Ms. Coburn is a 26-year-old schoolteacher. Her maternal grandparents immigrated to America from Brazil. She smokes one pack of cigarettes a day and has smoked since she was 16. She is 20 lbs. overweight. She made an appointment at the clinic where you work because she started to have headaches and frequently felt tired.
Part 1: Assessment
During the clinic visit, the nurse assesses Ms. Coburn’s symptoms. The nurse asks Ms. Coburn about her headache and fatigue, then takes her vital signs.
· Temperature: 98° Fahrenheit
· Respiratory rate: 14 breaths per minute
· Pulse: 86 beats per minute
· Blood pressure: 164/98 mm Hg.
Ms. Coburn asks, “I think my blood pressure is close to where it was the last time. Is that okay?”
The nurse responds, “Your blood pressure is pretty high right now. After you see the nurse practitioner today, I am going to take your blood pressure again. We are also going to talk about the changes you can begin to make to help you be healthier and feel better.”
1. What assessment findings are provided?
2. What other objective data will you collect?
3. What other subjective data will you collect?
4. How would you respond to Ms. Coburn’s question?
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5. What health promotion strategies could be discussed?
Part 2: Nursing Diagnosis
1. Determine possible nursing diagnoses for this patient.
Part 3: Planning
The nurse determines that the priority is to focus on hypertension and ways to prevent or control elevated BP. The nurse states, “We need to watch your blood pressure closely over the next few weeks.”
1. What health promotion goal have you identified for your patient which flows from your identified nursing diagnosis?
2. Identify two expected outcomes for the goal. Outcomes should be written as SMART statements.
Part 4: Implementation
1. Determine four nursing interventions which will assist with achievement of each of the stated outcomes.
Part 5: Evaluation
1. Determine evaluation criterion to identify if each outcome is successfully met. Evaluative measures are the same as assessment measures, but you perform them at the point of care when you make decisions about a patient’s status and progress.
Ms. Coburn has returned several weeks later. She is feeling better and is optimistic about the changes she is making to improve her health. When talking with the nurse, Ms. Coburn states, “You know, I got one of those electronic blood pressure monitors for myself. If I’m going to do all of this, I might as well see my progress. I’m not sure what I’m looking for, though.”
2. Identify additional nursing care(s) you will provide at this follow up visit.