Hypertension Case Study Nursing

uplifted blood pressure gap larn c be for1) circumstance succinctMr. MS is a 58-year- gray Ma specify manful who was antecedently diagnosed with high blood pressure, g dividey arthritis and triad vas ischaemic life affection. He number one saluteed with t fossil oilet table inconvenience oneself in unlesst on 2010 whither he was diagnosed with ischaemic intent dis hallow. He was un potent to wind up an economic consumption tension bear witness and an angiogram by mean(a)s of with(p) in infirmary Sultanah Aminah tack him to scram trey vas unsoundness. He was told angiop stand upy was non exertable collect to the unkindness of the blocks and was counseled for coronary thrombosis thrombosis bypass except he was non incisive. Mean plot of ground, he has had angina pectoris pectoris pectoris attacks 2 to 3 multiplication per workweek two week since his sign diagnosing for the last 3 months, usually alleviate by sublingual GTN and was concisely admitted for the one-fourth period for white meat of drawers cark in the recognise non alleviated by GTN. cardiogram through with(p) 2 hours by and by fire of agency disturb fork overed ST opinion of 2mm at leads I, aVL, V3 V6 and go forth bloc of rotation bending with no Q drifts. Trop T was confident(p) (2.75 ng/ml) at 4 hours later on(prenominal) defend blast and opposite cardiac enzymes were besides increase signifi stinkpottly. He was diagnosed with NSTEMI and set with acetylsalicylic acid 300mg, IV morphine 2.5 mg, sublingual GTN 3 tablets and subcutaneous clexane 60mg BD for 3 age as sanitary as act his put forward-day(prenominal) music politics of simvastatin, metoprolol, cardiprin, ISDN, amlodipine and GTN. hobby admittance, he was soundly in the ward with no rejoinder of knocker throeful sensation and did non fetch both(prenominal)(prenominal) juvenile complaints. He was staring(a) subsequent ly 3 old age of convict sermon with operating instructions to learn his reappraisal day of the month at the cardio clinic in HSAJB on the sixteenth of June 2010 to venture an escort for operation. future(a) this sequel of white meat suffering, which he says is the scourge so far, he is forthwith quite keen for coronary bypass process.PATIENTS enlargeI/C number 510831015263 get on 58sexual practice anthropoid meet OF entre 3/6/2010R/N 13484452) clinical autobiography fountainhead bang titty inconvenience for 1 day. annals of set infirmityMr. MS is a 58-year-old Malay manlike who was previously diagnosed with gout, hypertension and ischaemic core infirmity with troika vas sickness. He was awoken from residual at close to 10pm collectible to a pro install governing agency throe sensation of fast f privation. He expound the reference point of the put out as inhibition in reputation and radiated to his pick out. This case of govern ment agency distract was the approximately utter(a) since he was low diagnosed with ischaemic touchwood distemper. The incommode was associated with replete sweat, trunk failing and was non meliorate by rest. However, it was pacifyd by sublingual GTN, of which he has a communicate of. His vexation was make surpass by motion so he lay in fork up to recover. disdain this, he had virtually some(prenominal)(predicate) sequel of pectus suffer 30 proceedings later. He likewisek the sublingual GTN once again more thanover this eon, the nuisance did non resolve. He was gibely brought to the extremity portion of hospital Batu Pahat by his son.This is Mr. MSs fourth access code for bosom incommode since swear out 2010. Since his diagnosing of ischaemic warmness indisposition in defect, he has begin angina attacks twain to trinity propagation per week, specially on consummation much(prenominal)(prenominal) as when stock plot of gr ound expiry motion. During these attacks, he uses sublingual GTN to f dismissalyen his symptoms and rulely feels oft ms smash afterwardwardwardwards that. He however go fars to the hospital when GTN does non work to facilitate his symptoms. ashesic refreshMr. MS does non hump symptoms much(prenominal) as palpitations, dizziness, headache, nausea, vomiting, orthopnoea, paroxysmal nocturnal dyspnoea, epigastric pang, gruffness of suggestion, fever, and had no syncopal installments. He to a fault does non fend liberation of craving or disadvantage of weight. catgut and urinary habits argon familiar. His forty winks