CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY

1.0. Introduction

Nursing assessment begins the nursing process with appraisal of the health status of the

patient. Through observation, questioning and examination, data about the patient and his

family is gathered and analysed. This chapter documents pertinent data obtained during

interaction with Madam P.A. and her family at the assessment phase of the nursing process. It

entails biographical data, developmental, past and present medical history, the family’s

medical and socioeconomic history as well as the patient’s lifestyle, literature review on

Hypertension as well as validation of the data obtained during this phase of the nursing

process.

1.1 Patient’s Particulars

Madam P.A. is a forty-year-old woman, born on 15th December 1980 to Mr. A. A. and Mrs. J.

A. Her father is alive whereas her mother is late. She is the first of six siblings of both

parents. Madam P. A. resides at North Kaneshie with her daughter. Madam P.A. is single

with no children. Madam P.A. is a Christian and a Catholic. Mrs J.A. is her next of kin. She

attended L/A primary school in Tsito Awodome but got to form four and proceeded to Accra

Girls where she read Accounting. She is dark in complexion and has a height of 183 cm, her

weight on admission was 93 kilograms (kg). Madam P.A. is a Ghanaian from Tsito

Awodome - Ave District and speaks Ewe as her main native language otherwise speaks Twi

and English language as well.

1.2 Family Medical History/ Socio-Economic History

According to Madam P.A, there is a paternal family history of Hypertension and Diabetes

mellitus. Maternal family history on the other hand has no records of diseases such as
Hypertension, Diabetes mellitus, asthma, sickle cell disease or any chronic illness. There is

no history of communicable disease and drug or food allergy as well. However the family

sometimes experience headaches and gastric disorders which are sometimes relieved on Out-

Patient Department (OPD) basis. Madam P.A and her entire household are enrolled on the

National Health Insurance Scheme (NHIS) which they deem it relevant for accessing quality

healthcare in Ghana. She owns a clothing store. She gets enough income from her job to

support her family. Madam P.A has a child who is a university student.

Madam P.A is her parent’s first child, hence she is actively involved in social/communal

activities like attending engagement, wedding, naming ceremonies and funerals.

1.3 Patient’s Developmental History

Madam P.A. comes from a family of six children to Mr. A.A. and Mrs. J.A. She happens to

be the first of the six children and grew up with her parents. She was born through

spontaneous vaginal delivery (SVD) by a midwife at Tsito Awodome CHPS, located at Tsito

with no post-delivery complications. She said she was fortunate her mother practiced the

exclusive breast feeding (EBF) for her and got weaned off after two and half years with

supplemental feeds. According to Madam P.A, even though she cannot talk much about her

childhood, she could remember what her mother told him. She said she was given

immunization and even showed me a scar on her right shoulder. She is very healthy and

strong at her present age and attributed that to the exclusive breast feeding practiced by her

mother. She, therefore, encourages and promotes EBF among nursing mothers in and around

her residential area in North Kaneshie. Madam P.A. started crawling at 9 months and by age

12 months she was able to walk. By age 14years she had feminine features signifying onset

of puberty, at age 40years she realized she had developed grey hair.
1.4 Patient’s Lifestyle / Hobbies

According to Madam P.A, she sleeps around 10:00pm in the night and wakes up around

5:00am in the morning. After her early morning routines of ensuring her oral hygiene and

other activities of daily living, she usually leaves for work by 7:00am and usually gets home

by 5pm each day. She attends church service each Sunday. She usually takes porridge or tom

brown in the morning, boiled yam or plantain in the afternoon and she enjoys fufu with light

soup for supper. She loves to watch popular local Television series on the TV precisely UTV.

1.5 Patient Past Medical History

According to Madam P.A., she was admitted to the hospital a couple of times on account of

hypertension. She was on prescribed medications for her condition but defaulted. She usually

gets over-the-counter drugs anytime she suffers from common cold, headaches and

abdominal upsets.

