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CASE PRESENTATION
µPULMONARY
HYPERTENSION ¶
MATRIX NO. : 0154
GROUP : 3 (2/2009)
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LEARNING OBJECTIVES
1. State the Meaning or Definition of Pulmonary Hypertension.
2. State the Etiology of Pulmonary Hypertension.
3. Explain the Pathophysiology of Pulmonary Hypertension.
4. State the Clinical Manifestation of Pulmonary Hypertension.5. List down the Complication of Pulmonary Hypertension.
6. Explain the Management for patient with Pulmonary Hypertension.
7. Carry out the care for patient with Pulmonary Hypertension usingnursing process.
8. Appreciate the Health Education given for the patient in home care planning.
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NURSING ASSESSMENT
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NURSING ASSESSMENT
Name : Mr S
Sex : Male
MRN Number : 287828
Age : 41 years old
IC No. :681028-01-5703
Address :Tiang 6, belakang taman suraya, jalan kukup, 8200 Pontian Johor
Tel. No. : 013-7557575
Marital Status : Married with 4 children
Occupation : Factory worker(lorry driver)
Race : Malay
Religion : Islam
Language spoken : Malay, English Ward : 6th floor(premier)
Room No. : 621B
Consultant : Dr. Y
Date and Time of admission : 10th May 2010 @ 1915 hours
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NURSING ASSESSMENT
Reason of admission : c/o cough with blood x2/52
Medical history : Nil
Surgical history : Nil
Family history : Nil
Current Medication : Nil
Allergics : Nil Diagnosis : Pulmonary Hypertension
Date of discharge : 12 May 2010 @ 1030 hours
Date of follow up :
26 May 2010 @ 1130 hours at Dr. Y clinic
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NURSING ASSESSMENT
During the admission time in the ward, his vital sign has been taken
and the result is as follow :
Temperature : 35.70 C
Pulse : 82 beats/min
Respiration : 18 breaths/min
Blood Pressure : 146 / 101 mmHg
Weight : 79 kg
Height : 166 cm
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PHYSICAL EXAMINATION
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PHYSICAL EXAMINATION
Inspection Of The Head :
Hair : Mr S hair is curly; black in color. Its structure is fine and soft. Eyes : Mr S eyes is quite normal. His eyes is free from pale or jaundice
(yellow)
Ears : Mr S hearing is normal. He can hear without any complication andhe can hear clearly.
Mouth : Mr S mouth is moisture, there is no oral mucosa presence, nolesions at tongue. Gums and teeth are normal.
Neck : Mr S neck is normal, there is no swelling or surgical scars.
Face : Mr S face is round in shape, there is no presence of edema or scarsat his face.
Inspection Of The Body :
Chest : Mr S chest is normal, he can breath well without anycomplication. There is no edema or swelling.
Axilla: Mr S axilla is normal. There is no presence of lymph nodes, noinfection of fungal.
Abdomen : Mr S abdomen is normal, there is no surgical scars,tenderness or mass.
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PHYSICAL EXAMINATION
Inspection Of The Upper Limbs : Nails : Mr S nails are clean, no clubbing spoon shape. I pintch at his
nails to check his blood circulation and its normal.
Fingers : Mr S fingers is normal and adequate. Movement of the fingersalso normal.
Skin : Mr S has a good condition of skin, no rashes or sign of dehydration. No presence of lesion or scars.
Inspection Of Groin And Genitalia :
Actually for this part of examination, Mr S is refused, he don¶t want toexpose it. But he told me that he always take good care of his groin andgenitalia. He saids that there is no infection of fungal, no discharge or swelling.
Inspection Of The Lower Limbs :
All is normal, in correct allignment, good movement and bloodcirculation and there is no varicose vein.
Inspection Of Spine :
Mr S spine is normal, no tenderness, mass, backache or pressure sore.
There is no hordosis ( an abnormal forward curve of the lumbar spine ).
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ACTIVITY OF DAILY LIVING
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ACTIVITY OF DAILY LIVING
Breathing :Mr S can breath normally without any complication. His depthrespiration is normal. His rhythm of respiration is regular andnormal and the character of his breathing is normal and no moresound is out from her breathing.
Cough :
When Mr S is admitted he is having a coughing with blood.
Smoke :
Mr S is a smoker.
Eating / Drinking :
When Mr S is admitted at the hospital, I see that he is not havingany problems to eat but he verbalized that he cannot eat the diet atthe hospital, he loss appetite. At home, he eat all foods witout anygood diet, he likes to eat curry, all the kind of foods. Aboutdrinking, he drink a lot of water daily.
