Hypertension Student Worksheet I.Data Collection History of Present…

QuestionAnswered step-by-stepHypertension Student Worksheet I.Data Collection History of Present…Hypertension Student WorksheetI.             Data CollectionHistory of Present Problem:    Mike Kelly is a 51 year old Caucasian male. His BMI is 37.3, does not exercise, eats fast food 3-5 times per week, and smokes cigarettes. Prior to his admission, he had no diagnosed health problems. He is admitted with fatigue and headache x3 daysPersonal/Social History:           Mike is self-employed and owns an auto mechanic shop. He has no health insurance. His father died of a MI at the age of 50. His wife has been giving him castor oil, commonly used for illness in Puerto Rico, 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:RELEVANT Data from Social History:Clinical Significance:       II. Patient Care: Last documented VS:     WILDA Pain Assessment (5th VS):T: (oral) 98.4oWords:achingP:(regular)88/minIntensity: R:(regular)20/minLocation: BP:Duration:On and offO2 sat: 96% RAAggravate:Alleviate:nothingnothingWhat VS data is RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT VS Data:Clinical Significance: Last documented Assessment:GENERAL APPEARANCE:RESP:Breath sounds course bilaterallyCARDIAC:Pink, warm & dry, heart sounds regular, pulses strong, equal with palpation.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:Warm, dry, and intact What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT Assessment Data:Clinical Significance:Nursing Interventions:Rationale:Expected Outcome:        Medical Management: Rationale for Treatment & Expected OutcomesCare Provider Orders:Rationale:Expected Outcome:12 lead EKGChest xrayContinuous cardiac monitoringLabetolol (trandate) 10mg every 15 minutes. Goal BP 160/100  PRIORITY Setting: Which Orders Do You Implement First and Why?Care Provider Orders:Order of Priority:Rationale: 1.2.3.   Radiology Reports:What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT Results:Clinical Significance:Chest x-rayThe cardiac size is enlarged. There are no focal infiltrates or consolidations or pleural effusions.Impression:No acute disease in the chest.Medication Dosage Calculation:Medication/Dose: Mechanism of Action:Volume/time frame to Safely Administer:Nursing Assessment/Considerations:Labetolol (trandate) 10mg prn every 15 minutes for systolic BP =200. 5mg/mL vial.    Lab Results:What lab results are RELEVANT that must be recognized as clinically significant to the nurse?Complete Blood Count (CBC:)Last lab draw:High/Low/WNL?WBC (4.5-11.0 mm 3)10.5Hgb (12-16 g/dL)15Hct (38-46)42Platelets (150-450 x103/µl)182What lab results are RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT Lab(s):Clinical Significance: Basic Metabolic Panel (BMP:)Current:High/Low/WNL?Sodium (135-145 mEq/L)136Potassium (3.5-5.0 mEq/L)3.6Chloride (95-105 mEq/L)96Glucose (70-110 mg/dL)188 Calcium (8.4-10.2 mg/dL)8.9BUN (7-25 mg/dl)29 Creatinine (0.6-1.2 mg/dL)1.5 Miscellaneous LabBNP (<100ng/L)758  RELEVANT Lab(s):Clinical Significance: Health ScienceScienceNursingNUR C NURSINShare Question

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