Create a concept map for this case study using this template.
NUR2571_Module 04_Concept Map
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.
Concept Map: T.J.’s Health Assessment
[Patient Information]
- Name: T.J.
- Age: 30 years
- Ethnicity: African American
- Occupation: Law school student, clerking for a prestigious law firm
- Lifestyle: Engaged, consumes alcohol, fast-food diet, former jogger
[Chief Complaint]
- Dizziness
- Occipital headache
- Nocturia
[Medical History]
- Family history of hypertension (father)
[Assessment Data]
- Subjective:
- Dizziness (4 episodes)
- Occipital headache (2 days)
- Alcohol consumption
- Fast-food diet
- Former exercise routine
- Nocturia (3 weeks)
- Concerns about hypertension
- Objective:
- Temperature: 98.6°F (37°C)
- Pulse: 78 beats/min
- Respiratory rate: 16 breaths/min
- Blood Pressure: 142/92 mm Hg
- Weight: 190 lbs (optimum weight 160 lbs)
- No edema noted
[Diagnostic Data]
- Blood Pressure: 142/92 mm Hg (Elevated)
- Weight: 190 lbs (Above optimum weight)
[Expected Medical Orders]
- Blood pressure monitoring
- Comprehensive metabolic panel (CMP)
- Lipid panel
- Urinalysis
- ECG/EKG
- Lifestyle modifications counseling
- Dietary assessment and counseling
- Exercise recommendations
- Pharmacological intervention if indicated
[Interconnected Concepts]
- Hypertension
- Cardiovascular risk factors
- Lifestyle factors
- Diet and nutrition
- Exercise and physical activity
- Diagnostic evaluation
- Health promotion and education
- Pharmacological management