University of the Immaculate Conception

Fr. Selga St., Davao City, Philippines

A Case Study on Hypertensive Urgency

Presented by:
Francisquette, Edrene Joy
Gawilan, Apple Pearl Osheane
Goloran, Maxuel B.
Hernandez, Marianne Rose C.
Landasan, Sitti Shayra V.
Lumanggal, Bai Rahaaf M.
Macarambon, Aila M.
Malintad, Aisha V.
Manguiob, Jellie Aiko

Presented to:

Francis Paulo C. Oquendo, RN

John Grunart D. Lim, RN
Eunice Lyka M. Tabanao, RN

January 2023
 I. INTRODUCTION

Hypertension remains one of the most significant causes of mortality worldwide.

Blood is carried from the heart to all parts of the body in the vessels. Each time the heart

beats, it pumps blood into the vessels. Blood pressure is created by the force of blood pushing

against the walls of blood vessels (arteries) as it is pumped by the heart. The higher the

pressure, the harder the heart has to pump. Primary hypertension can be defined as an

elevated BP of unknown cause due to cardiovascular risk factors resulting from changes in

environmental and lifestyle factors. Another type, secondary hypertension, is caused by

various toxicities, iatrogenic disease, and congenital diseases. Complications of hypertension

are the clinical outcomes of persistently high BP that result in cardiovascular disease (CVD),

atherosclerosis, kidney disease, diabetes mellitus, metabolic syndrome, preeclampsia, erectile

dysfunction, and eye disease.

Hypertensive Emergency

A hypertensive emergency is an acute, marked elevation in blood pressure that is

associated with signs of target-organ damage. These can include pulmonary edema, cardiac

ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia.

Hypertension Urgency

Hypertensive urgency is a marked elevation in blood pressure without evidence of

target organ damage, such as pulmonary edema, cardiac ischemia, neurologic deficits, or

acute renal failure. Specific cutoffs have been proposed, such as systolic blood pressure

greater than 180 mmHg or diastolic blood pressure greater than 110 mmHg, but these are

arbitrarily derived numbers that have not been associated with short-term morbidity or

mortality. Given this, some have proposed reserving the term hypertensive urgency for
patients with severely elevated blood pressure and significant risk factors for progressive end-

organ damage such as congestive heart failure or chronic kidney disease.

STATISTICS

Davao City

Total Population of Hypertension in Davao City (1,432). Forty six percent (46%)

were males and 54% were females. Ages ranged from 15 to 82 years. The prevalence of

combined definite and borderline hypertension is 23% in Davao City. The prevalence was

higher among the males. In Davao City, 38.1% were aware of their hypertension. Only 6.7%

in Davao City were under proper treatment and control. Certain socio-cultural, clinical and

laboratory parameters were found to be significantly related to the occurrence of hypertension

in Davao City. Among these are: family history of hypertension, past history of kidney

disease, low educational attainment, low socio-economic status, poor reception of economic

sufficiency, migrant status and poor urban exposure prior to migration, high salt intake, low

levels of physical activity, smoking, abnormal blood sugar, cholesterol and serum uric acid.

Obesity was not found to have any significant influence on the prevalence.

Philippine

According to the latest WHO data published in 2020 Hypertension Deaths in

Philippines reached 34,500 or 5.12% of total deaths. The age adjusted Death Rate is 49.65

per 100,000 of population ranks Philippines #16 in the world. Hypertension ‐related stroke is

the top cause of mortality in our country.

In summary, hypertension still remains a major problem in the Philippines as it

accounts for more deaths and disabilities. Hypertension‐related stroke is the top cause of

mortality in our country. This is brought about by lack of awareness, poor compliance, and
inadequate BP control. With the availability of newer and practical tools such as the home BP

monitoring, it will certainly improve hypertension evaluation, patient awareness, physician's

alertness in achieving better BP control and hence, better outcomes.

Worldwide

Estimates suggest that in 2010, 31.1% of adults (1.39 billion) worldwide had

hypertension. The prevalence of hypertension among adults was higher in (31.5%, 1.04

billion people). The age-standardized prevalence of hypertension was slightly higher in men

(31.9%) than in women (30.1%). The number of adults with hypertension increased from 594

million in 1975 to 1.13 billion in 2015, with the increase seen largely in low- and middle-

income countries. This increase is due mainly to a rise in hypertension risk factors in those

populations. The number of adults aged 30–79 years with hypertension has increased from

650 million to 1.28 billion in the last thirty years, according to (WHO).
 II. OBJECTIVES

This research case study aims to give broad knowledge, develop skills and preventive

measures towards Hypertensive Urgency disease based on the collected data and survey from

the patient. This case study also demonstrates the student's understanding of a patient's

general health and health status, as well as the patient's diagnosis, illness process, potential

complications, treatment plan, and nursing interventions.

SPECIFIC:

1. Describe and demonstrate the appropriate technique for blood pressure assessment.
2. Describe the operator and patient factors that can artificially raise and lower blood
pressure.
3. Define how to diagnose hypertension in a family practice setting for different patient
groups, and identify the blood pressure targets for these groups.
4. Describe the role of patient determined blood pressure and 24-hour ambulatory blood
pressure assessment in diagnosis and monitoring of hypertension.
5. Describe the effects of hypertension on end-organs and how to assess a patient for these.
6. Propose an initial diagnostic workup for a patient with a new diagnosis of high blood
pressure to determine if there is a secondary cause for hypertension (versus essential
hypertension)
7. Define the diagnostic and treatment targets for various groups of patients with high blood
pressure.
8. Propose a treatment plan (incorporating non-pharmacologic and pharmacologic options)
for a patient with a new diagnosis of high blood pressure
9. Recognize and act on a hypertensive crisis
10. Describe the various drug classes used to treat high blood pressure and their mechanisms
of action, side effects, relative cost, and pharmacokinetics.
III. PATIENT’S DATA

Name: Reyes, Heraccleo Jr. Lanaja

Age: 21 years old

Address: PRK. Paglaom, Sawata San Isidro

Sex: Male

Civil Status: Single

Birthday: September 10, 2001

Birthplace: Sawata, San Isidro Davao Del Norte

Nationality: Filipino

Religion: Roman Catholic

Contact Number: None

Occupation: None

Father’s Name: Heracleo Reyes Sr.

Occupation: Deceased

Mother’s Name: Julia Reyes

Occupation: House wife

Case Number: 262406

Date Admitted: February 1, 2023

Time Admitted: 8:07 pm

Chief Complain: Headache, LOC, Increase BP

Final Diagnostic:

Residence on Duty: Riña- Razonable, MA. Elizabeth. M.D.

Attending Physician: Gazmen, Lew Ian L. M.D

Reason for Admission: MGT

IV. GENOGRAM

Figure 1. The figure above shows the patient’s genogram with its corresponding legends

being indicated below.

The genograms of the patient are exhibited in relation to their family histories as

illustrated above. Upon presentation to Figure 1, Heraccleo Reyes Sr. who is the patient's

father has a history of hypertension and unfortunately, died. Julia Reyes Is 62 years old and

the mother of the patient. Of all the siblings in the family, the patient is the fourth child. He

has three older brothers. The oldest brother is Junrie Reyes who is 36 years old, working as an

OFW. The second brother is a 35-year-old driver named Marjun Reyes. Anthony Reyes, the

third brother, is a 32-year-old man. Based on the family health history, there is clear evidence

that the patient has acquired the condition hereditarily. The patient, Heraccleo Reyes, is 21

years old, a student, and currently has hypertension.

V. HEALTH HISTORY

A. PRESENT HEALTH HISTORY

Before being admitted, the patient developed a headache and nape pain that lasted for

two weeks. He complained of headaches, LOC, and high blood pressure as his main

symptoms. With an admitting diagnostic of hypertensive urgency r/o aneurysm and coronary

artery disease r/o myocardial infarction, he was advised to be in the intensive care unit and

was subsequently admitted.

