HYPERTENSIVE URGENCY

Severe high blood pressure is defined as systolic pressure > 180 and/or diastolic pressure > 120. When pressures get this high, patients also are at risk
of serious complications like blood vessel rupture, swelling of the brain, and kidney failure. This is known as a hypertensive emergency. People with
severe high blood pressure usually develop symptoms which ultimately bring them into the doctor. These symptoms tend to develop quickly and may
include things like:

 Blurry vision or other vision disturbances

 Headache
 Dizziness
 Nausea or appetite changes

Sometimes, patients can have very high blood pressure and have no symptoms. In these cases, the elevated blood pressure is discovered incidentally.
These cases – severe high blood pressure without serious symptoms – are called hypertensive urgency. Hypertensive urgency indicates that the blood
pressure is high enough to cause serious risk of sudden, life threatening events, but that no such events are currently occurring. In other words, these
patients have no organ failure or other immediately life threatening conditions, but could quickly develop them if their blood pressure isn’t quickly
brought under control.

Treating Hypertensive Urgency Treated:

The goal is to reduce blood pressure before additional complications develop. There is no clear consensus on how quickly the blood pressure should
be reduced, but the goal typically ranges from hours to days depending on severity. While the regimen used to decrease the blood pressure depends on
the patient, treatment usually includes:

 Moving the patient to a dark, quiet, calming environment

 One or more oral medicines
 Careful monitoring
It is important to not lower the blood pressure too quickly, because rapid blood pressure reductions can cut off the supply of blood to the brain,
leading to brain damage or death.

Preventing Hypertensive Urgency:

The most important thing you can do to prevent hypertensive urgency is to take your blood pressure medications as directed. If you experience any of
the symptoms listed above, you should see a doctor as soon as possible. If you are unable to see your own physician, you should consider visiting an
emergency room close to your home.

CVD/CVA

Cerebrovascular disease refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of
the entire cerebrovascular system. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by a
partial or complete occlusion of the vessel lumen with transient or permanent effects. 

 Cerebral Ischemia-Infarction: Thrombotic occlusion and embolic occlusion (artery to artery and cardiogenic)

o Cerebral ischemia is caused by a reduction in blood flow that lasts for several seconds or a few minutes.
o If the cessation of flow lasts for more than a few minutes, infarction of brain tissue results.
o Generalized reduction in cerebral blood flow due to systemic hypotension (e.g., cardiac arrhythmia, myocardial infarction, or
hemorrhagic shock) usually produces syncope, infarction in the border zones between the major cerebral artery distributions, or widespread brain
necrosis, depending on the duration of hypotension
o FOCAL ischemia or infarction, on the other hand, is usually caused by disease in the cerebral vessels themselves or
by emboli from a proximal arterial source or the heart.
o Four Causes Of Ischemic Stroke
 (1) Thrombosis (53%): Atherosclerosis, vasculitis, arterial dissection, hematologic disorders
 Thrombotic strokes occur without warning symptoms in 80-90%. 10-20% are heralded by one or more
transient ischemic attacks (TIA’s). Thrombotic strokes often present with stuttering and fluctuating symptoms that worsen over several minutes or
hours.
 (2) Embolism (35%): can be cardiac source or atherothrombotic arterial source
 Embolic strokes usually present with a neurologic deficit that is maximum at onset
 (3) Vasoconstriction: Vasospasm and reversible cerebral vasoconstriction
 (4) Venous: Dehydration, pericranial infection, postpartum and postoperative states, systemic cancer

RELATED CONCERNS

Hypertension: severe

Craniocerebral trauma (acute rehabilitative phase)

Psychosocial aspects of care
Seizure disorders
Total nutritional support: parenteral/enteral feeding
Patient Assessment Database
Collected data are determined by location, severity, and duration of pathology.

