Student Name: Dimietris Thompson, CNL Student Case Study # 1 Case Study #2 Name and page of Case:Chest Pain Page 33 Leg Pain Page 62 List equipment required for a thorough assessment Exam room Adequate lighting • Gown • Stethoscope (bell and diaphragm) Sphygmomanometer Thermometer Watch with a second hand Computer program to record findings Exam room Adequate lighting • Gown • Stethoscope (bell and diaphragm) Sphygmomanometer Thermometer Watch with a second hand Computer program to record findings Preparation Verify that you have the correct patient and introduce self to patient.
• Ensure patient privacy at all times and comfort. Adjust lighting and room temperature as needed. Patient is sitting upright on examination table with legs hanging off or supine • Patient is disrobed to waist Wash hands and don gloves as necessary Explain to patient what to expect and the procedure you’re about to perform · Explain the use of equipment Obtain a general survey of how the patient looks like as a whole and baseline vital signs. •Obtain weight, height and calculate BMI by ( insert)
• Verify that you have the correct patient and introduce self to patient. • Ensure patient privacy at all times and comfort. • Adjust lighting and room temperature as needed. Patient is sitting upright on examination table with legs handing off or supine • Have patient put on gown. Wash hands and don gloves as necessary Explain to patient what to expect and the procedure you’re about to perform • Explain the use of equipment • Obtain a general survey of how the patient looks like as a whole and baseline vital signs and the overall appearance of the patient’s legs for any abnormalities. • Obtain weight, height and calculate BMI by ( insert) Focused Health History
1. Do you presently have, or in the past experienced high blood pressure or any symptoms of high blood pressure including dizzy spells and vertigo? . Can you list your current medications including any medications for high blood pressure? 3. What type of chest pain are you having? I. e. dulI, aching, tightness, sharp or stabbing. 4. On a scale of 1 to 10 with 10 being the worst and 1 being not so bad can you rate the pain? 5. Is the pain relieved by nitroglycerin or aspirin? If so, how many do you take? 6. When did the pain start? 7. Does the pain radiate to another location? 8. Is the pain increased by physical activity or exertion including walking, climbing stair or being fatigue or upset?
9. Does the pain occur during a particular time of day? I. e. morning or evening. 10. Are there any other associated symptoms that manifest including sweating, shortness of breath, feelings like your heart is skipping a beat or racing and/or nausea/vomiting? 11. Does the pain come and goes or is it constant and does it come unexpectedly and during what type of day? 12. Do you notice any changes in your skin? For example, any blue or ashen appearance? 13. Any history of any illnesses such as hypertension, high cholesterol or diabetes? 14. Any history of tobacco use, alcohol use or recreational drug use? 15. Any recent changes in weight? 16. Any family history of heart disease or any other medical condition?
17. What have been the results of any past ECGS or other cardiovascular test? 1. Do you have any history of smoking tobacco, drinking alcohol, and/or recreational drug use? 2. Any recent changes in weight? 3. Can you list your current medication including any high cholesterol, blood or heart medications? 4. Are you experiencing any numbness or tingling? 5. Describe the location and characteristic of the problem: a. What causes it to occur? b. What relieves it? c. Isit constant or intermittent? d. Does any medication relieve it? e. Do you notice any temperature changes in the area? f. Are the leg pains a problem while walking or running? . Does rest bring relief?
6. Any history of any illnesses such as hypertension, high cholesterol or diabetes? 7. Have you ever had any sores or wounds on your legs or arms that healed poorly? 8. Have you noticed any swelling in your arms or legs? 9. Any family history of heart disease, peripheral vascular disease or high cholesterol? 10. Any abdominal pain after meals or any weight changes? Focused Physical Assessment Steps Reference your information. In addition to the following focused physical assessment it would be important to assess the following systems: skin, HEENT, neck, thorax and lungs, and eripheral vascular/extremities.
Inspection: 1. Inspect the anterior chest and observe the heart area for any bulging, retraction or pulsation. 2. Inspect the neck for any distention of the vessels with an “indirect light” observes for venous pulsations and with the patient’s head extended and lying flat observe for arterial pulsations. 3. Observe the extremities. a. Note nail shape and color and the presence of clubbing or thickening. b. Note skin color for the distribution of pigment based on patient’s heritage and presence of pallor, cyanosis and any pigment changes. c. Note hair distribution. d. Note skin texture . Note any obvious pulsations. f. Note any edema (University of Nebraska Medical Center, n. d. ).
Palpation: 1. Palpate the precordium by having patient lie down flat and feel the right and left sternal borders as well as the apex and base of the heart. 2. Palpate for an apical impulse which may or may not be palpable, by feeling at the 5th left intercostal space at mid clavicular line and observing if you can feel hand being lifted off the chest wall or any vibrations 3. Palpate extremity pulses bilaterally except carotids. Palpate carotid arteries one at a time to prevent cutting off brain circulation.
Note pulses for rate, rhythm, amplitude and elasticity. 4. Palpate extremities and note skin temperature, capillary refill by pinching tip of fingernail and toe nail and noting the seconds it takes to return color to pink (University of Nebraska Medical Center, n. d. ). Percussion: 1. Percuss the outline of the heart and observe for the area on the left border at mid clavicular line for dullness (University of Nebraska Medical Center, n. d. ).
Auscultation: 1. Auscultate the heart sounds by inching along the precordium using stethoscope. May close eyes for increased concentration. 2. Observe for the S1 (best heard at apex or the bottom of heart) S2 (best heard at the base or top of heart) heart sounds “Lubb-Dubb”. 3. Observe for the presence of abnormal heart sounds: S3 and S4 which is heard at the apex. 4. Auscultate for heart murmurs and thrills (vibrations felt over the precordium that sound similar to purring cat). Palpable as thrill and heard as a murmur 5. If heart murmur heard, note: site, radiation, time, pitch, intensity, duration, and quality. 6. Auscultate carotid pulse for abnormality – bruits or blood rushing through the narrowed vessel which would sound like a “whooshing” sound by using the ell of the stethoscope and asking patient to hold his or her breath.
