Clearly explains who the patient is (age, gender, etc.) and distinguishing between subjective and objective data. Discusses what the principle problem is. Clearly and concisely discusses the disease pathophysiology as well as manifestations and cause. Clearly and concisely discusses patient’s health history and past treatments including any additional health history we should ask the patient (surgeries, medications, etc.) Clearly and concisely lists all patient’s assessment data from case study and includes any important nursing physical assessment needed for the patient. Clearly and concisely explains what treatments the patient is receiving because of their disease; and lists any additional treatments relevant to disease. Contains a minimum of 3 relevant nursing interventions related to principle case study diagnosis. Utilized 1st and 2nd level headings appropriately; at least 2-3 pages long; 2 credible resources; appropriate in text citations. The patient information: The patient is 61 y/o female, her height is 5’2 and 118 lbs, she is allergic to berries. He diet is vegan. The disease i chose for this case study is Hypertension. She have a Dx. of Hypertension, Hyperlipidemia, GERD, Ischemia, Atelectasis, Depression, Spodylolithesis Grade 1, low estrogen level, history of right breast cancer, history of kidney tumor and Renal mass, history of hernia, and Diverticulitis. The medication that she is currently taking: Aspirin 81 mg daily, Atorvastatin 10 mg daily, Calcium 1200-1000mg daily, Estradial Vaginal 1 g 2x a wk, Ibuprofen 200 mg daily, Multivitamin daily, Vitamin B12 daily, Tramadol 50mg daily, and Naproxen 500 mg daily. Her past surgery includes total mastectomy of both breast September 2014, Hernioplasty 2010, and Partial Nephrectomy of right kidney 2009. Past treatment, she had 16 sessions of chemotherapy; however, only did 14 because she had TIA after her chemo.
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