HTN Case Study Clinical.Basic Adult Health

Basic Adult Health Natasha Valcin Department of Nursing, Keiser University © 2016 Keith Rischer/www.KeithRN.com Hypertension Mike Kelly, 51 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Glucose Regulation 2. Pain 3. Clinical Judgment 4. Patient Education © 2016 Keith Rischer/www.KeithRN.com FUNDAMENTAL Reasoning: STUDENT History of Present Problem: Mike Kelly is a 51-year-old Caucasian male who 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 like to cook, and eats fast food three to five times during the week. He has smoked one pack per day since the age of 20 (31 pack years). He has a history of hyperlipidemia, but is unable to afford his medication (atorvastatin), and has not taken since he was diagnosed 5 years ago. He has no current diagnosed medical problems. He became concerned and came to the emergency department because he is more easily fatigued and has had a headache the past three days that has not improved. Personal/Social History: Mike is self-employed and owns his own auto mechanic business. He 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. She shares that he is usually stoic about health problems, so this must really bother him or he is afraid. He took Excedrin and Motrin for pain and it didn’t help. What data from the histories are RELEVANT and have clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: • Hyperlipidemia • Does not exercise • Obesity • Abnormal weight around abdomen. • Easily fatigued, with a headache for 3 days. • Smokes a pack a day for about 31 years • He eats fast food 3 – 5 times a week. • Abnormal amount of weight around his abdominal section may be due to hyperlipidemia, not exercising &eating fast food 3-5 times per week.. • Body Mass Index, (BMI) of 37.3% • Not exercising, can hyperlipidemia • Smoking may worsen hyperlipidemia.• RELEVANT Data from Social History: Clinical Significance: • No health insurance because he is self- employed (auto mechanic business). • Father had hypertension; died at age 50 from MI (increasing Mr. Kelly’s risk of developing a MI). • Stoic about health problems. • Has no health insurance; unable to afford medication, less likely to seek medical attention. • Family history of MI will increase his chances of having one especially since he smokes, eats fast foods frequently, does not work out and has hyperlipidemia. • Took Motrin and Excedrin for pain, NSAIDS may raise blood pressure. Developing Nurse Thinking by Identifying Significance of Clinical Data Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.9 F/37.2 C (oral) Provoking/Palliative: Nothing/Nothing P: 88 (regular) Quality: Ache R: 20 Region/Radiation: Global head ache (HA) BP: 220/118 Severity: 8/10 O2 sat: 95% room air Timing: Continuous What VS data are RELEVANT and must be recognized as clinically significant by the nurse? Current Assessment: GENERAL APPEARANCE: Appears uncomfortable, body tense with occasional grimacing RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort CARDIAC: Pink, warm and dry, no edema, heart sounds regular–S1S2, pulses bounding, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and 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, skin turgor elastic with no tenting What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: • General appearance • He appears uncomfortable, his body is tense with occasional grimacing; which indicates pain and/or discomfort. Developing Nurse Thinking through APPLICATION of the Sciences Fluid & Electrolytes/Lab/diagnostic Results: Radiology Reports: Chest x-ray What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: -The cardiac size is The enlarged heart “cardiomegaly” is a sign of another underlying condition. Since enlarged with moderate to hyperlipidemia is linked to hypertension, it has caused the heart to strain harder exerting more severe cardiomegaly. cardiac output. He has to get his cholesterol down, (he is at risk for heart attack, stroke, heart -There are no focal failure, etc.). infiltrates or consolidations or pleural effusions. Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? WBC (4.5–11.0 mm 3) 10.5 Normal Hgb (12–16 g/dL) 15.3 Normal Platelets (150–450x 103/µl) 422 Normal Neutrophil % (42–72) 68 Normal What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: His labs appear to be normal. • His WBC, although is within normal range, is still on the higher end. Chances are, Mr. Kelly’s underlying conditions are aiding in his increased WBC count (blood pressure, hyperlipidemia and hypertension). • His platelets, although within normal range, are still considerably high which can cause his blood to clot, obstructing the flow of blood within the arteries, which can increase cardiac output and cardiac afterload. • This can rule out certain disorders. ...............................................continued..............................................