1.6 Patient’s Present Medical History

Madam P.A. is a known hypertensive patient but defaulted her usual treatment. On 2 nd April 2021, she

experienced severe headache, difficulty in breathing, dizziness, palpitations, anxiety, insomnia, cough, and

blurred vision and was sent to Greater Accra Regional Hospital at 3:20pm for medical management. Initial

assessment was done and her vital signs were checked and recorded as Temperature 36.5 oc, pulse 110bpm,

respiration 45cpm, blood pressure 200/120mmHg, oxygen saturation 90%. Initial laboratory tests of FBC, Lipid

profile and BUE/Cr were ran and appropriate treatment commenced. She was admitted at the Emergency

department and later transferred to female medical ward for further treatment.

1.7 Admission of Patient

On 2nd April 2021, Madam P.A. an ambulant patient was brought to the Emergency

department of to Greater Accra Regional Hospital by her daughter and sister at 3:20pm. On

initial assessment, findings were difficulty in breathing, dizziness, palpitation, cough and

severe headache. She was examined by the Team A doctor. After critical examination, the
doctor recommended her to go and do laboratory test such as Full Blood Count, Lipid Profile

and BUE/CR.

After the laboratory results were shown to the doctor, he diagnosed the patient with

Hypertension and requested that she should be admitted at female medical ward. Madam P.A.

was brought into the ward with her relatives accompanied by a nurse. They were warmly

welcomed to the nurses’ station. I welcomed Madam P.A. and her relatives and offered them

seats at the nurses’ station. Her identity was confirmed by collecting her folder from the

accompanied nurse to cross check with the information given about her on the record system.

Her vital signs, weight and height were checked and recorded as follows:

Temperature 36.5 degree Celsius

Pulse 110 beats per minute

Spo2 90%

Respiration 45 cycles per minute

Blood pressure 200/120 mmHg

Weight 93 kilograms

Height 175 cm.

All these were recorded on the observation sheets. A simple unoccupied bed was made for

the patient. Patient was oriented to the ward and its annexes. I introduced the other staffs on

duty to Madam P.A. and the other patients on the ward. She was shown to places like the

nurses’ office, toilet, facilities and bathroom. After that she was allowed to ask questions

bothering her mind. I explained to Madam P.A. and relatives that the National Health

Insurance will cover her bills throughout hospitalization and in case the insurance does not
cover any treatment she would be made to pay for it. I explained to her Madam P.A. and her

daughter the visiting hours as 5:30am to 7:30am in the morning and 3:30pm to 5:30pm in the

evening. Client relatives were oriented to the ward environment and allowed to say goodbye

to the client. The ward routines such as time for doctor’s rounds, serving of medications,

checking of vital signs and others were also explained to the patient. She was then informed

of the need to sign consent form before further treatment could be carried on her. She was

then assisted to change into a hospital gown and put into a prepared bed. The properties of the

patient like wrist watch, patient’s bag containing different kinds of substances were collected

and were nicely arranged in the patient’s bedside locker. The sister and daughter were

allowed to bid her goodbye and inform other relatives at home. Patient’s name, sex, address,

diagnoses were entered into admission and discharge book and also on the daily ward state.

The following drugs were prescribed by the doctor and administered to Madam P.A during

his admission. They were:

Intravenous Hydralazine 5mg stat,

Tablet Lisinopril 10mg daily x14days,

Tablet Nifecard XL 30mg x 30days,

Tablet Atorvastatin 40mg nocte x 30days,

Tablet Aspirin 75mg daily x14days,

Intravenous Ringers Lactate 2L x24hrs,

Oral Rehydration Salt 3 sachets.

Oxygen 4L/min
1.8 Patient Concept of Illness

Madam P.A. does not attribute her illness to superstitions or someone being the cause of her

problems. She understands the causes and risk factors for hypertension. She believes that

with good medical and nursing care she will be better to go home.
 1.9 LITERATURE REVIEW ON CONDITION – HYPERTENSION

Definition

Hypertension is defined as a systolic blood pressure greater than 140mmHg and a diastolic

pressure greater than 90mmHg based on the average of two or more accurate blood pressure

measurement taken during two or more contact with a health care provider. (Hinkle and

Cheever, 2014)

Types of Hypertension: According to aetiology, hypertension can be grouped into primary

(essential) hypertension, and secondary hypertension.

