• The required coverpage is not included on this page. Posting the paper to the internet has changed the format (i.e. spacing & indenting), be sure to follow the format required by the the syllabus.
• This paper is from Fall 98. Instructor's corrections/comments are in (red parentheses).

Evaluation

Pathophysiology Paper

Pathophysiology of Hypertension

_____I. Description: EB is an 85 year old female with a primary diagnosis of high blood pressure or hypertension (HTN). The pressure that her blood exerts on the walls of her arteries is persistently higher than what is considered healthy. (Larson, 647-648) HTN is defined as a resting blood pressure that is greater than 140mmHg systolic and/or 90mmHg diastolic. The systolic pressure is the amount of force the blood puts on the arterial walls during the contraction of the heart's left ventricle. The severity of HTN is usually graded based on the diastolic reading, since it is the pressure on the arterial walls while the left ventricle is resting. EB's chart does not show any indication to the level of her hypertension prior to medication. On September 24, 1998 her right arm blood pressure was 140/84, in a sitting position.

(Clayman, 110)

_____II. Etiology: Incidence of HTN increases with age, people over the age are 65 are much more likely to have high blood pressure. The increase is normal because as people get older their arteries harden and lose their elasticity. (Clayman, 111) Earlier in life, HTN is more common in men than women. (Larson, 647-648) However, as men and women get older, HTN is much more common among women. The hormonal changes experienced during menopause may be related to the increased incidence in women over the age of 40. (Clayman, 111) According to her chart, her increase in blood pressure became significant in 1982, when she was 69 years old.
_____HTN has been dubbed as the silent killer because most people do not have symptoms and are unaware that they have it. (Larson, 647-648) It is estimated that only two thirds of the people that have hypertension are aware of it, and only one half of those that have been diagnosed are taking medication to help lower it. A hypertensive patient that feels healthy, but goes untreated, has a higher risk of having serious complications within the next few years. (Clayman, 111-112)

(Clayman, 113)

_____EB has essential HTN, that means that there is no underlying cause for her increased blood pressure. Only about 10 percent of the cases of HTN can be linked to another disease. The most common causes are listed in the following table.

(Clayman, 111)

_____Hypertension can be prevented by living an anti-coronary lifestyle. Individuals that have a family history of HTN should be educated about ways to reduce their risk:
1. Regular exercise improves cardiovascular fitness and helps keep weight at a healthy level.
2. Stop smoking and drink alcohol in moderation.
3. Learning to manage stress and use relaxation techniques is beneficial as well.
4. Have your blood pressure checked regularly, especially if using oral contraceptives. Early identification will help prevent progression. (Clayman, 112)

_____III. Medical Treatment: Not everyone diagnosed with HTN needs to be treated with medication. Sometimes taking the preventative measures above will lower the blood pressure to a more desirable level. Individuals may also benefit from reducing the amount of salt in their diet. Weight loss is more beneficial than sodium reduction, but it can reduce diastolic blood pressure by an average of 5 mmHg. (Clayman, 114)
_____If lifestyle modifications do not lower blood pressure, there are very effective medications available. Once medication is started, it will probably need to be continued for the rest of the patient's life. Patients should be instructed not to stop taking the medication without consulting their physician. It can cause a sudden increase in blood pressure that may result in seizures and strokes. (Clayman, 114) Antihypertensive drugs lower the blood pressure by widening the blood vessels or reducing the blood volume. The individual may be prescribed one or more medication depending on how they respond to treatment.(Clayman, 127)
_____The Systolic Hypertension of the Elderly Program (SHEP), found that hypertensive drugs decrease the occurrence of strokes by 36 percent and heart attacks by 27 percent. The study also concluded that drug treatment was almost as effective in preventing heart attacks as strokes. (Pickering)
_____EB takes 5-10mg Lotrel one capsule daily. It is a combination of 2.5 mg amlopidine, a calcium channel blocker, and 10 mg benazepril, an angiotensin-converting enzyme (ACE) inhibitor.(Skidmore-Roth, 1097) The calcium channel blocker dilates blood vessels by hindering the flow of calcium into the muscles around the blood vessels.(Clayman, 132) The ACE inhibitor stops the conversion of angiotensin I to angiotensin II.(Skidmore-Roth, 163) If the enzyme was not inhibited, it would cause the constriction of blood vessels.(Clayman, 131) Both medications increase the diameter of blood vessels and reduce the arterial resistance and lowers the force that the heart must produce to move the blood through the body.(Clayman, 132) I am concerned about the doctors order that meds may be crushed. This is a capsule and crushing will speed up the rate at which it is absorbed.
_____IV. Nursing Implications: Due to EB's age, mental status, and limited range of motion, most of her treatment must be initiated/carried out by the nursing home staff. Staff should ensure that EB is given her medication as prescribed by her physician. The elderly may be more prone to orthostatic hypertension and she should be taught to use caution when changing positions. The elderly may be more sensitive to medications, so her blood pressure should be monitored and deviations should be reported to her physician. (Nettina, 357) EB's diet has been ordered as routine as tolerated, but excessive amounts of sodium may cause an elevation in blood pressure. Her diet should also be low in cholesterol and high in fiber to help minimize her hypertension and constipation. Continued participation in the group activities and exercises will increase EB's cardiovascular fitness and constipation. EB is an ex-smoker and should be discouraged from starting to smoke again. (Clayman, 112)

