Capella FPX 4015 Assessment 5

Name

Capella University

NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care

Prof. Name

Date

Comprehensive Head-To-Toe Assessment

Hello, my name is ____. Based on the case study of Sentinel U., a comprehensive body examination of the patient Aiyana Tehanata will commence. Her primary symptoms involve foot tingling, moderate pain at a level of 5, and higher-than-normal blood sugar levels. Throughout the evaluation of all major body systems, I will narrate my actions while reporting findings to Aiyana and delivering appropriate patient instructions, which will enhance her understanding of her illness.

Thorough and Professional Evaluation

I have started by evaluating your health status. The manner in which you rest and breathe heavily with exercise while maintaining a tripod position signals possible respiratory distress because heart oxygenation has decreased. You display signs of inadequate blood flow due to your pale skin and low body temperature. Your lower legs show minor enlargement. The manifestation of peripheral edema in the legs and hands forms a common condition for patients with Coronary Heart Disease (CHD) due to venous congestion.

Your vital signs are being checked as I proceed with the examination. Your body temperature currently measures 98.4 degrees Fahrenheit, which falls within the normal parameters. Your current heart rate of 96 beats per minute shows your heart is putting in extra effort to move blood throughout your body. The pressure readings in your blood measure 140/88 mmHg, indicating a condition that often occurs in CHD and hypertension, resulting in increased cardiovascular strain. Your breath rate reaches 22 per minute, which constitutes an elevated level that clinicians link to dyspnea caused by ischemic conditions leading to decreased blood flow to the heart tissue. You have an oxygen saturation level of 94% while breathing room air, although it falls below normal. The medical staff needs continuous monitoring to identify the risk of hypoxia as well as worsening ischemic conditions (Bhutta et al., 2024).

I will conduct your assessment of neurological functions. You must provide your identity, together with your geographical position and the date. The results indicate your cognitive abilities are intact because you show proper awareness of your identity along with your present setting and current date. With the aid of a penlight, I check your pupils, which are equal to each other and round in shape, while showing normal light sensitivity. You show no localized brain deficits, and you do not present signs that would indicate either a stroke or TIA, which CHD patients may develop. Your slowness of speech suggests that your heart works harder to function normally (Mayo Clinic, 2024). Your ability to coordinate movements was preserved according to results from the standard finger-to-nose test and tests of alternating movements.

Your HEENT examination finds a typical head shape without any detectable issues. Your eyes show a mild pallor in the sclera area, possibly because anemia exists as a common CHD comorbidity that impairs oxygen delivery. You do not display the yellowing characteristic of jaundice. The examination of your ears indicates a normal appearance without hearing problems. The examination of your nose shows no sign of congestion or nasal passages being flared open. A dry appearance of your mucous membranes indicates slight dehydration, which results from the diuretic medications used in CHD treatment (Mayo Clinic, 2024). Your oral examination shows no lesions, and your complete HEENT assessment indicates typical organ health apart from some minimal issues.

Heart assessment is the next step of this examination. I identify an S4 heartbeat while listening with the stethoscope because these sounds frequently appear in CHD patients due to left ventricular hypertrophy and reduced ventricular compliance. An irregular apical pulse indicates that atrial fibrillation might be present as a typical heart condition that develops from heart failure due to diminished blood flow in CHD patients. Weak blood flow through your extremities is shown through the diminished pulses detected at the radial and dorsalis pedis. The blockage of blood vessels known as atherosclerosis leads to peripheral arterial disease (PAD) in CHD patients, resulting in foot tingling (Mayo Clinic, 2024). The 45-degree jugular vein observation reveals no enlargement of veins, which prevents a diagnosis of right-sided heart failure. The dependent edema in your lower legs appears low-grade, and I believe it is mainly caused by structural vessel injuries instead of fluid accumulation.

The examination of your respiratory system begins with the use of my stethoscope at present. Your breath sounds remain clear as you demonstrate neither crackles nor wheezing noises. Your quick breathing pattern seems to result from reduced cardiac output that causes exercise-related breathing difficulties. Your condition of optimized air intake occurs in an upright position, which is known as orthopnea. I will conduct the assessment of your abdominal area. You show no swelling during physical examination. Hearing bowel sounds occurs throughout each of the abdominal regions since gastrointestinal function remains normal. The right upper quadrant shows mild pain upon touch, whereas no liver congestion signs are seen, making this different from right-sided CHF symptoms. The absence of both hepatomegaly and ascites points away from heart failure, since these abnormalities often occur in cases of heart failure (NIH, 2023).