Primary hypertension is also referred to as essential or idiopathic hypertension. It is the

commonest type of hypertension accounting for 90% of hypertensive cases. It has no

identifiable cause and common among persons between the ages of 30 and 50 years. It is

asymptomatic until complications occur.

Secondary hypertension is distinguished from essential hypertension by having a known

underlying cause. Common causes include renal diseases, endocrine disorders, and drugs.

Causes of Secondary Hypertension

Renal Disease

A reduction of blood flow or a destruction of kidney structures causes hypertension. Diseases

such as nephritis, stenosis of the kidney and polycystic disease bring about changes in blood

flow in the kidney structures to cause hypertension. With a reduced blood flow to the kidney,

the kidney reacts by producing a proteolytic enzyme called rennin. In the blood stream,

rennin acts upon plasma protein to produce angiotensin I which is converted to angiotensin II.

This has a vasoconstrictive effect that leads to increase in blood pressure. Rennin also

stimulate the adrenal glands to secrete aldosterone which causes water and sodium retention.
Endocrine Disorders

A tumor of the adrenal medulla called pheocromocytoma secretes adrenaline that has a vaso-

constrictive effect which results in a raise in the blood pressure. Increased aldosterone

secretion also increases reabsorption of sodium and water to cause a raise in blood pressure.

For example; in Cushing’s disease, its increase secretion of adrenocorticoids causes

hypertension.

Certain medications

Drugs such as oral contraceptives are known to contain oestrogen. In the liver, oestrogen

increase angiotensin to cause hypertension. If the drug is discontinued for 6 months, blood

pressure returns to normal, corticosteroids, NSAIDS. (Hinkle and Cheever, 2014)

Other Type of Hypertension

Malignant Hypertension

It is a severe form of hypertension. Malignant hypertension progresses rapidly and results in

fibrinoid necrosis of the small arteries of the heart, kidneys, brain and eyes (target organ).

Dysfunction of the organ ensues and without medical treatment the course of malignant

hypertension is rapidly fatal. Most persons do not survive longer than two years. This

condition is seen most often in black men under the age of 40.Patient may experience

headache, seizures, papilloedema and retinal haemorrhage. (Smelter and Bare, 1992)

Incidence

About 20% of the entire population develops hypertension. More than 90% of these have

essential (primary) hypertension which is a type of the condition without medical or specific

cause. The remaining 10% develops the condition with specific cause (secondary
hypertension) such as renal disease, certain drugs, organs dysfunctions, tumours, and

pregnancy. It is more common in men above 50years and women above 65years and the

obese. It is high among the black race. It is more in urban dwellers than those in the rural

areas. (Drzymkwasi and Frazier, 2004)

Aetiology

The cause of essential hypertension has not yet been identified. Primary may develop as a

result of environmental or genetic factors. The predisposing factors include

1. High intake of saturated fat and cholesterol foods

2. Obesity

3. Alcoholic intake, Smoking

4. Lack of exercise (sedentary lifestyle)

5. Over intake of stimulants like coffee, tobacco and other stimulating drugs

6. Old age

7. Emotional disturbances

8. Stress

9. Genetics

(Hinkle and Cheever, 2014)

Prognosis

It is based upon several factors including genetics, dietary habits and overall lifestyle choices.

If individuals are conscious of their condition and take the necessary preventive measures to
lower their blood pressure, they are more likely to have a much better outcome than those

who do not. (Leob Stanley et al, 1994)

Pathophysiology

Stimulation of vasomotor centre in the medulla of the brain sends emotional impulses that

travel down through the sympathetic nerve to the sympathetic ganglion. At this point,

neurons release acetylcholine which stimulate the nerve fibers in the blood vessels where

norepeniphrine is released resulting in the constriction of the blood vessel.

