CASE PRESENTATION

1. By: Joseph Jude Valle CASE PRESENTATION

2. DEMOGRAPHIC DATA • Name: Patient D • Age: 55 • Sex: Male • Date of Admission: August 14, 2006

3. FINAL DIAGNOSIS • Diabetes Mellitus Type 2 • Hypertension • Post Cerebral Angioplasty

4. PHYSICAL ASSESSMENT HEAD Symmetric skull but with slight lesions at the nape area, dandruff present SKIN cool, moist skin and slightly bald EYES Moves randomly upon any stimuli NOSE NGT present with frequent discharges of mucus MOUTH Teeth present, no ulcerations and with slight odor NECK Tracheostomy tube present CHEST No discharges or abnormalities noted UPPER EXTREMITIES Unable to move voluntarily nor abduct or adduct, contracts momentarily upon any stimuli LOWER EXTREMITIES Unable to move voluntarily nor abduct or adduct, contracts momentarily upon any stimuli NAILS Rough, yellowish with delayed capillary refill GENITALIA Slight ulceration at the base of the penis

5. PAST MEDICAL HISTORY • The 55 yr. old gentleman presented to our hospital with history of dizziness and slurred speech. CT scan showed no abnormality, so MRA and MRI was done and showed evidence of cerebellar infarction. • The case was discussed with interventional radiologist and also discussed with the patient regarding possible intervention regarding his condition. The patient was fully explained about the possible complication of the procedure. The patient agreed to go on angioplasty and to receive the thrombolytic. The procedure was done, unfortunately the expected complication of this procedure happened. He bleed intracerebrally and was admitted to the ICU for almost three weeks intubated and later on extubated and the patient was transferred to the ward.

6. PRESENT MEDICAL HISTORY • He is quadriplegic and he is on tracheostomy dependent for his breathing. The patient can understand the vocal command but unable to respond and cannot express himself at all. He is on NGT and voiding on condom catheter and requires full assistance on daily bed bath. He is on Amlodipine for his blood pressure management and Movicol sachet for his regular bowel elimination.

7. HYPERTENSION • is defined as a disease of vascular regulation resulting from malfunction of arterial pressure control mechanisms. The two major types of hypertension are primary (essential) hypertension and the secondary hypertension. • High blood pressure is dangerous because it causes the heart to work too hard, making the walls of the arteries also hard. High blood pressure increases the risk for heart disease and stroke and can also cause other problems, such as heart failure, kidney disease and blindness.

8. ANATOMY OF THE CARDIOVASCULAR SYSTEM • HEART • BLOOD VESSELS • CIRCULATORY PATHWAYS • BLOOD PRESSURE

9. HEART • The heart is located in the mediastinum, the cavity between the lungs. It is a muscular organ that provides a continuous blood circulation through the cardiac cycle and is one of the most vital organs in the human body. • The wall of the heart consists of three layers: • The epicardium is the visceral layer of the serous pericardium. • The myocardium is the muscular part of the heart that consists of contracting cardiac muscle and noncontracting Purkinje fibers that conduct nerve impulses. • The endocardium is the thin, smooth, endothelial, inner lining of the heart, which is continuous with the inner lining of the blood vessels.

10. BLOOD VESSELS • The central opening of a blood vessel, the lumen, is surrounded by a wall consisting of three layers: • The tunica intima is the inner layer facing the blood. It is composed of an innermost layer of endothelium (simple squamous epithelium) surrounded by variable amounts of connective tissues. • The tunica media, the middle layer, is composed of smooth muscle with variable amounts of elastic fibers. • The tunica adventitia, the outer layer, is composed of connective tissue. • The cardiovascular system consists of three kinds of blood vessels that form a closed system of passageways: • Arteries carry blood away from the heart. • Capillaries are microscopic blood vessels with extremely thin walls. Capillaries penetrate most body tissues with dense interweaving networks called capillary beds. The thin walls of capillaries allow the diffusion of oxygen and nutrients out of the capillaries, while allowing carbon dioxide and wastes into the capillaries. • Veins carry blood toward the heart

11. CIRCULATORY PATHWAY • Blood is confined to a closed system of blood vessels and to the four chambers of the heart. Blood travels away from the heart through arteries, which branch into smaller vessels, the arterioles. Arterioles branch further into the smallest vessels, the capillaries. Gas, nutrient, and waste exchange occur across the capillary walls. The blood returns to the heart as capillaries merge to form venules, which further merge to form large veins, which connect to the heart.

12. BLOOD PRESSURE • Hydrostatic pressure created by the heart forces blood to move through the arteries. Systolic blood pressure, the pressure measured during contraction of the ventricles, averages about 110 mm Hg in arteries of the systemic circulation (for healthy, young adults). The diastolic blood pressure, measured during ventricle relaxation, is about 75 mm Hg in these arteries. As blood travels through the arterial system, resistance from the walls of the blood vessels reduces the pressure and velocity of the blood. Blood pressure drops sharply in the arterioles and falls to between 40 and 20 mm Hg in the capillaries. Blood pressure descends further in the venules and approaches zero in the veins.

