Create a concept map for this case study using this template.
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.
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Concept Map: T.J. – Hypertension
Subjective Data:
Four dizzy spells
Headache at base of skull for 2 days
Family history of hypertension
1 glass of wine at lunch, 2-3 beers in the evening
High-fat diet from fast-food establishments
No smoking
Used to jog but quit
Nocturia for 3
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Concept Map: T.J. – Hypertension
Subjective Data:
Four dizzy spells
Headache at base of skull for 2 days
Family history of hypertension
1 glass of wine at lunch, 2-3 beers in the evening
High-fat diet from fast-food establishments
No smoking
Used to jog but quit
Nocturia for 3 weeks
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
Diagnostic Data:
Blood Pressure measurement: 142/92 mm Hg, indicating hypertension
Medical Orders:
Repeat blood pressure measurement to confirm hypertension
Lifestyle modification counseling to address diet and exercise habits
Possible medication for hypertension
Referral for further Assessment, such as laboratory tests (e.g. CBC, electrolytes, kidney function test, lipid profile) and/or imaging studies (
Note: Blood pressure measurement of 142/92 mm Hg is considered elevated and may indicate hypertension, but further Assessment is necessary to confirm the diagnosis and determine the underlying cause, if any. The medical orders listed above are just a starting point and may be modified based on the results of the diagnostic tests and the individual’s specific health needs and goals.