B. PAST HEALTH HISTORY

Prior to admission the patient verbalized that he had dengue when he was 18 years old.

VI. PHYSICAL ASSESSMENT

I. GENERAL SURVEY

General Appearance
The client is a 21 years old male that is awake and weak. Under
continuous monitoring. Which chief complaints are headache,
LOC, and increased blood pressure.

Vital Signs Vital Signs Day 1 Day 2

Temperature 36.6 37.7
Cardiac Rate 58 76
Respiratory Rate 21 21
Blood Pressure 110/25 130/100

Height and Weight

Height: 162 cm or 5’3 inches
Weight: 90 kg or 198 lbs
Body Mass Index: 34.3 (Overweight)
Skin and Hair INTEGUMENTARY

● Skin: The client’s skin is normal with brown color, left

hands with IV sites
● Nail: Nail Bed is normal. Capillary refill; good.
● Hair: The client’s hair is normal neither too dry nor too oily
with no lesions.
Head, Eyes, Ears, HEENT:
Nose, and Throat
● Head: Is cephalic with no scars or lesions
● Ears: Appearance is normal and eardrums are intact.
● Eyes: Downturned eyes with pink palpebral conjunctivae.
● Nose: The client’s nose is typical with no lesions
● Mouth/ Throat/ Pharynx/ Teeth: Normal.

Lips, Neck, and ● Supple neck

Lymph Nodes ● bilateral cervical, axillary, and inguinal nodes
● (-) jugular vein, carotid bruits, nodules, and thyromegaly
distension.
Lungs and Thorax The patient's lungs are audibly clear throughout, producing good
breath sounds, and there are no spinal or costovertebral angle
tenderness.
Heart The patient's heart beats regularly, (-) rubs, and gallops. And a
strong systolic ejection murmur is present.
Abdomen There is no guarding, organomegaly, lumps, or bruits in any of the
patient's four abdominal quadrants, and the bowel sounds are
normal. The abdomen is soft and there is no pain being felt.
Rectum/ Genitalia The patient's genitalia and rectum are both in normal condition but
with an attached foley catheter. The organs are not out of place or
scarred.
Musculoskeletal and The dorsalis pedis and tibialis pedis have two or more peripheral
Extremities pulses bilaterally. There are no appearances of clubbing, ulcers,
and edema. There is a limited strength due to weakness and
fatigue. There is also a limited range of motion in the whole body.
In the upper extremities, there is an IV insertion in the left hand of
the patient.
 Neurological The patient is awake and well-focused. The deep tendon reflexes,
cranial nerves II-XII, and sensory and motor levels are all still
functioning. There are no visible focal abnormalities, and the
Babinski sign is not present. The patient is able to follow
instructions.

GCS: Normal (15)

Eye opening - spontaneous (4)

Verbal response - oriented (5)

Motor response - obeys command (6)

VII. DEFINITION OF TERMS

Hypertension – this is the patients’ main problem upon admitted to the hospital. Hypertension is

a blood pressure higher than normal. Your blood pressure changes throughout the day based on

your activities. Having a high blood measures consistently above normal may result in a

diagnosis of high blood pressure or hypertension.

Primary hypertension – this is the first onset of his hypertensive occurrence that he wasn’t able

to recognize. Primary hypertension formerly known as essential hypertension occurs when you

have abnormally high blood pressure that’s not the result of a medical attention. This form of

high blood pressure is often due to obesity, family history and an unhealthy diet.

Secondary hypertension – negligence of the patient of the s/sx in his primary hypertension leads

to this stage. Secondary hypertension a high blood pressure that’s caused by another medical

condition. It can be caused by conditions that affect the kidneys, arteries, heart or endocrine

system secondary hypertension can also occur during pregnancy.

Hypertensive emergency – is a condition in which there is elevation of both systolic and

diastolic blood pressure with the presence of acute target organ disease.
Hypertensive urgency – this was the final diagnosis of the patients’ problem. This is the

condition where the blood pressure is elevated (diastolic ˃120mmHg) with the absence of acute

target organ disease.

Iatrogenic disease – this is one of the causes of secondary hypertension. This is a type of disease

induced by a drug prescribed by a physician or after a medical surgical procedure, excluding

intentional overdose, nonmedical intervention or unauthorized prescription and environmental

events like falls or equipment defect.

Hypertensive crisis – it is a sudden, severe increase in blood pressure. The blood pressure

reading is 180/120 millimeters of mercury (mm Hg) or greater. This is a medical emergency that

can lead to a heart attack, stroke or other life-threatening health problems.

VIII. ERIK ERIKSON'S DEVELOPMENTAL TASK

STAGE OF GROWTH DEVELOPMENTAL EVALUATION

AND DEVELOPMENT TASK

At this stage, people begin to In this stage we begin to

share themselves more share more about ourselves to

Young Adult
intimately with someone other people. We examine
Intimacy vs. Isolation
other than their family non-family connections that

19-40 years old member. result in commitment over a

long period of time. The

(21 years old, Male)
patient is very active during
If this stage is successfully
his younger days. Engaging
completed, it will result in
into different activities that
happy relationships, and a
build connections and
 sense of commitment, safety, relationship to other same age

and care within a relationship. of him. The patient is very

Avoiding intimacy, fearing active during his younger

commitment and days. As soon as his problem

relationships can lead to shows sign and symptoms the

isolation, loneliness, and patient didn’t mind of it as he

sometimes depression. Love assume its just a normal

will turn into a virtue if this feeling after doing activities.

step is properly fulfilled. This abandonment leads to a

serious problem to the point it

requires a medical attention.

With the help of the medical

professionals and the care of

those closest to him, notably

his family who continuously

inspired and looked after him

during his hospitalization, the

patient was successful in

completing this stage.

IX. ANATOMY AND PHYSIOLOGY

Anatomy

Nervous System

Fibers called nerves carry important messages back and forth between your body and
your brain. The nervous system has two parts: Your brain and spinal cord make up your central
nervous system. The nerves in the rest of your body make up your peripheral nervous system.
Everything your body does is connected in some way to your nervous system. It tells
your heart to beat. It tells your lungs to breathe. It controls the way you move, the words you say,
and how you think and learn. It also controls your senses and memories.

The central nervous system is the body’s processing center. The CNS is the supreme
command center of the body. The CNS consists of two organs which are continuous with each
other; the brain and spinal cord. The brain is a complex organ that controls thought, memory,
emotion, touch, motor skills, vision, breathing, temperature, hunger, and every process that
regulates our body. The spinal cord is an extension of the brain. It carries messages to and from
the brain via the network of peripheral nerves connected to it. Nerves also connect the spinal cord
to a part of the brain called the brainstem. Together, the brain and spinal cord that extends from it
make up the central nervous system, or CNS. The eyes are responsible for detecting light that
enters the eyes. Then, the light gets converted into an image in the brain. The sensory and motor
innervation of the eyes originates from six paired cranial nerves. These nerves work in sync to
manifest movements, reflexes, and vision. Despite its peripheral location, the retina or neural
portion of the eye, is part of the central nervous system.

Circulatory System

The circulatory system is made up of blood vessels that carry blood away from and
towards the heart. Arteries carry blood away from the heart and veins carry blood back to the
heart. The heart and blood vessels make up the circulatory system. The main function of the
circulatory system is to provide oxygen, nutrients and hormones to muscles, tissues, and organs
throughout your body. Another part of the circulatory system is to remove waste from cells and
organs so your body can dispose of it.

