Case Study, Chapter 31, Assessment and Management of Patients With Hypertension

1. Joan Smith, 55 years of age, is a female patient who presents to the intensive care unit with the diagnosis of intracranial hemorrhage. The patient stopped taking her antihypertensives suddenly because of the cost of the medications and she recently lost her job to outsourcing. The patient is slightly drowsy and complains of a headache and blurred vision. The patient’s blood pressure is 220/130 mm Hg upon presentation.

(Learning Objective 6)

1. According to the definitions set by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), which type of hypertensive crisis is the patient currently experiencing?
2. Describe the treatment goals for handling the hypertensive crisis and apply the goals to the case study. Determine the current mean arterial pressure (MAP) and the goals for treatment.

The physician orders nicardipine hydrochloride (Cardene) 25 mg/250 mL, NS for peripheral IV starting at 2.5 mg/hr, and titrate by 2.5 mg/hr every 15 minutes to reach the goal for the first hour, which is to achieve 25% reduction of the initial MAP. 

• Call the physician if the dosing range of 15 mg/hr has been reached and the MAP is still not at target goal for the first hour of treatment, or up to four dose increases.
• Lower the BP within 6 hours to 160/100 mm Hg.
• Adjust the IV rate so that the IV fluids plus the nicardipine IV drip are equal to 100 mL/hr, in total. Call the physician if the IV fluids must go above 100 mL/hr to provide the nicardipine.

c. Explain what rate to set initially for both the nicardipine drip and the NS maintenance fluids.

d. Explain the process of titrating the nicardipine drip for the first hour to achieve the final MAP goal of 25% reduction of the original MAP. 

2. The community health nurse is preparing a program about hypertension for a local community center. The focus of the program is on the reduction of risk factors and compliance for those who have been diagnosed with high blood pressure. The target population includes older adults. (Learning Objectives 1 to 4) 

1. The nurse focuses on primary hypertension because it accounts for 90% to 95% of hypertension in the United States. What risk factors does the nurse include for this population?
2. The nurse prepares to discuss the changes in how the JNC 7 defines hypertension. What ranges and descriptions should the nurse include?
3. Because this is a gerontologic audience, the nurse needs to review why blood pressure increases with age. Explain how the structural and functional changes of aging contribute to higher blood pressure in the older adult.
4. What information does the nurse include about lifestyle modifications that may decrease risk of hypertension (or complications associated with diagnosed hypertension)?