The evaluation of your musculoskeletal system requires my attention at this time. Your hand grip reduces in strength, probably because of fatigue. You demonstrate weak leg muscle response when pushing against my hands with your feet through mild weakness, which indicates blood circulation issues, along with limited physical activity, while eliminating fluid retention as a factor. The reduced transport of oxygen alongside nutrients throughout your legs could result in the sensation in your feet becoming tingling. You do not present any deformities or contractures at the joints. The loss of muscle tissue in your lower limbs seems to stem from the combined effects of illness duration and limited physical movement.

I proceed with examining your skin. Your light-colored skin surface, along with slight coolness, suggests problems with circulation. The skin shows no markings such as rashes or lesions. The stretch on your lower legs manifests as shine because of prolonged fluid retention, yet lacks any dimples. The capillary refill test reveals white discoloration in your skin, which disappears and returns at a slow pace, indicating reduced blood circulation. The research results match symptoms that occur with arterial insufficiency, which is usually found in CHD patients (NIH, 2023).

Analysis of Diagnosis and Findings

Your insufficient blood flow to the heart stems from CHD, according to my evaluation of your condition. Your past history of blood pressure abnormalities, together with high cholesterol levels, raises your chances of getting this disease. Inadequate heart oxygen supply during my examination assessment led the heart to increase its workload, which generated elevated heart rate patterns along with unpredictable heartbeat patterns. The foot tingling sensation, together with dizziness, often indicates that poor circulation affects your condition, as seen with CHD patients.

The state of your heart becomes burdened by high blood pressure along with increased heart rate, yet the narrowing of your blood vessels results in reduced heart pumping effectiveness (NIH, 2023). CHD reduces heart function, which your doctor would manage through appropriate changes to your treatments and recommendations for better heart function, a recommended heart-healthy diet, and activity. Information about my evaluation with normal and abnormal results will help your physician create an optimal treatment plan. You can freely ask any questions you have.

Comprehension of Pharmacological Requirements

Treatment for CHD in Aiyana will require medication that supports heart pumping efficiency and prevents fluid accumulation in the body. The physician will select medication for your particular health needs, which include Furosemide (Lasix) and Methotrexate. The heart rate reduction and strain-decreasing properties of metoprolol help patients control their condition. Your exhaustion due to these medicines should decrease as weeks pass by. The medication Lisinopril manages blood pressure by relaxing blood vessels, enabling better heart pumping efficiency and reduced blood pressure levels. Tell our office right away if Lisinopril triggers a dry cough, since it is listed as a medication side effect. The aldosterone antagonist Spironolactone stabilizes fluid balance and reduces hypertension, and these benefits will help your condition.

Keeping track of your blood sugar closely becomes your priority because beta-blockers might affect the management of your diabetes. Assessment and management of heart failure must omit NSAIDs, including ibuprofen, because they induce fluid retention that worsens your symptoms (American Heart Association, 2023). Inform the healthcare provider about any side effects you experience so immediate assessments can take place whenever you notice dizziness or swelling or discover unusual symptoms. I want to know if you need clarification either on the medications or on how they help treat your heart issues and diabetes.

Comprehension of Pathophysiological Mechanisms

Knowledge of CHD body processes remains essential for understandable healthcare. The heart functions as the blood distribution center of the body, while CHD develops from atherosclerosis that produces plaque deposits, which cause either blocking or narrowing of the coronary arteries. The blocked path interrupts the flow of oxygen and nutrients towards the heart muscle tissue. The harmful effects of CHD on the heart and blood vessels extend to liver circulation restriction that worsens oxygen delivery. The blocked oxygen supply to heart muscles causes angina (chest pain) along with shortness of breath, and will result in heart attacks when oxygen becomes critically scarce.

