Mike Kelly is a 51 year old Caucasian male. He is 6 feet tall and weighs 275 pounds (BMI 37.3)
with an abnormal distribution of weight around his abdomen. He does not regularly exercise, does not
like to cook, and eats fast food 3-5x during the week. He has smoked 1 pack per day since the age of ...
Keith RN
LRCC Nursing II
Clinical 2.9.2017
RAPID Reasoning Case Study-STUDENT
I. Data Collection
History of Present Problem:
Mike Kelly is a 51 year old Caucasian male. He is 6 feet tall and weighs 275 pounds (BMI 37.3)
with an abnormal distribution of weight around his abdomen. He does not regularly exercise, does not
like to cook, and eats fast food 3-5x during the week. He has smoked 1 pack per day since the age of 20
(31 pack years). He has no current diagnosed medical problems. He becomes concerned and came to the
urgent care facility today because he is more easily fatigued and has a headache for the past 3 days that
has not improved. He didn’t go to work today and that is not typical for Mike.
Personal/Social History:
Mike is self-employed and owns his own auto mechanic business. He currently has no health
insurance. His father had hypertension and died of a myocardial infarction (MI) at the age of 50.
Angelina, his wife, came with him to urgent care and shares that he is usually stoic with health problems
so this must really bother him or he is afraid. He took Excedrin and Motrin for pain and it didn’t help that
she gave him a dose of Castor oil since she is from Puerto Rico and that is the first thing they do for any
illness in her country of origin.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the
nurse?
RELEVANT Data from Present Problem: Clinical Significance:
-more easily fatigued Etiology of essential hypertension (Ignatavicius 710)
-headache for past 3 days Includes:
-BMI of 37.3 -smoking
-fast food eaten 3-5x per week -excessive intake of sodium
-smoker for the past 31 years -obesity
-does not regularly exercise -physical inactivity
-self employed -high stress
RELEVANT Data from Social History: Clinical Significance:
-father has medical history of hypertension -family history puts him at a greater risk for a heart
and MI attack
-took Excedrin, Motrin, and castor oil before - Excedrin is a combo of Tylenol, aspirin, and caffeine
coming in (Caffeine can create tachycardia)
-Castor oil relieves pain and promotes healing used
culturally, more useful for open wounds
-Motrin is a NSAID as well that thins the blood
(Prescription)
II. Patient Care Begins:
Current VS: WILDA Pain Scale (5th VS)
T: 98.9 (oral) Words: Ache
1
, Keith RN
LRCC Nursing II
Clinical 2.9.2017
P: 88 (regular) Intensity: 8/10
R: 20 Location: Global head ache
BP: 220/118 Duration: Continuous
O2 sat: 95% RA Aggravate: Nothing
Alleviate: Nothing
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
-BP 220/118 -BP over 140/90 is suggestive of hypertension for ages under 60
Pain: Ache, 8/10 (Swearingin 179)
Headache -the headache pain can be an indicator of a hypertensive
Continuous urgency or crisis (Ignatavicius 718)
Current Assessment:
GENERAL Appears uncomfortable
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory
effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats,
pulses bounding, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four
quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact
What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
-uncomfortable -being uncomfortable isn’t normal and indicates a possible
-bounding pulse problem
- increase in blood pressure may create a bounding pulse
suggesting inadequate perfusion (Ignatavicius)
III. Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
Hypertension is the most likely problem that my patient is presenting with.
2. What is the underlying cause/pathophysiology of this problem?
2
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