EB's Other Diagnoses

_____EB experiences constipation, difficult or infrequent bowel movements, at least once per month. A common cause of constipation is not eating enough vegetable fiber. (Rush, 213) EB doesn't like the taste of most vegetables and may not be getting enough fiber in her diet. Constipation can also be caused by drugs that are used as treatment for hypertension and rheumatic disorders. (Rush, 213) Several of EB's medications have constipation as a possible side effect. (Skidmore-Roth & Wilson). Straining to defecate and constipation can contribute to hemorrhoid development and EB had a hemorrhoid- ectomy in 1957. (Anderson, 749) Her physician has prescribed one 500 mg capsule of Colace daily, as needed for constipation. The staff can help reduce the incidence of constipation by encouraging EB to continue participating in the group exercises, ensuring that water is available at all times, encouraging her to eat foods that are high in fiber, and monitoring her daily bowel habits. (Moore, M., 123)
_____Osteoarthritis is the most common form of arthritis in elderly clients. As the cartilage lining in a joint deteriorates the connecting surfaces of the joint rub together and become rough. (Rush, 52-53) Weight bearing joints, like the hip, knee and spine, are most commonly effected. EB complains of pain in her left knee and hip, her hip was also dislocated in 1985. Her hands and feet are also affected, they are stiff, painful and have the "bulbous knobs" characteristic of osteoarthritis. Non-steroidal anti-inflammatory drugs are useful in treating the pain and inflammation of affected joints. (Rush, 52-53) EB takes 400 mg Motrin every morning. During periods of increased pain, EB may request 400 mg Motrin every 6 hours, as needed. At her September 10, 1998 visit, her physician prescribed two 500 mg tablets of Extra Strength Tylenol daily, at 1900 hours, for pain. The Extra Strength Tylenol is also prescribed two tablets every 4 hours, as needed for pain or fever. During flare ups EB's gait and ability to perform activities of daily living may be impaired. Encourage more activity in the morning, after stiffness has been abated and before she is fatigued. Range of motion and isometric exercises can be taught and assisted to maintain joint mobility. Providing rest and heat applications to the involved joints may stop aggravation and relieve muscle spasms. Use of a heating pad must be monitored, too much heat can increase swelling and inflammation. (Nettina, 879-880) EB has lost some mobility and it is difficult for her to reach her feet and back. She needs one person to assist her with her personal hygiene and getting dressed.
_____Her confusion is symptomatic of dementia (Anderson 383), an organic brain syndrome in which the individual loses intellectual functioning. (Rush, 241) EB is not always firmly oriented to person, place, time and situation. The disorientation leads to lack of orderly thought, impaired decision making, and the inability to perform ADL. (Anderson, 383) Another facet of her dementia is hallucinations, EB sees people that are not there. By definition, hallucinations may be seen, heard, felt, tasted or smelled. (Rush, 391) According to the nursing home staff, EB's hallucinations most frequently occur when bedding is being moved or is piled on a chair or bed. That is consistent with the episode I observed when changing her sheets on September 27, 1998. Staff should be aware of her condition and reminded to speak slowly and clearly, identify themselves, address her by name, acknowledge her feelings, and reinforce reality. EB's environment should be well lit, equipped with objects to orient her to time, and have personal items. Her stressors should be identified and avoided, her care plan indicates that she is easily distracted from upsetting situations. EB should be encouraged to continue her participation in the group exercises and activities. (Nettina, 1439-1440)
_____EB has been diagnosed with a vitamin deficiency. She has an inadequate intake of or inability to use one or more vitamins. The symptoms and manifestations are dependent on each vitamin's function in growth, development and maintenance of the body. (Anderson, 1717) She takes one Theragram M tablet daily for vitamin deficiency. EB weighed only 84 lbs. when she was admitted on July 17, 1997. She currently weighs 103.3 lbs. Although her condition has improved the staff should provide EB with a positive, well-lit, congregate dining environment and encourage her to eat a diet that includes all of the food groups. (Moore, M. 122-123) EB may need to be reminded of meal times and called when it is time to eat.
_____EB's physician has prescribed her 10 mEq potassium chloride daily for hypokalemia. A low level of potassium in blood and tissue may result in muscular weakness or an irregular heartbeat. EB does not take a diuretic, the most common cause of potassium depletion. (Rush, 474) EB's chart indicates that her potassium level is frequently checked and her dosage has been decreased as her condition has improved. An increases in EB's potassium level may also improve her leg cramps (Nettina, 612) and hypertension (Moore, M., 287).
_____EB takes one tablet of Quinine 260 as needed for her history of muscle cramps and pain. Her chart does not elaborate on the condition or the cause, but there can be relationship between muscle cramps and the potassium level. (Nettina, 612)

