Patient , a 30 year old African American client, during last week,…

Patient , a 30 year old African American client, during last week,… Patient , a 30 year old African American client, during last week, he has had four dizzy spells and a headache at the base of his skull upon awakening for the past 2 days. His father has history of hypertension, so patient is aware that his symptoms may indicate high blood pressure. On his way home from work, patient stops by the clinic and asks the nurse to check his blood pressure. The assessment yields the following data.  Subjective data: States he ha had four dizzy spells and has awakened with a headache in the occipital lobe the last tow mornings. Patient has 1 glass of wine at lunch and 2-3 beers in the evening to relax from tension of school and work. Most of his meals are at fast-food establishments and have a high fat content. Patient does not smoke. He used to jog 4 mornings a week but quit when he started clerking. He has had nocturia for the past 3 weeks. He is taking acetaminophen 650 every 4 hours, Lisinopril (Prinivil) 10 mg,  Diuretics 40 mg, dimenhydrinate (Dramamine) 50 mg, and Xanax 0.25-0.5 taken 3x a day, Oral Route. Objective data: T 98.6F (37C), 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. Lab valueCO2: 21.0Anion GAP 16.7Albumin: 3.4Glucose: 94Magnesium: 1.7ALP: 46GFR 760Sodium: 141Bun: 18 Chloride: 98CRP 14.5Potassium: 4.2Calcium: 8.8   Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)Goals & Outcome (Two statements are required for each nursing diagnosis.   Must be Patient and/or family focused; measurable; time-specific; and reasonable.) Nursing Interventions (List at least three nursing or collaborative interventions with rationale for each goal & outcome.)Rationale (Provide reason why intervention is indicated/therapeutic; provide references.)Outcome Evaluation & Replanning(Was goal met?  How would you revise the plan of care according the patient’s response to current plan ?)OBJECTIVE: #1  SUBJECTIVE #2Statement #1 Short Term: Statement #2  Long Term:1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6.  Outcome #1Short Term: Outcome #2Long Term:List patient mediations, indications, and nursing considerations for this patient Medication, Dose, RouteIndications for MedicationNursing Consideration for Patient/ Side Effects                          List Patient abnormal lab values, normal ranges, and why they are altered. Abnormal Lab ValueNormal RangeCause of Abnormal Lab Value                      List all Patients Nursing Diagnosis in priority Order and explain why. Nursing DiagnosisExplanation                   References:  Health Science Science Nursing NURS 3802 Share QuestionEmailCopy link Comments (0)

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