The heart pumps blood to the body through a network of arteries and veins (blood
vessels). The circulatory system can also be defined as your cardiovascular system. Cardio means
heart, and vascular refers to blood vessels. Another part of the circulatory system is to remove
waste from cells and organs so your body can dispose of it. The circulatory system provides
blood to all the body's tissues so they can function.

Urinary System

The urinary system's function is to filter blood and create urine as a waste by-product. The
organs of the urinary system include the kidneys, renal pelvis, ureters, bladder, and urethra.
 After the body has taken the food components that it needs, waste products are left behind
in the bowel and in the blood. Sodium kidney and urinary systems help the body to eliminate
liquid waste called urea, and to keep chemicals, such as potassium and sodium, and water in
balance. Urea is produced when foods containing protein, such as meat, poultry, and certain
vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys, where
it is removed along with water and other wastes in the form of urine.

Other important functions of the kidneys include blood pressure regulation and the
production of erythropoietin, which controls red blood cell production in the bone marrow.
Kidneys also regulate the acid-base balance and conserve fluids.

Major organs of every part of body system and its function:

ORGANS FUNCTIONS
Brain The brain is the most complex part of the human body. This
three-pound organ is the seat of intelligence, interpreter of
the senses, initiator of body movement, and controller of
behavior. Lying in its bony shell and washed by protective
fluid, the brain is the source of all the qualities that define
our humanity. The brain is the crown jewel of the human
body.
Heart It's the muscle at the center of your circulation system,
pumping blood around your body as your heart beats. This
blood sends oxygen and nutrients to all parts of your body
and carries away unwanted carbon dioxide and waste
products.

Kidney The kidneys act as very efficient filters for ridding the body
of waste and toxic substances, and returning vitamins,
amino acids, glucose, hormones, and other vital substances
into the bloodstream. The kidneys receive a high blood
flow, and this is filtered by very specialized blood vessels.

Eyes The eye is an important and one of the most complex

sensory organs that we humans are endowed with. It helps
us in visualizing objects and helps us in light perception,
color, and depth perception.
 A. Disease Process

PREDISPOSING FACTORS PRECIPATATING

FACTORS
Genes, Sedentary lifestyle, Environmental factors,
Obesity Age

Vasoconstriction

Increase the peripheral resistance

Increase blood pressure

Hypertensive crisis

Sign and Symptoms HYPERTENSIVE HYPERTENSIVE

Sign and Symptoms
URGENCY EMERGENCY
 Headache
 Chest pain
 Shortness of  Shortness of
breath breath
 Nosebleed  Backpain
Blood pressure is high
 Severe Blood pressure super  Numbness
anxiety that reach levels that
 Weakness
elevated, no acute or damage target organs.  Change of
sudden damage to
vision
organs.  Difficult
speaking

IF TREATED: IF NOT TREATED:

- Reduce the risk of - Aneurysm
cardiovascular events, - Myocardial infarction
such as heart attack or - Strokes
stroke
NARRATIVE

Usually if you have hypertension, your blood pressure gets higher and higher over the

course of several years even. And this slow rise also slowly causes complications. But because

it's happening so slowly, there usually aren't any symptoms directly caused by high blood

pressure. The predisposing factors are genes, sedentary lifestyle, and obesity. The precipitating

factors are environmental factors and age. Because of this causes, vasoconstrictions of the blood

vessels. If the vasoconstrictions are consistent there will be increased peripheral resistance that

leads increase of blood pressure. If the blood pressure could rise quickly and severely enough to

cause what we call a hypertensive crisis. And there are essentially two categories of hypertensive

crises. And the first is hypertensive urgency, and the other is hypertensive emergency. Let's just

go over urgency first. So, this hypertensive urgency is defined as the situation where your blood

pressure is super elevated, but there's no acute or sudden damage to any of your target organs like

your kidneys, your heart, or your brain. Well in general, it'd be above about 180 millimeters of

mercury on the systolic side or above about 110 millimeters of mercury on the diastolic side. So,

it's like the blood pressure goes up super high and really fast, but none of those target organs get

hit, right but even though these organs aren't damaged, there can be symptoms associated with

hypertensive urgency like a severe headache or shortness of breath, nosebleeds, and severe

anxiety. An emergency is when blood pressure is so high that it's reached levels that damage

target organs. Sometimes this is also referred to as malignant hypertension. During one of these

hypertensive emergencies, systolic blood pressure might increase above 180 millimeters of

mercury, while diastolic might be above 120 millimeters of mercury, but it can also happen at

lower pressures in patients whose bodies maybe aren't as used to higher blood pressures. Because

target organs can be damaged, the consequences of hypertensive emergency are very, very

serious and can have severe and permanent effects on the brain, heart, and kidneys. Some signs

and symptoms of these emergencies can include chest pain, shortness of breath, back pain,

numbness, and weakness, change in vision, and difficulty speaking.

B. Etiology

A sudden, dramatic rise in blood pressure is referred to as a hypertensive crisis. At least

180/120 millimeters of mercury (mm Hg) are measured for the blood pressure. A medical

emergency is a hypertensive crisis. It may result in a heart attack, stroke, or other serious health

issues. The heart, brain, kidneys, and eyes are just a few of the body parts that might suffer

damage from extremely high blood pressure. The heart may struggle to adequately pump blood

during a hypertensive crisis.

A hypertensive crisis can be caused by:

 missing a blood pressure medicine dose

 abruptly quitting beta blockers and other cardiac meds

 Med-drug interactions

Hypertensive crises can result from a variety of triggering circumstances. Most hypertensive

emergencies affect people who have been given a chronic hypertension diagnosis. Two of the

most frequent causes are the use of sympathomimetics and noncompliance with antihypertensive

treatment. These cause the blood pressure to rise quickly and above the body's natural ability to

regulate it.

Despite being frequently stated, the thresholds for hypertension to be considered an

emergency are arbitrary and not consistently recognized. Patients without chronic hypertension

may exhibit hypertensive emergency symptoms at much lower blood pressure levels, while those

with chronic hypertension may tolerate extremely high blood pressure without experiencing acute

organ dysfunction. The rate of rise above baseline is likely a more significant contributor and

helps to explain why.

C. Predisposing

Genes, a sedentary lifestyle, and obesity are the risk factors. According to the patient's

family, the patient's father carries the inherited gene for hypertension in this situation. The

patient's sedentary lifestyle also plays a role in the disease's triggering factor. His family and the

patient both expressed these ways of living. He admitted to smoking throughout the patient

interview. Each day, he can finish 10 sticks. He drinks occasionally but is also an alcoholic. He

eats a lot of fatty and oily stuff. He also mentioned how much he enjoys eating sweet and salty

things. This diet resulted in obesity, which is a significant risk factor for potential harm or illness.

D. Precipitating

Environmental factors and aging are the triggering variables. He had previously worked

as a mechanic at a motor shop close to their village. He was a student for ALS at the same time.

As a result, the environment also plays a role in the disease's triggering factor. According to the

patient, he is working with a machine and is exposed to heat in a highly stuffy workplace. He

continued by saying that when he is at work, the disease's symptoms and indicators usually start

to manifest. He occasionally experiences headaches, blurred vision, neck and head pain, as well

as muscle weakness that prevents him from lifting large objects. Base to his age, the patient is

currently 21 years old. old; this kind of illness is significant for his age. He is still surrounded by

a lot of things at this stage, especially those that help the disease progress, and peer pressure is

one major contributing factor.

E. Symptomatology

To identify which of the patients who have noticeably increased blood pressure is actually

experiencing a hypertensive emergency, a thorough history and examination are required. Further

assessment is required if you experience symptoms such a headache, dizziness, altered mental

status, shortness of breath, chest pain, decreased urine output, vomiting, or changes in eyesight.
For treatment planning purposes, it is also important to look into the cause of the sudden

development of hypertension.