Nutritional Assessment Tool

PART A: CLIENT INFORMATION (15 Points)

PART B: SENSORY INFORMATION (5 Points)

PART C: NUTRITIONAL INFORMATION (20 Points)

Caloric and Protein Requirements for Name: EB Room: 116 Date: 9/15/98
TOTAL CALORIC NEED = BASAL ENERGY EXPENDATURE (BEE)(Calories) x ACTIVITY FACTOR x INJURY FACTOR
Female 6.55.10 + (9.56 x 47 kg) + (1.85 x 147 cm) - (4.68 x 85 yo) = 978.57 BEE (Cal)
978.57 x 1.3 x n/a = 1272 TOTAL CALORIC NEED
1272 x 0.0416 = 52 PROTEIN NEED

Narrative Assessment

_____General appearance: general appearance is alert and responsive. She cheerfully greets me and expresses her willingness to work with me.
_____Weight: EB weighs 47 kg and is 147 cm tall. She is within 1.6 kg of her ideal weight according to the Metropolitan Life Insurance Companies standard.
_____Posture: EB's posture is erect. Most of the time her shoulders, head, and neck appear to be moved slightly forward in a sagging manner. Her back is not humped and her chest is not sunken.
_____Muscles: EB's muscles have moderate tone and development. She is able to walk slowly and must use extra caution to prevent falls. She participates in the group exercises that are coordinated by the nursing home's activity directory.
_____Nervous control: EB is very attentive and is not irritable. Her reflex responses are normal (2+). Her chart states that she has confusion and hallucinations due to dementia. With exception to a few comments that contradict her chart, I have only experienced slight confusion during the time that I have spent with her.
_____Gastrointestinal function: According to her chart, EB eats between 75-100% of her meals and experiences constipation at least once/month. Colace 100mg; 1 cap po daily prn is ordered for her constipation. She has regular bowel movements at least every three days and there are no palpable organs or masses. A C-scan dated 9/11/98 found two masses that I was unable to palpate. The C-scan report doesn't relate the masses to GI problems and a C-scan will be repeated in 6 months.
_____Cardiovascular function: EB's heart rate and rhythm is normal with no murmur present. She is currently taking Lotrel 5-10mg; cap 1 po daily for hypertension and her blood pressure is within normal limits(BP-120/80).
_____General vitality: EB does not appear to tire during our conversations and activities. She naps daily and sleeps from 7:30pm to 6:00am each night. She says she doesn't "need anything (medication) to get to sleep" and sleeps well, however, her chart states that she has insomnia 5/week.
_____Hair: EB's hair is shiny, full, and not easily plucked or broken; her scalp is healthy. The hair on rest of her body is sparse to absent.
_____Skin (general): EB's skin is smooth and soft with good (pink) color. It is not chapped, irritated, or swollen, but bruises easily. The large bruise on her left arm appears (is) to be healing slowly.
_____Face and neck: EB's face and neck are uniform in color, smooth texture and appearance. No edema is present. Wrinkles, due to aging are present and there is excess under her chin down to her neck.
_____Lips: EB's lips are smooth, moist and pink. There are no signs of chapping or cracking.
_____Mouth, oral membranes: EB's mouth/oral membranes are reddish pink and moist. There are no lesions or irritated areas.
_____Gums: EB's gums are pink without any swelling, bleeding or lesions. She has no bottom teeth and doesn't wear dentures.
_____Tongue: EB's tongue is moist and pink and not swollen or smooth in appearance. Papillae are present and there are no lesions.
_____Teeth: All of EB's lower teeth are absent. Teeth 1, 2, and 3 (back, upper, right) and 15 & 16 (back, upper, left) have also been removed/lost. Her remaining teeth are clean, intact and there are no visually detectable cavities. She states that she is not experiencing any dental pain or discomfort at this time.
_____Eyes: EB's eyes are bright, clear and shiny. Her conjunctiva are pink and there are not any sores, prominent blood vessels, mounts of tissue on sclera or fatigue circles under eyes. She does complain of excessive tearing.
_____Neck (glands): EB's thyroid gland is not enlarged.
_____Nails: EB's fingernails are firm and not brittle, due to opaque polish, they cannot be assessed for color. Her toenails are yellow and very thick.
_____Legs, feet: EB's legs and feet have good (pink) coloring and no swelling is present. The only weakness and tenderness that she is experiencing is attributed to arthritis. It radiates from her left hip to her left knee. She takes Motrin 400mg; ibuprofen; 1 tab po qam for arthritis. Her physician has also ordered it as q6h prn with food for arthritis.
_____Skeleton: EB has no major skeletal malformations. The joints in her hands and toes are enlarged and/or stiff.

(Very thorough, but please avoid good and "normal.")

