I. INTRODUCTION Discussion would be about HASHD meaning Hypertensive Arteiosclerotic Heart Disease.

In this research, the disease will be divided so it would be understood better. The heart must work harder to pump blood through the narrowed arteries. Often called the silent killer, hypertension usually causes no symptoms until it reaches a life-threatening stage. Hypertension would lead to a disorder called arteriosclerosis meaning hardening of the arteries. If the condition persists, damage to the heart and blood vessels is likely, increasing the risk for stroke, heart attack, and kidney or heart failure. II. OBJECTIVES The objective of a case study is to create and reach that goal using the nursing process applied to a patient. In general, a case study is done to achieve the following objectives: To gain a deeper understanding and knowledge of the subject chosen. To have other references for those who want to improve their skills. In particular, it aims to: Apply the earned knowledge for our nursing responsibilities Identify the patients health problems and possible interventions Carry out these possible interventions and its outcomes

III. THEORETICAL FRAMEWORK Virginia Hendersons Theory Hendersons Theory includes concepts and definitions of nursing, health, person (patient), environment, and 14 needs. According to Virginia Hendersons nursing theory, she believes health is attained when a patient has reached independence. In order to reach autonomy one must be able to fulfill the 14 basic needs without any assistance. To achieve this goal, a nurse is required to assist the patient. At first, the nurse will complete the 14 goals and produce an environment that is effective for this process. The role of the nurse should decrease and the role of the patient should increase during the process of meeting the his health care needs. This will continue until the patient no longer requires the assistance from the nurse. The following are Hendersons 14 needs: Breathe normally Eat and drink adequately

Eliminate body wastes Move and maintain desirable position Sleep and rest Select suitable clothes-dress and undress Maintain body temperature within normal range by adjusting clothing and modifying Keep the body clean and well groomed and protect the integument Avoid dangers in the environment and avoid injuring others Communicate with others in expressing emotions, needs, fears, or opinions Worship according to ones faith Work in such way that there is a sense of accomplishment Play or participate in various forms of recreation Learn, discover, or satisfy the curiosity that leads to normal development and health and

environment

use the available health facilities IV. PATIENTS PROFILE Name:L.B.P. Age: 78 Birthday: June 13, 1928 Birthplace: Bulacan Gender: Female Status: Married Religion: Roman Catholic Nationality: Filipino Attending Physician: Dra. Leticia Yao How Admitted: E.R. Chief Complaint: Epigastric Pain V. HISTORY OF PRESENT ILLNESS: 4h PTA (+) epigastric pain, burning in character, non-radiating, pain scale (8/10) (+) bowel movement (-) fever (-) vomiting (-) change in bowel habits

2h PTA, still with above signs and symptoms prompted consult to another hospital wherein she was given nubain, ranatidine and buscopan TIV which afforded slight relief of pain (4/10). She was then advised admission but they opted to transfer her here in our institution for further management VI. PAST MEDICAL HISTORY: (-) Diabetes Mellitus (+) Hypertension - 4 years presently maintained on Plendil 5 mg OD HBP=140/90 UBP=120/80 (-) Bronchial Asthma (-) Pulmonary Tuberculosis (+) History upper GI bleeding 3 years ago (+) Improved glucose VII. FAMILY HISTORY: (-) Diabetes Mellitus (-) Hypertension (-) Bronchial Asthma (-) Pulmonary Tuberculosis (-) Cancer (-) Cardio Vascular disease (-) Psychiatric Disorder (-) Thyroid Disorder IX. PHYSICAL EXAMINATION: Conscious, coherent, not in distress BP 140/90 HR 60 RR 19 Temp 37 Pink skin, pupil: 2-3 mm, anicteric sclerae, Supple neck Symmetrical, normal breath sound Normal Rate Flabby, soft Positive edema (grade II edema) VIII. SOCIAL HISTORY: (-) Smoker (-) Alcoholic Beverage drinker (-) Allergy to food/drugs (-) History of drug intake

