Client: Lisa Johnson
Date: August 4, 2020
Worker: Clinician
Objective Information:
BP 165/100 mm Hg.
Lab results show decreased cardiac output, as indicated by the diminishing pulses in her legs.
The presence of pallor on her skin is an indication of decreased cardiac output.
The client is overweight and has shortness of breath.
Subjective Information
The client complains of feeling dizzy all the time, especially when carrying out tasks.
She seems to be easily agitated when responding to questions and is breathing heavily.
Lisa also keeps taking water and breaks when talking.
Medical History / Intervention
Medical History:
Lisa says her father had high blood pressure and heart-related illness.
Lisa’s grandmother was diagnosed with depression.
Her brother has a heat-related illness.
Lisa’s mother is overweight but has no diagnosed condition.
Lisa is currently seeing a therapist trying to manage post-traumatic stress disorder.
Intervention:
Provide relaxation techniques as a way of dealing with stress.
Issue medication such as; loop diuretics, thiazide diuretics, and beta-blockers.
To monitor the effect of medication.
We are recommending physical activity as guided by an expert.
Employment History
Lisa works in a restaurant as the cashier, and she is stressed that she does not earn enough to assist her family. In the course of her work, she eats a lot and rarely has time to exercise or move around. She drives to and from work and, as a result, never gets a chance to walk.