Hypertensive Crisis - Case Study: Blood Diagnostics Interventions Meds
Hypertensive Crisis - Case Study: Blood Diagnostics Interventions Meds
Hypertensive Crisis - Case Study: Blood Diagnostics Interventions Meds
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.
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
2. What are your top concerns for Mrs. Phillips at this time? Why?
3. What medications do you anticipate the provider ordering for Mrs. Phillips?
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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
5. Based on previous orders you have received, what action(s) should you take at this time?
Why?
6. What modifiable risk factors have you identified that put Mrs. Phillips at risk for
hypertensive crisis?
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.
7. 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%.
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.
9. What education topics would you want to provide to the patient before discharge?
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ANSWERS:
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b. The goal is to decrease the blood pressure by max 20% for the first 6-12 hours,
then to aim for a SBP of 160 mmHg with IV or short-acting PO antihypertensives,
then to transition to long-acting PO meds to target a SBP < 140.
8. What, physiologically, is going on with Mrs. Phillips at this time?
a. Mrs. Phillips is in hypertensive crisis. Because her blood pressure is extremely
high, it has caused a bleed within the vessels of her brain - leading to a hemorrhagic
stroke.
9. What education topics would you want to provide to the patient before discharge?
a. Diet & Lifestyle changes - she needs to be on a low-sodium diet and needs to lose
weight. She should also cut caffeine and try to decrease stress.
b. Medication management - Mrs. Phillips should be taught how to prevent
orthostatic hypotension by rising slowly, and what symptoms to report to her
provider. Also, make sure she knows the schedule for taking her meds so that she
doesn’t take them all at the same time and experience hypotension.
c. Follow-Up - she needs to see a healthcare provider regularly and should probably
start checking her blood pressure at home or at a local pharmacy. Because
hypertension can be asymptomatic, it’s important that she continues to take her
medication and monitor her blood pressure even after she feels better. She will
also likely need to follow up with a neurologist because of her stroke.
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