Hypertension Diagnosis Assignment

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Hypertension Diagnosis Assignment

Patient’s information:

86-year-old female with history of A fibrillation on Eliquis, Hypertension, Heart failure presenting to the ED for evaluation in increasing weight of 7lbs over the last 2 week with an increase orthopnea, intermittent dyspnea and fatigue over the last several days. Her daughter who notices the new findings contacted the health care provider. Upon arrival, patient endorses the above symptoms along with non- productive cough, occasional tightness. She states she sleeps with pillow at home. She denies recent illness, fever, chill, vomiting, abdominal pain, diarrhea, constipation, blood in her urine or stool. She is vaccinated for covid-19 with her booster administration.

Diagnosis: Hypertension

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

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Student Name: Week: Dates of Care:

                                                    

Patient Initials

 

 

 Sex Age Room Admitting Date Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

 

 

 
Attending physician/Treatment team:

 

 

 

 

 Consults:
Present Diagnosis: (Why patient is currently in the hospital)

 

 

 

 

 

 

 

 ER Management: (if applicable)

 

 

 

 
Allergies:

 

 

 

 Code Status: Isolation: (type and reason)
Admission Height:

 

 

 Admission Weight: Arm Band Location (colors & reasons)

 

 
Communication needs: (verbal, nonverbal, barriers, languages)

 

 

 

 

 

 
Past Medical History: (pertinent & how managed)

 

 

 

 

 

 
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Hypertension Diagnosis Assignment

 

 

 

 

 

 

 

 

 

 

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

 

 

 

 

 

 

 

 

 

 

 

Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day)

 

 

 

Time    
T    
P    
R    
B/P    

 

 

 

Time    
T    
P    
R    
B/P    

 

 

 

 GI:

 

Diet:

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

 

 

 

 

 

 

 

 
Respiratory:

 

02 modalities:

02 Saturation:

Suction:

Resp Rx’s:

Trach:

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

 

 

 

 

 Neurosensory:

 

Neuro checks:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
Cardiovascular:

 

Telemetry:

Pacemaker/IAD:

DVT Prevention:

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

 

 Musculoskeletal:

 

Activity:

Traction:

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

 

 

 

 

 
Renal:

 

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

 

 

 

 

 

 

 Skin:

 

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

 

 

 

 

 

 

 

 

 

 
Pain:

 

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

 

 

 

 

 

 Vascular Access: (IV site)

 

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

 

 

 
Gyn:

 

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

 

 

 

 

 

 

 Post-operative /procedural:

 

Assessments/Interventions:

(immediate post procedure care)

 

 

 

 

 

 
Safety:

 

Call light:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Sitter use:

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

 

 

 

 

 

 

 

Hypertension Diagnosis Assignment

 Advance Directives/Ethical considerations:

 

DPOA:

Hospice:

 

 

 

 
Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient
WBC      
RBC      
HGB      
HCT      
MCV      
MCH      
MCHC      
Platelets      
RDW      
MPV      
       
PT      
INR      
APTT      
       
Glucose      
BUN      
Creatinine      
Sodium      
Potassium      
Cloride      
Calcium      
T Protein      
Albumin      
SGOT      
SGPT      
Alk Phos      
Magnesium      
Amylase      
Lipase      
       
CPK      
LDH      
Cholestrol      
       
CK      
CK-MB      
Troponin I      
Myoglobin      
LDI      
       
       
Urinalysis      
Color      
Character      
Spec. Grav.      
pH      
Protein      
Glucose      
Acetone      
Bilirubin      
Blood      
Nitr      
Urobili      
RBC      
WBC      
Epithelium      
       
Urine Culture      
       
Chest X-ray      
       
MRI      
       
CT Scan      
       
Others test:      
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

 

 

 

 
Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)
Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

 

 

 

 

 

 

 

 

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

 

 

 

 

 

  Hypertension Diagnosis Assignment

 

Discharge plans and needs:

 

 

 

 

 

 

 
Teaching needs:(Disease process, medications, safety, style, barriers)

 

 

 

 

 

 

 

 

 

 

Pathophysiological Discussion:  Discuss the current disease process at the cellular level (in your own words).  Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

 

ADH II: attach a research article pertaining to diagnosis of patient. Write a summary about the article.

 

 

 

List of nursing diagnoses (NANDA format).  Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis. Hypertension Diagnosis Assignment

 

 

Priority Nursing Diagnosis Related to As Evidence By Rationale (reason for priority)
1  

 

      
2  

 

      
3  

 

      
4  

 

      
5  

 

      

 

 

 

Medications

Classification

Dose

Route

  

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications
 

 

 

 

 

 

              
 

 

 

 

 

 

              
 

 

 

 

 

 

              
 

 

 

 

 

 

 

              
 

 

 

 

 

 

 

 

 

 

 

 

              
 

 

 

 

 

              
 

 

 

 

 

 

              
 

 

 

 

 

              
 

 

 

 

 

 

              

 

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

 

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome      (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

 

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation.       (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

  

 

  

 

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

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Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome         (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

 

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation.       (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

  

 

  

Hypertension Diagnosis Assignment