Unfolding Case Study, Hypertension-Complete

Unfolding Case Study: Hypertension FOR EDUCATIONAL CLINICAL PURPOSES ONLY! Objectives: 1. Identify, trend, and interpret relevant clinical data. 2. Trend the data while recognizing the status of client. 3. Apply SBAR if needed. 4. Determine nursing priority. 5. Focus on each step of the nursing process as the student cares for the client. History of the Present Problem: Steve is 51 yr old African American who is 6 feet tall, wt. 275 #, BMI 37.3, large abd girth. He does not exercise, cook, or follow a diet. He eats out 5 times a week. He smokes a pack of cigarettes per day since age of 20. He has not taken his medication (atorvastatin) for hyperlipidemia which was prescribed 5 yrs ago because of no money to buy it. He has no other medical diagnosis. Today he is in ER with severe h/a for 3 days and fatigued. Personal Social History: Steve is self-employed and owns his own mechanic business. He has no health insurance. His father had hypertension and died of MI (myocardial infarction) at the age of 50. Sara his wife came with him to the urgent care clinic. 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 did not help his headache. WHAT IS RELEVANT DATA AND PRESENT PROBLEM THAT THE NURSE MUST IDENTIFY?