Aphasia, ataxia, or other cerebellar dysfunction, as well as unilateral numbness or weakness, can

all be signs of neurologic dysfunction. It can also cause altered mental status. It is important to

perform a thorough neurologic examination that includes testing for sensation, strength, and

cerebellar dysfunction as well as gait and strength.

X. SUMMARY OF DOCTOR’S ORDER

02/02/2023
 Admit to ICU
@ 12:00 AM
 To follow: ECG
DR. GAZMEN
 Close monitor Vital Signs
WT: 90 kg
Medications:
HT: 162 cm
 Amlodipine 5 mg, once a day
T: 36 °C

PR: 63 bpm  Trimetazidine 35 mg, once a day

RR: 23 bpm  Omeprazole 20 mg, 1-3 times daily

BP: 120/80 mmHg  Citicoline 500 mg, 1-2 times daily

SPO2: 99 %
RBS: 140 mg/dl

XI. DIAGNOSTIC EXAM

TEST RESULTS SIGNIFICANCE

X - ray Reyes, Trachea is midline. The An X- ray is a common

lungs are clear. The pulmonary imaging test that has been
vasculatures are within normal around for decades. It allows
- February 01, limits. The heart is slightly your doctor to see into your
2023 enlarged. The diaphragm and body without the need for an
costophrenic sulci are intact. The incision. This can aid in
rest of the chest findings are diagnosis, monitoring, and
 unremarkable. treatment of a variety of
medical disorders.

Impression:

Mild Cardiomegaly

XII. LABORATORY EXAMS WITH SIGNIFICANCE

February 1, 2023

BLOOD CHEMISTRY (Creatinine, .CPK - MB)

TEST RESULT NORMAL SIGNIFICANCE

VALUES

HIGH

Creatinine 473.9 M 80 - 115 umol/L F A creatinine test is a measure

53 - 97 umol/L of how well your kidneys are
performing their job of
filtering waste from your
blood. High levels of
creatinine in the blood or
urine can be a sign that the
kidneys are not filtering the
blood effectively. Having
high levels of creatinine is
not life threatening, but it
may indicate a serious health
issue, such as chronic kidney
disease.

CPK - MB 8. 00 0.8 - 5. 1 ng/mL HIGH

If you have higher than

normal CK-MM enzymes, it
may mean you have a muscle
injury or disease, such as
muscular dystrophy or
rhabdomyolis. If you have
higher than normal CK-MB
enzymes, it may mean you
have an inflammation of the
 heart muscle or are having or
recently had a heart attack.

February 01, 2023

HEMATOLOGY RESULT

TEST RESULTS NORMAL VALUES SIGNIFICANCE

NORMAL

Hemoglobin, massc 13.8 g/dl M 13.0 -18.0 g/dl Hemoglobin is a protein in your
red blood cells that carries oxygen
to your body's organs and tissues
and transports carbon dioxide from
your organs and tissues back to
your lungs. If a hemoglobin test
reveals that your hemoglobin level
is lower than normal, it means you
have a low red blood cell count
(anemia).

HIGH

Leucocytes, numc 11.72 x 10 9/L M 4-10 Leukocytes are part of the body's
immune system. They help the
body fight infection and other
diseases. High leucocytes This
means you have more white blood
cells than normal. Leukocytosis is
a normal immune response and
isn't always a cause for concern.
Most of the time, it means that
your body is fighting off infection
or inflammation.

NORMAL

Erythrocytes, numc 5.13 x 10 12/L M 4.5 – 6.2 Red blood cells, also known as
erythrocytes, deliver oxygen to the
tissues in your body. Oxygen turns
into energy and your tissues
release carbon dioxide. Your red
blood cells also transport carbon
dioxide to your lungs for you to
exhale.

HIGH
Neutrophils 85 55-65 % Neutrophils increase naturally to
fight infection, but if your count is
above normal levels, your
healthcare provider will detect and
treat any infection or reaction to
medication that might be the
cause. Treatment for infection
typically involves taking
antibiotics.

VERY LOW

These cells help protect your body

from infection. If you have low
Lymphocytes 12 25 -35% numbers of lymphocytes
(lymphopenia), you are at higher
risk of infection. Lymphopenia
symptoms can range from mild to
serious and are correlated to the
severity of the lymphopenia as
well as its duration. Some people
have no symptoms.

VERY LOW

3 4 -12 % Low levels of monocytes tend to

develop as a result of medical
Monocytes conditions that lower your overall
white blood cell count or disease
treatments that suppress the
immune system. Having low levels
of monocytes may mean your
body is more susceptible to
infection.

NORMAL

Packed Cell 44.8 M 40 -50% A PCV (Packed Cell Volume) Test

Volume is done to diagnose anemia or
polycythemia in patients. It is
generally done along with a full
blood count test that is conducted
to estimate the need for any blood
transfusions and monitor the
response to the blood transfusion
treatment.

NORMAL
Thrombocytes, 241 x 10 9/L 150 -400 Platelets, also known as
numc thrombocytes, are small blood
cells that are essential for blood
clotting. Clotting is the process
that helps you stop bleeding after
an injury.

NORMAL

MCV 87.3 80 -100 fl Normal MCV may indicate

normocytic anemia. This can occur
when an individual experiences
symptoms of anemia due to
sudden blood loss, kidney failure,
or aplastic anemia, a rare disorder
where the body does not produce
enough RBC. High MCV means
that the RBC are too large and
indicates macrocytic anemia

LOW

MCH 26.9 27 – 34 pg A low MCH value typically

indicates the presence of iron
deficiency anemia. Iron is
important for the production of
hemoglobin. Your body absorbs a
small amount of iron that you eat
in order to produce hemoglobin.

LOW

MCHC 30.8 32 – 36 g/dl An MCHC result below 32 means

that the red blood cells contain less
than the normal concentration of
hemoglobin or are hypochromic, a
condition that occurs with iron-
deficiency anemia and
thalassemia. Because there is a
physical limit to the amount of
hemoglobin that can fit into an
RBC, an MCHC level above 35 is
rare.
 February 2, 2023

TYROID FUNCTION TEST

TEST RESULT NORMAL RANGE SIGNIFICANCE

TSH 0.981 0.38 – 4.3ulU/ml In most healthy

individuals, a normal
TSH value means
that the thyroid is
functioning properly.

February 2, 2023

BLOOD CHEMISTRY (Magnesium, Sodium subs, Potassium subs, Calcium inonized, glucose,
uric acid, sgpt, activity C., Cholesterol, Triglyceride, HDL, LDL, Urea nitrogen)

TEST RESULTS NORMAL VALUES SIGNIFICANCE

Magnesium 0.96 0.7 – 1.0 mmol/L NORMAL

Magnesium is a nutrient that the

body needs to stay healthy.
Magnesium is important for many
processes in the body, including
regulating muscle and nerve
function, blood sugar levels, and
blood pressure and making
protein, bone, and DNA

Sodium, subs 113.02 135 – 155 mmol/L VERY LOW

Low blood sodium is common in

older adults, especially those who
are hospitalized or living in long-
term care facilities. Signs and
symptoms of hyponatremia can
include altered personality,
lethargy and confusion.

Potassium, subs 3.08 3.4 – 5.3 mmol/L LOW

A low potassium level can make

muscles feel weak, cramp, twitch,
 or even become paralyzed, and
abnormal heart rhythms may
develop. The diagnosis is based on
blood tests to measure the
potassium level. Usually, eating
foods rich in potassium or taking
potassium supplements by mouth
is all that is needed.

Calcium, inonized 1.06 1.03 – 1.32 mmol/L NORMAL

Ionized calcium is calcium in your

blood that is not attached to
proteins. It is also called free
calcium. All cells need calcium in
order to work. Calcium helps build
strong bones and teeth. It is
important for heart function.

