Running head: PLAN OF CARE: HYPERTENSION, PAIN, AND ALCOHOLISM 1

Plan of Care: Hypertension, Pain, and Alcoholism

Christina Collins

Delaware Technical Community College

NUR 320
PLAN OF CARE: HYPERTENSION, PAIN, AND ALCOHOLISM 2

Plan of Care: Hypertension, Pain, and Alcoholism

Nursing Assessment

Mr. H. is a 57-year-old, Caucasian businessman. He is of Roman Catholic faith,

attending church every Sunday. He is single, never married, with no children, and is one of eight

children. Both parents are deceased. His father died of a heart attack and his mother died from

dementia, both in their mid-eighties. The patient also has one deceased brother, who died of lung

cancer two years ago. The patient does not smoke, use alcohol, or recreational drugs. He has

battled alcoholism in his twenties, for which he recently celebrated his twenty-eighth year of

sobriety. He reports that he has attended weekly Alcoholics Anonymous (AA) meetings for the

past twenty-eight years. In his spare time, the patient enjoys playing golf and watching comedy

movies. The patient reports that he exercises two days a week and his diet has been plagued with

poor choices, such as high carbohydrate food and fried food.

The patient presents with complaints of recent high blood pressure readings, weight gain,

and intermittent pain in his left lower abdomen, which has been identified as a hernia. The

patient states that at his last doctor visit, the doctor said that he would like to keep an eye on the

hernia for now. Upon examination, vitals are: BP 175/98, Pulse 72, weight 215 lbs., height 59,

temp. 98.6. He states that when his lower left abdomen area is in pain, it is an 8/10, but at rest is

a 0/10. Lungs are clear, and there is no edema in his extremities. Current medications are Fish

Oil 1g daily, and Red Rice Yeast Extract 600 mg, two capsules, daily.

Plan of Care: Need/Problems addressed

The three identified needs addressed are an intermittent pain in the left lower side of the

abdomen, increased blood pressure, and alcoholism.

PLAN OF CARE: HYPERTENSION, PAIN, AND ALCOHOLISM 3

Intermittent Pain.

The patient states that his pain started about one year ago when he was exercising. He

feels that he may have been lifting too much weight. The patient states that initially the pain felt

like a tenderness in the lower left abdomen area, but over time the pain has become worse and

more frequent. He reports that he has a flare-up, 1 to 3 times a month. When the patient has a

flare-up, he reports that the pain feels like a wave of muscle contractions, sometimes with a

stabbing pain, then the pain radiates upwards. He states that it usually last for 30 seconds to 1

minute. The patient states that the pain is often triggered during abdominal exercises and if he is

lying down and tries to sit up too fast. The patient states that when the pain comes on he tries to

stand straight up, breathe, or puts pressure using his hands over the area in the abdomen area.

The identified outcomes for this patient are: reduce amount and frequency of pain,

maintain a healthy weight, education about hernias, add fiber into his diet, and to educate the

patient of symptoms of a strangulated hernia which is a very serious condition. To meet the

following goals, the interventions chosen to assist the patient are:

Exercise to reach a healthy weight, bending at the knees, not the back and splinting the

area with a hand when coughing; these interventions will help decrease intra-abdominal

pressure. If there is an increase in intra-abdominal pressure, it will push a hernia through

an opening creating pain.

Add fiber to the diet - fiber helps prevent strain when having a bowel movement, and

Educate the patient about hernias - if the patient understands his situation, he is more

likely to adhere to his plan of care.

PLAN OF CARE: HYPERTENSION, PAIN, AND ALCOHOLISM 4

Increased Blood Pressure.

The patient states that he has been taking his blood pressure reading lately because he just

didnt feel right. The readings have been running around 170/100. The patient has gained

weight, maintained a poor diet and has been less active than in the past.

The identified outcomes are: have BP within acceptable limits with medication management,

increase exercise, incorporate low-sodium and low-fat diet, and to verbalize the importance of

following the recommended plan to succeed.

To meet the outcome goals, the following interventions are recommended:

Take medication as ordered will reduce BP

Aerobic exercise 5 days a week for 30 minutes tones the cardiovascular system

Implement dietary restrictions reduces fluid retention, which reduces the workload

of the heart

Communicate understanding of HTN and plan of care, which will increase success

rate of maintaining a healthier lifestyle

Alcoholism.

Alcoholism was chosen as a need because it is important to continually, day by day, make

decisions that lead to success for a sober life.

The identified outcomes are: continue to attend AA meetings, use relaxation techniques,

maintain spiritual well-being, have a support group to reach out to during times of high stress.

The interventions chosen to help this patient succeed are:

Create a list of people who are part of the patients support group, so that in times

of need they are readily accessible

PLAN OF CARE: HYPERTENSION, PAIN, AND ALCOHOLISM 5

Meditate or use breathing techniques brings clarity, reduces stress, and helps

patient to become present focused.

Attending regular meeting this allows the patient to identify with others who

have had the same problem and incorporate coping mechanisms shared

Talk to a therapist reduce stress and maintains mental stability

Participate in alcohol-free hobbies and attend church weekly alcohol-free

hobbies eliminate the temptation and church encourages spiritual well-being

Evaluation of Goals/Community Resources

To evaluate whether the patient has implemented the interventions and met the

goals set forth, the patient would have to follow-up in a month to verbalize what he has been

doing related to the plan of care and identify what changes have occurred related to the

interventions. If the patient meets the goals, he would be encouraged to continue with his current

plan of care. If any goals have been unmet, further evaluation would have to be completed and

new goals, outcomes, and interventions instituted. To further support the patient, he has been

given many resources to help him achieve his goals, which can be found in the plan of care chart

provided.
PLAN OF CARE: HYPERTENSION, PAIN, AND ALCOHOLISM 6

References

Ackley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis handbook: an evidenced-based guide

to planning care. 8th ed. St. Louis, MO.: Mosby Elsevier.

Swearingen, RN, P. L. (2004). All-in-one Care Planning Resource: Medical-Surgical, Pediatric,

Maternity, and Psychiatric Nursing Care Plans. St. Louis, MO: Mosby Elsevier.