MENNONITE COLLEGE OF NURSING

AT

ILLINOIS STATE UNIVERSITY

Family Nurse Practitioner I 471

Case Study: Hypertension

Client #1:

Mrs. Frances Long is a 70-year-old white woman who visits you regularly for treatment of type II diabetes mellitus for which she takes insulin. She is 5 ft. 9 in tall. Weight and blood pressure readings for her last three office visits were:

6 months ago: 190 lb., 170/70 mm Hg

3 months ago: 192 lb., 175/74 mm Hg

Today: 194 lb., 180/78 mm Hg

Her blood pressure is 175/80 mm Hg after she has been standing for 2 minutes. She denies chest pain, shortness of breath, or claudication. She does not smoke or drink alcohol.

PE: On physical examination Mrs. Long has a cataract obscuring the view of one eye, but normal vessels can be seen in the other. She has a somewhat diminished carotid upstroke on the left with a soft bruit. The lung fields are clear, and the heart examination is only significant for an S4. The abdominal examination is benign. She has 2+ dorsalis pedis pulses and no peripheral edema.

Labs: Mrs. Long has a hematocrit of 45%, sodium of 138 mmol/L, potassium of 4.0 mEq/L, creatinine of 1.2 mg/dl, and glucose of 257 mg/dl. The EKG shows some nonspecific ST and T wave changes in the lateral leads. Her chest x-ray shows clear lung fields, some calcium in the aortic arch, and a normal-sized heart.

QUESTION: Mrs. Long asks if it is recommended that she begin to take medication for her blood pressure. What are your plans for Mrs. Long? How will you respond to her question?

Client #2:

Mr. Philip Garvin is a 78-year-old black man with a long history of hypertension. He had a heart attack 3 months ago. Since discharge from the hospital, he has been taking these medications: furosemide (Lasix), 40 mg/day; metoprolol (Lopressor), 25 mg twice daily; and nifedipine (Procardia XL), 30 mg/day. He is 6 ft. tall. Weight and blood pressure readings for his last three office visits were:

2 months ago: 190 lb., 140/90 mm Hg

1 month ago: 195 lb., 145/95 mm Hg

Today: 198 lb., 150/100 mm Hg

His blood pressure is essentially the same when measured after 2 minutes of standing. He reports that he is a little tired and somewhat short of breath. He has not had any chest pain. Although he quit smoking after his heart attack, he had been a pack-a-day smoker for 60 years.

PE: On physical examination Mr. Garvin has moderate arteriovenous nicking in the fundi. The carotid arteries have normal upstrokes. He has bibasilar rales, and the heart examination is significant for an occasional irregular beat and a soft systolic murmur heard best in the aortic area. The liver is slightly enlarged, and he has 2+ peripheral edema. His peripheral pulses are only barely palpable.

Labs: Mr. Garvin has a hematocrit of 35%, sodium of 140 mmol/L, potassium of 3.2 mEq/L, creatinine of 2.5 mg/dl, and glucose of 90 mg/dl. His EKG shows an anteroseptal myocardial infarction, unifocal premature ventricular contractions, and diffuse nonspecific ST and T wave changes. His chest x-ray shows moderate cardiomegaly, fluid in the fissures, and small bilateral pleural effusions.

QUESTION: Mr. Garvin asks why his blood pressure is going up when he is taking all of his medicines. What are your plans for Mr. Garvin? How will you respond to his question?