Include diagnostic data and medical orders that you expect to be ordered on the patient.
T.J., a 30-year-old African American client, is in his last year of law school and is clerking for a prestigious law firm. He and his fiancé plan to marry as soon as he graduates. During the last week he has had four dizzy spells and a headache at the base of his skull upon awakening for the last 2 days. His father has a history of hypertension, so T.J. is aware that his symptoms may indicate high blood pressure. On his way home from work, T.J. stops by the clinic and asks the nurse to check his blood pressure. The nursing assessment yields the following data.
Subjective data: States he has had four dizzy spells and has awakened with a headache in the occipital lobe the last two mornings. T.J. has 1 glass of wine at lunch and 2-3 beers in the evening to relax from the tension of school and work. Most of his meals are at fast-food establishments and have a high fat content. T.J. does not smoke. He used to jog 4 mornings a week but quit when he started clerking. He has had nocturia for the last 3 weeks. He is not taking any medication. T.J. states he is concerned about having hypertension because he does not want to take medication.
Objective data: T 98.6°F(37°C), AP 78 beats/min, R 16 breaths/min, BP 142/92 mm Hg, Wt 190 lbs (optimum weight 160). No edema noted in hands, feet, or legs.
Needs at least one citation and reference
Interventions for each disease process should have at LEAST:
3 things you would monitor/reassess,
3 things you would do or action,
3 things you would teach your patient,
Medications you would administer.
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Diagnosis: Hypertension
Medical Orders:
Obtain a 12-lead ECG to rule out any cardiac abnormalities.
Obtain a urinalysis to rule out any renal dysfunction.
Obtain a fasting lipid profile and glucose level to evaluate for any metabolic abnormalities.
Initiate lifestyle modification measures, including weight loss, dietary modification, and exercise regimen.
Prescribe an antihypertensive medication, such as lisinopril or amlodipine, to lower blood pressure.
Interventions:
Monitor/Reassess:
Blood pressure at each visit to evaluate the effectiveness of the prescribed medication.
Weight and dietary intake to ensure adherence to the lifestyle modification measures.
Symptoms of hypertension, such as headache, dizziness, and nocturia, to evaluate for improvement or worsening of the condition.
Action:
Refer T.J. to a dietitian to assist with dietary modification and weight loss.
Encourage T.J. to engage in regular physical activity, such as brisk walking or jogging.
Monitor for side effects of the prescribed medication, such as cough or hypotension, and report any adverse reactions to the provider.
Teach:
The importance of adhering to a healthy diet, including reducing the intake of high-fat foods and increasing the intake of fruits and vegetables.
The importance of regular physical activity in controlling hypertension.
The importance of monitoring blood pressure at home and reporting any changes to the provider.
Medications:
Lisinopril (Prinivil, Zestril)
Amlodipine (Norvasc)
Reference:
Centers for Disease Control and Prevention. (2021). High blood pressure (hypertension). Retrieved from https://www.cdc.gov/bloodpressure/index.htm
