Develop and Concept Map, using the form provided, on the following patient. Include Diagnostic data and medical orders that you expect to be ordered on the patient.
T.J., a 30-year-old African American client, is in his last year of law school and is clerking for a prestigious law firm. He and his fiancé plan to marry as soon as he graduates. During the last week he has had four dizzy spells and a headache at the base of his skull upon awakening for the last 2 days. His father has a history of hypertension, so T.J. is aware that his symptoms may indicate high blood pressure. On his way home from work, T.J. stops by the clinic and asks the nurse to check his blood pressure. The nursing assessment yields the following data.
Subjective data: States he has had four dizzy spells and has awakened with a headache in the occipital lobe the last two mornings. T.J. has 1 glass of wine at lunch and 2-3 beers in the evening to relax from the tension of school and work. Most of his meals are at fast-food establishments and have a high fat content. T.J. does not smoke. He used to jog 4 mornings a week but quit when he started clerking. He has had nocturia for the last 3 weeks. He is not taking any medication. T.J. states he is concerned about having hypertension because he does not want to take medication.
Objective data: T 98.6°F(37°C), AP 78 beats/min, R 16 breaths/min, BP 142/92 mm Hg, Wt 190 lbs (optimum weight 160). No edema noted in hands, feet, or legs.
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Introduction:
This assignment requires developing a concept map for a patient named T.J. who presents with symptoms of dizziness, headache, and high blood pressure. The concept map should include relevant diagnostic data and medical orders that could be expected for this patient.
Answer:
The concept map for T.J. would include various interconnected components, namely subjective and objective data, diagnostic tests, medical orders, and potential complications. This concept map would help in visualizing the various aspects of the patient’s health condition and guide healthcare professionals in providing appropriate care.
The subjective data obtained from the patient reveals that T.J. has been experiencing dizziness and headaches for a while and has a history of hypertension in his family. He also consumes a diet high in fat and drinks alcohol regularly. Objective data obtained from the nursing assessment shows that T.J. has a high blood pressure of 142/92 mmHg and weighs more than what is ideal for his height.
Based on these findings, the following diagnostic tests could be ordered for T.J.:
1. Blood tests to determine lipid levels, blood glucose levels, and kidney function
2. Electrocardiogram (ECG) to assess heart function and detect any abnormalities
3. Complete blood count to check for anemia or infections.
Likewise, the following medical orders could be placed for T.J.:
1. Begin anti-hypertensive medication to control his high blood pressure.
2. Referral to a nutritionist to help with dietary changes and weight management.
3. Begin a regular exercise program, such as jogging or cycling, which would help reduce blood pressure and promote weight loss.
Potential complications that could arise from T.J.’s condition and require close monitoring could include the risk of developing heart disease, stroke, kidney failure, and diabetes.
In conclusion, developing a concept map for a patient like T.J. requiring a diagnostic evaluation and medical orders helps healthcare professionals organize the information logically and plan an appropriate course of action.