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Care Plan for Hypertension

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Submitted By lissahow7
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PAST MEDICAL/SURGICAL HISTORY: Patient has a history of a myocardial infarction (MI, or also known as a heart attack) in 2004, she had a hip pinning in 2005, and a traumatic amputation of fingers on her left hand in 1974 from a lawnmower accident.

Pt lived on her own until 4-27-12 when her family found her lying on the floor in her home. Pts family brought her to live with them but pt continued to have episodes of falling and hitting her head. Pt was taken to the ER and given a Ct of the brain where all results turned up normal. After at least 5 more falls the pts family took her back to the hospital with complaints of chest pain and palpitations. Pt was more confused than usual & and was having increased difficulty in gait. Physician suspected pt to have some left-sided weakness greater than left-sided weakness and chest pain. A second CT of the brain turned up normal. VS stable, but pt remains confused, weak, & complains of some dizziness and palpitations. Physician referred pt for admission to nursing home with admitting chief complains: chest pain, palpitations and frequent falls.

PRESENT ILLNESS HISTORY: Patient currently has a diagnosis of essential (primary) hypertension, chest pain, palpitations, chronic kidney disease, dementia w/o behavioral disturbances, hyperlipidemia, and anemia.

*Give a brief definition/description of each diagnosis.
Essential hypertension is another term for high blood pressure. It is a systolic reading that is above 140 or a diastolic reading that is above 90 continuously. 120/90 is a normal blood pressure reading. (Burton & Ludwig. 2015, Pg. 345)
Hyperlipidemia is a condition where high levels of fat accumulate in the blood (Hopper & Williams. 2015, pg. 471).
Coronary Artery Disease (CAD) is a disease that damages the hearts major blood vessels when fat deposits (plaque) build up in the...

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