Hypertensive Crisis Case Study (45 min)

NCLEX RN

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Mrs. Phillips, a 43-year old African American female, presents to the Emergency Department (ED) complaining of the worst headache of her life. She says it started about 3 hours ago. She reports taking 1,000 mg of Acetaminophen with no relief. Upon further questioning, Mrs. Phillips also reports blurry vision. She denies any past medical history.

Critical Thinking Check

Bloom's Taxonomy: Application

What initial nursing assessments need to be performed for Mrs. Phillips?

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Upon further assessment, Mrs. Phillips’ lungs are clear, pulses are 2+ bilaterally in radial and pedal pulses, S1/S2 are present with no extra sounds. Her vital signs were as follows:

BP 216/108 mmHg
Ht 162 cm

HR 92 bpm and regular
Wt 107 kg

RR 20 bpm
SpO2 96% on Room Air

Temp 36.9°C

Critical Thinking Check

Bloom's Taxonomy: Analysis

What are your top concerns for Mrs. Phillips at this time? Why?

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Critical Thinking Check

Bloom's Taxonomy: Analysis

What medications do you anticipate the provider ordering for Mrs. Phillips?

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The ED provider orders the following:

Blood – CBC, BMP, BNP.
Diagnostics – CT head, CXR.
Interventions – Insert 2 large bore IV’s.
Nasal Cannula to keep SpO2> 92%.
Meds –
- Metoprolol 5mg IV push x 1 dose now.
- Hydralazine 10mg IV push, PRN q1h for SBP >200.
- Morphine 2 mg PRN q4h for pain.

Critical Thinking Check

Bloom's Taxonomy: Analysis

Which order would you implement first and why?

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You initiate two large bore IV’s for Mrs. Phillips and send off blood work. You administer 5 mg Metoprolol over slow IV push and attach Mrs. Philips to a bedside cardiac monitor. She is still complaining of 7/10 pain in her head, so you also administer 2 mg Morphine IV push. You return 30 minutes later to take another set of vital signs and find the following:

BP 204/102 mmHg
Pain 7/10
HR 86 bpm
SpO2 94% on Room Air
RR 14 bpm

Mrs. Phillips’s lab results have also resulted, the following abnormal values were reported:
Glucose 193 mg/dL
Hgb A1c 9.2%
BNP 160 pg/mL

Critical Thinking Check

Bloom's Taxonomy: Application

Based on previous orders you have received, what action(s) should you take at this time? Why?

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Critical Thinking Check

Bloom's Taxonomy: Analysis

What risk factors have you identified that put Mrs. Phillips at risk for hypertensive crisis?

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Mrs. Phillips’ blood pressure after the Hydralazine 10mg IV push went up to 218/110 and her heart rate went up to 104 bpm. She is transferred to the ICU to be started on a Nicardipine infusion, which is initiated at 2.5 mg/hr to keep her SBP between 180-200 mmHg.

Critical Thinking Check

Bloom's Taxonomy: Analysis

Why don’t the providers want her SBP going below 180 mmHg at this time?

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Shortly after arriving in the ICU, Mrs. Phillips is no longer able to speak, the right side of her face is drooping, and she cannot lift her right arm. You check another set of vital signs to find her BP is 208/112 mmHg, HR 110, SpO2 92%.

Critical Thinking Check

Bloom's Taxonomy: Analysis

What, physiologically, is going on with Mrs. Phillips at this time?

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Mrs. Phillips is taken to the OR to evacuate a large subarachnoid hematoma from around her brain. You inform her family that she has had a hemorrhagic stroke because of her high blood pressure. After 2 days in the ICU, she has recovered all movement in her arms, her speech and facial symmetry are normal, and she has been transitioned from IV nicardipine to PO metoprolol, amlodipine, and hydrochlorothiazide. She is tolerating these medications well and has been ambulating to the bathroom easily needed. Her blood pressure is now averaging 140-150 systolic. She tells you she had no idea that she had high blood pressure, she’s never been sick or even felt bad until she got the headache. She reports not getting yearly check-ups because she “felt fine”. She will be discharged on the same medications tomorrow.