7. Obtain BP in both arms while patient is lying down, sitting and standing with 2-3 minutes in between to obtain orthostatic blood pressure (University of Nebraska Medical Center, n. d. ) In addition to the following focused physical assessment it would be important to assess the following systems: skin, HEENT, neck, thorax and lungs, cardiovascular, and abdomen. Inspection: 1. Observe patient’s arms, legs, feet and toes. Note: color including presence of blackening of extremities, size, symmetry, swelling, presence of ulcers, scars, rashes, (be sure to check in- etween toes), and any other skin changes including color (pallor, cyanosis) and venous pattern (Bickley & Szilagyi, 2013).
Palpation: 1. Palpate patient’s legs for temperature by starting distally feeling with back of hand and comparing bilaterally and noting differences. 2. Check capillary return by compressing nail bed and releasing and noting the seconds it takes to return to pink 3. Any varicosities, which you noted in the observation, should now be palpated. 4. Palpate abdominal aorta (estimate width by measuring it between two fingers) and each of the peripheral pulses bilaterally, comparing one side to the other.
Including: a. Aorta, this should be palpated just to the left of the midline in the epigastrium. b. Femoral, feel at the mid inguinal point, below the inguinal ligament. c. Popliteal – ask the patient to flex their knee (45 degrees) keeping their foot on the bed relaxed, place both hands on the front of the knee and place your fingers in the popliteal fossa. d. Posterior tibia – curve fingers behind and a little below the medial malleolus of the ankle e. Dorsalis pedis- feel on the dorsum of the foot, lateral to the extensor tendon of the great toe.
5. Assess pitting edema by pressing firmly using thumb for about 2 seconds over the dorsum of each foot and observing any depression caused by the pressure, if any measure using four point scale from slightly to very marked (Bickley & Szilagyi, 2013). Auscultation: 1. Listen for aortic, renal, femoral and abdominal aortic bruits (Bickley & Szilagyi, 2013). Health promotion nursing interventions The likely diagnosis for this case study is a Myocardial Infraction based on his health history of hypertension x 25 years, tobacco use of 1 pack a day since age 15, family history of myocardial infraction and hypertension, characteristics of the hest pain and his physical assessment findings of: obesity, pale/ diaphoretic appearance, elevated blood pressure, etc. As a Clinical Nurse Leader I would recommend the following evidence base practice interventions and health care promotion initiatives for Mr. F. The American Heart Association (2015) suggest the following:
1. Encourage smoking cessation and to avoid second hand smoke, as smoking is a controllable risk factor. 2. Maintain healthy diet, which is the best weapon against heart disease. Diet has the power to affect other controllable risk factors like cholesterol, blood pressure, diabetes and obesity. Diet should be rich in foods that contain vitamins, minerals, and fibers that are low in calories. Diets should contain mostly vegetables, fruits, whole grains, low-fat dairy products, fish, legumes, nuts and limited intake of sweet, carbonated drinks and red meat. Avoid salty food, which can cause high blood pressure, which is a major risk factor for stroke and heart diseases.
3. Encourage physical activity 3-4 per week, averaging 40 minutes involving moderate to vigorous intensity activity which research has shown helps lower blood pressure, cholesterol, and maintains health weight. Research also shows that people who do moderate levels of fitness versus low levels live longer. 4. Reducing weight helps, as obesity heightens risk for cardiovascular diseases. 5. Reducing stress can affect risk factors for heart disease and stroke. 6. Drinking excessive alcohol can raise blood pressure and increase heart diseases.
If an individual does drink, it is best to limit alcohol to n more than two drinks per day for men and no more than one drink per day for women. The likely diagnosis for this case study is Peripheral Vascular Disease based on his health history of leg pain characteristics, hypercholesterolemia, hypertension, two packs of cigarettes daily x 45 years, three beers per night intake, surgical history of coronary angioplasty and inguinal hernia repair and his physical assessment findings of: obesity, elevated blood pressure, murmur, liver span, cool to touch extremities, hair and skin ppearances on extremities and pulses. As a Clinical Nurse Leader I would recommend the following evidence base practice interventions and health care promotion initiatives for Mr. V. Mayo Foundation for Medical Education and Research (2016) suggest the following:
1. Smoking cessation: Smoking contributes to the constriction and destruction of the body’s arteries and a major risk factor for the development and worsening of peripheral artery disease. Quitting smoking can reduce the risk of complications significantly. 2. Exercise: an indicator of successful treatment of PVD is the how far an individual can walk without pain. With the right exercise routine an individual can condition their muscles to utilize oxygen more vely. There are claudication exercise rehabs available. 3. Diet: A heart-healthy diet low in saturated fats can help manage blood pressure and blood cholesterol levels. A good diet and exercise can reduce weight, which can help, as obesity is also another risk factor for PVD.
4. Limitation of certain cold medications: There are some over the counter medications that contain the ingredient pseudoephedrine like Tylenol Cold, Claritin-D and Advil Cold which can contribute to the construction of the blood vessels and can worsen symptoms of PVD. 5. Proper Foot care: Encourage proper foot care including washing feet daily, keeping them dry and moisturize to prevent cracks and infections, wear good fit shoes, trim nails as needed, inspect feet for injuries and seek doctor for any sign of sore or injury to skin on feet. Individuals with PVD are at risk for poor healing of sores on lower legs and feet so it is important.
