Question

Develop and Concept Map, using the form provided, on the following patient. Include Diagnostic data and medical orders that you expect to be ordered on the patient.

T.J., a 30-year-old African American client, is in his last year of law school and is clerking for a prestigious law firm. He and his fiancé plan to marry as soon as he graduates. During the last week he has had four dizzy spells and a headache at the base of his skull upon awakening for the last 2 days. His father has a history of hypertension, so T.J. is aware that his symptoms may indicate high blood pressure. On his way home from work, T.J. stops by the clinic and asks the nurse to check his blood pressure. The nursing assessment yields the following data.

Subjective data: States he has had four dizzy spells and has awakened with a headache in the occipital lobe the last two mornings. T.J. has 1 glass of wine at lunch and 2-3 beers in the evening to relax from the tension of school and work. Most of his meals are at fast-food establishments and have a high fat content. T.J. does not smoke. He used to jog 4 mornings a week but quit when he started clerking. He has had nocturia for the last 3 weeks. He is not taking any medication. T.J. states he is concerned about having hypertension because he does not want to take medication.

Objective data: T 98.6°F(37°C), 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.

Answer 1

   patient data    - age 30yrs

name -t.j

   community -African american

education - studying last year of school

  

family history - father has hypertension

personal history- nocturia past 3 days

physical activity- 4 jogs per week

smoking - no

alcohol- wine and beer

diet - faty diet

cheif complaints : 4 dizzy spells ,head ache at occipital lobe

subjective data - headache at occipital lobe , last 2 days , and nocturia , dizzy spells

objective data - temperature =98.6 f

   AP=78 b/ min ,

   BP 142/920mmhg

R=16 b/min PHYSICAL EXAMINATION = no edema noted in hands feet or legs

DIAGNOSTIC DATA = evidence of signs and symptoms and objective data patient suffer with hypertension

patient has to get these medical orders -

blood pressure with sphygmomanometer, eye examination ecg , echo cbc , electrolyte cholestrol and tri glycerides levels

treatment pharmavcaological - beta blockers, diuretics , vasodilators

nutrition = low salt diet , and dietary ssuplliments

accupressure for stress