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ACTIVITY OF DAILY LIVING
Bowel elimination :
Mr S past motion daily everyday.
Bladder elimination :
Mr S past urine every 3 ± 4 hours per day. And he don¶t have any problems to passing his urine and he don¶t get up at night to pasturine.
Sleeping :
Mr S said to me, he hasn¶t any problem in sleeping.
Mobility :
Mr S is independent. He able to move without any assisstant.
Personal Hygiene :
Mr S personel hygiene is maintain. He said to me that he alwayshave his shower twice a day.
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ACTIVITY OF DAILY LIVING
Safe Environment :
Mr S safe environment is safety, he just need a siderails to prevent hisfrom accident and drop to the floor .
Communication :
Mr S can speak in English and Malay language clearly and he can
understand properly.
Spiritual :
Hospital is allowed his to bring any prayers for his safety frommosque or surau.
Hobby :Mr S likes to reading when he in free time. He likes to read newspaper and books.
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ANATOMY AND PHYSIOLOGY
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ANATOMY AND PHYSIOLOGYHeart
The heart is roughly cone-shape hollow muscular porgan. It is about10cm long and is about the size of owners fist. It weight about 225g inwomen is heavier in men about 310g.
Position Of The Heart
The heart lies in the thoracic cavity in the media sternum between thelungs. It lies obliquely, a little more to the left than the right, and presentsa base above, and an apex below. The apex is about 9 cm to the left of the midline at the level of the 5th intercoastals spaces, a little below thenipple and slightly nearer the midline. The base extends to the level of the 2nd rib.
Structure Of The Heart
A double-layered membrane called the pericardium surrounds like a sac.The outer layer of the pericardium surrounds the roots of the heartsmajor blood vessels and is attached by ligaments to spinal column,diaphragm and other part of body. The inner layer of the percardium isattached to the heart muscle.
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ANATOMY AND PHYSIOLOGY
The heart has 4 chambers. The upper chambers are called the left andright atria, and the lowers chambers are called the left and rightventricles. A wall of muscle called the septum separates the left and theright atria and the left and the right ventricles. The left ventricles is thelargest and the strongest chamber in the heart. The left ventricles
chambers walls are only about a half-inch thick, but they have enoughforce to push blood through the aortic valve and into the body.
Function Of The Heart
The role of the heart is to deliver the oxygen in order to live andfunction. The role of heart is to deliver the oxygen-rich blood to everycell in the blood. The arteries are the passageways through which the blood is delivered. The largest artery is the aorta, which branches of the
heart and then divides into many smaller arteries. The veins carrydeoxygenated blood back to the lung to pick up more oxygen, and then back to the heart once again. Blood flows continuously through thecirculatory system, and the heart muscle is the pump which it all possible.
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ANATOMY AND PHYSIOLOGY
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ANATOMY AND PHYSIOLOGY
L O O L O O D T H O G H T H H A T
UNOXYGENATED BLOOD
S I
P
P
L
OXYGENATED BLOOD
P
L
L
L
A
A
* D
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ANATOMY AND PHYSIOLOGY
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ANATOMY AND PHYSIOLOGY
Blood Vessels
Arteries And Arterioles
Transport blood away from the heart. Consist more elastic tissue andless smooth muscle. It also has thicker walls and enables them towithstand the blood pressure.
Veins And Venules :
Return blood at lower pressure to the heart. The walls are thinner because less muscle and elastic tissue.
Structure Of Blood Vessels Walls
The blood vessels walls consist of three layers :
Tunica Intema
Inner most layer.
EndotheliumI ± Simple squamous
Some larger vessels have subendothelium
I ± Loose connective tissue.
II ± Basement membrane.
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ANATOMY AND PHYSIOLOGY
Tunica Media
Middle layer. Circulatory arranged smooth muscle.
Chemical and nervous control of degree of contraction.
I ± Sympathetic nervous system.
Change in diameter
I ± Vasoconstiction
II ± Vasodilation
Tunica Adventitia
Made of collagen fibers
Function : protection, reinforcement, anchor to surrounding tissue.
Accessory tissue : nerve fibers, lymphatic vessels, elastic network, tiny blood vessels within layer ± vasa vasorum.