Glucose 5.72 3.9 – 5.8 mmol/L HIGH

High blood glucose levels

(hyperglycemia) may be a sign of
diabetes, a disorder that can cause
serious, long-term health
conditions. High blood sugar may
also be caused by other conditions
that can affect insulin or glucose
levels in your blood, such as
problems with your pancreas or
adrenal glands.

Uric acid 611.4 M 210 – 420 umol/L HIGH

F 150 – 350 umol/L A high uric acid level is too much

uric acid in the blood. Uric acid is
made during the breakdown of
purines. Purines are found in
certain foods and are formed by
the body. Blood carries uric acid to
the kidneys. The kidneys pass
most uric acid into the urine,
which then leaves the body.

SGPT, activity C., 20.3 0 – 41 U/L HIGH

Increased levels of SGPT, then it

can be indicative of conditions
such as hepatitis, cirrhosis of the
liver, inflammation, etc. Also
 called alanine transferase and
serum glutamate pyruvate
transaminase.

Cholesterol 4.41 0 – 5.2 mmol/L HIGH

Your body needs cholesterol to

build healthy cells, but high levels
of cholesterol can increase your
risk of heart disease. With high
cholesterol, you can develop fatty
deposits in your blood vessels.
Eventually, these deposits grow,
making it difficult for enough
blood to flow through your
arteries.

Triglyceride 1.51 0 - 1.7 mmol/L HIGH

High triglycerides are often a sign

of other conditions that increase
the risk of heart disease and stroke,
including obesity and metabolic
syndrome — a cluster of
conditions that includes too much
fat around the waist, high blood
pressure, high triglycerides, high
blood sugar and abnormal
cholesterol levels.

HDL 1.22 0.9 – 1.6 mmol/L HIGH

HDL (high-density lipoprotein)

cholesterol, sometimes called
“good” cholesterol, absorbs
cholesterol in the blood and carries
it back to the liver. The liver then
flushes it from the body. High
levels of HDL cholesterol can
lower your risk for heart disease
and stroke.

LDL 2.50 0 – 2.9 mmol/L HIGH

 High levels of LDL cholesterol
raise your risk for heart disease
and stroke.

Urea nitrogen 18.89 2.8 – 7.2 mmol/L HIGH

Urea nitrogen is a waste product

that your kidneys remove from
your blood. Higher than normal
BUN levels may be a sign that
your kidneys aren't working well.

XIII. DRUG STUDY

SANDOZ

BRAND STOCK/ INDICATION MECHANISM CONTRAINDI SIDE – NURSING

NAME/ DOSAGE/ S OF ACTION CATIONS EFFECTS/ INTERVENTION
ADVERSE
GENERI FREQUE REACTIONS
C NAME NCY

Brand Frequency Treatment of Omeprazole is a Known Adverse 1. Assess for possible

Name: : duodenal and common proton hypersensitivity Effects: contraindications and
gastric ulcer, pump inhibitor to omeprazole cautions: history of allergy
Sandoz Once a day NSAID - that interferes or to any of the Gastrointestinal to a proton pump inhibitor
@ 6:00 associated with the hepatic other disturbances, in to reduce the risk of
AM gastric acid and activation of constituents of particular hypersensitivity reaction
duodenal ulcers clopidogrel and the formulation. diarrhea, and current status of
Generic or erosions, potentially Omeprazole like constipation, pregnancy or lactation
Name: Helicobacter reduces its other PPIs abdominal pain, because of the potential for
Stock/ pylori platelet- should not be nausea and adverse effects on the fetus
Omeprazol vomiting and
eradication in inhibitory administered or nursing baby.
e Dosage: flatulence. Skin
peptic ulcer effect. with atazanavir.
disease, reflux Omeprazole has rash, pruritus 2.Perform a physical
Intravenou
oesophagitis, been shown to and urticaria examination to establish
s Solution:
Classificat symptomatic increase P2Y12 baseline data before
40 mg
ion: gastro- levels and beginning therapy to
oesophageal adverse determine the effectiveness
Proton reflux disease, cardiovascular of the therapy and to
Pump acid related outcomes in evaluate for the occurrence
Inhibitors dyspepsia and patients treated of any adverse effects
Zollinger - with drug- associated with drug
Ellison eluting stents. therapy.
syndrome.
3.Inspect the skin for
lesions, rash, pruritus, and
dryness to identify possible
adverse effects.

4. Assess neurological
status, including level of
orientation, affect and
reflexes to evaluate for
CNS effects of the drug.

5.Inspect and palpate the

abdomen to determine
potential underlying
 medical conditions; assess
for changes in bowel
elimination and GI upset to
identify possible adverse
effects.

6.Assess respiratory status,

including respiratory rate
and rhythm; note evidence
of cough, hoarseness, and
epistaxis, to monitor for
potential adverse effects of
the drugs.

KEPPRA

BRAN STOCK/ INDICATIONS MECHANISM CONTRAINDI SIDE – NURSING

D DOSAGE/ OF ACTION CATIONS EFFECTS/ INTERVENTION
NAME ADVERSE
/ FREQUE REACTIONS
NCY
GENE
RIC
NAME

Brand Frequency Levetiracetam is The most relevant Levetiracetam is Side Effects: 1.Document the number,
Name: : indicated as mechanism of contraindicated duration, and severity of
monotherapy in action is believed in: dizziness, seizures to help determine
Keppra Twice a the treatment of: to be binding to a hypersensitivity drowsiness, if this drug is effective in
day at 6 partial onset unique synaptic to the active tiredness, reducing seizure activity.
Generi AM and 6 seizures with or vesicle protein 2A substance or weakness; feeling
c PM without secondary (SV2A). SV2A other aggressive or 2.Assess dizziness or
Name: generalization in protein is a part of pyrrolidone irritable; loss of weakness that might affect
Stock/ adults and secretory vesicle derivatives or to appetite; stuffy gait, balance, and other
Levetir adolescents from membranes that any of the nose; or infection. functional activities.
acetam Dosage: 16 years with mediates calcium- excipients. Report balance problems
newly diagnosed dependent Adverse Effects: and functional limitations
Oral to the physician, and
epilepsy. vesicular
Tablet: 500 Asthenia, caution the patient and
Classif neurotransmitter
mg Headache family/caregivers to guard
ication release. The
binding of Infection, against falls and trauma.
: Increased blood
levetiracetam to
SV2A appears to pressure, 3.Monitor daytime
Ligand Somnolence,
decrease the rate drowsiness, somnolence,
s Drowsiness,
of vesicle release. or other changes in
Fatigue, behavior. Repeated or
Anorexia, excessive symptoms may
Weakness, require change in dose or
Nasopharyngitis, medication.
Cough
4.Assess any
incoordination to rule out
neuromusculoskeletal
pathology; that is, try to
determine if incoordination
is drug induced rather than
caused by neurologic or
musculoskeletal problems.

5.Advise patients to avoid

alcohol and other CNS
 depressants because of the
increased risk of sedation
and adverse effects.

6.Advise patients on
prolonged anti seizure
therapy not to discontinue
medication without
consulting their physician.
Abrupt withdrawal may
cause increased seizures.

7.Advise patient about the

risk of daytime drowsiness
and decreased attention
and mental focus. Use care
if driving or in other
activities that require
strong concentration and
fast responses.

