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Treatment of Hypertensive Emergencies

Deborah Anderson, a 65 year old female was admitted to the emergency department as she encountered a collapse at home. After she was presented with right sided facial droop, dysarthria, incomprehensible sounds along with the weekness in right sided limb. On assessment it was revealed that she has BP: 184/93 mmHg, HR: 98 beats per minute, SpO2: 94% R/A, RR: 20 breaths per minute, Temp: 36.4 OC (oral), and Glasgo Coma Scale (GCS): 12/15. This assessment is about to identify patient’s health issues and to place them as per their order of priority along with addressing them and discussing the role of registered nurses in it.

The three identified patient health issues from the case scenario are patient’s blood pressure, SpO2, and Glasgow Coma Scale that can be addressed by the nurses within their scope of practice. 

Patient’s blood pressure would be the first order of priority because the patient’s blood pressure reading is 184/93 mm Hg and this indicates a situation of hypertensive crisis or hypertension Stage 3. The readings that show blood pressure above 180 systolic pressure and diastolic pressure between 90 and 99 indicates a situation of hypertensive crisis. Such condition is considered as the most severe condition of high blood pressure. If such a condition is left untreated then it may result into the progression of some other complications of the other organs (Varounis et al. 2017). Hypertensive crisis if left untreated then, can lead to:

  • Cardiac failure: As the blood pressure increases, the heart starts pumping the blood at a faster rate than it normal does and this continues until the muscle of the heart goes weak because of this much of exertion. Weakening of the heart muscles lead to the heart/cardiac failure (Aronow 2017).
  • Renal failure: Because of the high blood pressure, the blood vessels get constricted due to which blood carrying the oxygen and nutrients become unable to reach the renal system and this result in the failure of the system (Derhaschnig et al. 2014).
  • Impaired vision: High blood pressure leads to sudden drop in the oxygen and this result into the ineffective peripheral perfusion which in turn affects the eye. This often causes serious vision problems (Stacey Sozener and Besirli 2015).
  • Myocardial infarction: High blood pressure causes the constriction of blood vessels which leads to the decrease in oxygen that often results in the myocardial infarction (Varounis et al. 2017).

Patient’s Glasgow Coma Scale would be the second order of priority because on patient’s assessment it has been seen that patient’s GCS score is 12/15. The Glasgow Coma Scale is used to indicate the level of consciousness in patients that have been through a traumatic brain injury. The score shown by GCS is helpful in defining the broad categories of the head injury. The scale has 3 sections: E, M, and V i.e., eye opening, motor response, and verbal response respectively. The score is based on the sum total of these 3 categories. The maximum score is 15 while the minimum score is 3. The overall total score of the patient’s assessment helps in classifying the head injuries. It has been seen that score 3-8 depicts the severe head injury; moderate head injury shows 9-12 GCS score while the mild head injury shows the score between 13-15. The patient’s GCS score is 12/15 which means the patient has a moderate head injury that needs to be addressed. Being more precise, The GCS score for eye is 4 which indicate that the patient is spontaneous in terms of vision. While, the score for verbal is 2 i.e., the patient is making incomprehensible sounds or moaning in response to the pain. Motor response is 6 which reveal that the patient is just obeying the commands. So, this is needed to be addressed (Jain and Iverson 2020).

Patient’s SpO2 would be the third order of priority because the normal SpO2 ranges 95% while the patient’s SpO2 has revealed that it is 94% so, there is a need to elevate the SpO2 upto 95%. This is so, because the ratio of oxygen-carrying hemoglobin in the blood to that of the hemoglobin not carrying oxygen is termed as the oxygen saturation. An appropriate level of oxygen in the blood is needed by the body which has to be 95% at least. If not, then it would not function efficiently (Vold et al. 2015). Though, the patient has 94% SpO2 which is just 1% less than the normal. But, the patient is undergoing clinical deterioration so, if this will not be addressed, there are chances of drop in oxygen saturation. This situation can later on, result in serious medical conditions. This condition is termed as hypoxemia. Hypoxemia can lead to shortness of breath, increase in heart rate, coughing and wheezing. Apart from this, considerable damage could also be occur to the vital organs in the because of the presence of low amount of oxygen. The vital organs of the patient that could be at risk are brain and heart. If the situation goes worse and this remains untreated then, it can also be a threat to patient’s life (Sarkar Niranjan and Banyal 2017).

Role of Registered nurses in addressing the first priority i.e., in the management of high blood pressure of the patient

The significant role the registered nurses play in addressing this health issues is in achieving a normal blood pressure with the help of either independent or dependent interventions or even both. For this, nurses play an important role at each stage from the assessment to the nursing care plans. They are involved in regular and careful monitoring of the patient’s blood pressure at frequent scheduled intervals in order to determine the effectiveness of the medications given to the patient along with detecting the changes in the blood pressure. The major role they play in this is the maintenance of the cardiovascular as well as in enhancing its functioning. Along with this preventing complications, providing the information regarding the prognosis of the disease process and the treatment regimen are considered as the core duty of the nurses in addressing this health issue (Himmelfarb et al. 2016).

