Medical History Of Diabetes Type I, Hypertension, Cardiac Vascular Disease And A Valve Repair

Medical History Of Diabetes Type I, Hypertension, Cardiac Vascular Disease And A Valve Repair

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Patients Situation
Patient J.H, 80 years old African American male with no religious preference was brought to the hospital because of shortness of breath. J.H admitted diagnose was acute coronary syndrome and have a past medical history of diabetes type I, hypertension, cardiac vascular disease and a valve repair. Physical assessment for J.H was conducted on 2/3/16, he was alert and orient when asked for name, date of birth, purpose of visit, and the year. While conducting a physical assessment, his chief complaint was chest pain. When auscultating the heart, the heart sounds for J.H was s1, s2, s3. The founding has been noted by the nurse, vital signs were taken and beta-blocker was administered. Patients J.H is also having a high risk for stroke because of his age and the heart diseases he has, therefore he is currently taking warfarin to prevent stroke. Patients is alert and orient thus patient teaching for beta-blocker, self-administer insulin, warfarin, cardiac diet should be cover before discharge.
Structural Variable
Structural Variable Quotes/ Sources Rationale
Age- 80
Sex- Male
Religion- None
Ethnicity- African American
Education- High school
Relation- Widower
Placement on health continuum- Low level wellness
Nursing Diagnosis
Some nursing diagnosis for patient J.H that might impact his ability to learn will be knowledge deficit related to lack of interest in learning as evidence by inaccurate follow- through of instruction or performance of test. Patient J.H is currently taking many medications such as Beta-blocker, insulin, warfarin to treat his high blood pressure, acute coronary syndrome, diabetes and heart diseases. It is important for J.H to obtain the correct parameter for blood pressure and glucose...


... middle of paper ...


...e for this medication is based on patient’s lab value, thus a detail hand out for warfarin could help.
Evaluation
At the end of the teaching section patients J.H was able to demonstrate how to obtain his own blood pressure with the blood pressure machine and identify if the value is within parameters to consume the medication. J.H was also able to demonstrate how to obtain his own blood sugar level, verbalize when to obtain blood sugar, and self-administer insulin to his left lower abdomen region. The goal is met, patient was able to perform the task with efficiency and accuracy. The patient response to teaching as helpful that he gets to realize signs and symptom of warfarin overdose, and the significant of keeping a log of blood pressure. The teaching will help J.H to maintain his health and recognize for abnormality or unusual events if it ever strikes him again.

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