LIPITOR

BRAND STOCK/ INDICATIONS MECHANISM CONTRAINDI SIDE – NURSING

NAME/ DOSAGE/ OF ACTION CATIONS EFFECTS/ INTERVENTION
ADVERSE
GENERI FREQUENCY REACTIONS
C NAME

Brand Frequency: Used together Atorvastatin Patients with Side Effects: 1.Assess any muscle
Name: with a proper diet competitively active liver pain, tenderness, or
Once a day @ to lower inhibits 3- disease, the Cough, weakness, especially
Lipitor 9:00 PM cholesterol and hydroxy-3- benefits of lipid- difficulty with if accompanied by
triglyceride (fats) methylglutaryl- lowering swallowing, fever, malaise, and
levels in the coenzyme A therapy in dizziness, fast dark-colored urine.
blood. This (HMG-CoA) chronic liver heartbeat, fever, Advise patients that
Generic Stock/ medicine may reductase. By diseases, such as hives, itching, these symptoms may
Name: help prevent preventing the non-alcoholic skin rash, represent drug-
Dosage: muscle cramps,
medical problems conversion of fatty liver induced myopathy,
Atorvastati pain, stiffness,
Oral Tablet: 80mg (eg, chest pain, HMG-CoA to disease and and that myopathy
n swelling, or
heart attack, or mevalonate, hepatitis, likely can progress to
stroke) that are statin outweigh the weakness severe muscle
caused by fats medications possible risks. puffiness or damage
Classificat clogging the decrease swelling of the (rhabdomyolysis).
ion: blood vessels. cholesterol eyelids or Report any
production in around the eyes, unexplained
Statins the liver. face, lips, or musculoskeletal
Atorvastatin tongue tightness symptoms to the
also increases in the chest physician
the number of unusual immediately, and
LDL receptors tiredness or suspend exercise and
on the surface of weakness gait training until
hepatic cells. these symptoms can
be evaluated.
Adverse 2.Monitor signs of
Effects: angioneurotic edema
and other
Arthralgia, hypersensitivity
dyspepsia, reactions, including
diarrhea, rashes, raised patches
nausea, of red or white skin
nasopharyngitis, (welts),
insomnia,
 urinary tract burning/itching skin,
infection, and swelling in the face,
pain in the and difficulty
extremities. breathing. Notify
physician of these
signs immediately.

3.Assess dizziness
and weakness that
might affect gait,
balance, and other
functional activities.
Report balance
problems and
functional limitations
to the physician, and
caution the patient
and family/caregivers
to guard against falls
and trauma.

4.Assess peripheral
edema using girth
measurements,
volume displacement,
and measurement of
pitting edema. Report
increased swelling in
feet and ankles or a
sudden increase in
body weight due to
fluid retention.

5.Monitor chest pain

or symptoms of
bronchitis (cough,
production of
sputum, shortness of
breath, wheezing).
Report prolonged or
severe symptoms to
the physician.

LEVEGET IV

BRAND STOCK/ INDICATIONS MECHANISM CONTRAINDI SIDE – NURSING

NAME/ DOSAGE/ OF ACTION CATIONS EFFECTS/ INTERVENTI
ADVERSE ON
GENERIC FREQUENCY REACTIONS
NAME

Brand Name: Frequency: Leveget is Modulation of Hypersensitivity Adverse 1.Monitor &

indicated as synaptic . Effects: notify physician
Leveget IV Every 12 hours monotherapy in neurotransmitter of difficulty
the treatment of release through Suicidal with gait or
partial onset binding to the ideation and coordination.
seizures with or synaptic vesicle behaviour,
Generic Name: Stock/ without secondary protein SV2A in psychotic 2.Monitor for
generalization in the brain. symptoms and changes in
Levetiracetam Dosage: irritability, phenytoin blood
adults and
adolescents from aggressiveness, levels with
 Intravenous 16 years of age somnolence, coadministered
Therapy: 500mg with newly fatigue, drugs.
Classification: diagnosed coordination
epilepsy. difficulties, 3.Do not drive
Anticonvulsants Stevens- or engage in
Johnson potentially
syndrome, toxic hazardous
epidermal activities until
necrolysis, acute response to drug
kidney injury,. is known.
agranulocytosis,
leucopenia, 4.Do not
neutropenia, abruptly
thrombocytopen discontinue
ia, drug. MUST use
pancytopenia, gradual dose
exacerbated reduction/taper.
seizure
frequency or
severity,
prolonged QT
interval.

XIV. NURSING CARE PLAN

ACTUAL

Name of Patient: Reyes, Heraccleo Jr. Lanaja

Attending Physician: Gazmen, Lew Ian L. M.D
Address: PRK. Paglaom, Sawata San Isidro
Medical Diagnosis: Hypertensive Urgency r/o Aneurysm
Age: 21 Sex: M

DATE/ CUES Needs NURSING OBJECTIVE OF NURSING EVALUATION

TIME (Needs DIAGNOSIS CARE INTERVENTION
(Maslow’s WITH WITH RATIONALE
/G ordon’s RATIONALE
Health
Patterns)

Subjective: Activity At the end of my 8 NI: Establish rapport

P After 8 hours of
Intolerance hours shift the patient
J R: To gain trust and duty the goal is
related to will be able to:
H cooperation. fully met.
insufficient
A “Nag-undang Evidence by:
Y energy to
ko ug trabaho NI: Assess vital signs.
complete
kay naglisod 1.Identify negative a. Patient has been
N S activities of R: Changes in vital
nakog hakwat factors affecting able to identify
I daily living activity tolerance and signs are good
sa butang” negative factors
O secondary to eliminate or reduce indicators of the
U affecting activity
hypertension as their effects when response of the patient tolerance and
L evidenced by possible.
to interventions and eliminate or reduce
A O fatigue and 2. Use identified
techniques to enhance increasing physical their effects.
G muscle tolerance. GOAL MET
Objective: activity tolerance.
R I weakness 3.Report measurable
C increase in activity NI: Note patient’s
-muscle A b. Patient has been
tolerance. reports of weakness,
Y weakness able to identify
L 4.Demonstrate a fatigue, pain, and
techniques to
decrease in
 -fatigue physiological signs of difficulty enhance activity
2, intolerance (e.g., pulse, tolerance.
2023 N respirations, and blood R: Symptoms may be
GOAL MET
pressure remain within a result of or
E
@ patient’s normal contribute to
E range).
7 AM- D
intolerance activity.
3 PM
S NI: Assess
cardiopulmonary c. Patient has been
response to physical able to decrease
activity, including physiological signs
vital signs, before, of intolerance
during, and after GOAL MET
activity. Note
accelerating fatigue.

R: Dramatic changes
in heart and rhythm,
changes in usual blood
pressure, and
progressively
worsening fatigue
result from an
imbalance of oxygen
and supply demand.

NI: Note the factors

that may contribute to
the presence of fatigue
(age, overall physical
health, stage of
illness).

R: Patient’s ability to
perform physical
activities depends on
several factors

NI: Allow the patient

to perform simple
tasks before
progressing to more
complex ones while
ensuring that these are
done with level of
tolerance.

R: This helps increase

the confidence of the
patient to perform
ADL’s while also
helping the body to
slowly increase
tolerance.

NI: Encourage the

patient to continuously
perform activities
within the level of
 tolerance, increasing
intensity gradually.

R: To help him sustain

an optimum level of
functioning while
maintaining safety.

