Care plan help...please!

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Hey,

I am working on developing a care plan for a 40 year old male. This male was diagnosed with hypertension 2 years ago, but has notbeen put on any medication. 2 months ago he went to his family doctor complaining od of fatigue, headaches and dizziness and was reffered to a blood pressure clinic.

Upon assessment he is very tense, restless, as well as very talkative. Due to his situation at home I have come up with the diagnosis of anxiety, however I need at least 2 more and am having trouble coming up with these...could someone please help!!!!?

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Specializes in med/surg, telemetry, IV therapy, mgmt.
upon assessment he is very tense, restless, as well as very talkative. due to his situation at home i have come up with the diagnosis of anxiety, however i need at least 2 more and am having trouble coming up with these...could someone please help!!!!?

diagnoses are based on the symptoms the patient has:

  • physical symptoms of their medical diseases
  • problems accomplishing adls
  • statements by the patient of their negativity or doubts about their health status

if after a thorough assessment you can only come up with tense, restlessness and talkative which i am assuming you are using as evidence of this patient's anxiety, then i guess you are stuck. how about a wellness diagnosis or a knowledge deficit?

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Thanks...I think knowledge deficient will work...but I still need one more, my problem is that all of the information above is all I have to go on... it was given to me in a case study... the only other information i have is that he doesnt take much time to relax, but he usually gets a full night rest (6ish hours) because he is ethier working or spending time with his kids, and he doesnt exercise very often...

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maybe knowledge deficit...i don't know what he understands about htn.

maybe ineffective mgmt of therapeutic regimen?

i'll think about it.

leslie

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Bambam22. . .case studies are meant to be learning exercises and are designed as such. You can be sure that your instructors already know which 3 nursing diagnoses are the ones you need to come up with. You need to research information about the signs and symptoms, diagnosis, treatment and pathophysiology of the medical diseases that are mentioned; substitute the information that is given to you about the patient for assessment that you would normally be doing if this were a real patient; then, proceed with the writing of a care plan, if that is what you are asked to do by using the information you have learned above in following the nursing process.

  1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. Evaluation (determine if goals/outcomes have been met)

Now, there are a couple of things that I noticed when I first read your post that may or may not have been deliberately put into this case study for a reason.

  • even though a patient has not been put on a medication for hypertension does not mean he doesn't have the disease. Please read about this condition. Perhaps the patient needs some education about it and its complications. Headache and dizziness are symptoms of hypertension.
  • while fatigue is a defining characteristic of the NANDA nursing diagnosis of Anxiety, anxiety is a related factor of the NANDA nursing diagnosis of Fatigue. There is also a medical diagnosis of fatigue and you should look up information about it.
  • I see the possibility for 2 or 3 actual nursing diagnoses (anxiety, fatigue, knowledge). This patient, because of his hypertension, is at a risk for heart attack or stroke. You would have discovered that in reading about hypertension. You can design a "Risk for" diagnosis for either one of those possibilities.

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Specializes in Cardiac Care.

Excellent advice!

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Thanx...I did look up the symptoms of htn, but I did not see how it would apply to nursing diagnosis, because they were all related to the medical diagnosis...The nursing diagnosis handbook I have doesnt related anxiety and fatigue... I really appriciate your help, and would really appriciate if you could refer a good nursing diagnosis book...I think I am good to go now...Thanks again!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Nursing Diagnosis Handbook: A Guide to Planning Care by Betty J. Ackley and Gail B. Ladwig.

Any of the nursing diagnosis books by Lynda Carpenito.

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Specializes in being a Credible Source.

I'll second Daytonite's recommendation of Ackley. I find it much more useful than the care plan book that I have and the others that I've looked at.

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