ACTIVITY/REST
May report:
Difficulties with activity due to weakness, loss of sensation, or paralysis (hemiplegia) tires easily; difficulty resting (pain or muscle twitching)
May exhibit:
Altered muscle tone (flaccid or spastic); paralysis (hemiplegia); generalized weakness
Visual disturbances
Altered level of consciousness

CIRCULATORY

May report:
History of postural hypotension, cardiac disease (e.g., myocardial infarction [MI], rheumatic/valvular heart disease, HF, bacterial endocarditis),
polycythemia

May exhibit:
Arterial hypertension (common unless CVA is due to embolism or vascular malformation)
Pulse rate may vary (preexisting heart conditions, medications, effect of stroke on vasomotor center)
Dysrhythmias, electrocardiogram (ECG) changes
Bruit in carotid, femoral, or iliac arteries, or abdominal aorta

EGO INTEGRITY

May report:
Feelings of helplessness, hopelessness
May exhibit:
Emotional liability and inappropriate response to anger, sadness, happiness
Difficulty expressing self

ELIMINATION
May exhibit:
Change in voiding patterns, e.g., incontinence, anuria
Distended abdomen (overdistended bladder); absent bowel sounds (paralytic ileus)

FOOD/FLUID
May report:
Lack of appetite
Nausea/vomiting during acute event (increased ICP)
Loss of sensation in tongue, cheek, and throat; dysphagia
History of diabetes, elevated serum lipids
May exhibit:
Mastication/swallowing problems (palatal and pharyngeal reflex involvement)
Obesity (risk factor)

NEUROSENSORY
May report:
Dizziness/syncope (before CVA/transient during TIA)
Severe headache (intracerebral or subarachnoid hemorrhage)
Tingling/numbness/weakness (commonly reported during TIAs, found in varying degrees in other types of stroke); involved side seems “dead”
Visual deficits, e.g., blurred vision, partial loss of vision (monocular blindness), double vision (diplopia), or other disturbances in visual fields
Touch: Sensory loss on contralateral side (opposite side) in extremities and sometimes in ipsilateral side (same side) of face
Disturbance in senses of taste, smell
History of TIA, RIND (predisposing factor for subsequent infarction)
May exhibit:
Mental status/LOC: Coma usually present in the initial stages of hemorrhagic disturbances; consciousness is usually preserved when the etiology is
thrombotic in nature; altered behavior (e.g., lethargy, apathy, combativeness); altered cognitive function (e.g., memory, problem-solving, sequencing)
Extremities: Weakness/paralysis (contralateral with all kinds of stroke), unequal hand grasp; diminished deep tendon reflexes (contralateral)
Facial paralysis or paresis (ipsilateral)
Aphasia: Defect or loss of language function may be expressive (difficulty producing speech); receptive (difficulty comprehending speech); or global
(combination of the two)
Loss of ability to recognize or appreciate import of visual, auditory, tactile stimuli (agnosia), e.g., altered body image awareness, neglect or denial of
contralateral side of body, disturbances in perception
Loss of ability to execute purposeful motor acts despite physical ability and willingness to do so (apraxis)
Pupil size/reaction: Inequality; dilated and fixed pupil on the ipsilateral side (hemorrhage/herniation)
Nuchal rigidity (common in hemorrhagic etiology); seizures (common in hemorrhagic etiology)

PAIN/DISCOMFORT

May report:
Headache of varying intensity (carotid artery involvement)
May exhibit:
Guarding/distraction behaviors, restlessness, muscle/facial tension

RESPIRATION
May report:
Smoking (risk factor)

May exhibit:
Inability to swallow/cough/protect airway
Labored and/or irregular respirations
Noisy respirations/rhonchi (aspiration of secretions)
 SAFETY
May exhibit:
Motor/sensory: Problems with vision
Changes in perception of body spatial orientation (right CVA)
Difficulty seeing objects on left side (right CVA)
Being unaware of affected side
Inability to recognize familiar objects, colors, words, faces
Diminished response to heat and cold/altered body temperature regulation
Swallowing difficulty, inability to meet own nutritional needs
Impaired judgment, little concern for safety, impatience, lack of insight (right CVA)

SOCIAL INTERACTION
May exhibit:
Speech problems, inability to communicate

TEACHING/LEARNING
May report:
Family history of hypertension, strokes; African heritage (risk factor)
Use of oral contraceptives, alcohol abuse (risk factors)

Discharge plan considerations

DRG projected mean length of inpatient stay: 6.4 days
May require medication regimen/therapeutic treatments
Assistance with transportation, shopping, food preparation, self-care, and homemaker/ maintenance tasks
Changes in physical layout of home; transition placement before return to home setting
Refer to section at end of plan for postdischarge considerations.