Arterial Systems
Classification based on size and function.Elastic ( conducting ) arteries
Characteristics :
I ± Thick ± walled
II ± Near heart
III ± Largest diameter
IV ± More elastic
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ANATOMY AND PHYSIOLOGY
V ± Large lumen
Properties :
I ± Dampen BP changes associated with heart contraction.
II ± Passive accomodation results in smooth flow of blood.
Size : 2.5 cm
Muscular arteries ± distributing arteries
Distal to elastic arteries.
Deliver blood to specific organs.
Thick media layer.
I ± More smooth muscle.
Size : 0.3 ± 1.0 cm
Arterioles
Determine flow into capillary beds. Mostly smooth muscle.
Size : 10 um ± 0.3 cm.
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ANATOMY AND PHYSIOLOGY
Capillaries
Smooth blood vessels.
I ± 8 ± 10 um
Tunica intema only.
Exchange of materials.
Control Of Blood Vessels Diameter.
Vasometer centre in the medulla oblongata supplies nerves to the smoothmuscle fibres, of all blood vessels except capillaries.
These nerves can change the diameter of the lumen of the blood vessels andcontrol the volume of blood they contain.
Small arteries and arterioles respond to nerve stimulation whereas thediameter of large arteries varies according to the amount of blood theycontain due to the quantity of muscle tissues.
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ANATOMY AND PHYSIOLOGY
Vasodilation and vasoconstriction.
Decreased muscle stimulation ± smooth muscle relax, vessel wallthinned, lumen enlarged ± VASODILATION ± increased blood flow.
Increased nerve stimulation ± increased thickness and contraction ± VASOCONSTRICTION ± decreased blood flow.
Peripheral resistance :
Provided by arterioles to maintain homeostasis of blood pressure. Determined by 3 factors : diameter, length and viscosity of fluid
involved.
Auto regulation.
Accumulation of metabolities in local tissues can influence the degree of dilation of arterioles to ensure adequate blood supply to meet tissueneed.
Example : lactic acid accumulates in muscles after exercise causesvasodilation.
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DEFINITION OF PULMONARY HYPERTENSION
The right ventricle pumps blood returning from the body into the
pulmonary arteries to the lungs to receive oxygen. The pressures in the
lung arteries (pulmonary arteries) are normally significantly lower than the
pressures in the systemic circulation. When pressure in the pulmonary
circulation becomes abnormally elevated, it is referred to as pulmonaryhypertension.
(http://www.medicinenet.com/pulmonary_hypertension/article.htm#tocc)
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Pulmonary hypertension is defined as the mean pulmonary artery blood
pressure greater than 25 millimeter of mercury (mmHg) measured by right
heart catheterization. The pressures can be much higher than 25 mmHg in
some people. Therefore, the pulmonary hypertension can be labeled as
mild, moderate, or severe based on the pressures.
Mean arterial pressure is two-thirds of the difference between systolic and
diastolic blood pressure (systolic is the upper number and diastolic is the
lower number in measuring blood pressure).
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Pulmonary hypertension generally results from constriction, or stiffening,
of the pulmonary arteries that supply blood to the lungs. Consequently, it
becomes more difficult for the heart to pump blood forward through the
lungs. This stress on the heart leads to enlargement of the right heart and
eventually fluid can build up in the liver and other tissues, such as the in
the legs.
In the conventional classification, pulmonary hypertension, is divided
into two main categories:
1) primary pulmonary hypertension (not caused by any other disease or
condition)
2) secondary pulmonary hypertension (caused by another underlying
condition)
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Primary pulmonary hypertension has no identifiable underlying cause.
Primary pulmonary hypertension is also referred to as idiopathic
pulmonary hypertension.
Primary pulmonary hypertension is an unusually aggressive and often
fatal form of pulmonary hypertension that commonly affects young people. Whereas it is known that the arterial obstruction is caused by a
building up of the smooth muscle cells that line the arteries, the
underlying cause of the disease has long been a mystery.
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ETIOLOGY ± FOR ESSENTIAL PULMONARY
HYPERTENSION
1. HEREDITY
2. SMOKING
3. OBESITY
4. DIABETES
5. DIET
6. STRESS
7. RACE
8. MINERAL INTAKE
9. INSULIN RESISTANCE
10. *UNKNOWN
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ETIOLOGY ± FOR SECONDARY HYPERTENSION
1.RENAL DISEASE(renal vascular and parenchymal disease).
Example : glomerulonephritis, pyelonephritis, renal tumors.
2. ENDOCRINE DISORDER
Example : primary aldosteronism, crushing¶s syndrome.
