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Practicum Case Scenario/ Study The following outlines general instructions for a case scenario/study submission. Please remember not to include any HIPPA information. Concerns and questions related to care should be included. Include references to treatment plans using APA format You can use https://nurseslabs.com/ or your choice. Completion of the case study counts toward the practicum experience. Case studies are expected to be a minimum of 500 words, detailed and comprehensive. 

In this case, this patient is seeking care for an (asthmas exacerbation). Please add symptoms for seeking clinic visits and please add another medical diagnosis. Treatment was with oral steroids, rescue inhaler, and albuterol nebulizer treatment.  ICD-10 Diagnosis for the related symptoms and diagnosis. 

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Please follow the outline as below when submitting your case study:

NURSING 2021 Case Scenario/Study

Student Name: 

Submission Date: 

Case Study:

Patient Initials, Age, Gender

Subjective information from the patient (History of Present Illness/Symptoms)

Current Medications 

Medical History – Medical Problems

Objective findings from physical examination

Vital Signs, Weight, Height, BMI

Focused examination findings based on diagnoses being addressed.

Assessment

ICD-10 Diagnosis (include ICD-10 code) for contact dermatitis. 

Nursing Diagnoses https://nurse.org/resources/nursing-diagnosis-guide/

Or  https://nurseslabs.com/

Plan

Care Plan based on the diagnosis.

Include specific nursing care planning for patients to include.

Potential issues with achieving quality, comprehensive care.

Information on best practice care considerations.

Care outcomes from current treatment

Possible side effects of medications or treatments

CASE SCENARIO: PATIENT WITH UNCONTROLLED HYPERTENSION

Patient Initials: JR Age: 47 Gender: Male

Subjective Information

HPI: The patient presents to the healthcare facility with uncontrolled high blood pressure. The patient complains of severe headaches and feeling dizzy. He rates the pain from the headache as 7 out of 10. The patient indicates that he has not been taking his blood pressure medication for the last two months as he cannot afford them. The patient was diagnosed with hypertension at the age of 36 years, and it has been in a controlled state until recently. 

Current Medications

Lisinopril 10 mg once daily – Last taken two months ago.

Amlodipine 5 mg once daily – Last taken two months ago.

Lantus 10 units at bedtime.

Metformin 1000mg twice daily.

Medical history

Hypertension – was well controlled with his diet and exercising until two months ago when he stopped taking his medication.

Type 2 Diabetes – Diagnosed at the age of 24 years and is currently on medication. 

Gastrointestinal bleeding – Diagnosed four years ago. 

Underwent Inguinal Hernioplasty at the age of 22 years.

Objective data

Vital signs: The patient has a B/P of 160/96; P 92; Temp 99.8; RR 16; HT 5’ 10”; Weight 248 lbs; BMI of 35.6.

Assessment

Patient was observed with the following B/Pof 160/96; P 92.

Nursing Diagnosis: Acute Pain (Typically Headache) possibly from uncontrolled hypertension.

Uncontrolled hypertension that is associated with acute pain is diagnosed. The pain, in this case, arises from potential tissue damage that causes the intensity from mild to severe. Some of the symptoms of this type of uncontrolled hypertension include neck stiffness, severe headache, dizziness, blurred vision, nausea, and vomiting, and changes in appetite (Agarwalet al., 2016). That indicates why the patient feels severe headaches and dizziness. 

Plan

The desired outcome is to ensure that the patient no longer experiences a headache, appears to be comfortable and pain-free, and is given a care plan to control his high blood pressure. 

A care plan will be formulated about the diagnosis that has been made. The first step in the care plan should be to ensure that the patient is in a restful surrounding to minimize the noise and environmental activity. That helps to lessen the sympathetic stimulation that will promote relaxation. The patient should also be instructed that to lessen their physical activities in a quest to reduce the tension and the stress that may affect the blood pressure negatively. After ensuring that the patient is under such conditions, the primary caregiver should monitor the patient to determine their responses. 

Apart from the therapeutic interventions, the patient should take his medications . Since the patient has been taking Lisinopril 10 mg once daily and Amlodipine 5 mg once daily for more than ten years now and the medication has been working well, he should be administered the same medication. The primary caregiver should ensure that the patient has the medication to ensure that their blood pressure is controlled (Lee & Park, 2017). Additionally, the nurse should educate the patient on the need of taking medical insurance. That is because, through the medical insurance, a patient can access the medications thus avoiding having uncontrolled blood pressure. Moreover, the patient should be educated on the need of following the medication that has been prescribed to ensure that the blood pressure is controlled. The patient should be required to visit the healthcare facility monthly for a checkup. That will ensure that he follows the care plan effectively.

Lisinopril is an ACE inhibitor, and it is used to control hypertension when a patient has diabetes or the other methods have failed (Helmer et al., 2018). Some of its side effects are light-headedness, dizziness, headache, or tiredness. On the other hand, Amlodipine is a calcium channel antagonist. It is used either with a diuretic or a sympathetic inhibitor to effectively control hypertension. Some of its side effects include dizziness, headache, nausea, and fatigue. 

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