NURSING PRIORITIES

1. Promote adequate cerebral perfusion and oxygenation.

2. Prevent/minimize complications and permanent disabilities.
3. Assist patient to gain independence in ADLs.
4. Support coping process and integration of changes into self-concept.
5. Provide information about disease process/prognosis and treatment/rehabilitation needs.

UGIB with BPUD

Upper gastrointestinal bleeding (UGIB) is a significant and potentially life-threatening worldwide problem. Despite advances in diagnosis and
treatment, mortality and morbidity have remained constant.1 Bleeding from the upper gastrointestinal tract (GIT) is about 4 times as common as
bleeding from the lower GIT. Typically patients present with bleeding from a peptic ulcer and about 80% of such ulcers stop bleeding. Increasing age
and co-morbidity increase mortality. It is important to identify patients with a low probability of re-bleeding from patients with a high probability of
re-bleeding.

Aetiology
A cause is found in 80% of cases. Approximate percentages given.
Note the predominance of peptic ulcer disease:
 Peptic ulcer disease 35 to 50%:
o Duodenal ulcer 25%
o Gastric ulcer 20%
 Gastroduodenal erosions 8 to 15%
 Oesophagitis 5 to 15%
 Oesophageal varices 5 to 10%
 'Mallory-Weiss' tears 15%
 Upper gastrointestinal malignancy 1%
 Vascular malformations 5%
 Rare causes - less than 5%:
o Dieulafoy's lesion (a vascular malformation of the proximal stomach)
o Angiodysplasia
o Haemobilia (bleeding from the gallbladder or biliary tree)
o Pancreatic pseudocyst and pseudo-aneurysm
o Aortoenteric fistula
o Bleeding diathesis
o Ehlers-Danlos syndrome
o Pseudoxanthoma elasticum
o Gastric antral vascular ectasia
o Rendu-Osler-Weber syndrome
 The strong association of Helicobacter pylori (H. pylori) infection with duodenal ulcer is worthy of special mention. The organism
disrupts the mucosal barrier and causes inflammation in the gastric and duodenal mucosae. Eradication reduces the risk of both recurrent ulcers and
recurrent haemorrhage.
 Non-steroidal anti-inflammatory drugs (NSAIDS) are the second most important aetiological factor. They exert an effect on
cyclooxygenase-1 leading to impaired resistance of the mucosa to acid.
 The size of the bleeding vessel is important in prognosis. Visible vessels are usually between 0.3 mm and 1.8 mm. Large bleeding vessels
cause faster blood loss. Generally larger vessels are found deeper in the submucosa and serosa and more specifically high in the lesser curve of the
stomach and postero-inferiorly in the duodenal bulb.

Management2

Resuscitation is a priority
 It has been demonstrated that early and aggressive resuscitation reduces mortality in UGIB.4
 Maintain airway - remember vomitus can lead to airway obstruction.
 Provide high flow oxygen - this will aid tissue perfusion.
 Correct fluid losses (place 2 wide bore cannulae and also send bloods at the same time). Initial fluid resuscitation may be with crystalloids
or colloids; give intravenous blood when 30% of circulating volume is lost.2 Major haemorrhage protocols should be in place.2

Once patient is more stable

 Assess the patient, taking history and examining the patient as above - a collateral history might be needed.
 Identify and treat any co-morbid conditions.
 Estimate the severity of bleeding (as above).
RELATED CONCERNS

Cirrhosis of the liver

Fluid and electrolyte imbalances, see Nursing Care Plan CD-ROM
Psychosocial aspects of care
Renal failure: acute
Subtotal gastrectomy/gastric resection, see Nursing Care Plan CD-ROM

Patient Assessment Database

ACTIVITY/REST
May report: Weakness, fatigue
May exhibit: Tachycardia, tachypnea/hyperventilation (response to activity)

