Blood Pressure f/u Nurse note 1
Pt Presents today for a Nurse Visits with [text name="variable_1" default="sample text"] [date name="variable_1" default="12/02/2018"] Subjective: Pt is pleasant 79-year-old Female Africa America, presenting today for a nurse visit for an f.u a recent in-office high blood pressure reading. During last visit, pt was giving a DASH diet food checklist and a DASH diet food goal. pt was educated to limit processed food in diet and t9 restrict sodium in the diet, avoiding canned food and avoiding. today patient brought bach checklist which indicated she was compliant with 50 percent of the items on the list. Nurse rewarded patient with a reward package of water mug, keychain, bag, and book and pen. Nurse encouraged the patient to use the book as a food/BP diary. Objective: Pt current medication includes Amlodipine, atorvastatin, chlorthalidone, furosemide, irbesartan, vit d. Today pt VITALS WAS: wt 159 bp152/84 hr 76. Nursing Diagnosis: [checkbox name="variable_1" value="Knowledge, deficient regarding condition, treatment plan and lifestyle changes related to lack of knowledge evidenced by statements reflecting misconceptions|Activity intolerance|Imbalanced nutrition: more than body requirements"] Desired outcomes [checkbox name="variable_1" value="-Verbalize understanding of condition/disease process and treatment -Initiate necessary lifestyle changes and participate in the treatment regimen -Exhibit increased interest/assume responsibility for own health -Maintain blood pressure within the normal range|-Demonstrate a decrease in physiological signs of intolerance -Participate in desired activity -Use identified techniques to enhance activity tolerance -Report an increase in physical activity|-Demonstrate appropriate changes in lifestyle and behaviors, including eating patterns, food quantity/quality, and exercise Program -Attain desirable body weight"] Nursing Interventions/Rationale [checklist name="variable_1" value="-Assess the level of knowledge and be alert to signs of avoidance. Patient must be ready to receive information for intervention to be effective. -Define and specify the desired blood pressure limits. this Enables the patient to have a clear understanding of normal values. -Describe what hypertension is and how it affects the heart, kidneys, brain and blood vessels. Enables the patient to understand that high blood pressure can happen without any symptoms. -Gives the patient a clearer understanding of what caused the condition. -Teach patient or his relative on how to take proper blood pressure measurement. Monitoring blood pressure at home can help determine if the existing treatment plan is working or not.|-Evaluate current limitations/degree of deficit in light of usual status. Provides a baseline information on interventions needed to improve the quality of life. -Assess cardiopulmonary response to physical activity, including vital signs before, during, and after activity. Indicates a patient’s physiological response to the stress of the activity. -Assess emotional/psychological factors affecting the current situation. Depression about changes in health can affect motivation to participate in activities. -Adjust activities to prevent overexertion (performing activities slowly, sitting down when brushing teeth and combing hair). Reduces energy expenditures, aiding in balancing out oxygen supply and demand. -Increase exercise/activity levels gradually and plan rest periods between activities (resting for 3 minutes in a 10-minute walk). Prevents sudden increase in cardiac workload; reduces fatigue. -Promote comfort measures and provide for the relief of pain, if there’s any. Enhances patient’s ability to participate in activities.|-Record height, weight, body build, gender, and age. Serves as baseline data. Determine a patient’s desire to lose weight. -Reassess dietary choices. The motivation to lose weight is internal; patient must be ready and willing to lose weight before the process begins. -Discuss the need to have a lower intake of calories, salt, fats, and sugar. Provides a baseline for creating a dietary program. -Set realistic goals for weekly weight loss. Excessive intake of salt causes an increase in intravascular fluid volume which can damage the kidneys and aggravate the condition. Too much sugar in the diet can lead to diabetes which can complicate hypertension. -Encourage the patient to keep a log of food intake. Drastic weight loss can put a strain on the heart; helps determine emotional conditions that can affect eating. Aid in the selection of appropriate food and DASH (Dietary Approaches to Stop Hypertension), like increasing intake of whole grains, low-fat dairy, fruits, and vegetables. -DASH provides the patient with key nutrients that can aid in lowering blood pressure. Refer to a dietitian as needed. Provides assistance and additional counseling."] Plan/eval Current bp goal for pt is 140/90 Pt increased ccb amlodipine to 5mg Per Provider. Pt is aware and receptive. agrees to f.u in 2 weeks for BP. and DASH diet. pt daughter is going to purchase home monitoring kit.
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