Concurrently, the adrenal gland is stimulated due to emotional stimuli, the adrenal medulla

secrete epinephrine which causes vasodilatation. The adrenal cortex secretes cortisol and

other steroids which enhance vasoconstriction. The vasoconstriction results in reduced blood

flow to the kidney causing the release of rennin. Rennin acts on angiotensinogen causing the

release of angiotensin converting enzyme which convert angiotensin I to angiotensin II.

Angiotensin II is a potent vasoconstrictor and turns to stimulate the secretion of aldosterone

by the adrenal cortex. This hormone promotes sodium and water retention in the kidney

tubules causing increase in the intravascular volume, raising the blood pressure.

The raised blood pressure commonly causes rapture of certain arteries especially the cerebral

arteries leading to cerebral haemorrhage. Increase blood volume increases the burden of the

heart and tends to sustain an increase blood pressure. (Hinkle and Cheever, 2014)

Signs and Symptoms

Persons with hypertension can remain asymptomatic for many years. The appearance of

symptoms usually indicates vascular damage and symptoms are related to the organ involved.

Common features include:

90mmHg for a long period without symptoms.

2. Severe frontal headaches or morning occipital headache.

3. Dizziness and giddiness

4. Tachycardia

5. Anxiety

6. Nocturia

7. Palpitations

8. Insomnia

9. Coma

10. Papilloedema

11. Seizures

12. Left ventricular hypertrophy

13. Blurred vision

14. Breathlessness (dyspnoea) (Smelter and Bare, 1992)

Diagnostic Investigations

1. History from patient and clinical features can assist to establish diagnosis

2. Chest x-ray to show enlargement of the heart

3. Electrocardiogram to confirm cardiac enlargement and functioning

4. Blood urea creatinine to assess the involvement of the kidney

6. Echocardiogram to assess for left ventricular hypertrophy

7. Urinalysis

8. Blood Chemistry (analysis of sodium and potassium).

9. Magnetic resonance imaging (MRI)

10. Full blood count (FBC). (Hinkle and Cheever, 2014)

Medical Management

If the hypertension is secondary to a condition, that condition is treated to return the blood

pressure to normal. However if the hypertension is of the primary type, treatment is aimed at

lowering the blood pressure, and assisting patient to adjust lifestyle to reduce the demand on

the cardiovascular system and kidneys.

Drug Treatment

1. Diuretics; reduce interstitial fluid volume causing decreased vascular stiffness

Thiazides e.g. bendroflumethiazide 2.5mg daily oral

Potassium sparing diuretics e.g. Spironalactone 100-200mg daily

Amiloride hydrochloride 5-10mg daily

Loop e.g. Frusemide 20-80mg daily

2. Anticholesterol Agents E.G. Statin

3. Angiotensin Converting Enzyme Inhibitors (ACE-I)

10-20mg maximum 40mg daily, Captopril 25-50mg bd

4. Vasodilators; relax arteriolar vascular muscles e.g. Hydralazine 2.5mg oral bd or

slow IV injection over 20mins, 5-10mg diluted with 10mls normal saline, sodium

nitroprusside, nitroglycerine.

5. Centrally Acting Agents; displace noradrenalin from receptor sites decreasing SNS

activity e.g. Methyldopa; 250mg 2-3 times daily max 3g daily, Serpasil, Clonidine.

6. Calcium Channel Blockers; slows down the movement of calcium into cells of the

heart and blood vessels thereby reducing contractility. E.g. Nifedipine 10-40mg oral bd.

7. Alpha Blockers; peripheral arteriolar dilator. E.g. Prazosin 0.5-20mg oral in 3

divided doses

8. Beta Blockers; Blocks the beta adrenergic receptors of SNS slowing down the heart

rate. E.g. Atenolol 50-100mg oral daily, Propranolol 180-320mg daily in divided doses.

9. Angiotensin Receptor Blockers; E.g. Losartan 25-100mg oral daily, Valsartan.

(Leob Stanley et al, 1994)

Nursing Management

Psychological Care
Patient and relatives should be reassured not to panic because the condition will be controlled

as measures are in place for it.

Patient and family should be made to understand that with their maximum co-operation, the

condition can be managed.