CIRCULATION
May report: Palpitations
Dizziness with position change
May exhibit: Hypotension (including postural)
Tachycardia, dysrhythmias (hypovolemia/hypoxemia)
Weak/thready peripheral pulse
Capillary refill slow/delayed (vasoconstriction)
Skin color: pallor, cyanosis (depending on the amount of blood loss)
Skin/mucous membrane moisture: Diaphoresis (reflecting shock state, acute pain, psychological response)

EGO INTEGRITY
May report: Acute or chronic stress factors (financial, relationships, job-related)
Feelings of helplessness
May exhibit: Signs of anxiety, e.g., restlessness, pallor, diaphoresis, narrowed focus, trembling,
quivering voice

ELIMINATION
May report: Change in usual bowel patterns/characteristics of stool
May exhibit: Abdominal tenderness, distension
Bowel sounds often hyperactive during bleeding, hypoactive after bleeding subsides
Character of stool: Diarrhea; dark bloody, tarry, or occasionally bright red stools; frothy, foul-smelling (steatorrhea); constipation may occur (changes
in diet, antacid use)
Urine output may be decreased, concentrated

FOOD/FLUID
May report: Anorexia, nausea, vomiting (protracted vomiting suggests pyloric outlet obstruction
associated with duodenal ulcer)
Problems with swallowing; belching, hiccups
Heartburn, indigestion, burping with sour taste
Bloating/distension, flatulence
Food intolerances, e.g., spicy food, chocolate; special diet for preexisting ulcer disease
Weight loss
May exhibit: Vomitus: coffee-ground or bright red, with or without clots
Mucous membranes dry, decreased mucus production, poor skin turgor (chronic bleeding)
Urine specific gravity may be elevated

NEUROSENSORY
May report: Fainting, dizziness/lightheadedness, weakness
Mental status: Level of consciousness (LOC) may be altered, ranging from slight
drowsiness, disorientation/confusion, to stupor and coma (depending on
circulating volume/oxygenation)

PAIN/DISCOMFORT
May report: Pain described as sharp, dull, burning, gnawing; sudden, excruciating (can accompany perforation)
Vague sensation of discomfort/distress following large meals and relieved by food (acute
gastritis)
Left to midepigastric pain and/or pain radiating to back, often accompanied by vomiting
after eating and relieved by antacids (gastric ulcer)
Localized right to midepigastric pain, gnawing, burning, occurring about 2–3 hr after
meals when stomach is empty, and relieved by food or antacids (duodenal
ulcers)
Midepigastric pain and burning with regurgitation (chronic gastroesophageal reflux disease
[GERD])
Absence of pain (esophageal varices or gastritis)
Precipitating factors may be foods (e.g., milk, chocolate, caffeine), smoking, alcohol, certain drugs (salicylates, reserpine, antibiotics, ibuprofen),
psychological stressors
 May exhibit: Facial grimacing, guarding of affected area, pallor, diaphoresis, narrowed focus

SAFETY
May report: Drug allergies/sensitivities, e.g., acetylsalicylic acid (ASA)
May exhibit: Temperature elevation
Spider angiomas, palmar erythema (reflecting cirrhosis/portal hypertension)

TEACHING/LEARNING
May report: Recent use of prescription/over-the-counter (OTC) drugs containing ASA,
alcohol/recreational drugs, steroids, or nonsteroidal anti-inflammatory drugs (NSAIDs) (leading cause of drug-induced GI bleeding)
Current complaint may reveal admission for related (e.g., anemia) or unrelated (e.g., head
trauma) diagnosis, intestinal flu, or severe vomiting episode; long-standing health problems, e.g., cirrhosis, alcoholism, hepatitis, eating disorders
History of previous hospitalizations for GI bleeding or related GI problems, e.g.,
peptic/gastric ulcer, gastritis, gastric surgery, irradiation of gastric area

NURSING PRIORITIES

1. Control hemorrhage.
2. Achieve/maintain hemodynamic stability.
3. Promote stress reduction.
4. Provide information about disease process/prognosis, treatment needs, and potential complications.

