Nur 320 Health Assessment

Individualized Plan of Care
Individualized Plan of Care for Mr. Billy Madison
Veronica Payne
Delaware Technical and Community College
1
Mr. Billy Madison is a thirty-two-year-old male, diagnosed with moderate obstructive
sleep apnea (OSA) in July of 2018. Since then, Mr. Madison has worn a continuous positive
airway pressure (CPAP) machine each night for a minimum of four hours. He reports feeling
well rested in the morning, no longer wakes with a headache, and no longer takes naps during the
day. Mr. Madison reports a medical history of hypertension, with his last blood pressure reading
being 138/90. Standing at six feet tall and weighing two-hundred and fifteen pounds, Mr.
Madison has a body mass index (BMI) of 29.2, indicating he is overweight. Mr. Madison’s
health history assessment revealed his diet mostly consists of Wawa, fast food, vending machine
snacks and little water consumption, his drink of choice is Wawa iced tea. Mr. Madison has a
family history significant for maternal hypertension, and his paternal grandfather passed away
from having a stroke. Using multiple resources, a plan of care was developed to address Mr.
Madison’s most pressing health concerns, which include; hypertension: weight management: and
poor nutrition.
Mr. Madison has not had his blood pressure checked since being diagnosed with OSA.
“Obstructive sleep apnea is a recognized cause of secondary hypertension. OSA episodes
produce surges in systolic and diastolic pressure that keep mean blood pressure levels elevated at
night. In many patients, blood pressure remains elevated during the day time, when breathing is
normal” (Dopp, Reichmuth, Morgan, 2007). For the past four months, Mr. Madison reports
compliance with using his CPAP machine. He reports improvement in his sleep patterns, with
more restful sleep, decreased headaches and less lethargy during the day. Mr. Madison is
encouraged to check his blood pressure and heart rate regularly, and a goal has been set to
achieve a blood pressure reading of equal to or less than 120/80 six months from now.
2
Mr. Madison’s current BMI indicates that he is overweight. In order to achieve a normal
BMI of less than 24, Mr. Madison needs to lose thirty-eight pounds. A goal has been set for him
to achieve this weight loss through diet and exercise, by May of 2019. Being overweight,
coupled with hypertension and a family history of stroke, Mr. Madison is at an increased risk for
having a cerebrovascular event. Mr. Madison was provided with information on exercise
facilities in his community, as well as recommendations for increasing daily activity. “To attain
the most health benefits from physical activity, adults need at least 150-300 minutes of
moderate-intensity aerobic activity, like brisk walking or fast dancing, each week. Adults also
need muscle-strengthening activity, like lifting weights or doing push-ups, at least two days each
week” (ODPHP, 2018).
Mr. Madison admits that his diet is mostly made of poor nutritional choices, which
includes most meals from Wawa or fast food places, vending machine snacks or candy. He skips
breakfast, doesn’t drink enough water and is only able to prepare cereal, pancakes and steak-
umms at home. Mr. Madison agrees to keep a food diary in order to hold himself accountable
for food choices, and to meal prep at home for the week. A goal was set to limit Wawa and fast
food meals to two meals per week, while completely cutting out candy and vending machine
snacks. “For weight loss of 1-1 ½ pounds per week, daily intake should be reduced by 500 to
750 calories. In general… Eating plans that contain 1,500 to 1,800 calories each day are suitable
for men” (NIH). Mr. Madison was given information on nutritional services available to him in
the community.
Mr. Madison admits that he struggles with finding the motivation to exercise and
maintain a healthy diet. The seriousness of his health issues were discussed, and Mr. Madison
agrees to try better in 2019. Fortunately for Mr. Madison, his health concerns are modifiable.
3
With diet and exercise, he will be able to achieve a health weight and maintain a normal blood
pressure. Thus decreasing the risks associated with hypertension and obesity.
4
References
Dopp, JM., Reichmuth, KJ., Morgan, BJ. (2007). Obstructive sleep apnea and
hypertension: mechanisms, evaluation, and management. Department of orthopedics and
rehabilitation, Madison, WI 53706, USA. Retrieved on November 27, 2018 from
http://www.ncbi.nlm.nih.gov/pubmed/18367017
NIH. Key recommendations. U.S. department of health and human services. Retrieved on
November 27, 2018 from http://www.nhlbi.gov/health/education/lose_wt/recommen.htm
ODPHP. (2018). Physical activity guidelines for Americans. (2nd Ed.). Retrieved on
November 27, 2018 from http://health.gov/paguidelines/second-edition/resources

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Individualized Plan of Care

Individualized Plan of Care for Mr. Billy Madison

Delaware Technical and Community College

Mr. Billy Madison is a thirty-two-year-old male, diagnosed with moderate obstructive

“Obstructive sleep apnea is a recognized cause of secondary hypertension. OSA episodes

week” (ODPHP, 2018).

hypertension: mechanisms, evaluation, and management. Department of orthopedics and

rehabilitation, Madison, WI 53706, USA. Retrieved on November 27, 2018 from

November 27, 2018 from http://www.nhlbi.gov/health/education/lose_wt/recommen.htm

November 27, 2018 from http://health.gov/paguidelines/second-edition/resources

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