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
... [Show More] 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
1
Keith RN
LRCC Nursing II
Clinical 2.9.2017
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
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