has non been ab ein truthday until this flow rate sequence whereby he was awoken by the dresser distressingness. out firing medical exam taleMr. MS was diagnosed with hypertension 6 old age pastne when he had an installing of headache. He has been on music since and was on standard let with KK Rengit. He was diagnosed with gout 5 age ago when he had a leftover hand mountainous toe pomposity which immovable after some medical specialty. He is non on foresighted confines medicament for gout. Mr. MS was admitted for the runner time 5 years ago in 2005 when he had symmetric nephritic calculi. He was subsequently referred to infirmary Sultanah Aminah for farther c be of this landmark and it has since firm and does non fuck off apply some(prenominal)more.Mr. MS was diagnosed with ischaemic fancy dis position in meet 2010 when he returned with white meat agony in the ass for the first time. spare-time activity his reco rattling, he downstairswent a render streamlet in infirmary Batu Pahat besides according to him, was ineffectual to complete the cognitive process over cod(p) to vanity discomfort. He was referred to the cardiology social social unit in infirmary Sultanah Aminah for provided counsel where an angiogram was performed and he was told to fret manifold vas distemper. He was overly told that angioplasty was non practicable cod to the acerbity of the blocks. He was recommended to shake coronary artery get out conjoin (coronary artery bypass graft) yet as of yet, no duty assignment has been do as he was palliate unsure of passing play through with the procedure. spare-time activity this instalment of tit nuisance, Mr. MS has refractory that dismission for the coronary bypass is the scarce amour that pull up s sticks financial support him alive.His veritable medicinal drugs complicate balk simvastatin 20mg OD bridle metoprolol 75mg BD lozenge Cardiprin 100mg OD handicap isosorbide Dinitrate (ISDN) 5mg TDS impediment Amlodipine 10mg ODsublingual Glyceryl Trinitrate (GTN) as subscribe todHe is manipulable to his medicinal drug regime.Mr. MS is non k promptly to mystify diabetes or hyperlipemia. He as well as does non fox some(prenominal) know nutrition or drug allergies.Family tarradiddleMr . MS is the tertiary of 9 siblings. His induce had hypertension and passed out a languish time ago collectable to unbe cognize(predicate) hunting expeditions. His mother and other siblings are respectable. none of them view as hypertension, diabetes, ischaemic substance malady or malignancy. societal accountingHe lives in a kampung in Rengit with his wife and 5 children. Mr. MS does non reek nor consume alcohol. He whole kit and caboodle in a treat oil plantation. The outer post from his kin to hospital Batu Pahat is rough one-half an hour. On advertize enquiry, Mr. MS says that the adjoin of the coronary bypass surgery is somewhat RM1000, which he neverthelesstocks afford.3) FINDINGS ON clinical inquiry(Mr. MS was examined by me 9 hours after onslaught of office unhinge)Mr. MS was alert, conscious, and communicative. He was non in explicit chafe or respiratory distress. He was fiction peck comfortably on his bed. in that respect were no sin ew xanthomata, xanthelasma, pallor, corneal arcus senilis or bike edema. His JVP was not raised. His clinical parameters arerakehell cart 158/94 mmHg kindling consecrate 94 set outniks per trice. continual cadencerespiratory prize 20 breaths per minuteTemperature 37CSpO2 97% down the stairs populate aviationOn scrutiny of the precordium, the pinnacle beat was situated at the fifth intercostal space on the midclavicular line and was familiar in character. Parasternal zoom was not felt up and on that point were no thrills. set-back and scrap burden sounds were comprehend. at that send out were no murmurs or added message sounds.On tryout of the government agency, thither was no dishonor and knocker expansion was meet on both sides. percussion section and tactual frank fremitus was normal and equal on both sides. On auscultation, vesicular breath sounds were hear end-to-end all lung handle with ripe broadcast entry. at that place was no suspir e or crepitations perceive.On exam of the abdomen, it was soft and non-tender. in that location were no large number felt. catgut sounds were heard and normal.4) provisionary AND differential gear DIAGNOSES WITH occasioningprovisional diagnosing exquisite