General Survey HEENT Neck Chest/Lungs Heart Abdomen Extremities

Admitting Impression: APO (Acute Pulmonary Oedema), HASHD (Hyprtensive Arteriosclerotic Heart Disease), CFC 2B, No DUA X. LABORATORY DATA Hematology Hemoglobin Hematocrit RBC WBC Neutrophil Lymphocytes Monocytes Eosinophils Basophils Stab. Atypical Lymphocytes Platelet Count MCV MCH MCHC RDW Urinalysis January 31 Macroscopic Color Yellow Character Hazy Sp. Gravity 1.020 Reaction 6.0 Sugar +1 Protein Trace Ketone +1 Bile (-) Blood Trace Arobilinogen ( - ) Amylase ABG pO2 pH pCO2 HCO3 Sat O2 72.1 mEq/L 7.395 mEq/L 39.3 mEq/L 23.5 mEq/L 94.51 % RR 18 bpm BE/BD Tot CO2 Aa DO2 P/F ratio Vd/vt 1.1 24.7 31.4 343 0.70 38 n/L Microscopic Pus cells 1-3/hpf RBC 0-2/hpf Bacteria few Epithelial cells many Mucus threads none Casts none February 1 Macroscopic Ketone (-) January 31 125 .36 3.83 12.3 .83 .06 .04 .00 .00 .07 .00 Adequate 94 32.50 34.50 13.4 February 1 130 .39 4.18 10.5 .82 .11 .06 .01 .00 .00 .00 Adequate 94.00 31.20 33.20 12.8 Unit g/L g/L 10^6ul 10^3ul 10^3ul 10^3ul 10^3ul 10^3ul 10^3ul 10^3ul 10^3ul 10^3ul Fl Pg g/dL %

Others Amorphous rates

Rare

Serology report - February 1 Ultrasound - Transivaginal Uterus: Anteverted Length - 37mm Width - 43mm Height -31mm Cervix: 26 mm 32mm Nabothian cyst ( + ) (-) Endometrium: Thickness - 6mm Others: cul - de -sac ( ) + few fluid (x) no fluid Impression: Thickened endometrium with systic spaces

Hg6A1C - 4.27-6.07% A1C

Ovaries: (R) Length 11mm Width Height 7mm

(L) 10mm 7mm

Phase: Proliferative ( ) Preovulatory ( ) Secretory (x)

Cannot totally rule out the possibility of endometric pathology

Anteverted small uterus with right lateral intramural myoma with calciifications measuring 9x6 mm

Atrophic ovaries Minimal pelvic ascites Abdominal Sonography There is considerable amount of intestinal gas minimal few intraperitoneal fluid collection is noted. Fluid collection in the right hepatorenal space measures 2.1x1.6x0.9 (1.7 ml) Gallbladder is within normal size containing fine low-level echoes. Gallbladder wall is not thickened . Common duct measures 0.4 cm. Intrahepatic ducts and radicals are not dilated Liver, pancreas and spleen are in normal size showing smooth antiines and homogenous parenchymal echopattern . No sonographically discernible focal solid or cystic lesion appreciated Abdominal aorta shows atherosclerotic plaques: its widest AP diameter measures 1.3 cm Right kidney measures 9.6x4.4 cm with cortica thickness of 1.6cm. Left kidney measures 9.3x4.7 cm with cortica thickness of 1.5 cm Both kidneys are in normal size showing smooth outlines and homogenous parenchymal echopattern, cortico medullary junctions are intact There is a 0.3 cm intense echo in the middle calyceal area of the left kidney. No caliectasis noted No caliectasis more lithiasis seen in the right kidney

Ureters not delineated Urinary bladder was not satisfactorily distended precluding its proper evaluation Impression: There is considerable amount of intestinal gas Minimal ascites Gallbladder bile sludge formation Non-dilated biliary tree ( - ) ultrasound of the liver, pancreas, spleen and right kidney Atherosclerotic abdominal aorta Calyceal calcula, left kidney XI. ANATOMY AND PHYSIOLOGY: Vascular System There are three types of blood vessels forming a complex network of tubes throughout the body. Arteries carry blood away from the heart, and veins carry it toward the heart. Capillaries are the tiny links between the arteries and the veins where oxygen and nutrients diffuse to body tissues. The inner layer of blood vessels is lined with endothelial cells that create a smooth passage for the transit of blood. This inner layer is surrounded by connective tissue and smooth muscle that enable the blood vessel to expand or contract. Blood vessels expand during exercise to meet the increased demand for blood and to cool the body. Blood vessels contract after an injury to reduce bleeding and also to conserve body heat. Arteries have thicker walls than veins to withstand the pressure of blood being pumped from the heart. Blood in the veins is at a lower pressure, so veins have one-way valves to prevent blood from flowing backwards away from the heart. Capillaries, the smallest of blood vessels, are only visible by microscopeten capillaries lying side by side are barely as thick as a human hair. If all the arteries, veins, and capillaries in the human body were placed end to end, the total length would equal more than 100,000 km (more than 60,000 mi)they could stretch around the earth nearly two and a half times. The arteries, veins, and capillaries are divided into two systems of circulation: systemic and pulmonary. The systemic circulation carries oxygenated blood from the heart to all the tissues in the body except the lungs and returns deoxygenated blood carrying waste products, such as carbon dioxide, back to the heart. The pulmonary circulation carries this spent blood from the heart to the lungs. In the lungs, the blood releases its carbon dioxide and absorbs oxygen. The oxygenated blood then returns to the heart before transferring to the systemic circulation.