Diet Analysis

_____The physician's order shows EB's diet as regular diet as tolerated. There are nutritional concerns with several of her conditions: hypertension, vitamin deficiency, muscle cramps, constipation, confusion and dementia. Although a regular diet will usually meet the recommended daily allowances for most nutrients, it does not include all of my concerns. Most of the medications that EB's physician has prescribed for her should be taken with food or milk to prevent gastrointestinal upset.
_____The care plan indicates that extra attention needs to be given to her nutritional status. It states that EB has very distinct food preferences that should be catered to, that her lab values need to be monitored, and to have the registered dietitian do a nutritional assessment.
_____EB is 4'10" (147 cm) and weighed only 84 lbs (47 kg) when admitted to the facility on August 26, 1997. She was placed on a diet with increased protein and calories and encouraged to eat snacks. In addition to other medications, she was put on potassium chloride and a multivitamin. Her current weight is 103.3 lbs (47 kg), she takes Theragram M; 1 tab po daily for vitamin deficiency and her potassium has been reduced to K+ 10 mEq; 1 tab po daily for hypokalemia.Many of the nutrients that I have listed as areas of concern may be included in EBs vitamin supplement, however, it is ideal to obtain these nutrients from the diet. It is also important to note that her hypokalemia is not due medication side effects.
_____The goal of early nutritional assessment and intervention is to ensure that eating is a health preserver rather than just a health corrector. (Phaneuf, 58) Keeping that in mind, the following nutritional considerations and modifications should be made when planning EB's diet.
_____EB's hypertension responds well to Lotrel, however, diet modifications including a mild sodium restriction (2-3g/day) may assist her medication in maintaining a healthy level. Foods to be omitted from diet include: salt at the table, also limit salt or salt/sodium containing spices when cooking; smoked, cured, or salt preserved foods; salted snack foods; cheese and peanut butter. (Moore, 285) Licorice should also be avoided since it causes sodium retention. (Williams, 484) Physicians should be consulted before using over the counter medications, like antacids, that may be high in sodium. (Moore, 287) EB has stated she uses antacids on occasion. The physician has not ordered an antacid, so the type is not specified and should be investigated.
_____Inadequate calcium can contribute to hypertension. An increase to 1000-1200mg/daily may be beneficial to EB. (Moore, 288) There is also evidence that postmenopausal women may benefit from an increased intake of calcium. The increase helps to prevent bone calcium loss and the development of osteoporosis. (Williams, 398)
_____Potassium therapy is improving EB's hypokalemia, however, increasing the amount of potassium rich food in her diet may eliminate the need for a daily potassium supplement. A potassium intake of 4.5-7g or 120-175 mEq/day may slightly lower blood pressure. Because she is on a potassium suppliment, any increase in potassium should be discussed with her physician first. Hypokalemia can cause leg and generalized body cramps (Dudek, 160) and caution should be used with salt substitutes that contain potassium. (Moore, 434) EB has been diagnosed with muscle cramps and has stated that she uses antacids, so the potassium in her diet should be monitored. (Moore, 287) Potassium chloride, used to treat hypokalemia, causes loss of vitamin B12, this is discussed again in a later paragraph. (Williams, 