Role of Registered nurses in addressing the second priority i.e., in the management of GCS score of the patient

Deterioration has been considered as the most common thing that occurs during the acute phase of the stroke. The registered nurses play a crucial role in the early identification and detection of stroke and in this case, there are chances that the patient might encounter with another stroke. So, early detection of this would be done by the nurses. In this health issue, the major role is played by the registered nurses as they help in improving the GCS competencies of the nurses (Catangui 2019). Nurses’ importance in this particular issue is also in differentiating localizing in pulling out from the pain stimulus, differentiating the abnormal flexion from the extension and in interpreting the range of the GCS score. Maintenance of patient’s safety and improving the health outcomes also comes under the functions played by the registered nurses in this issue because any kind of inaccuracies could potentially violate the patient safety that will lead to the inability in recognizing the early signs regarding the neurological deterioration of the patient. And, such a condition affects the patient’s health outcome adversely (Catangui 2019). Registered nurses must conduct the assessment comprehensive, accurately, and systematically as per the standard 4 of Nursing and Midwifery Board of Australia, (2017).

Role of Registered nurses in addressing the third priority i.e., in the management of Sp02 of the patient

Nurses role play a major role in this as they help the patient with their positioning by elevating the bed. The upright position will enable the patient in an increased thoracic capacity as well as in increased expansion of the lungs that will help in preventing the contents of the abdomen from crowding. Nurses keep checking the patient’s position on a regular basis in order to avoid any slumping down because slumped positioning will make the abdomen to compress the diaphragm and this leads to limit the expansion of the lung (Mehta and Parmar 2017). The nurses also provide a scheduled care that will help the patient in minimizing the fatigue. Nurses evaluate the efficacy of the given oxygen therapy in order to identify any chance of early hypoxia (Myatt 2017). Registered nurses are responsible for the effective planning as well as the communication regarding the nursing practice. Patient positioning must be done as per agreed plans and developed in partnership (Nursing and Midwifery Board of Australia 2017).

The patient has been certain health issues that are needed to be addressed and nursed plays a major role in it. The three identified patient health issues from the case scenario are patient’s blood pressure, SpO2, and Glasgow Coma Scale that can be addressed by the nurses within their scope of practice. Effectively addressing them can help the patient to avoid other medical conditions that can result in her deterioration also. 

References for Deborah Anderson Case Study

Aronow W. S. 2017. Treatment of hypertensive emergencies. Annals of Translational Medicine, vol. 5, no. 1. https://doi.org/10.21037/atm.2017.03.34

Catangui, E. 2019. Improving Glasgow Coma Scale (GCS) competency of nurses in one acute stroke unit - A nursing initiative project. Journal of Nursing and Practice, vol. 3, no. 1. doi: 10.36959/545/370

Derhaschnig, U., Testori, C., Riedmueller, E., Hobl, E L., Mayr, F B., and Jilma, B. 2014. Decreased renal function in hypertensive emergencies. Jounal of Human Hypertension, vol. 28,pp. 427–431. https://doi.org/10.1038/jhh.2013.132

Himmelfarb, C R., Commodore-Mensah, Y., and Hill, M N. 2016. Expanding the role of nurses to improve hypertension care and control globally. Annals of Global Health, vol. 82, no. 2, pp. 243–253. https://doi.org/10.1016/j.aogh.2016.02.003

Jain, S and Iverson, L M. 2020. Glasgow Coma Scale. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513298/

Mehta, J N, and Parmar, L D. 2017. The effect of positional changes on oxygenation in patients with head injury in the intensive care unit. Journal of Family Medicine and Primary Care, vol. 6, no. 4, pp. 853–858. https://doi.org/10.4103/jfmpc.jfmpc_27_17

Myatt, R. 2017. Pulse oximetry: What the nurse needs to know. Nursing Standards, vol. 31, no. 31, pp. 42-45. doi:10.7748/ns.2017.e9940

Nursing and Midwifery Board of Australia. 2017. Registered nurse standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Sarkar, M., Niranjan, N., and Banyal, P. K. 2017. Mechanisms of hypoxemia. Lung India : Official Organ of Indian Chest Society, vol. 34, no. 1, pp. 47–60. https://doi.org/10.4103/0970-2113.197116

Stacey, A W., Sozener, C B., and Besirli, C G. 2015. Hypertensive emergency presenting as blurry vision in a patient with hypertensive chorioretinopathy. International Journal of Emergency Medicine, vol. 8, no. 13. https://doi.org/10.1186/s12245-015-0063-6

Varounis, C., Katsi, V., Nihoyannopoulos, P., Lekakis, J., and Tousoulis, D. 2017. Cardiovascular hypertensive crisis: Recent evidence and review of the literature. Frontiers in Cardiovascular Medicine, vol. 3, no. 51. https://doi.org/10.3389/fcvm.2016.00051

Vold, M. L., Aasebo, U., Wilsgaard, T., and Melbye, H. 2015. Low oxygen saturation and mortality in an adult cohort: The Tromso study. BMC Pulmonary Medicine, vol. 15, no. 9. https://doi.org/10.1186/s12890-015-0003-5

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