3. COARCTATION OF THE AORTA
4. NEUROGENIC
Example : Brain tumors, Encephalitis.
5. PREGNANCY
6. INCREASE INTRAVASCULAR VOLUME
7. BURNS
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PATHOPHYSIOLOGY
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CLINICAL MANIFESTATION
1. Morning occipital headache
2. Weak/fatigue
3. Dizziness
4. Nausea and vomiting
5. Palpitation
6. Flushing
7. Hemoptysis(coughing up blood)
8. Shortness of breath
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COMPLICATION
1. Hypertensive heart disease
2. Heart attacks
3. Congestive heart failure
4. Blood vessels damage (arterosclerosis)
5. Aortic dissection6. Kidney failure
7. Stroke
8. Brain damage
9. Loss of vision
There is no complications that occurs to Mr S.
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MANAGEMENT OF PATIENT WITH
HYPERTENSION
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INVESTIGATION
The investigation that done to
Mr S are :
1. Urine FEME
2. Blood Test
3. Chest X-ray
4. CT Scan Angiogram
5. Electrocardiogram(ECG)
6. Echocardiography
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INVESTIGATION
PATHOLOGY REPORT
Date :10 May 2010 @1932 hours
examination result unit Reference range
Urine FEME (urinalysis)
Appearance,urine Yellow clear Yellow /pale yellow
Specific gravity,urine 1.005 1.005-1.025
pH,urine 7.0 4.8-7.5
Protein,urine Negative Negative
Glucose,urine Negative Negative
Ketone,urine Negative Negative
Bilirubin screen,urine Negative Negative
Urobilinogen,urine Normal Normal
Nitrite,urine Negative Negative
Leukocytes esterase,urine Negative Negative
Blood,urine Negative Negative
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INVESTIGATION
PATHOLOGY REPORT
examination Result unit Reference
range
Microscopic
examination,urine
WBC,urine 3/hpf 0-5
RBC,urine 0/hpf 0-3
Epithelial cell,urine Nil
Cast,urine Nil
Crystal,urine Nil
Bacteria,urine Nil
yeast, cell,urine Nil
Others,urine Nil
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INVESTIGATION
PATHOLOGY REPORT
Date :10 May 2010 @ 1802 hours
Full executive screening male(GP61J)
examination Result unit Reference range
H aematology
Haemaglobin 16.3 g/dL 13.0-18.0
Red cell count 5.6 10 12/L 4.5-5.9
Haematocrit (PCV) 48% 41-53
MCV 86 fl 80-96
MCH 29 pg 26-34
MCHC 34 g/dL 31-36
Platelet count 260 10 3/UL 150-450
ESR 5 mm/hr 0-15
White blood cell count 9.9 10 3/UL 4.3-10.5
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INVESTIGATION
PATHOLOGY REPORT
examination Result
unit
Reference range
White blood cell differential count
Neutrophil 51.2% 40-75
Lymphocyte 41.0% 20-45
Eosinophil 2.0% 0-6
Monocyte 5.5% 1-11
Basophil 0.3% 0-2
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INVESTIGATION
PATHOLOGY REPORT
Peripheral blood film comment:
Red cells show normochomic and normocytic picture.
White cell appear normal.
Platelet are adequate.
~coagulation test~
INR 1.18 0.85-1.35
T he INR (International normalised ratio) is a good indicator of t he
affectiveness and risk of bleeding during warfarin t herapy and is kept
about 2.5,wit h a target range of 2.0-3.0 for most clinical conditions.