The circulatory deficiencies lead to dizziness and fatigue, as well as unpredictable irregularities in heartbeating patterns. While resting, normally, fluid accumulation in the lungs makes it harder to breathe until the situation is explained. Worsening CHD conditions will potentially result in the development of secondary heart problems, including heart failure and arrhythmias. Blood pressure checks, along with cholesterol tracking and symptom observation, must happen every day to properly control CHD (Schwinger, 2021). Inform your doctor right away about worsening chest pain, together with breathlessness, dizziness, or swelling, because this allows for fast heart health management.

Analytical Thinking and Clinical Decision-Making

The blockage of the heart arterial pathways diminishes heart oxygen delivery, which raises heart attack dangers and produces chest pain (angina) and foot numbness. The medication aspirin or clopidogrel stops blood clotting to prevent blockages, whereas atorvastatin, along with other statins, helps decrease cholesterol levels to prevent artery plaque formation. Medical staff use Nitroglycerin as an angina treatment because this medication expands blood vessels while relaxing their muscular walls. Blood flow improvement and symptom relief of foot tingling require medical treatments, and patients must follow healthy eating habits and exercise regularly for effective results (Kim & Schaller, 2023).

The use of beta-blockers including metoprolol assists in controlling hypertension and decelerating heart rate which reduces strain on the heart. Therapeutic use of ACE inhibitor lisinopril helps veins to relax thus enhancing blood circulation and decreasing heart stress. Listening to blood pressure alongside heart rate assessment is crucial for both checking treatment effectiveness and stopping complications from developing. Medical providers need to change medications when patients present differing responses to their prescribed treatments (American Heart Association, 2023).

CHD patients face an elevated risk for heart attacks, together with arrhythmias and strokes, which require proper complication prevention. To treat severe artery blockages, doctors usually perform angioplasty or implement bypass surgery to restore standard blood circulation in the body. Medical professionals provide blood-thinning drugs to decrease the possibility of blood clots forming in patients. Cholesterol testing, along with blood pressure monitoring, and laboratory assessments form important elements for early detection of heart-related problems. Patients must obtain lifestyle and self-care education because this knowledge helps them deal with CHD while eliminating other health difficulties.

Patients need to follow a diet that contains low amounts of saturated fats, cholesterol, and sodium to sustain healthy arteries. Regular physical exercise combined with smoking cessation reduces the likelihood of heart attacks, along with enhancing overall heart health. Patients need to know the early signs of chest pain, together with shortness of breath and dizziness, to immediately report to their healthcare provider (Diab et al., 2023).

CHD management according to the American Heart Association (AHA) and American College of Cardiology (ACC) requires medicine combinations together with lifestyle modification and routine patient monitoring. Medical research indicates that proper management of blood pressure and blood sugar and cholesterol levels helps decrease heart attack possibilities alongside enhancing lasting health. Healthcare providers achieve better patient success through the combination of updated CHD management guidelines and patient data integration to develop individualized care strategies that reduce complications (American Heart Association, 2023).

Conclusion

The management of CHD needs clinical examinations combined with medication and lifestyle changes, as well as ongoing medical check-ups. A combination of medication control, which includes beta-blockers, ACE inhibitors, and statins, with lifestyle adjustments involving healthy eating and exercise, helps patients regulate their symptoms to avoid further complications. Patient outcomes, together with long-term heart health improvement, require prompt detection as well as early medical intervention. Healthcare providers, alongside patients, must work together for better disease management that leads to enhanced quality of life.

References

American Heart Association. (2023, July 10). Medications used to treat heart failure. Www.heart.org. https://www.heart.org/en/health-topics/heart-failure/treatment-options-for-heart-failure/medications-used-to-treat-heart-failure

Bhutta, B. S., Alghoula, F., & Berim, I. (2024). Hypoxia. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK482316/

Diab, A., Dastmalchi, L. N., Gulati, M., & Michos, E. D. (2023). A heart-healthy diet for cardiovascular disease prevention: Where are we now? Vascular Health and Risk Management, 19(19), 237–253. https://doi.org/10.2147/VHRM.S379874

Capella FPX 4015 Assessment 5

Kim, K. H., & Schaller, D. J. (2023). Nitroglycerin. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482382/

Mayo Clinic. (2024, August 13). Heart disease – diagnosis and treatment – mayo clinic. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/heart-disease/diagnosis-treatment/drc-20353124

NIH. (2023, December 20). Coronary heart disease – diagnosis | NHLBI, NIH. Www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/coronary-heart-disease/diagnosis

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302