Submitted By :
Dilasha Gurung
ACKNOWLEDGEMENT
The case study report is prepared on the basis of the study preformed on this problem during the 28 months duty at home care. This case study report is prepared for the fulfillment of requirement of Home care to assist the acknowledgement gained by the staff regarding their allocated patient.
First of all, I would like to extend my thanks to Heal Home Care, Baluwatar for providing me an opportunity to fulfill the requirement.
It is a great pleasure for us to express and grant my special thanks to home care team and Mrs Yamuna for our supervision of the continuous supervision guidance encouragement and help. It is indeed a great home to express our heartfelt gratitude to my co-work (Nursing Staff) and Pradhananga family members for their kind support.
OBJECTIVES
General Objective
At the end of 28 months of home nursing care practice at New Baneshwor in the house of Rama Lama, I was able to observe and provide hostile care at the client’s home with the problem of hypertension(H.T.N).
Specific Objective
- To provide hostile nursing care to the patient.
- To apply the knowledge of nursing process.
- To communicate effectively with the client and family members.
- To gain & upgrade advance knowledge about the disease.
- To provide health education and preventive measure.
- To minimize the stress of patient and her family.
CHIEF COMPLAINTS
- Breathlessness
- Dizziness
- Headache
HISTORY TAKING
Past history
There is no past medical history.
History of present illness
The patient is suffering from anxiety and according to the patient there was a symptom of pain in the legs.
Family History
Number of family members : 3
- History of any chronic illness : No significant
- Any communicable disease in family : No significant
| Name of member |
Relation |
Health status |
Age |
| Rama Lama |
Patient |
Unhealthy |
76 years |
| Raj Bir Lama |
Husband |
Healthy |
78 years |
| Raju Lama |
Son |
Healthy |
28 years |
VITAL SIGNS
| EX No |
Vital signs |
Normal Value |
Patient value |
Remarks |
| 1 |
B.P |
120/80mm Hg |
110/80mm Hg |
Normal |
| 2 |
Temp |
98.6f |
99f |
Nomal |
| 3 |
Pulse |
72-80b/min |
78b/min |
Normal |
| 4 |
Respiration |
16-24b/min |
24b/min |
Normal |
LAB INVESTIGATIONS
| Ex No |
Lab Test |
Normal Value |
Patient Value |
Remarks |
| 1 |
ECG |
Normal |
Normal |
Normal |
| 2 |
ECHO |
Normal |
Normal |
Normal |
| 3 |
HB |
12-16gm |
9gm |
Animia |
| 4 |
TLC |
14000cu mm |
11000 cu mm |
Decrease |
TREATMENT CHART
| Medicine |
Dose |
Route |
Action |
frequency |
| Injection Mentoc |
2ml |
I.V |
Analgesic |
B.D |
| Injection ritarlix |
2ml |
I.V |
Antibiotic |
B.D |
| Injection sigil |
2ml |
I.V |
Antibiotic |
O.D |
PHYSICAL EXAMINATION
- Body built : Obese
- Health : Unhealthy
- Activity : Dull
Mental Status
- Consciousness : Conscious
- Looks : Depressed
Skin Condition
Color : White in Color
Texture : Wrinkle present
Temperature : Warm
Scar : No Scar
Edema : Lower extremity edema
Head and Face
Head : Round in shape presence of sea
Hair : Black and White event distributed in head
Face : Is one side of their face drooping & Hard to move
Eye
Eye brows : Normal
Eyelids : No swelling & edema
Saliva : White in color
Cornea : Clear
Conjunctive : Pallor
Ear
Size and Position : symmetrical
No any discharge
Hearing capacity intact
Nose
External mucus : Discharge
Mouth and Pharynx
Mouth : No swelling or bleeding
Teeth : No artificial teeth
Tongue : Pink and uncoated
Tonsils : Not enlarged
Neck
- Symmetrical
- Thyroid gland not palpable
- Not lymph node enlargement
Chest
Symmetrical absence of scar
Extremities
Movements of joints : Normal
Black
Corves : Sacliosis
HYPERTENSION
Hypertension is a condition in which the force of the blood against wall is too high usually systolic blood pressure greater than 140mm hg & a diastolic bp above 90 mm hg or both over a sustained period.
DIAGNOSTIC EVALUATION
| In Book |
In Patient |
| Electrocardiogram |
Done |
| Chest x-ray |
Done |
| Echo cardiogram |
Done |
| Stress test |
Done |
| Blood test |
Done |
| Urinary |
Done |
| Calcium |
Done |
Nursing Diagnoses:
- Risk of decreased cardiac output related to high blood pressure as evidence by self observation.
- Activity intolerance related to the disease condition as evidence by self observation.
- Actual pain related to the disease condition as evidence by patient.
- Knowledge deficient related to the disease condition.
- Anxiety related to the disease condition.
Intervention
- To assess the general condition of the patient.
- To provide comfortable position to the client.
