Case
Clinical Judgment plan
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- NURS 121L
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- West Coast University
Case study, lab values, Clinical Judgment Plan
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(VM/GP/KL-V5)History of Present Illness (HPI):P.P is a 75 years old Mexican female with past medical history significant for CHF who recently has not been taking her Lasix regularly as prescribed in the last couple of weeks due to her pain in the knee which she states it hurts to get up to urinate in the bathroom. She was brough in to the hospital by paramedics which was called by her son who found her this morning to be weak and lethargic. She presented with shortness of breath and progressive leg swelling. Her condition worsened over the last two days where she had a cough productive of clear sputum. The patient denies the following signs and symptoms: chill, fever, chest pain and abdominal pain. Medical History: 1. Diabetes type II. 2. Hypertension. 3. Dyslipidemia. 4. COPD
5. Diastolic congestive heart failure. 6. Lymphedema, venous insufficiency. 7. Morbid obesity. 8. GERD. 9. Anxiety. 10. Anemia
Surgical History: 1. Tonsillectomy is a procedure to treat tonsils that get infected and inflamed. P.P is having trouble with breathing therefore, tonsillectomy is necessary to treat breathing and enlarged tonsils (Mayo Clinic, 2020).
2. Breast biopsy is a procedure that is needed when there is a suspicious of lump or signs and symptoms of breast cancer (Mayo Clinic, 2021). P.P is at the age of doing check up for any possible lumps or masses in the breast. 3. C-section is a procedure to deliver a baby through the incision on the abdomen and uterus instead of delivery vaginally (Mayo Clinic, 2022). P.P has given birth to her son through C-section instead of vaginally. 4. Orthopedic surgery involves with musculoskeletal system problems such as hip surgery knee surgery, and spine surgery. Which in P.P’s case she has complained of knee pain for the last couple of weeks which knee surgery is needed. Social History:
No history of tobacco, alcohol or recreational drug use. Previous Hospitalizations:
She was last hospitalized here in January with COPD, possible obesity, hypoventilation syndrome, possible obstructive sleep apnea, acute kidney injury, bilateral lower extremity cellulitis, possible congestive heart failure. Patient Information (1)
Patient Initials: P.P
Age & Gender: 75, Female Height/Weight: 5’8/ 300lbs
Code Status: Full code Living Will/ DPOA: Yes Concept Map Student Name: Instructor: DATE Care Provided and UNIT: (VM/GP/KL-V5)Chief Complaint: Altered mental status. Admitting Diagnosis & Admission Date: Congestive Heart Failure & 6/27/2022
Patho for: CHF The pathophysiology of Congestive Heart Failure involves cardiac disorders in the presence of cardiomegaly, dyspnea, pulmonary edema, and tachycardia. It happens when the heart is unable to get sufficient CO for the rest of the body. Reduction of myocardial contractility usually caused by an individual who has systolic dysfunction therefore resulting in a low ejection fraction. Reduction of a low ejection fraction occurs when ATP is low due to inadequate supplies of O2 which impair the contractility (Banasik et al., 2019). Signs & Symptoms:
Clinical signs of CHF are respiratory crackles, coughing and hypoxemia. Coughing is caused by the congestion of bronchial irritation which in severe stage the sputum could contain blood in it due to the breakage of capillaries (Banasik et al., 2019).
Diagnostic Tests:
CHF is diagnosed with sings and symptoms, X-ray findings, echocardiographicfindings. Patient with S/S of shortness of breath could be used to diagnose with a plasma BNP or NT proBNP (Banasik et al., 2019).
Treatment Plan:
HF therapy which will help increase the cardiac output and reduce the congestive symptoms. Medications like diuretics can help promote the excretion of fluid by blocking NaCl reabsorption and increase renal blood flow. Other medications like SNS effects can help promote CO although dramatically demanding for more myocardial O2 consumption (Banasik et al., 2019).PATIENT EDUATION : P.P is alert and oriented X4, cranial nerves and motor are intact throughout. There is no barrier to learning
at this time since she is ready to learn. Husband also at bedside to receive education about patient’s care. Her learning preferences are demonstration and discussion. I will teach my patient about the pathophysiology of the diseases including the one from admitting diagnosis by having a discussion of CHF since it is her new admitting diagnosis which I think she will need to learn more on that. I will inform her that taking Lasix will help increase her cardiac output which help managing her CHF condition. I will teach her how to control and manage her pain through demonstration due to her knee injury such as providing relaxation technique since stress correlates with increasing in pain perception (Wayne, 2022). Since the patient is back in the hospital with new diagnosis of CHF due to her not taking her prescribed Lasix caused by the knee pain which prevented her from taking the medication that she must be taking. Therefore, it is important to teach pain control as my priority teaching so that pain could not prevent her to follow orders as ordered by the provider such taking Lasix as prescribed to avoid further complications. I will teach her about Cefuroxime that was prescribed which is an antibiotic about the dose, route, frequency and that it is a must to finish the whole course of medication even if signs and symptoms has subsided while taking it. Due to her condition and age, P.P is at high risk for fall therefore, I will show her a demonstration how to use a call light and ask for assistance whenever needed. DISCHARGE PLANNING: . Discharge planning to home when medically stabled . P.P will go home to live with her husband
. P.P needs to go to short term SNF for rehab and diuresis . P.P needs assistance with ADLs . Durable medical equipment use at home including hand held nebulizer, and walker
. P.P needs home Oxygen when discharge home Interprofessional Consults: 1. Pulmonary consultation is to evaluate the patient’s respiratory and lung function. Pulmonary consultation involves upper respiratory tract, lungs and bronchial tubes which deals with diseases that is affecting the respiration which in P.P’s case she has troubled breathing and on top of that she recently got diagnosed with CHF that is presenting with respiratory crackles. Rationale: To detect narrowing in the airways of the lungs. 2. Cardiology consultation is to evaluate the electricity of the heart and to detect any possible heart muscle damage. Cardiology consultation involves checking medical history and perform a medical examination where they check your blood pressure, cholesterol level and weight. In P.P’s case, her medical history included hypertension, dyslipidemia and morbid obesity therefore having this medical examination can help detect any new elevated cholesterol, blood pressure or BMI. Rationale: Since the patient is diagnosed with CHF, this consultation will help to further discuss about her
cardiac problems.