~biochemistery~
Diabetes mellitus screen
**glucose 6.7 mmol/L
3.9-6.1
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INVESTIGATION
Renal function & bone metabolism screen
examination Result unit Reference range
**uric acid 499 u mol/L 202-434
Creatinine 70 u mol/L 51-133
Urea 4.4 mmol/L 2.0-6.8
Sodium 139 mmol/L 135-155
Potassium 4.5 mmol/L 3.5-5.5
Chloride 102 mmol/L 95-111
Calcium 2.31 mmol/L 2.20-2.55Phosphate 1.23 mmol/L 0.78-1.50
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INVESTIGATION
examination Result unit Reference range
Lipid profile
**total cholesterol 5.7 mmo/L <5.2
**tryglycerides 2.30 mmo/L <2.28
**HDL cholesterol 1.15 mmo/L >1.42
**LDL cholesterol 3.5 mmo/L <2.6**chol/HDL cholesterol 4.8 mmo/L Up to 4.0
Risk classification of lipid profile of Laboratory Standardization Panel of National
C holesterol Education Program (adult treatment panel III) in United states:
-----------------------------------------------------------------------------------------------------------------------------------------
Risk classificationc holesterol T ryglycerides HDL-c hol
LDL-c hol
Desirable <5.2 <1.71 >1.42
<2.6
Borderline 5.2-6.2 1.71-2.28 1.03-1.42 -
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INVESTIGATION
Examination Result unit Reference range
Liver function screen
Total protein 73 g/L 63-83
Albumin 43 g/L 35-50
Globulin 30 g/L 25-40
A/G ratio 1.4 1.0-2.0Total bilirubin 5.3 u mol/L 2.0-28.0
Direct bilirubin 1.6 u mol/L <6.8
Indirect bilirubin 3.7 u mol/L <20.5
SGOT/AST 18 U/L 7-44
SGPT/ALT 18 U/L 7-48
CKMB 19 U/L <25
Lactate dehydrogenase, LDH 403 U/L 211-423
Alkaline phosphate 65 U/L 45-122
**Gamma ±GT 52 U/L 11-50
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INVESTIGATION
PATHOLOGY REPORT
Examination result unit reference
range
-serology-
--blood group--
ABO group O
Rheusus group (D) positive
--T hyroid function screen--
Free T4 17.9 p mol/L 9.1-24.4
TSH 1.38 m IU/L 0.30-4.50
--r heumatoid factor screen--
Rheumatoid factor 4.7 10 /mL
<15
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INVESTIGATION
PATHOLOGY REPORT
Examination result unit reference
range
--veneral disease screen--
VDRL(RPR) non reactive non reactive
-- AI DS screen--
HIV I/II antigen/antibodies non reactive non
reactive
H .pylory antibody (qualitiative) negative
negative
--hepatitis screen--
*Hep A virus (HAV)IgG non reactive
Interpretation : positive to H ep A virus antibody.
May indicate absence of immunity against H ep A virus. Advice vaccination.
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PATHOLOGY REPORT
Examination result unit
reference range
--H ep B screen--
HBs antigen non reactive non reactiveHBs antibody <2.0 mIU/ML
H bsAb interpretation: non reactive ,no protective level of anti H bs
Recommendation :vaccination/booster if H bsAg is non reactive
--cancer marker screen--
Alpha-fetoprotein 1.9 ng/mL<15.0
Prostate specific antigen(PSA) 0.19 ng/mL <4.0
As an acid in t he detection of prostate cancer w hen used in conjection wit h
digital rectum exam( DRE) in men 50 years old or older.
Prostatic biopsy in required for diagnosis of cancer.
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INVESTIGATION
RADIOLOGIST REPORT
Service:
Doppler USG lower limbs:
Both femoral, popliteleal and posterior tibial veins and arteries have
normal wavepattern.
These veins are compressible.
Augmentation test was positive for both veins.
No trombus within.
IMP: The deep veins of both lower limbs are patent.
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INVESTIGATION
Service:
CT Thorax:
Post contrast contigous 10mm axial images from the apixes of the thorax to the adrenal.
There are scattered ground glass changes in both lungs, predominantly in lateral segment of
the middle lobe,superobasal and medialbasal segments of both lower lobes and
apicoposterior segment of the left upper lobe.
There are no areas of decrease vascularity or eligmia in both lungs fields.
The bronchial walls are not thickened.
No fluid within bonchi.
There are no mediastinal or hilar masses.
There are no pleural abnormalities.
The thoracic aorta and pulmonary vasculature are intact.
There are no intra luminal filling defects to suggest foci of emboli in the main pulmonary
artery and branches.
No aortic dissection or aneurysmal dilatation seen.
The heart size is normal.
The adrenals are not enlarged.
RADIOLOGIST REPORT
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MEDICATION
NAME DOSAGE FREQUENCY ROUTE PACKING DATE ON
VERAPAMIL 40 mg BD Oral Tablet 11/5/2010
INDEX 30 mg DAILY Oral Tablet 11/5/2010
PARACETAMOL 50 mg DAILY Oral Tablet 12/5/2010
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NURSING CARE PLAN
1. Knowledge deficit related to home care management of
hypertension.