- To administrate the medication prescribed by the doctor.
- Assess the level of B.P and respiration.
Types and causes of Hypertension
| Primary hypertension (90-95% or essential ) |
Secondary hypertension (5-10) |
| Cause of essential hypertension is unknown |
Secondary hypertension is cause by on identified cause : |
| Genetic and family history |
Narrowing of arteries that supply blood to your kidneys |
| Life style |
Renal parenchymal disease
Advenal gland disease
Constriction of aorta
Preeclampsia
Medication – oral contraceptive pills over the counter, cocaine & amphamna |
| Age |
76 |
| Metabolic Disorders |
Obstruction sleep apnea |
Diet Management
The patient should eat salt free diet & restrict the salt.
Medical Management
The patient should take proper medication at particular time.
PROGRESS REPORT
| Preface |
A
(1st Day )
|
B
(2ndDay)
|
C
(3rdDay)
|
D
(4th Day)
|
E
(5thDay)
|
| Pulse |
80b/m |
80b/m |
80b/m |
80b/m |
80b/m |
| Respiration |
32b/m |
32b/m |
32b/m |
32b/m |
32b/m |
| Temperature |
98.6f |
98.6f |
98.6f |
98.6f |
98.6f |
| Blood pressure |
140/110 mmHg |
160/20 mmHg |
17/121 mmHg |
175/125 mmHg |
180/130 mmHg |
HEALTH EDUCATION
Health education is most important for the patient. We educate the patient about hypertension and its laws. We ask the patient to reduce sodium, alcohol, and they should eat more fruits & vegetables, fiber & more fish. Exercise is very important for the health and avoid taking medications & supplement that increase blood pressure.
- Getting regular physical activity.
- Limiting the amount of alcohol.
- Smoking should be avoided.
- Manage your stress level.
- Control blood pressure during pregnancy.
INCREASED BLOOD PRESSURE
| In Book |
In Patient |
| Healthy with mild hypertension are easy symptomatic and hypertension is diagnosed as a result of routine BP measurement. |
Sometime |
| Severe hypertension may leave symptoms like headache, dizziness, nausea, vomiting, irritation and personality changes. |
Present |
| Occasionally with complications like neurological CHF, renal dis function Stulbe |
Present |
CLINICAL FEATURES
| In Book |
In Patient |
| Headache |
Present |
| Visual disturbance |
Present |
| Nausea & Vomiting |
Present |
| Abdominal |
Present |
| Obgligwua |
Present |
| Ehi |
Present |
| Rapid rise in B.P |
Present |
NURSING CARE PLAN FOR HYPERTENSION
| Nursing Assessment |
Nursing Diagnosis |
Goul Outcome |
Planning |
Implementation |
Evaluation |
| Subjective Data:
Patient says that they have dizziness. |
Risk to decrease cause related due to disease condition as evidence by physical examination |
To increase cardiac output. |
Assess the condition of the patient.
Check the vital signs.
Provide comfortable position.
Provide clean and noise free environment to patient.
Provide antihypertensive drugs preorder. |
Assess the condition of the patient.
Check the vital signs.
Provide comfortable position.
Provide clean and noise free environment to patient.
Provide antihypertensive drugs preorder. |
The goal is achieved(129/78mm Hg) blood pressure level. |
| Objective:
We observed the patient’s condition evidence by physical
examination.
|
|
|
|
|
|
| Subjective Data:
Patient should come in ward with pain in body and a
feeling of dizziness.
|
Risk to decrease cause related due to disease condition as evidence by
physical examination |
To increase cardiac output. |
Assess the condition of the patient.
Check the vital signs.
Provide comfortable position.
Provide clean and noise free environment to patient.
Provide antihypertensive drugs preorder. |
Assess the condition of the patient.
Check the vital signs.
Provide comfortable position.
Provide clean and noise free environment to patient.
Provide antihypertensive drugs preorder. |
The goal is achieved(129/78mm Hg) blood pressure level. |
| Objective:
We observed the patient’s condition evidence by physical
examination. |
|
|
|
|
|
HEALTH EDUCATION
Personal Hygiene:
- Advice the patient to maintain personal hygiene daily.
- Advice the patient to bath daily.
Diet
- Encourage the patient to take proper diet.
- Advice the patient to take less amount of sodium.
- Advice the patient to take more fiber.
Physical Activity
- Advice the patient to do physical exercises.
- Encourage the patient to do aerobics.
SUMMARY
Hypertension also known as high or raised blood pressure is a condition in which the blood vessels have precisely raised pressure. The 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 .
The exact causes at high blood pressure are not known, but several things may play a rule, including smoking, over weight or obese lack of physical activity. Hypertension is a very important disorder in aged people is association with higher risk of cardiovascular morbidity and mortality. The effect of reduction of blood pressure we value, decreases the risk for cardiac death as well as neurological, metabolic, and musculoskeletal system sequelac in aged people . The systolic pressure usually increase with age.
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