturbed body image related to diagnosis of hypertension - Ineffective tissue perfusion related to complications of hypertension (specify) The most common complications of hypertension are target - organ disease occurring in the heart (hypertensive headisease), the brain(cerebrovascular disease), the peripheral vasculature (peripheral vascular disease), the kidneys(nephrosclerosis), and the eyes (retinal damage). Collaborative problems:1. Adverse effects from antihypertensive therapy a). Enalapril (Vasotec) 5mg/day Dry cough, angioedema, gastrointestinal irritation, tachycardia, proteinuria, rash, hyperkalemia. b). Hydrochlorothiazide 12.5 mg /dailyHypokalemia (200 mmHg Accelerated malignant hypertension with papilloedema Following severe body burns Severe epistaxis Cerebrovascular: Hypertensive encephalopathy Atheroembolic brain infarction with severe hypertension Intracerebral hemorrhage Subarachnoid hemorrhage Cardiac: Acute aortic dissection Acute refractory left ventricular failure Acute myocardial ischemia or infarction with persistent ischemic pain After coronary bypass surgery Renal: Acute glomerulonephritis Renal crises from collagen vascular diseases Severe hypertension following renal transplantation Excessive circulating catecholamines: Pheochromocytoma Tyramine containing foods or drug interactions with monoamine-oxidase inhibitors Sympathomimetic drug use (e.g., cocaine use) Rebound hypertension after cessation of anthypertensive drugs (e.g., clonidine or guanabenz) Toxemia of pregnancy: Eclampsia Surgical: Severe hypertension in clients requiring emergency surgery Severe post-operative hypertension Post-operative bleeding from vascular suture lines.

3. Stroke Hypertensive crisis related to cocaine or crack use is becoming a more frequent problem that may be complicated by stroke.