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
... [Show More] 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 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 Less]