Name of Patient: Reyes, Heraccleo Jr. Lanaja

Attending Physician: Gazmen, Lew Ian L. M.D
Address: PRK. Paglaom, Sawata San Isidro
Medical Diagnosis: Hypertensive Urgency r/o Aneurysm
Age: 21 Sex: M

DATE/ CUES Needs NURSING OBJECTIVE OF NURSING EVALUATION

TIME (Needs DIAGNOSIS CARE INTERVENTION
(Maslow’s WITH WITH RATIONALE
/G ordon’s RATIONALE
Health
Patterns)

Subjective: Acute pain At the end of my 8 NI: Establish rapport

P After 8 hours of
related to hours shift the patient
J R: To gain trust and duty the goal is
increased will be able to:
H cooperation. fully met.
cerebral
A “Sakit akoang Evidence by:
Y vascular
batok, lisod NI: Assess vital signs.
pressure as
ilingi ug iduko 1.Patient will report a. Patient know how
N S evidenced by R: To check whether
tapos lipong relief of to communicate pain
I reports of pain/discomfort the blood pressure is
kayo ug sakit to medical
O stiffness of 2. Patient will verbalize still high in every four
U akoang ulo” practitioners.
neck, dizziness, methods that provide hours and to give
relief. GOAL MET
L and headache. medication if blood
A O 3.Patient will follow
pharmacological pressure do not return
G b. Patient is well
regimen. normal after four aware of things
R I 4.Patient will hours.
Objective: C needed to do in order
demonstrate use of to manage the pain.
A NI: Note patient’s
Y -grimace face relaxation skills and GOAL MET
L attitude toward pain
diversional activities,
2, -Pain scale as indicated for and use of pain b. Patient takes
2023 level at 8 individual situation. medications, including medication on time.
N any history of
@ -moaning pain E substance abuse. GOAL MET
3-11 associated E
with sounds D R: To assess etiology b. Patient knows how
PM
S or precipitating to monitor pain and
contributory factors.
demonstrate ways on
NI: Determine how to decrease pain
specifics of pain level by verbalizing
(location, such activities to
characteristics, improve health.
intensity (0-10 scale),
onset, and duration. GOAL MET

R: Facilitates
diagnosis of problem
and initiation of
appropriate therapy.
Helpful in evaluating
the effectiveness of
therapy.

NI: Encourage and

maintain bed rest
during the acute
phase.

R: Minimizes
stimulation and
promotes relaxation.

NI: Provide or
recommend non-
pharmacological
measures to relieve
headache such as cool
cloth to forehead;
back and neck rubs;
quiet dimly lit room;
relaxations
techniques; and
diversional activities.

R: Measures that
reduce cerebral
vascular pressure and
slow or block
sympathetic response
effectively relieve
headaches and
associated
complications.

NI: Eliminate or
minimize
vasoconstricting
activities that may
aggravate headache.

R: Activities that
increase
vasoconstriction
accentuate the
headache in the
presence of increased
cerebral vascular
pressure.
 POTENTIAL

Name of Patient: Reyes, Heraccleo Jr. Lanaja

Attending Physician: Gazmen, Lew Ian L. M.D
Address: PRK. Paglaom, Sawata San Isidro
Medical Diagnosis: Hypertensive Urgency r/o Aneurysm
Age: 21 Sex: M

DATE/ CUES Needs NURSING OBJECTIVE OF NURSING EVALUATION

TIME (Needs DIAGNOSIS CARE INTERVENTION
(Maslow’s WITH WITH RATIONALE
/G ordon’s RATIONALE
Health
Patterns)

Subjective: Risk for At the end of my 8 NI: Establish rapport

P After 8 hours of
decreased hours shift the patient
J -Patient can R: To gain trust and duty the goal is
cardiac output will be able to:
feel H cooperation. fully met.
related to
A discomfort Evidence by:
Y inadequate
NI: Assess vital signs.
oxygenated
-Patient 1.Exhibit stability in a. The patient's
N S blood pumped R: Blood pressure and
experiences the cardiac rate and capacity to endure
I by the heart to rhythm. pulse rates are good
difficulty in activities without
O meet metabolic 2.Maintain blood indicators of cardiac
U breathing experiencing
demands due pressure within volume and cardiac symptoms of
L to increase acceptable/stable range.
-Patient is output. Decreased dyspnea, syncope, or
A O blood pressure. 3.Engage in
experiencing cardiac output and chest discomfort
G interventions to help
anxiety attacks irregularities in blood reveals adequate
R I decrease cardiac load
pressure may also cardiac output, as
C and blood pressure. seen by blood
indicate complications
A brought about by pressure, pulse rate,
Y Objective: L hypertension. and rhythm that are
3, within the patient's
-decreased
2023 NI: Thoroughly check normal range.
cardiac output N the patient’s GOAL MET
@ E laboratory results such
-restlessness
7-3 E as blood cell count’s b. In addition to
AM -tachypnea D ABG’s, electrolytes eupnea without
S and cardiac marker pulmonary crackles,
- Decreased studies. the patient has warm,
peripheral dry skin.
pulses; cold, R: Cardiac output may GOAL MET
clammy be affected by
skin/poor conditions other than c. The drugs taken by
capillary refill hypertension. the patient to achieve
Thoroughly checking a sufficient cardiac
-abnormal laboratory data would output continue to
heart sounds help in planning better have no negative side
care for patient. effects.
-change in NI: Help the patient to GOAL MET
level of plan alternate periods
consciousness of rest and activity. c. The patient
describes the
R: This helps to precautions and steps
conserve energy, to be taken in the
improve overall tissue
event of cardiac
perfusion and reduce
illness.
cardiac demands.

NI: Advise the patient

GOAL MET
to limit intake of food
high in sodium and
cholesterol.

R: To help manage
and maintain blood
pressure within an
acceptable range.

NI: If the patient is

smoking, advise the
patient to stop.

R: Cessation of
smoking helps in
managing blood
pressure by relaxing
the vessel walls.

NI: Encourage the

patient to be vigilant
in the take of his
maintenance
medications.

R: Maintenance
medications for
hypertension helps
manage blood
pressure, improving
cardiac output and
ensuring adequate
tissue perfusion.
 Name of Patient: Reyes, Heraccleo Jr. Lanaja
Attending Physician: Gazmen, Lew Ian L. M.D
Address: PRK. Paglaom, Sawata San Isidro
Medical Diagnosis: Hypertensive Urgency r/o Aneurysm
Age: 21 Sex: M

DATE/ CUES Needs NURSING OBJECTIVE OF NURSING EVALUATION

TIME (Needs DIAGNOSIS CARE INTERVENTION
(Maslow’s WITH WITH RATIONALE
/G ordon’s RATIONALE
Health
Patterns)

Subjective: Risk for injury At the end of my 8 NI: Establish rapport

S After 8 hours of
related to hours shift the patient
J [As per R: To gain trust and duty the goal is
A presence of will be able to:
verbalized by cooperation. fully met.
home hazards
A the patient:] F Evidence by:
(poor lighting,
E NI: Determine the
slippery floors,
-Patient serves 1.Determine the factors client’s age, a. The patient is able
N T unanchored
as a house that increases the risk developmental stage, to identify the
rugs). for injury and will
helper in their Y health status, lifestyle, elements that raise
U demonstrate behaviors their risk of injury
home. mobility, cognitive
to avoid injury. and exhibit behaviors
2.Remain free of awareness, and
-Patient likes N decision-making to prevent damage.
A injuries.
to use house E ability. GOAL MET
tools like
E
R knife, blade, R: These factors play
D
axe, etc. a role in the client’s Within 4 hours of
S ability to keep
Y nursing interventions
-Patient’s themselves safe from
surroundings and teaching:
3, injury.
2023 in their home
a. Patient will remain
settings have NI: Person through
free of injuries.
@ lots of busy assessments regarding
household and safety issues when GOAL MET
3-11
AM busy streets. planning for patient
care and/or preparing
for discharge from
care.
Objective:
R: Failure to
-alterations in
accurately assess and
cognitive
intervene or refer
performance
these issues can place
-exposure to the patient at needles
harmful risk and creates
substances negligence issues for
the healthcare.
-Physical
obstacles NI: Assess mood,
-home dangers coping abilities,
are present personality styles
(poor lighting, (e.g., temperament,
slippery aggression, impulsive
floors, behavior, level of self
unanchored – esteem) that may
rugs, unsafe result in careless or
toys, loose increased risk taking
electrical without consideration
outlets) of consequences.