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PSH
NURSING CARE PLAN 1
DIAGNOSIS : PULMONARY HYPERTENSION
Name : Mr S
MRN No. : 287828
Age : 41 years
Sex : Male
Dr. Y
S/N Nursing Diagnosis Goal Nursing Action Initiated
By Sign
Evaluation Sign
1. Date /
Time
Data Date/ Time /
Data
10May
2010
@
1910
hours
Knowledge deficitrelated to home care
management of
pulmonary
hypertension.
This is evidenced in
:
yPatient verbalized
that he does notunderstand well
regarding to
pilmonary
hypertension.
Patient willverbalize that he
will better
understanding
about management
of disease after
explanation given
within 2 hours
duringhospitalization.
1. Assess patientunderstanding
about his disease.
® As a baseline
data to plan
nursing
intervention.
(I) During
assessment, Iidentify my
patient knowledge
about management
of diet, exercise,
etc is not clear. STN
SULAIMI
10 May 2010@ 2110
hours.
1. Patient
verbalized
that he
understands
how to
manage hisdisease.
2. Patient
verbalized
that he will
follow the
advice.
STN
SULAIMI
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2. Re-explain to
the patient by
using layman
what the doctor
said.
® To ensure thathe understand
about his
condition.
(I)I used µBahasa
Malaysia¶ when
communicate with
my patient.
3. Encourage patient to ask
question about
management of
disease.
® To ensure
patient understand
and clear
explanation given.(I) My patient
asks about diet
and hour to
control tension.
STN
SULAIMI
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SULAIMI
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4. Advice patient
to take low salt
diet, diabetic diet,
soft diet, take
more vegetables
and fruits.
® Salty food may
increase patient
Blood Pressure
and fat food
increase body
weight.
(I)I advice my
patient to not
taking high
cholesterol.
5. Teach patient to
do an exercise
once a week.
® For better
healthy living.(I)I ask patient to
go for jogging
once a week.
STN
SULAIMI
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SULAIMI
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6. Ensure patient
to complete his
medications at
home.
® Because at
home there wasno nurse to
remind him to
take his
medications
everyday.
(I)I advice patient
to take his
medications athome & do not
stop without
doctor advice.
7. Advice patient
to come for follow
up as ordered by
doctor.
® To monitor his progress and
condition.
(I)I encourage
patient top come
for his next follow
up because it is
important to see
his progress.
STN
SULAIMI
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SULAIMI
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8. Ask patient to
change his
lifestyle to reduce
his stress.
® Tension
increase the blood
pressure which
can cause
hypertension.
(I)I advice patient
to take for relax.
9. Explain to the
patient about the
early clinical
manifestation and
the complication.
® To detect any
abnormalities
earlier.
(I)I encourage
patient to see
doctor if hecomplain having
numbers of the
extremities /
severe headache
and giddiness.
STN
SULAIMI
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SULAIMI
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HEALTH EDUCATION
LIFESTYLE-Encourage patient to do tolerated exercise
such as jogging.I also advice my patient to stop smoking.
MEDICATION-I advice to my patient to take the
medications following right time and dosage.
FOLLOW UP-I advice my patient to come foe follow up
after discharge with doc Y.
DIET-Encourage patient to take well balanced diet and
avoid taking oily foods.
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DISCHARGE
During discharge time, his condition of vital sign is stable with :
Temperature :36.80CPulse :70 bpm
Respiration :20 bpm
Blood Pressure :140 / 90 mmHg
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FOLLOW UP
During the first follow up, his condition of vital sign is more stable
with :
Temperature :36.5
0
CPulse :80 bpm
Respiration : 21 bpm
Blood Pressure : 130 / 90 mmHg
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SUMMARY
During the admission time in the ward, his vital sign has been takenand the result is as follow :
Temperature : 35.70 C
Pulse : 82 beats/min
Respiration : 18 breaths/min
Blood Pressure : 146/ 101 mmHg
Weight : 79 kg
Height : 166 cm
Mr S next appoinment on 23 June 2010 at clinic doctor Y.
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REFERENCES
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www.yahoo.com/hypertension
http://www.americanheart.org/-- American College of Cardiology
(800-253-4636)
http://www.ash-us.org/ -- American Society of Hypertension
www.nhlbi.nih.gov/hbp -- National Heart, Lung, and Blood Institute http://www.heartinfo.org/ -- Information on the heart
http://www.heartriskevaluations.com/ -- A useful heart risk evaluation
test
http://www.ishib.org/ -- International Society on Hypertension in
Blacks
REFERENCES
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THE END,
THANK YOU!!!!!
PREPARED BY
STN SULAIMI SADIRAN