Client Profile Mr. Cowens employer-sponsored a free blood pressure (BP) screening program for its employers. Mr. Cowens BP is 160/90 mm Hg when measured with a large BP cuff. The nurse observes that the client is overweight. The nurse assesses the client for risk factors for Hypertension and learns that Mr. Cowen sits at a desk all day long answering telephone calls from customers with questions about the use of the companys computer software. He does not exercise regularly and admits that he does not follow a special diet stating, My wife is a great cook. Ill eat anything she puts in front of me. At night I like to have a snack while I watch television. The client denies tobacco and recreational drug use and reports drinking socially. I have four of five beers on the weekend watching the football game. Mr. Cowen does not take any prescription medications or herbal supplements but reports taking Tylenol on occasion when I have a headache. The nurse records Mr. COwens BP and gives the client the reading materials with instructions to make an appointment with his primary health care provider (HCP) as soon as possible for a more thorough assessment and to discuss treatment options. Case study Mr. Cowen calls his primary HCP to schedule an appointment. Before the appointment, Mr. Cowen goes to a local laboratory and has a series of blood tests drawn as prescribed by the HCP. At his appointment with the HCP, the nurse weighs Mr. Cowen. He is 5 feet 9 inches tall and weighs 225 pounds. Mr. Cowens BP is 166/92 mm Hg with a large cuff in the right arm and 168/96 mm Hg in the left arm. His heart rate is 84 beats per minute with a regular rhythm, respiratory rate is 18, and he is afebrile. His total cholesterol is 260 mg/dL. During the health history assessment, the HCP learns that Mr. Cowen drinks at least four to six ounces of regular coffee per day and that his father has coronary artery disease and Hypertension. Mr. Cowen denies feeling stress because of his job, relationship with his wife and family, or other factors. I am a pretty laid back guy. I am not worked up or excited about much. I leave that worrying to my wife. The HCP notes that Mr. Cowen carries the majority of his weight in his upper body. He has an increased amount of subcutaneous fat around his waist and his abdomen. The HCP prescribes Hydrochlorothiazide (HCTZ) daily for the client and askes the nurse to provide Mr. and Mrs. Cowen with instructions regarding the education and lifestyle modifications. A follow-up appointment is scheduled for one month. Questions 1. Briefly explain what the systolic and diastolic BP readings indicate? 2. According to the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), what is the definition of prehypertension, stage 1 HTN, and stage 2 HTN? Describe primary and secondary HTN. Based on Mr. Cowens clinical manifestations and history, how would you classify his HTN, and does he have primary or secondary HTN? 3. Generate at least 5 questions the nurse should ask the client to assess for the possible symptoms of HTN. 4. Identify Mr. Cowens risk factors for HTN. Indicate which of the clients risk factors are nonmodifiable and which are modifiable. 5. Mr. Cowen asks the nurse, Is my cholesterol that bad? What should my numbers be? How should the nurse respond? 6. The HCP prescribes Hydrochlorothiazide for Mr. Cowen. Discuss the benefits of monotherapy with Hydrochlorothiazide to treat the clients HTN. 7. The nurse is providing Mr. Cowen with instructions regarding his newly prescribed HCTZ. What are the most common adverse effects of HCTZ that Mr. Cowen should monitor and what should Mr. Cowen do if he forgets to take his daily dose of medication as prescribed? 8. The nurse warns Mr. Cowen not to discontinue the medication abruptly. Briefly explain why the nurse offers this precaution? 9. The nurse is providing Mr. and Mrs. Cowen with instructions regarding lifestyle modifications to help reduce the clients HTN. Identify at least 2 points of discussion the nurse will include in the teaching plan? 10. In priority order, identify 5 nursing diagnoses the nurse will include in the teaching plan? 11. One month later, Mr. Cowen returns for a follow-up appointment with his HCP. His BP is 138/82. The nurse congratulates Mr. Cowen on his success and asks him about his compliance with the DASH diet. He states, I dont like it but I am following it as you said. My wife has been keeping a close eye on me and everything that I eat. She walks with me every night to give me the push I need to exercise. To confirm his compliance with the DASH diet, the nurse asks him to recall his last 3 meals and any snacks. Which meal or snack is least compliant with the DASH diet and what alternative(s) can the nurse suggest? Breakfast: a bowl of whole-grain cereal with low-fat milk, a banana, and a glass of orange juice Lunch: roast beef sandwich on white bread with mayonnaise and a soft drink Dinner: fish, cooked vegetables, brown rice, and a glass of low-fat milk Snack: a toasted slice of bread with grape jelly
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