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?
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
HR92 bpm and regular Wt107 kg
RR20 bpm SpO296% on Room Air
Temp36.9°C
Critical Thinking Check
Bloom's Taxonomy: Analysis
What are your top concerns for Mrs. Phillips at this time? Why?
The first intervention should be to insert two large bore IV’s. This will allow for drawing of labs and administration of the Metoprolol IV. The top priority is to get the blood pressure down using the scheduled dose of Metoprolol, but that can’t happen until the patient has IV access
You would not yet administer Hydralazine as there is a scheduled dose that should be attempted first – you wouldn’t want to give multiple antihypertensives at the same time without knowing how the patient will respond. It could bottom out their blood pressure.
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 HR86 bpm SpO294% on Room Air RR14 bpm
Mrs. Phillips’s lab results have also resulted, the following abnormal values were reported: Glucose193 mg/dL Hgb A1c9.2% BNP160 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?
She is an African American female which also puts her at higher risk
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?
Dropping the blood pressure too low too fast can cause perfusion issues. The organs are used to perfusing at a higher blood pressure. This phenomenon is called relative hypotension. The patient can experience signs of hypotension even with a numerically high blood pressure because their body is used to the high pressures.
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.
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?
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.
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.
Critical Thinking Check
Bloom's Taxonomy: Application
What education topics would you want to provide to the patient before discharge?
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.
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.
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.
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 