Assessment Data Analysis
Health History
The patient presents with high blood pressure. He complains that current medication does not improve his condition. He wants a new medicine. He has no other health concerns.
Client’s strengths
The client is aware of the importance of healthy living. He exercises every day in the morning and has two-hour walks every day. He is aware of his blood pressure problem, and he strives to manage it, and therefore, he came to seek help without any other complaints. According to Buttaro, Trybulski, Bailey, and Sandberg (2013), a patient cognizant of his key health issues and the importance of lifestyle alternation to promote health will have better health outcomes. Based on this theoretic information, a conclusion can be made that the client can be evaluated as willing to cooperate with the health care provider and having a good prognosis.
Areas of concern
The patient has elevated blood pressure despite being compliant with the prescribed medication regiment. He has a family history of hypertension and stomach cancer, which of concern with regards to his current condition (Barker, 2015). The client smokes 2 times a month.
Health teaching topics
Health education needs
The patient needs education on the risk factors of hypertension. He needs to understand which risk factors are modifiable so that he could actively partake in his health promotion and disease prevention (Barker, 2015).
The patient needs to be educated about smoking-related health issues. Even though he might think that smoking occasionally is not a problem, he needs the scientific data provision to learn that such an attitude is dangerous (Buttaro et al., 2013).
Nursing Plan of Care
Diagnosis
The hypertension problem is the major health issue for this patient currently. Hypertension in its turn is the risk factor for multiple other more complex health conditions (Buttaro et al., 2013). First of all, these are cardiovascular conditions such as myocardial infarction, CAD, PAD, and stoke. Next, high blood pressure is associated with the aneurism, kidney problems, brain damage, and dementia, to name just the central risks (Buttaro et al., 2013).
Plan
The care plan goal for this client is to offer medications for his problem and involve him in the treatment process by helping him quit smoking, evaluate his nutrition regime, and make updates if necessary (Falaschetti, Mindell, Knott, & Poulter, 2014). The expected outcome for the patient is the blood pressure rate decrease to the baseline (Falaschetti et al., 2014). Cultural considerations for this client are based on the fact that he is an American of European origin, respecting western values of quality life. He wants to stay healthy as long as possible to be able to see his grandchildren and live a quality life with his family he loves so much. Therefore, a conclusion can be made that the client has an excellent support system and his cultural background contributes to the success of treatment (Buttaro et al., 2013).
Intervention
I will prescribe Tenormin 50 mg a day for blood pressure modification (Falaschetti et al., 2014). I will recommend urgent smoking cessation and will offer practical suggestions to join the local community support group and obtain free nicotine replacement if needed (Falaschetti et al., 2014). I will refer the patient to the local nutritionist to evaluate his dieting regime and whether it is not a contributing factor to his problem (Falaschetti et al., 2014).
Evaluation
To carry out the evaluation, I will trace the patient’s blood pressure rate improvement, his overall health condition, and his involvement in his further health promotion activities.
References
Barker, A. M. (2015). Advanced practice nursing. Burlington, MA: Jones & Bartlett Publishers.
Buttaro, T. M., Trybulski, J. A., Bailey, P. B., & Sandberg, J. (2013). Primary care (4th ed.). New York, N. Y.: Elsevier.
Falaschetti, E., Mindell, J., Knott, C., & Poulter, N. (2014). Hypertension management in England: a serial cross-sectional study from 1994 to 2011. The Lancet, 383(9932), 1912-1919.