479)
_____Vitamin K has an antihemorrhagic effect (Dudek, 102) because it is needed for blood \par \par clotting (Williams, 480). An increase in EB's intake may help prevent bruising from being as severe. (Dudek, 102) The recommended daily allowance of vitamin K is 65ug/day. (Whitney, inside front cover)
_____Vitamin C deficiency leads to increased susceptibility to infection and promotes wound healing. (Dudek, 107) Since elderly at higher risk for infection and EB has an increased risk of falling and bruises easily, a vitamin C may have preventative significance. The recommended daily allowance of vitamin C is 60mg/day. (Whitney, inside front cover)
_____Thiamine, Vitamin B-1, is necessary for normal nervous system functioning. Deficiency can cause painful calf muscles and mental confusion. EB has been diagnosed with muscle cramps and confusion, so adequate intake of thiamine should be ensured. Use caution when administering antacids to EB, they break down thiamine. (Dudek, 111) The recommended daily allowance of vitamin B-1 is 1.0mg/day. (Whitney, inside front cover)
_____Elderly people with marginal calorie intakes are at risk for riboflavin, vitamin B-2, deficiencies. (Dudek, 111) EB's appetite is good, but considering her history or poor intake and low body weight the risk of riboflavin should be noted and possibly monitored. The recommended daily allowance of vitamin B-2 is 1.2mg/day. (Whitney, inside front cover)
_____Dementia is one of the "four D's" or four classic symptoms of Niacin deficiency. Since EB's hallucinations are due to dementia, special attention should be given to ensure adequate niacin intake. (Dudek, 113) The recommended daily allowance of niacin is 13mgNE/day. (Whitney, inside front cover)
_____The secretion of digestive juices decreases with age (Williams, 400) and EB is at risk for a vitamin B12, cobalamin, deficiency. She may not have enough gastric acid and pepsin to extract B12, cobalamin, from food. (Dudek, 119) Symptoms of B12 deficiency include recurring constipation and potassium chloride decreases the absorption of Vitamin B-12. (Dudek, 119-120)
_____Since EB experiences constipation at least once each month and takes a daily potassium supplement, efforts should be made to ensure adequate B12 intake. The recommended daily allowance of vitamin B-12 is 2.0ug/day. (Whitney, inside front cover)
_____A symptom of pantothenic acid deficiency is insomnia. (Dudek, 121) EB's care plan indicates that she has insomnia 5/week, so EB's diet should include an adequate amount of pantothenic acid. The recommended daily allowance of vitamin pantothenic acid is 10mg/day. (Whitney, inside front cover)
_____Zinc is the only trace elements that need special attention. Zinc is necessary for the development of the immune system. Since the elderly are at risk for a decreased immune response, special attention should be given to meeting the recommended daily allowance for zinc. The recommended daily allowance of zinc is 15mg/day. (Whitney, inside front cover)
_____The recommended daily allowance for iron should be included in EB's diet. EB should be encouraged to meet this dietary requirement because of it's relation to anemia. (Williams, 402) The recommended daily allowance of iron is 10mg/day. (Whitney, inside front cover)
_____According to the patients chart constipation is experienced at least once/month. Including 25-30g dietary fiber in daily diet, offering prunes or prune juice regularly, and having a large fluid intake may help prevent this from occurring. (Moore, 123 & 352)

(Triglycerides and cholesterol should also be controlled because of her HTN. Otherwise excellent analysis.)