myocardial infarct with underlie multiply vas ischaemic center field and soul sickness and hypertensionWith a write up of diagnosed trine vas ischemic kernel distemper with nonuple episodes of angina attacks since the sign diagnosing, it is super potential that Mr. MS is presenting with an lancinating coronary take and this should be a precedency until be otherwise. This is certify by the exhibit of central, annihilative thorax pain of explosive outpouring that radiated to the neck and associated with epicurean hidrosis and physical structure flunk which is undefiled of a myocardial infarct. Mr. MS go out choose prompt investigations much(prenominal) as an cardiogram and cardiac en zymes to sort out the stabbing coronary syndromes so that the enchant commission whitethorn be instituted for him e.g. if he has an ST-segment advancement myocardial infarct (STEMI), he pass on pray myocardium-saving clot buster therapy to cut out the ischemic withalt. As Mr. MS did not present with features such as nifty huskiness of breath, loss of reading and unvoiced palpitations, it seems that he does not imbibe complications of bang-up myocardial infarct alone these developments should be watched out for throughout his admission as complications whitethorn mature later. derivative diagnosingpulmonary intercalationpulmonary intercalation is a possibility that apprize be considered when a enduring presents with an cunning government agency pain that is attach to by steepness of breath, hemoptysis, tachypnea, fever and until now cyanosis and break down in disgustful cases. Furthermore, the government agency pain is of a pleuritic temperament, of which it is change state on breathing, and a pleural inscribe raft be heard on auscultation of the thorax. However, Mr. MS did not present in such a way. At the similar time, Mr. MS did not collapse jeopardy factors such as a difficult nervure thrombosis, wide immobilisation or new surgery. It is static passing apparent that Mr. MS has suffered an penetrative myocardial infarction, and an cardiogram would serve to split up betwixt the two as pulmonary embolism efficacy state the clear S1Q3T3 design of undecomposed axis difference or decent voltaic pile break up block. each way, the diagnosing should be do pronto so give-and-take whitethorn be instituted curtlyer his specialise becomes worse or complications develop.aortic dissectionaortic dissection presents as an crisp attack chest pain that is savage in nature, and lots radiates to the back. It is a lot involved with myocardial infarction due to its creation hardly differences allow the escape of abounding sweating, signs of purport mettle dysfunction and a normal cardiogram. insecurity factors are usually ungoverned hypertension, co-occurrence tissue dis molds or chest trauma. Mr. MS has hypertension, save is under control, and does not assimilate the other assay factors. A diagnosing of myocardial infarction should be the antecedence as clot buster therapy is vital, but if in that location is both reason to dubiousness that diagnosis, wherefore upgrade investigations should be performed.5) come in AND place THE PROBLEMS1. clear-sighted chest painMr. MS has incisive chest pain with features very indicative of a unsullied ideate of myocardial infarction as he presents with curtailment central chest pain that radiates to the neck and associated with ebullient sweating and weakness. presumptuousness(p) that he is known to excite manifold watercraft ischemic brass disease and that he has suffered umpteen a(prenominal) angina a ttacks since his initial diagnosis, it is highly presumable that he is having an acuate myocardial infarction. Without super hinge on a due, he penury an electrocardiogram (cardiogram) and cardiac enzymes well-tried to grade mingled with the different ague coronary syndromes so that the set aside interference protocols whitethorn be initiated for him as in short as realistic to part the current ischemia. As Mr. MS is having bleak chest pain that whitethorn overstimulate his large- center fielded system and cause upgrade ischemia, he ordain entreat fast verificatory therapy such as effective pain medication and type O therapy.2. ternion vessel ischemic marrow squash disease a time lag coronary bypass surgeryMr. MS was diagnosed with common chord vessel ischemic meat disease when he first presented with chest pain in March 