-Lack of R: that may result in

understanding careless or in careless
of or increased risk
environmental taking without
risks consideration of
consequences.

NI: Assess client’s

muscle strength and
gross and fine motor
coordination.

R: To identify risk for

falls.

NI: Provide healthcare

within a culture of
safety (e.g., adherence
to nursing standards of
care and facility safe
care policies)

R: To prevent errors
resulting in patient
injury, promote client
safety, and model
safety behaviors for
patients.

NI: practice hand

hygiene at all times,
and device safety
when client has IV
lines and catheters.

R: To prevent health
care associated
infections and
potential for
bloodborne pathogens.

NI: Utilize bed/chair

alarms

R: that alert when

client is trying to get
up alone.
NI: Identify
interventions and
safety device.

R: To promote safe
physical environment
and individual safety.

NI: Refer to physical

or occupational
therapist, as
appropriate.

R: To identify high
risk task, conduct site
visits; select, create,
and modify equipment
or assistive device;
and provide education
about body mechanics
and musculoskeletal
injuries, in addition to
providing therapies as
indicated.

NI: Review
consequences of
previously determined
risk factors that client
is reluctant to modify.

I: Many consequences
may occur.

NI: Discuss the

importance of self-
monitoring of
condition or emotions
that can contribute to
occurrence of injury.

I: Client/SO may be
able to modify risk
through monitoring of
actions or
postponement of
certain actions,
especially during
times when client is
likely to be highly
stressed.
XV. DISCHARGE PLANNING METHOD

During the hospital's discharge planning process, patients' anticipated health-care

requirements after being released from the hospital are recognized and taken into account. If a

patient is being released from the hospital, it is utilized. The development of a thorough plan

that involves the patient and their family members in the hospital's post-discharge planning

procedure is essential for a patient's successful transition from the hospital to their home.

Included are details on the place the patient will be discharged from the hospital, the kind of

care the patient's family will receive, as well as suggestions for precautionary actions and

things to keep in mind. All medications, including dosages and usage instructions that should

be recorded in your medication log and additional health practices and teachings to guardians

and family members assisting with the patient's care, are described in clear and concise detail

in the information provided below.

Medication ●Take medication as prescribed.

●Encourage the patient to report unusual
pain that the medicine might cause.
●Discuss all medicine regarding its adverse
effects.
●Take medication with food if not
contraindicated.

Exercise ●Perform aerobic exercises 3 to 4 times a wake

for an average of 40 minutes a time to
lower blood pressure, like walking or
gardening.
● Perform meditation to reduce autonomic
dysfunction.
Treatment ●Take medication as prescribed.
●Never stop treatment on your own.
●Never forget to take your medicine at the
same time every day.
●Always keep in touch with your healthcare
provider and always alert them
immediately when you experience
symptoms such as chest pain or shortness
of breath, moderate to severe headache,
extreme drowsiness.
Health Teaching ●Wear clothing with long sleeves, and refrain
from spending too much in the sun to
prevent the worsening of dermatologic
symptoms.
●Maintain a normal and healthy lifestyle.
●Do not overperform activities, rest as much
as possible.
●Control the stress. Learn ways to manage
stress.
●Break the smoking habit.
●Extra vigilant against foods with known link
to heart disease, such as red meat, fried
foods, and dairy.

Diet ●Increase oral fluid intake

●Limit canned, dried, packed and fast
foods.
●Eat season foods with herbs instead
of salt when cook.
●Eat food rich in potassium.
●Eat lots of fruit and vegetables
● Low fat, low salt diet

Outpatient Order ●Call your doctor or proceed to the nearest

hospital when you experience symptoms
such as pain in the area the back of the
neck, much higher fever than usual, chest
pain or shortness of breath.
XVI. PROGNOSIS

GOOD FAIR POOR JUSTIFICATION

I. Precipitating The precipitating factors mentioned are rated fair

Factors: since these can’t be cured anymore, however on
the brief history stated that 3 days PTA PX had
a. Environmental an onset of fever moderate to high grade
factors: workplace:
associated with weakness, persistence prompted
exhibits
uncomfortable this ADM. vaccine sinovac x2.
working area and
exposed to heat
from machineries.
b. Age: expose to
peer pressure

II. Predisposing None

Factors

a. Sedentary
lifestyle:
Smoking, alcohol
intake, use of
illegal drugs
b. Hereditary:
disease is passed
from their father’s
health history side
to their son
(patient)

3. Medications As admitted the patient medication is given to her

via Oral, IV administration. Thus, the patient
receives the medications he needs without a
chance of refusal.

4. Treatments No cure, only management.

5. Family Support The patient has a good support system, despite the
absence of the mother who is already deceased.
By her sister and father, they make sure that her
needs are well provided, especially his
medication.
6. Environment The patient's environment is conducive for her
recovery, since she stays at the hospital where
medical team members are present every time the
patient needs them.

7. Diet The patient's diet is prepared in accordance with

her needs, served and delivered via nutritionist.

8. Spiritual The patient was a religious kind of person. She

was able to preserve life because for her God is
always at her side.
9. Patient Patient is willing to listen to teachings rendered
Teachings to her. And following the instructions of their
physician.

10. Family The patient's family is also a good listener. They

Teachings accept and follow whatever is good for the
patient.

Prognosis Rating Tally Total

GOOD 3 7 21

FAIR 2 2 4

POOR 1 1 1

Total 26/10= 2.6

Ranges:

Poor = 1.0-1.7
Fair = 1.8-2.3
Good = 2.4 - 3.0

XVII. GENERAL PROGNOSIS

The overall result is 2.6 meaning she has a good prognosis, where his path of admitting

for what she felt slowly achieve; however, due to her condition she still needs continuous management

of care to not worsen her condition. The patient has learned and following the instructions of her

physician, these things make herself promote good feelings, because if she does not follow those

things it will only make things worse as part of the patient's education. With the days being said the

patient now has a chance of continuous healing from admitting and if she will be discharge, she can

help herself even if she gets home. She still has proper nutrition. Not to mention, the support that he

receives from her family, this will be a great opportunity to help her because patients with supportive

families oftentimes survive their conditions, thinking they're not alone in their fight. Furthermore, this

kind of
condition usually chronic, relapsing and unpredictable. Remissions may last for years. 10-year
survival rate exceed.

CONCLUSION

SLE, or systemic lupus erythematosus, is the most prevalent form of lupus. It is an

autoimmune condition where the immune system targets its own tissues, leading to extensive

tissue destruction and inflammation in the organs that are afflicted. It can have an impact on

blood vessels, the brain, the lungs, the skin, and the joints. Although there is no known

treatment for lupus, medical procedures and dietary adjustments can help manage its

symptoms. SLE can range in severity from mild to potentially fatal. Although the causes of

SLE are unknown, it is thought that hormonal, genetic, and environmental factors may all

have a role. Our body's defense against infection is provided by the immune system, a

complex network of organs, cells, and proteins that also safeguards the body's own cells.

Since lupus is an autoimmune condition, the immune system itself attacks the cells rather

than defending them. By targeting the cell, the body's organs will also be impacted, which

will result in harm and organ dysfunction.

The patient is more prone to a more organ damages particularly the heart, joints,

lungs, kidneys, brain, and the blood system. SLE can be managed with certain medication but

there is no treatment for it. This type of disease is more common in women. The factors that

might affect and trigger the disease is most commonly from the sunlight that is why the

patient had a reoccurrence of the disease. This pertains to the type of work she is in and that

she verbalizes that the work requires more outdoor activities. The patient has been discharged

from the hospital after admitting complains are being managed and resolved.