3. Palliative care consultation is based on need where they assist in managing patient and family communication and pain. Open communication is every essential for P.P since one of her medical histories is anxiety, having this consultation will help put P.P at ease and calm down.
Rationale: Patient able to talk about her feelings about living with serious illnesses such as CHF which could help reduce stressful situations at times. (VM/GP/KL-V5)
Pathophysiology of Medical History
Patho for Diabetes type II:Pathophysiology for diabetes type II involves insulin receptor issue where it is insulin-resistant in producing lack of insulin due to beta cell dysfunction. Impaired beta cell is unable to make sufficient insulin therefore, it could not overcome insulin resistance. Development of insulin resistance can be first compensated by hyperinsulinemia and increased in insulin production. Insulin secretion can be further diminished by an increased insulin resistance from hyperglycemia that is resulted from hyperglucagonemia whereas continued insulin resistance is due to relatively decreased in insulin levels. Excessive abdominal fat in individuals who have BMI that is above the expected range could be potentially at threat for diabetes mellitus where the more fat tissue it is the more resistance of muscle and tissue cells become to insulin hormone (Banasik et al., 2019).Signs & Symptoms:Signs and symptoms of type 2 diabetes are polydipsia, polyuria, polyphagia and weight loss may be more subtle (Banasik et al., 2019).Diagnostic Tests:Screening for diabetes are now common for all older adults that are 43 years old and over at least every three years due to a high level of undiagnosed type 2 diabetes. Diabetes can be diagnosed by fasting plasma glucose level and the two hour oral glucose tolerance test repeated on separate days. Another test that could help confirm diabetes is a single random plasma glucose level that is greater than 200 mg/dL and HbA1C can help confirm the diagnosis when is lower or equal to 6.5% (Banasik et al., 2019).Treatment Plan:There is no cure to treat type 2 diabetes but there are ways that can help maintain an optimal health. Implementation of an exercise regimen and appropriate dietary choices can play the part to keep blood sugar level at a good range. Blood sugar monitoring can also help in delaying and preventing further complications that could caused by type 2 diabetes if the blood sugar is not well controlled (Banasik et al., 2019).Patho for Hypertension:Pathophysiology for hypertension involves an increased peripheral vascular resistance and increased blood viscosity through the main arteries that is impeded. It is a chronic elevation of blood pressure where there is no cure but could be managed. In the long term, chronic hypertension could lead to end organ damage due to the main cause of cardiac output and peripheral vascular resistance. With an increase in systemic vascular resistance and its stiffness could induce hypertrophy on the left ventricle and diastolic dysfunction. Within hypertension, there is an abnormal relationship between blood pressure and Na+ excretion by the kidneys that is called pressure natriuresis. It plays a role in hypertension by parallel shift to high blood pressure or decreased in blood pressure along with salt insensitive and sensitive hypertension (Banasik et al., 2019).Signs & Symptoms:People with high blood pressure experience shortness of breath, chest pain, muscle tremors and headache when they reach a life threatening stage of hypertension. Hypertension could asymptomatic that is considered as silent killer where most people are unaware of the problem including no warnings of its signs and symptoms. Uncontrolled hypertension where elevated pressure reduced the blood flow, it could lead to some serious issues to the body system such as heart failure due to function of the heart that could not sufficiently pump the blood and oxygen to vital organs and can lead to heart attack where heart muscle cells die from the lack of oxygen which then makes the heart blocked (Banasik et al., 2019).Diagnostic Tests:Hypertension is diagnosed by electrocardiogram that detects the heart activity and can be evaluating for damage of the heart muscles that caused by heart attack which falls under one of the uncontrolled hypertension manifestations. Another detector ofthe heart is echocardiogram that could detect any enlargement or abnormalities of the heart wall and valve. Since hypertension involves kidneys, measurement of electrolytes within the blood test help with assessing kidney involvement such as blood urea nitrogen and creatinine levels (Banasik et al., 2019).Treatment Plan:Treatment interventions for hypertension involve with lifestyle modifications such as weight reduction, DASH diet that is high in fruits and vegetables and low fat dairy products, decreased sodium intake, implement an exercise plan and moderate intake of alcohol (Banasik et al., 2019).Patho for Dyslipidemia:The pathophysiology of dyslipidemia involves components of genetic, environment or both. Dyslipidemia includes deficiency or overproduction of lipoproteins that is called lipoprotein metabolism disorder. Within deficiency or overproduction of lipoproteins, it is the imbalance between low density lipoprotein cholesterol and high density lipoprotein. When presence of fat gets accumulated, it leads to narrowed blood vessels which blood flow gets obstructed. Normal body needs blood vessels toremain dilated to continuously provide and receive adequate supply and nutrition to various parts of the body. However, once the blood vessels gets harden due to accumulated fats, there is a disturbance of the blood flow that affected the heart and the brain due to insufficient of blood supply to the rest of the body which the chances are stroke and death could occur (Banasik et al., 2019).Signs & Symptoms:There is no apparent sign of dyslipidemia, people could have it and could be unaware of it at the same time therefore, it is often found during a routine blood test. Since dyslipidemia can affect cardiovascular, coronary artery disease can be symptomatic which begins from chest pain and lead to heart attack (Banasik et al., 2019).Diagnostic Tests:Due to the asymptomatic nature of the disease, dyslipidemia can be diagnosed by measuring serum lipids including LDL and HDL level to determine the amount of cholesterol can be found in the body which helps in evaluating whether it is dyslipidemia or not (Banasik et al., 2019).Treatment Plan:To defense against high cholesterol and to encourage healthy blood lipid levels, eating healthy by reducing consuming unhealthy fats and exercise regularly could play a huge role in maintain a good balance of blood lipid levels. Satin medications can teat high cholesterol by interfering with the production of cholesterol in the liver. There are possibilities that satin can fail to lower LDL levels therefore additional medications such as fibrates and niacin can be recommended to help to lower LDL levels (Banasik et al., 2019).Patho for COPD:The pathophysiology of COPD involves airway inflammation and airway obstruction that leads to decreased gas transfer capacity. COPD consist of 2 types that are irreversible such as chronic bronchitis and emphysema. The cause airflow obstruction is due to bronchial thick wall that resulted from scarring and swelling bronchial mucosa. Hyperplasia of bronchial mucous goblet cells make sputum which increased in mucus production with formation of mucus plugs and later become sputum build up leading to obstructive pulmonary disorder. With an increased in bronchial wall thickness, there is an increased in resistance of breathing and increase in high demand of oxygen. There is an increased in pulmonary artery resistance due to hypoxemia and hypercarbia being mismatch with ventilation perfusion in the system (Banasik et al., 2019).Signs & Symptoms:People with chronic bronchitis presenting with excess body fluids and seen as overweight, chronic cough which is more severe in mornings, shortness of breath on exertion, increased sputum and in the later stage would be cyanosis (Banasik et al., 2019).Diagnostic Tests:COPD can be diagnosed by chest X ray to determine signs of pulmonary hypertension, pulmonary function tests to evaluate the normal total lung capacity, residual volume and the increase or decrease of FEV1 and FEV1/FVC. ABG test to determine the level of CO2 and O2 saturation and an ECG to find evidence of right ventricular hypertrophy and atrial arrhythmias (Banasik et al., 2019).Treatment Plan: Management of COPD are smoking cessation, bronchodilator therapy and reduction to exposure of irritants. Medications like inhaled short acting B2 agonists and cough suppressants could help with COPD treatment. And other management are adequate rest, and proper hydration (Banasik et al., 2019).Patho for Anemia: Anemia is a red blood cell deficit while having a low oxygen carrying capacity of the blood. Due to the increased of red blood cell destruction and deficiency in circulating red blood cells, red blood cell production is low. Since the function of the red blood cell is to deliver and transport O2 from the lungs to the tissues and CO2 the other way around, a decreased number in red blood cells can impair the body’s ability in gas exchange activity (Harding, 2020).Signs & Symptoms:Most common clinical manifestations are pallor, fatigue, malaise, shortness of breath and decreased in activity tolerance (Harding, 2020).Diagnostic Tests:Anemia can be diagnosed through complete blood count such as red blood cell count and Hb electrophoresis since function of hemoglobin is to carry oxygen to the rest of the body (Banasik et al., 2019).Treatment Plan:Foods high in iron, vitamin B12 supplements and transfusion of red blood cells (Banasik et al., 2019).
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