Nutritional Profile/Menu

NUTRITIONAL PROFILE

SUGGESTED MENU

Ensure that client drinks 6-8 glasses of water by offering water at all meals and making it readily available throughout the day. Food may need to be cut into smaller pieces than those listed for measurement purposes.
* Fiber in g; K and Ca are in mg
(She likes pasta)

(Whitney; 35, H1-H99)

Nursing Interventions for Promotion of Nutritional Intake

_____Since the thirst mechanism can work less effectively with age, dehydration can easily occur. (Williams, 402) Fluid intake should be encouraged to prevent dehydration and aide in the prevention of constipation. It is recommended that adults drink 6-8 glasses of water each day.
_____EB does not have any of her lower teeth and is missing most of her upper molars. She states that she is able to chew food if it is tender or cut into small pieces. Each meal should be evaluated and cut or softened if necessary. EB avoids one or more food groups, so she is at risk for vitamin deficiencies. (Moore, 117). She does not like the taste of most vegetables. Her daughter works in the facility's kitchen and states that her mother likes corn, but is getting better about trying to eat other vegetables. Her diet should consist of foods that are high in essential nutrients and appeal to EB's tastes.
_____An increase in physical activity, as tolerated, could have several nutritional benefits for EB. It would help decrease her incidents or severity of constipation (Moore, 123) and may improve her appetite. EB says that she likes to walk outdoors and participates in the group exercise and activities, she should be encouraged to continue doing so.
_____Dementia and confusion may cause inadequate food intake. To help prevent problems staff should encourage adequate intake by announcing mealtime to the resident. Providing adequate time for eating and taking measures to avoid meal distractions would also be helpful. (Moore, 353-4) The facilities current practice of eating in a group setting allows for behavior modeling and may increase intake. (Phaneuf, 60)
_____Increased intake may also be encouraged by asking family members to visit during meal times. (Phaneuf, 60) EB's daughter works in the kitchen, so she is usually in the facility during meals. She takes measures to ensure that EB's food is tender or cut into small pieces, so she is actively involved during meal time.
_____Serving the main meal for breakfast or lunch may be beneficial. (Phaneuf, 60) EB goes to bed early and most of her activity is early in the day, her appetite may be better in the morning and afternoon.
_____EB denies having experienced a diminished sense of taste and smell, but she has an obvious attraction to desserts and sweets. Her preference may be due to a decrease in these senses. Individuals experiencing decreased taste tend to heavily salt and sugar food (Moore, 111). EB should be encouraged to eat her more nutrient dense foods before eating the sweets/desserts on her tray.
_____Finally, I have included about 50 extra calories in the diet I created for EB. She only eats 75-100% of the food she is served and a diet that included only the optimal number of calories would mean that she is only taking in 75-100% of what she needs to.

References

Dudek, S. (1997) Nutrition Handbook for Nursing Practice. Philadelphia, Pennsylvania: Lippencott-Raven Publishers.

Moore, M. (1997) Mosby's Pocket Guide Series: Nutritional Care. St. Louis, Missouri: Mosby-Yearbook, Inc.

Phaneuf, C. (1996) Screening Elders for Nutritional Deficits. American Journal of Nursing 16 (3), 58-60.

Williams, S.R. (1993) Nutrition and Diet Therapy. St. Louis, Missouri: Mosby-Yearbook Inc.

Wilson, B., Shannon, M., & Stang, C. (1995) Nurses Drug Guide. Norwalk, Connecticut: Appleton & Lange.

Whitney, E., Cataldo, C, & Rolfes, S. (1994) Understanding Normal and Clinical Nutrition. St. Paul, Minnesota: West Publishing Co.

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