Chief Complaint/ History of Present Illness:
Mr. Pearson is a 36-year-old African American who comes to the ED with dizziness, SOB, lower extremities edema and a headache that has been present over the past 2 weeks and has not gotten better. He has not been able to afford his BP medications and has not taken them since he lost his job 2 months ago. Hypertension and Complications Essay
1. What is the medical problem that your patient is most likely presenting with?
2. What is the underlying cause/pathophysiology of this concern?
3. Based on the data you collected, what is your primary concern right now?
4. What interventions will you initiate based on this primary concern? (start with A-B-C priorities)
5. What body system will you mostly thoroughly assess based on the patient's chief complaint and what are your primary/priority or concern.
6. What is the worst possible complication to anticipate?
7. What nursing assessments will you need to initiate to identify and respond to quickly if this complication develops?
8. What VS & assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
Hypertension and Complications. 1. The patient is most likely presenting with hypertension and its complications, including heart failure and cerebral vascular accident (CVA). 2. Hypertension is a condition in which the blood pressure in the arteries is elevated above normal levels. This causes the heart to work harder to pump blood throughout the body, which can lead to heart failure. Hypertension can also cause damage to the blood vessels in the brain, which increases the risk of a CVA or stroke.
3. The primary concern is the patient's unstable blood pressure and the potential for complications related to hypertension, such as heart failure and stroke. 4. The nursing interventions based on ABC priorities include: A: Airway and Breathing: Ensure the patient has a clear airway and is able to breathe adequately. Administer oxygen as needed to maintain adequate oxygen saturation. B: Blood pressure: Administer antihypertensive medications to lower the patient's blood pressure to a safe level. C: Circulation: Assess and monitor the patient's cardiac function and fluid status to prevent and manage heart failure. 5. The cardiovascular system will be most thoroughly assessed based on the patient's chief complaint, with a focus on assessing for hypertension, heart failure, and peripheral edema. 6. The worst possible complication to anticipate is a CVA or stroke. 7. Nursing assessments that will need to be initiated to identify and respond to a potential CVA or stroke include assessing the patient's level of consciousness, motor function, and speech. A rapid response team should be activated immediately if a stroke is suspected.
8. Relevant VS and assessment data that must be recognized as clinically significant includes the patient's blood pressure, oxygen saturation, heart rate, respiratory rate, and level of consciousness. The presence of peripheral edema and headache should also be noted, as they may indicate heart failure or a CVA. Hypertension and Complications Essay
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