Blood Pressure is the pressure of circulating blood against the walls of the arteries. Blood pressure is an important diagnostic index, especially of circulatory function. Because the heart can pump into the large arteries a greater volume of blood than can be absorbed by the tiny arterioles and capillaries, the resulting back pressure is exerted against the arteries. Any condition that dilates or contracts the blood vessels or affects their elasticity, or any disease of the heart that interferes with its pumping power, affects the blood pressure. Controlled by both cerebrospinal and sympathetic nerve centers, the complex nervous system mechanisms that balance and coordinate the activity of the heart and arterial muscles permit great local variation in the rate of blood flow without disturbing the general blood pressure. HASHD means Hypertensive Arteiosclerotic Heart Disease as it was introduced. To know what this whole disease process is all about, let's divide it into the process that we do understand. First off is Hypertension or High Blood Pressure. A medical condition in which constricted arterial blood vessels increase the resistance to blood flow, causing the blood to exert excessive pressure against vessel walls. Pathophysiology Although the precise cause for most cases of hypertension cannot be identified, it is understood that hypertension is a multifactorial condition. Because hypertension is a sign, it is most likely to have many causes, just as fever has many causes. For hypertension to occur, there must be a change in on or more factors affecting peripheral resistance or cardiac. In addition, there must also be a problem with the control systems that monitor or regulate pressure. Single gene mutation have been identified for a few rare types of hypertension, but most types of high blood pressure are thought to be polygenic (mutation in more than one gene) (Dominiczak et al., 2000) Several hypotheses about the pathophysiologic bases of elevated blood pressure are associated with the concept of hypertension as a multifactorial condition. Given the overlap among these hypotheses, it is likely that aspects of all of them will eventually prove correct. Hypertension may be caused by one or more of the following: Increased sympathetic nervous system activity related to dysfunction of the autonomic nervous system Increased renal reabsorption of sodium, chloride, and water related to a genetic variation in the pathways by which the kidneys handle sodium

Increaed activity of the renin-angiotensin-aldosterone system, resulting in the expansion of extracellular fluid volume and increased systematic vascular resistance Decreased vasodilation of the arterioles related to dysfunction of the vascular endothelium

Arteriosclerosis is a group of disorders of the arteries, the tubular vessels that carry oxygencarrying blood from the heart to the bodys organs and tissues. In arteriosclerosis, the walls of the arteries thicken, harden, and lose their elasticity. The blood vessel channels develop twists and turns and become narrowed so that the heart must work harder than normal to pump blood through the arteries. In the diseases advanced stage, there is a risk of a decrease in blood flow and oxygen supply to all parts of the body. The disorder, commonly known as hardening of the arteries, develops as people age, but its severity varies greatly from person to person. Little is known about the cause of arteriosclerosis. Heredity appears to play a role in many cases. Lifestyle factors, such as continual stress or a diet abundant in animal fats, also appear to contribute to the condition. Pathophysiology The most common direct results of atherosclerosis (a form of arteriosclerosis) in arteries include narrowing (stenosis) of the lumen, obstruction by thrombosis, aneurysm, ulceration and rupture. Its indirect results are malnutrition and the subsequent fibrosis of the organs that the sclerotic arteries supply with blood. All actively functioning tissue cells require an abundant supply of nutrients and oxygen and are sensitive to any reduction in the supply of these nutrients. If such reductions are severe and permanent, the cells undergo ischemic necrosis (death of cells due to deficient blood flow) and are replaced by fibrous tissue, which require much less blood flow. Atherosclerosis can develop at any point of the body, but certain sites are more vulnerable, typically bifurication or branch areas. In the proximal lower extremity, these include the distal abdominal aorta, the common iliac arteries, the orifice of the superficial femoral and profunda femoris arteries, and the superficial fermoral artery in the adductor canal. Distal to the knee, atherosclerosis occurs anywhere along the artery. There are no specific areas, such as arterial bifucrications, that are more vulnerable for atherosclerosis. Although many theories exist about the development of atherosclerosis, no single theory fully explains the pathogenesis; however, parts of several theories have been combined into reaction-to-injury theory. according to this theory, vascular endothelial cell injury results from

