RAPID Reasoning Case Study-Keith RN LRCC Nursing II

RAPID Reasoning Case Study-STUDENT I. Data Collection History of Present Problem: 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 like 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 becomes 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 that 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: -more easily fatigued -headache for past 3 days -BMI of 37.3 -fast food eaten 3-5x per week -smoker for the past 31 years -does not regularly exercise -self employed Etiology of essential hypertension (Ignatavicius 710) Includes: -smoking -excessive intake of sodium -obesity -physical inactivity -high stress RELEVANT Data from Social History: Clinical Significance: -father has medical history of hypertension and MI -took Excedrin, Motrin, and castor oil before coming in -family history puts him at a greater risk for a heart attack - Excedrin is a combo of Tylenol, aspirin, and caffeine (Caffeine can create tachycardia) -Castor oil relieves pain and promotes healing used culturally, more useful for open wounds -Motrin is a NSAID as well that thins the blood (Prescription) II. Patient Care Begins: Current VS: WILDA Pain Scale (5th VS) T: 98.9 (oral) Words: Ache P: 88 (regular) Intensity: 8/10 R: 20 Location: Global head ache BP: 220/118 Duration: Continuous O2 sat: 95% RA Aggravate: 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: Ache, 8/10 Headache Continuous -BP over 140/90 is suggestive of hypertension for ages under 60 (Swearingin 179) -the headache pain can be an indicator of a hypertensive urgency or crisis (Ignatavicius 718) Current Assessment: GENERAL APPEARANCE: Appears uncomfortable RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses bounding, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact .................................................continued.................................................