NURSING N352 - Mike Kelly is a 51 year old Caucasian Male - Rapid Reasoning Case Study

Keith RN LRCC Nursing II Clinical 2.9.2017 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 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 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 What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: -uncomfortable -bounding pulse -being uncomfortable isn’t normal and indicates a possible problem - increase in blood pressure may create a bounding pulse suggesting inadequate perfusion (Ignatavicius) III. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Hypertension is the most likely problem that my patient is presenting with. 2. What is the underlying cause/pathophysiology of this problem? 2 Keith RN LRCC Nursing II Clinical 2.9.2017 It is a combination of bad lifestyle choices and a paternal history of hypertension and MI. Bad lifestyle choices include: bad diet, poor physical activity, smoker for 31 years, and an obese BMI. 3. What nursing priority(s) will guide your plan of care?(if more than one-list in order of PRIORITY) First I would start an IV for potential antihypertensive medication I would conduct and electrocardiogram I would monitor the BP every 5-15 minutes I would then observe for neuro/cardiac complications such as chest pain, dysrhythmias, numbness/weakness and tingling of extremities. 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 1. Start an IV(Ignatavicius 713) 2. ECG 3. Monitor BP 4. Observe for complications (Ignatavicius 713) 1. An IV would give access for any antihypertensive therapy that may be infused 2. ECG would monitor the patient for signs of MI 3. Monitoring the BP would give us an idea of how the BP is trending 4. Observing for further complications can prevent future problems such as MI 1. BP would go down 2. Normal sinus rythmn 3. The BP would steadily go down after pharmological intervention 4. No other complications would result 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Cardiac, and neuro to watch for further complications. 6. What is the worst possible/most likely complication to anticipate? Heart disease, heart attack, stroke 7. What nursing assessments will you need to initiate to identify this complication if it develops? Monitor the blood pressure, assess the pulse, ECG, assess face symmetry, assess speech, and assess grip strength. (Ignatavicius 713) 3 Keith RN LRCC Nursing II Clinical 2.9.2017 8. What will be the consequences of uncontrolled hypertension to the rest of Mike’s body if it remains out of control? List body systems and potential permanent injury. Body System: Potential permanent injury: Cardiac Neuro Urinary Endocrine (Ignatavicius 709) Heart disease, leading to coma or death Stroke leading to permanent disability or death Renal Failure Diabetes Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Rationale: Expected Outcome: Basic metabolic panel (BMP) Complete cell count (CBC) BNP (B-natriuretic Peptide) Lipid profile Urine analysis (UA) 12 lead EKG Chest x-ray Labetalol (Trandate) 10-20 mg IV push every 15 “. Goal BP: 160/100 To identify contributing factors To look for infection To look at how hard the heart has been working To see if they are elevated because it would signify plaque in the arteries To check for kidney abnormalities To check for signs of MI To actually look at the heart To lower blood pressure All within normal range No signs of infection It would be elevated due to such high blood pressure With a blood pressure, so high I would expect an elevated lipid panel Signs of kidney dysfunction Possible signs of MI, but hopefully normal sinus rhythm Signs that the heart has been working harder than normal Blood pressure would steadily decline with each push