prolonged hemodynamic forces, such as shearing stresses and turbulent flow, irradiation, chemical exposure, or chronic hyperlipidemia in the arterial system. Injury to the endothelium increases the aggregation of platelets and monocytes at the site of the injury. Smooth muscles cells migrate and proliferate, allowing a matrix of collagen and elastic fibers to form. It may be that there is no single cause or mechanism for the development of atherosclerosis; rather, multiple processes may be involved (Moore, 2002). Morphologically, atherosclerotic lesions are of two types: fatty streaks and fibrous plaque. Fatty streaks are yellow and smooth, protrude slightly into the lumen of the artery, and are composed of lipids and elongated smooth muscle cells. These lesions have been found in the arteries of people of all age groups, including infants. It is not clear whether fatty streaks predispose the person to the formation of fibrous plaques or if they are reversible. They do not usually cause clinical symptoms. The fibrous plaque characteristic of atherosclerosis is composed of smooth muscle cells, collagen fibers, plasma components, and lipids. It is white to whitish yellow and protrudes in carious degrees in to the arterial lumen, sometimes completely obstructing it. These plaques are found predominantly in the abdominal aorta and the coronary, popliteal, and internal carotid arteries. This plaque is believed to be and irreversible lesion. Gradual narrowing of the arterial lumen as the disease process progresses stimulates the development of collateral circulation. Collateral circulation consists of preexisting vessels that enlarge to reroute blood flow in the presence of a hemodynamically significant stenosis or occlusion. A collateral flow allows continued perfusion to the tissues beyond the arterial obstruction, but it is often inadequate to meet imposed metabolic demand, and ischemia results.

Pre-disposing Factor Age Sex

Risk Factor Atherosclerosis

Etiologic Categories Rate or volume of blood increases Increased resistance of arteries

Hypertensive Arteriosclerotic Heart Disease

Arteries and arterioles will be damaged

Arteriosclerosis

XII. DRUG STUDY: Drugs Generic name: Metronidazole Brand name: Flagyl Classification: Antibiotic Dosage/Route: 500mg IV Q6 Generic name: Cefuroxime Brand name: Zinacet Classification: Antibiotic
-

Actions Inhibits DNA synthesis in specific anaerobs causing cell death

Indications - Acute infection with susceptible anaerobic bacteria - Acute intestinal amoebiasis - Amoebic liver abscess

Contraindications Hypersensitivity to metronidazole

Inhibits synthesis of bacterial cell wall, causing cell death

Dosage/Route: 750mg IV Q8
-

Generic name: Felodipine Brand name: Plendil Classification: Calcium Channel Blocker Dosage/Route: 5mg PO OD in am Inhibits movement of calcium ions across membranes of cardiac and vascular smooth muscle cells -

Phryngitis, tonsillitis caused by Streptococcus pyogens Otitis media caused by Streptococcus pneumoniae LRI caused by Streptococcus pneumoniae UTI caused by Escherichia coli Treatment of early Lyme disease Essential hypertension

Hypersensitivity to cephalosporins or penicillins

Adverse Effect CNS - headache, dizziness, ataxia GI - metallic taste, anorexia, nausea, vomiting, diarrhea GU - dark urine Local - redness, burning, dryness, skin irritation GI - nausea, vomiting, diarrhea, anorexia, abdominal pain Local - pain, phlebitis, rash, fever

Hypersensitivity to felodipine or other calcium channel blockers, sick sinus syndrome, heart block

CNS - headache, dizziness, light headedness, fatigue - CV - peripheral edema - Dermatologic flushing - GI - nausea
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Generic name: Pantoprazole Brand name: Pantoloc Classification: Antisecretory agent Dosage/Route: 40mg IV OD

Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cell

Treatment of gastric esophageal reflux disease (GERD) - Maintenance healing of erosive esophagitis - Treatment of pathological hypersecretory conditions associated with Zollinger-Ellison syndromeand other neoplastic conditions -

Hypersensitivity to proton pump inhibitor or any drug components

CNS - headache, dizziness - GI - nausea, vomiting, diarrhea, abdominal pain - Respiratory - URI symptoms
-

XIII. NURSING CARE PLAN: Assessment Subjective "Masakit ang ulo ko" as verbalized by the patient Objective facial grimace restlessness irritation pain scale (6/10) TPR: 37-60-19 BP: 140/90 Nursing Diagnosis Pain (headache) due to increased intracranial pressure secondary to high blood pressure Planning After 8 hours of nursing intervention, pain will be reduced/ alleviated and high blood pressure will be in normal range place the patient in a comfortable high fowler's position encourage patient to relax discuss ways of continuing care and to maintain normal blood pressure to lessen stress Intervention Monitor blood pressure Rationale to monitor progress of care for blood pressure to decrease intracranial pressure Evaluation After 8 hours of nursing intervention pain was alleviated as evidenced by patient's facial expression blood pressure was reduced to normal range (120/80)

maintenance of blood pressure give medications as prescribed by the doctor XIV. DISCHARGE PLANNING Health Teachings - aims to provide more helpful information for faster improvement. Health Teachings given: Encouraged eating foods rich in Vitamin C, Iron and Fiber Encouraged increasing fluid intake Control intake of food and drink designed for health to improve her medical condition. Advised follow up to check if the she has improved better after leaving the hospital for a certain amount of time. to alleviate pain an decrease blood pressure to normal

Advised to always pray to God especially for the maintenance of her health.