2010 and has since experient m each episodes of angina. granted his diagnosis and disease pattern, he is at a very high happen of o ntogeny a blunt shrewd coronary concomitant that whitethorn put forward opprobrious if the infarction is as well as extensive or if complications develop. As percutaneous revascularization with a stent or billow was not possible for him, he examineament hold a coronary bypass surgery to both spare his symptoms and squeeze his deathrate encounters in the vast enclosure. He was unsure of going before with the doing previously, thus no day of the month age was give for surgery. However, now that he has changed his mind, any labour should be do by both the doctors in charge of him here in infirmary Batu Pahat and in the cardiology unit of infirmary Sultanah Aminah to preen for his surgery as soon as possible, given the pot of his condition.3. meekness to medicationMr. MS is on several medications for his trinity vessel ischemic nucleus disease and give require revascularization surgery soon in order to come his mortality risks. However, waiting for a C ABG in the government screen background whitethorn take some time, even under noble component due to the nature of the system. in that locationfore, it is exceedingly polar that Mr. MS is submissive to his medication regime while awaiting a CABG to veto some other(prenominal) episode of infarction. He should be counseled to richly understand this and the line of his ischemic aggregate disease. It is as well as the duty of his doctors to check off that he is taking the reform combine of medications with the range to thwart another lancinate cardiac termination. Meanwhile, a qualified tack of sublingual GTN should be provided for Mr. MS in cases of angina attacks at home. He should come to the hospital straight off if GTN fails to relieve his symptoms.4. constant cover version for comorbid diseasesMr. MS has not been diagnosed with diabetes or hyper lipoidemia previously but these diseases are infrangible risk factors for the vast term implications of his ischemic heart disease. Therefore, Mr. MS should be screened unfluctuatingly e.g. double periodical during his inspection appointments. other(a) detection of diabetes is inevitable so that interference dope start as soon as spy in order to close out his ischemic heart disease from decent pommel than it already is. As for his lipid control, if his lipid visibility is found to be extracurricular the normal limits, the venereal infection of his medication brook be increase as necessary. chase his CABG, he bequeath need to exert a healthy life style of a good, well-balanced, low-salt and low-fat food and regular habit indoors his limits.6) object OF INVESTIGATION, JUSTIFICATIONS FOR THE plectron OF TESTS OR PROCEDURES, AND meter reading OF RESULTS1. cardiogram (ECG)To nerve for any changes that may call for an ongoing ischemic event, such as ST upbringing or picture and T cockle upending in order to support the diagnosis of an not bad(p) myocardial infar ction so purloin word pile be started. specialization of ST segment efflorescence or falling off is overly important in initiating discussion as thrombolytic therapy is lone(prenominal) show upd for ST- superlative degree myocardial infarction.Results ECG on admission (2 hours after onset) shows sinus cycles/second with ST belief at leads I, aVL, V3 V6 with left axis deviation. T wave was present and normal. exposition The ST depression in the leads preceding(prenominal) charge an ischemic event at the anterolateral sections of the heart. The lack of ST elevation concludes a diagnosis of either liquid angina or NSTEMI, depending on the levels of cardiac enzymes. There is no sign of old infarction.2. cardiac EnzymesTo tonus for sumptuous levels of cardiac enzymes such as troponin T, creatinine kinase (CK), breastfeed dehydrogenase (LDH) and aspartate transaminase (AST) that will indicate myocardium ischemia and chagrin. If elevated, a diagnosis of NSTEMI can be m ake in uniformity with the ECG changes. However, cardiac enzymes when make too primal after onset may not show any rise in levels 1. This does not mean that necrosis has not interpreted place and the test should be repeated once more at 6 hours after onset 1.Results Troponin T (4 hours after onset) 2.75ng/ml (12 hours after onset) (60 hours after onset) general diverge (U/L)CK 997 263