Cellulitis is a common infection of the skin and the soft tissues underneath the skin. It occurs when bacteria invade broken or normal skin and start to
spread under the skin and into the soft tissues. This results in infection and inflammation. Inflammation is a process in which the body reacts to the
bacteria. Inflammation may cause swelling, redness, pain, and/or warmth.

People at risk for developing cellulitis include those with trauma to the skin or other medical problems such as the following:

Diabetes 

Circulatory problems such as inadequate blood flow to the limbs, poor venous or lymphatic drainage, or varicose veins 

Liver disease such as chronic hepatitis or cirrhosis 

Skin disorders such as eczema, psoriasis, infectious diseases that cause skin lesions such as chickenpox, or severe acne

Cellulitis Causes

Injuries that break the skin 

Infections related to a surgical procedure 

Any breaks in the skin that allow bacteria to invade the skin (examples are chronic skin conditions such as eczema or psoriasis) 

Foreign objects in the skin 

Infection of bone underneath the skin (An example is a long-standing open wound that is deep enough to expose the bone to bacteria. Sometimes this
occurs in people with diabetes who have lost sensation in their feet.)

Cellulitis Symptoms

Cellulitis can occur in almost any part of the body. Most commonly it occurs in areas that have been damaged or are inflamed for other reasons, such
as inflamed injuries, contaminated cuts, and areas with poor skin condition or bad circulation. The common symptoms of cellulitis are as follows:

 Redness of the skin

 Red streaking of the skin or broad areas of redness

 Swelling

 Warmth

 Pain or tenderness

 Drainage or leaking of yellow clear fluid or pus from the skin; large blisters may occur

 Tender or swollen lymph nodes near the affected area

 Fever can result if the condition spreads to the body via the blood

Medical Treatment

 If the infection is not too severe you can be treated at home. The doctor will give you a prescription for antibiotics to take by mouth for a
week to 10 days. 

 The doctor may use intravenous (IV) or intramuscular antibiotics in these situations: 

o If the infection is severe 

o If you have other medical problems 

o If you are very young or very old 

o If the cellulitis involves extensive areas or areas close to important structures; for example, infection around the eye socket

o If the infection worsens after taking antibiotics for two to three days

 You may need hospitalization if the infection is well developed, extensive, or in an important area, like the face. In most of these cases, IV
(intervenous) antibiotics need to be given until the infection is under good control (two to three days) and then you can be switched to oral
medications to be taken at home.

Nursing Diagnosis for Cellulitis

Skin Integrity
 Cellulitis makes skin susceptible to other damage, including bed sores. Even if there are no open sores from the infection, the swelling can
weaken the skin and lead to problems. This can be expressed as "risk for impaired skin integrity related to edema." If sores are present, "impaired skin
integrity related to edema as manifested by open wounds" is a likely diagnosis. Interventions include avoiding friction against the infected area,
turning the patient regularly and keeping the area dry.

Pain
 Severe cellulitis can be very painful, especially if it has spread throughout the system. A possible diagnosis is "acute pain related to skin infection
as manifested by patient reporting extreme discomfort." Ask the patient to describe the type and intensity of the pain and monitor the effect of pain
medication. If the medication isn't helping, contact the patient's doctor to determine if a higher dose needs to be given. Regularly assess vital signs, as
pain can increase heart rate and blood pressure.

Activity
 The patient's tolerance for activity can be affected by cellulitis. The related factor may include pain, fatigue due to medication or general
weakness as expressed by the patient. For example, "activity intolerance related to side effects of medication as manifested by patient saying she feels
weak." Encourage the patient to engage in as much physical activity as she feels possible, help her perform range of motion exercises and allow for
adequate periods of rest and relaxation.

Fever

 Fever is a common symptom of cellulitis and could be expressed as "hyperthermia related to bacterial infection." The evidence may include
elevated heart rate, flushing, warm skin or excessive sweating. Since fever can lead to dehydration, it is important to make sure your patient gets
plenty of fluids. Fever can also be the cause of a diagnosis, such as "risk for deficient fluid volume." In this case, your interventions would involve
keeping the patient free of fever by administering doctor-prescribed fever reducers and monitoring vital signs.