Primary Dx: Hypertension

Interventions: SN assessed all body systems noted above. SN determined if patient is on hypertensive
medications and blood pressure was taken to determine the effectiveness and detect changes in the
blood pressure. Complete history is obtained by the SN to assess for signs and symptoms that indicate
target organ damage. SN payed attention to the rate, rhythm, and character of the apical and peripheral
pulses. SN educated patient about the restriction of sodium and fat; gave emphasis on the increase
intake of fruits and vegetables; implementing regular physical activity; limiting alcohol consumption and
avoidance of tobacco.

Visit Narrative: Patient seen by SN awake, alert, and oriented to time and place. Patient can answer
questions that are being asked by the SN. Patient denies chest pain, headaches, dizziness, SOB, cough,
abdominal pain, nausea, vomiting or diarrhea. Patient reports tingling sensation felt at the back of the
neck. SN educated patient about hypertension. Blood pressure is essentially the amount of blood the
heart pumps. If there is more blood and/or smaller arteries, naturally the pressure will be higher. When
someone has higher pressure for an extended period, it begins to cause problems. Signs and symptoms
of hypertension include headaches, SOB, visual changes, dizziness, cheat pain/angina. Hypertension
frequently presents without symptoms; therefore, the listed symptoms are not the typical presentation.
If symptoms present, that means the disease process has most likely progressed significantly. Advised
patient to regularly visit physician and get checkups and possibly be prescribed with antihypertensive
medications. Educated on hypertensive medications - are often used to treat high blood pressure.
Patient verbalized understanding.