Summary: Medication Focused Case Study

Medication Focused Case Study Patient Overview M.S. is a 35-year-old female who came into urgent care at Kaiser Permanente Riverside. She presented with a sore ankle that was causing her problems after accidently twisting it by missing a step in going down a set of stairs. The only prior medical history that M.S. has is a history of asthma that is currently managed with appropriate medications. Even though she has a history of asthma, she reports smoking cigarettes and often drinks alcohol. She also reported not having a very healthy diet. Upon examination of M.S. ankle, it is concluded that she minors sprained. During normal examination, her vitals signs are obtained which showed a respiratory rate of 16, pulse of 100, temperature 97.2OF, blood pressure of 151/91, pulse oximetry of 99%. Since it was noted that her blood pressure and heart rate where both high, it is assessed on the opposite arm and it showed a blood pressure …show more content…
Another blood pressure and pulse is obtained a few hours later as it was still both high at 148/91 blood pressure and a heart rate of 100. When assessing her routine labs, there is no significant abnormalities noted. After presenting the data to the physician and the physician assesses the patient, it is concluded that M.S. has the medical diagnosis of stage 1 hypertension. According to ATI, stage 1 hypertension is a blood pressure reading of “systolic 140 to 159 mm Hg; diastolic 90 to 99 mm Hg” (ATI, RN Medical Surgical Nursing, pg.411). In the patient care plan, the priority nursing diagnosis is risk for decrease cardiac output related to increased vascular resistance. Another nursing diagnosis in the patients care plan is, knowledge deficit related to lack of knowledge of new diagnosis. In order to get her blood pressure and heart rate to go down, the physician ordered metoprolol