13. Risk Factors: • Diabetes Mellitus • Family History • Advance age • Obesity • Sedentary Lifestyle • Stress • Smoking • High intake of NA, saturated fats and alcohol Kidney release RENIN into the bloodstream RENIN helps convert angiotensin I in liver Angiotensin I is converted to angiotensin II ( a potent vasoconstrictor) in lungs Angiotensin II

14. Aldosterone: Cause NA and water retention Retained NA and Water Increased Blood Volume Arteriolar constriction Increased Peripheral vascular resistance Increased Blood Pressure and Vascular Resistance to Hypertension

15. Etiology • Hypertension may be primary, which may develop as a result of environmental or genetic causes, or secondary, which has multiple etiologies, including renal, vascular, and endocrine causes. Hypertensive emergencies are most often precipitated by inadequate medication or poor compliance. • Risk factors • Family history • Race • Stress • Obesity • Tobacco use • Sedentary lifestyle • High diet saturated in fats and sodium • Aging

16. Signs and Symptoms • No symptoms - many people are unaware they have hypertension until it is accidentally found at a doctor visit or they develop complications of hypertension • Headache • Morning headache • Tiredness • Irregular heartbeat • Blurred vision • Confusion • High blood pressure • Nausea • Vomiting • Heart palpitations • Chest pain • Increased sweating • Hypertension usually doesn’t show any clinical symptoms until vascular changes in the major organs occur. Symptoms produced by this process depend on the location of the damaged vessels. • Brain – stroke • Retina – blindness • Heart – myocardial infarction • Kidneys – proteinuria, edema and renal failure • HTN also increases the heart’s workload, causing left ventricular hypertrophy and later, left and right sided heart failure and pulmonary edema

17. Complications • Damage to your arteries. • This can result in hardening and thickening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications. • Aneurysm. • Increased blood pressure can cause your blood vessels to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening. • Heart failure. • To pump blood against the higher pressure in your vessels ,your heart muscle thickens. Eventually, the thickened muscle may have a hard time pumping enough blood to meet your body's needs, which can lead to heart failure. • A blocked or ruptured blood vessel in your brain. • High blood pressure in the arteries leading to your brain can either slow the blood flow to your brain or cause a blood vessel in your brain to burst, causing a stroke. • Weakened and narrowed blood vessels in your kidneys. • This can prevent these organs from functioning normally. • Thickened, narrowed or torn blood vessels in the eyes. • This can result in vision loss. • Metabolic syndrome. • This syndrome is a cluster of disorders of your body's metabolism — including increased waist circumference, high triglycerides, low high-density lipoprotein (HDL), or "good," cholesterol, high blood pressure, and high insulin levels. If you have high blood pressure, you're more likely to have other components of metabolic syndrome. The more components you have, the greater your risk of developing diabetes, heart disease or stroke. • Trouble with memory or understanding. • Uncontrolled high blood pressure also may affect your ability to think, remember and learn. Trouble with memory or understanding concepts is more common in people who have high blood pressure

18. Treatment • Lifestyle Modifications • Weight Loss • Moderation of alcohol intake • Regular exercise • Low fat and low salt diet • Smoking cessation • Stress reduction • Drug therapy • Thiazide diuretics • Angiotensin-converting Enzyme (ACE) inhibitors • Beta-adrenergic blockers • Calcium channel blockers • Angiotensin receptor blocker

20. Nursing Health Teaching • Promote monotherapy (treatment with a single agent) if appropriate to simplify the medication regimen and make it less expensive. • Include the family in the teaching program so that they understand the patient’s need

21. CONCLUSION • Hypertension is identified by WHO as the leading cause of cardiovascular mortality and 50% of the hypertensive population are unaware of their condition. Hypertension may present no signs and symptoms but indeed is a major risk factor of different life-threatening disease and is associated with shortened life expectancy. Therefore, us nurses play an important role not just in providing care to manage hypertension but also in educating our patients for their participation in preventing certain complications. • As in the case of our long term patients, significant others are important. We have to stress that dietary and lifestyle changes can improve blood pressure control and decreased risk of associated health complications. Although drug treatment is necessary in people for whom lifestyle changes prove ineffective or insufficient, therefore compliance is a must.

22. REFERENCES • Lippincott Williams and Wilkin’s Professional Guide to Diseases, Ninth Edition • Textbook of Medical and Surgical Nursing 10th Edition Lippincott Williams and Wilkins • PubMed Health • clinical.diabetesjournals.org/content/22/3/137.full • www.scribd.com/doc/37423398/Case-Study-Hypertension • http://www.cliffsnotes.com/study_guide/The-Heart.topicArticleId-277792,articleId-277685.html • Carretero OA, Oparil S (January 2000). "Essential hypertension. Part I: definition and etiology". Circulation101 (3): 329–35. • Kearney PM, Whelton M, Reynolds K, Whelton PK, He J (January 2004). "Worldwide prevalence of hypertension: a systematic review". J. Hypertens.22 (1): 11–9 • Shaw, Gina (2009-03-07). "Prehypertension: Early-stage High Blood Pressure". WebMD. Retrieved 2009-07-03