Rest and Sleep

Patient is given a complete bed rest for the first two weeks because of dizziness experienced

by patient. A serene atmosphere is enhanced such as quiet environment, ensuring dim light,

adequate ventilation and a comfortable bed free from creases and cramps. This is done to

conserve energy, relax patient, promote healing, and reduce stress.

Position

Patient is made to assume a suitable position which is not contrary to her condition. However,

for an effective respiration, patient should be in a sitting up position supported with back rest

or pillows.

Observation

1 Check vital signs every four hours especially the blood pressure and record accurately

to detect any deviation.

2 Observe for desired effect and side effects of drugs

3 Observe for possible complication that can occur.

4 Assess for mental state of patient to know if he is oriented to time, place and person

5 Monitor input and output chart and record them accurately.

Personal Hygiene
 1. Patient should be assisted to take his/her bath twice daily including his oral hygiene

in order to remove dirt, microbes, and sweat from the skin.

It also improves circulation, comfort and relaxation.

2 Patient hair should be washed with shampoo and blow-dried if female to prevent hair

infestation like pediculosis and dandruff.

3 Care of the mouth is done by use of toothbrush and paste, and in an unconscious state

gauze swap and normal saline is used.

4 Hand and feet are cared for by soaking them in water to soften it after which it

trimmed to the likeness of patient.

5 Dirty and soiled bed linens are changed including clothing

6 Ensure proper hand washing with soap and water before and after eating and also after

visiting the toilet to prevent infection.

Nutrition

Patient’s nutritional level is met by serving patient with a well-balanced diet that is low in

sodium; low carbohydrate, low protein, low fat to prevent hyperlipidemia, enough potassium

supplement such as banana and enough roughage to help reduce constipation.

Exercise
The patient is encouraged to undertake passive exercises by assisting patient to stretch her

hands and legs, turning of the head gradually whiles sitting up in bed. Active exercises like

walking around his cubicle should also be encouraged.

Elimination

Bladder elimination is ensured by serving urinals on patient’s request. Where patient is not

able to pass urine, application of cold compresses on the abdomen and catheterization can be

carried out. Bowel elimination is also ensured by serving bedpan on patient’s request. More

fluids and roughages are given to soften stools.

Health Education

Health education is given on hypertension, taking into consideration the definition, the cause,

treatment and most especially the dietary changes. Patient should be educated on the drug

regimen and importance of taking it appropriately to prevent any complication. The

chronicity of the disease condition and specific instruction concerning prescribed therapy

should also be emphasized. Patient who smokes must be educated on the effect of smoking

on hypertension. A balance between activity and relaxation should be touched on. Because

the condition is hereditary, other members of the family should be educated to go for regular

checking of blood pressure.

Medication

Prescribed drugs such as anti-hypertensives should be served to reduce blood pressure.

Diuretics are also given to get rid of excess fluid in the body. Drugs should be served in their

right dose, right time, right route, right patient, right drug, and also the patient’s right to

refuse drug. (Hinkle and Cheever, 2014)

Complications
 1. Cardiovascular accident

2. Renal failure

3. Myocardial infarction

4. Hypertension encephalopathy, Hypertension retinopathy, Hypertension nephropathy

5. Left ventricular hypertrophy

6. Cerebral oedema

7. Hypertension cardiomyopathy

8. Blindness

9. Impotence in men

10. Arrhythmias

11. Transient Ischemic Attack (T I A ) (Drzymkwasi and Frazier, 2004)

1.10 Validation of Data

Information utilized in rendering care to the patient as reported in this care study has been gathered from well

informed sources and efforts were made to ensure that they are accurate and valid. Subjective data was taken

from the patient himself while objective data is obtained from significant others (relatives) and various tests to

identify the patient’s problems and their sources. Data about the plan and progress of treatment as instituted by

the physician team was collected from the patient’s folder, as well as from direct discussion with the doctors.

Literature reviews on the conditions were obtained from textbooks, and articles. Others were obtained through

my own observation and questioning and examination of the patient. The data collected were free from

discrepancy and therefore, valid.