Primary Health Care Diagnostic Case


Subjective Data

It has been long established that elevated blood pressure is linked to increased incidence of headaches and migraines (Fagernaes et al., 2015). It is expected that Mr. C will share information common for hypertensive patients with headaches: anxiety, depression, lack of physical activity, and smoking among others (Fagernaes et al., 2015). The patient is also likely to report high caffeine consumption. If the underlying causal agent of the patient’s symptoms is type 2 diabetes, he will complain of frequent urination and blurred vision.

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Objective Data

It is important to assess whether the patient has abnormal heart rhythms. If abnormalities are detected with the help of a stethoscope, it is necessary to order an electrocardiogram. The measurement of blood glucose levels is also needed (Pickering & Marsden, 2014).


It is appropriate to consider the following guidelines when diagnosing the patient and managing their condition: 2013 ACCF/AHA guideline for the management of heart failure and 2016 American Diabetes Association standards of medical care in diabetes.


Taking into consideration the fact that the patient is obese and has hypertension, he is at an increased risk for diabetes. Therefore, it is necessary to order diagnostic tests for the disease: the A1C, the FPG, and 2-h PG (American Diabetes Association, 2014). A 12-lead ECG has to be performed to detect abnormal heart rhythms that might be indicative of congestive heart failure diagnosis. Additional tests that are needed to confirm the diagnosis are complete blood count, urinalysis, fasting lipid profile, blood urea nitrogen, and serial monitoring (Yancy et al., 2013).


It is necessary to consult a cardiologist because the patient is at an increased risk of congestive heart failure. Mr. C’s symptoms that are indicative of a heart condition are fatigue, edema (swelling of ankles), and heartache. There is no diagnostic test that can be used for congestive heart failure; therefore, it is necessary to conduct a comprehensive history and physical examination (Yancy et al., 2013).

Medical and Nursing Diagnoses

The following nursing diagnoses can be made: fatigue related to pain, hypertension, fluid volume excess, and sedentary lifestyle. The following medical diagnoses are applicable to the patient’s case: congestive heart failure, chronic kidney disease, and diabetes.

Legal/Ethical Considerations

A nurse should be guided by the consideration of autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity (Dunphy, Winland-Brown, Porter, Thomas, 2015). Taking into consideration the fact that the patient is mentally capable of issuing a voluntary consent, there should not be any legal consequences.

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Plan of Care

Goal: fatigue related to pain are lost or reduced

Desired outcomes: reports that pain and fatigue are relieved, verbalizes relief-producing approaches; and demonstrates strong relaxation skills.

Interventions: monitor vital signs, encourage Mr. C to rest more in bed, teach him relaxation techniques, encourage him to adhere to a diet, and administer orally nonopioids (acetaminophen).

Healthy People 2020

Healthy People 2020 objectives that should be considered in this case are PA-1 “reduce the proportion of adults who engage in no leisure-time physical activity” and HDS-5 “reduce the proportion of persons in the population with hypertension” (“Heart disease,” n.d., para. 1; “Physical activity,” n.d., para. 1).

The Circle of Caring

Under the Circle of Caring model, it is necessary to use spousal participation as a part of a broadened therapeutic approach (Dunphy et al., 2015). The participation can be viewed as a key component of the social support system involvement of which is instrumental for that attainment of optimal health.


American Diabetes Association. (2014). Diagnosis and classification of diabetes mellitus. Diabetes Care, 37(1), 81-90.

Dunphy, L., Winland-Brown, J., Porter, B., Thomas, D. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis.

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Fagernaes, C. F., Heuch, I., Zwart, J. A., Winsvold, B. S., Linde, M., & Hagen, K. (2015). Blood pressure as a risk factor for headache and migraine: A prospective population-based study. European Journal of Neurology, 22(1), 156-161.

Heart disease and stroke. (n.d.). Web.

Physical activity. (n.d.). Web.

Pickering, D., & Marsden, J. (2014). How to measure blood glucose. Community Eye Health, 27(87), 56-57.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H.,… Wilkoff, B. L. (2013). 2013 ACCF/AHA guideline for the management of heart failure. Circulation, 128, 1-206.

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