Mike Kelly - Hypertension Case Study UNFOLDING Reasoning

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 5. Communication 6. Collaboration UNFOLDING Reasoning Case Study: STUDENT Hypertension 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 is RELEVANT and has clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: 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 is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Appears uncomfortable, body tense with occasional grimacing RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored 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 is RELEVANT and must be recognized as clinically significant by the nurse? ..................................................continued...........................................