Nursing Case Study Hypertension
This is Mrs. H, a 70-year-old African American female presented to the clinic with complex health problems. Some of her problems include: hypertension, heart failure. Patient has genetic predisposition to some diseases like DM2, hyperlipidemia, and hypertension. This could be a contributing factor to her health problems. She has diabetes with an A1c of 8.5, this indicates that her diabetes is not within the normal range of less than 7% (National Guideline Clearinghouse, 2015). Her serum creatinine level of 2.0mg/dl, and BUN of 30mg/dl which are indicative of kidney function are all out of normal range. This means her kidneys are not at their optimum performance and therefore, she could be retaining water as indicated …show more content…
H the following questions starting with her medical history which is a vital component of any patient assessment. …show more content…
Hypertension /Heart Failure
Mrs. H’s heart is supported with a pace maker. Provider would monitor her closely by assessing her blood pressure on a regular basis. Provider would auscultate her apical pulse, asses her heart rate and rhythm for any abnormal sound (S3 and S4) because tachycardia is sometimes present at rest. Provider would ask her to report early signs and symptoms of heart failure exacerbation, monitor daily weight before meal at the same time each day, and report any weight gain of 3 to 5 pounds in one week. Provider will also assess her lungs to check for fluid overload and probably recommend monitoring her sodium intake (Remme, & Swedberg, 2001).
Type 2 Diabetes
The provider would recommend that patient engage in a physical activity for 30 minutes a day and up to 4-5days a week to help lower her blood glucose. Patient will be advised to perform blood glucose test before meal and at bed time. Hemoglobin A1C give a picture of how well blood glucose was controlled for a period of about 3 months. A level of 6.5% is recommended (National Guideline Clearinghouse, 2015). Provider would encourage her to take her diabetic medication as directed and asses her current knowledge about diet related to her