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Mike Kelly is a 51-year-old Caucasian male. He is 6 feet tall and weighs 275 pounds (BMI 37.3) with an abnormal distribution of weight around his abdomen. He does not regularly exercise, does not lik... e to cook, and eats fast food 3–5x during the week. He has smoked 1 pack per day since the age of 20 (31 pack years). He has no current diagnosed medical problems. He became concerned and came to the urgent care facility today because he is more easily fatigued and has a headache for the past 3 days that has not improved. He didn’t go to work today and that is not typical for Mike. Personal/Social History: Mike is self-employed and owns his own auto mechanic business. He currently has no health insurance. His father had hypertension and died of a myocardial infarction (MI) at the age of 50. Angelina, his wife, came with him to urgent care and shares that he is usually stoic with health problems so this must really bother him or he is afraid. He took Excedrin and Motrin for pain and it didn’t help. She gave him a dose of Castor oil since she is from Puerto Rico and that is the first thing they do for any illness in her country of origin. What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: - BMI 37.5 (abnormal distribution of weight in the abdomen) - No regular exercise - Fast food 3-5x/ week - Smoked 1pack/day - Headache - Direct correlation to Hypertension - Exercise = Helps heart become stronger, and exerts less effort in pumping blood into circulation. Less work from heart = less force on arteries = Lower BP - Fast food: Possible development of atherosclerosis that increases peripheral vascular resistance = Therefore Increase BP - Smoking narrows arteries and Hardens walls. Also causes blood to clot RELEVANT Data from Social History: Clinical Significance: Self employed/ No health insurance (stress) Father has medical history of hypertension and MI Took Excedrin and Motrin for pain and castor oil Family history put him at greater risk of heart attack Excedrin is a medication that has a combination of Tylenol, aspirin and caffeine, which can create tachycardia Motrin is a NSAID, which can contribute to raising blood pressure II. Patient Care Begins: Current VS: WILDA Pain Assessment (5th VS): T: 98.9 (oral) Words: Ache P: 88 (regular) Intensity: 8/10 R: 20 Location: Global headache BP: 220/118 Duration: Continuous O2 sat: 95% room air (RA) Aggravat e: Alleviate : Nothing Nothing What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: ● BP: 220/118 ● Pain 8/10 ● Continuous global headache ● patient has an extremely high blood pressure, can cause further complications such as left ventricular hypertrophy, coronary atherosclerotic disease, arrhythmias, heart failure, nephrosclerosis & renal failure ● management of pain Current Assessment: GENERAL APPEARANCE: Appears uncomfortable RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular-S1S2, pulses bounding, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: -Blood Pressure of 220/118 -bounding pulses >190 systolic is hypertensive emergency Fluid overload and hypertensive III. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Primary Hypertension 2. What is the underlying cause/pathophysiology of this concern? In primary hypertension, there is no clear cause, but is thought to be linked to: modifiable poor diet: doesn’t like to cook, eats fast food 3-5x per week lack of exercise: does not exercise regularly obesity: BMI 37.3 abnormal distribution around abdomen non modifiable genetics: father had hypertension and diet of MI 3. What nursing priority will guide your plan of care? Lower blood pressure Order blood works including BMP, BUN, serum lipid profile 12 Lead EKG Routine Urinalysis Taking blood pressure Serum uric acid Restricted diet (salts) Encourage exercise Visual changes, dizziness, headache, chest pain, dizziness 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: Pharmacology: Beta Blocker Get him in calm and quiet room Explain all procedures in detail/ listen to patient’s needs and request Explain diet restriction: Less red meat, salts, sweets, added sugar and sugar containing beverages Encourage weight loss if client is obese plan exercise regularly Evaluate evidence of extreme onset fatigue, swelling, and weight gain To educate patient on what to expect, what they could do to decrease symptoms Dash diet will help decrease BP and LDL Physical activity can help control high blood pressure by strengthening the heart to pump more blood with less effort, thus lowering blood pressure To assess for poor ventricular function or impeding cardiac function create open communication with patient to encourage a trusting patient/provider relationship Education provided to reduce symptoms Lowered/ reduced BP levels Lower and potentially eliminate high blood pressure [Show More]

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