Capella 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

My name is __________, and I will be performing a comprehensive head-to-toe assessment on the patient, Aiyana Tehanata, featured in the Sentinel U case study. Aiyana reports tingling sensations in her feet, a pain intensity of 5/10, and elevated blood glucose levels. This assessment involves evaluating all essential body systems, documenting key findings, and providing educational insights. Each step and corresponding finding will be verbally described for clarity and to enhance patient understanding.

Holistic and Structured Assessment

Initially, I observe the patient’s general condition. Aiyana displays visible fatigue, labored breathing, and maintains a tripod posture, indicative of respiratory difficulty potentially due to reduced oxygenated blood flow to the heart. Pale skin tone and mild swelling in the lower extremities could suggest impaired circulation, possibly linked to coronary heart disease (CHD) (Alevroudis et al., 2024).

Table 1: Vital Signs and Observations

Measurement/Observation	Findings	Interpretation
Temperature	98.4°F	Within normal limits
Heart Rate	96 bpm	Elevated; increased cardiac workload
Blood Pressure	140/88 mmHg	Suggestive of hypertension, a CHD risk factor
Respiratory Rate	22 breaths/min	Slightly elevated; possible ischemic dyspnea
Oxygen Saturation	94% (room air)	Slightly low; requires monitoring for hypoxia

Neurological and HEENT Evaluation

The patient correctly identifies her name, location, and date, confirming orientation. Pupils are round, equal, and reactive to light. No signs of stroke or TIA are present. Speech is slow but coherent, possibly due to cardiac strain. Coordination remains intact. HEENT inspection reveals a normal head shape, mild conjunctival pallor indicating anemia (Siddiqui et al., 2022), and no abnormalities in the ears or nose. Dry mucous membranes may suggest dehydration, often resulting from CHD medications like diuretics.

Cardiovascular, Respiratory, and Abdominal Systems

Heart auscultation reveals an S4 sound, commonly associated with CHD due to ventricular stiffness (Pechetty & Nemani, 2020). Irregular apical pulse indicates possible atrial fibrillation. Peripheral pulses are diminished, and lower limb tingling may point to peripheral arterial disease, a CHD complication (NHLBI, 2024). Jugular vein distension is absent, helping rule out right-sided heart failure. Lung auscultation shows no adventitious sounds, but the patient breathes faster with orthopnea, preferring to sit upright for relief (Mukerji, n.d.).

Abdominal assessment reveals no distention, normal bowel sounds, and mild discomfort in the right upper quadrant without hepatomegaly or ascites, suggesting an absence of right-sided CHF symptoms.

Musculoskeletal and Integumentary Examination

The patient exhibits reduced grip strength and lower limb weakness, likely due to poor circulation and inactivity. No joint deformities or contractures are noted, though minor muscle wasting is observed. Skin assessment reveals pallor and coolness, indicating vascular insufficiency. Shiny, taut skin on the lower legs may suggest chronic edema. Capillary refill is slightly delayed, consistent with compromised peripheral perfusion (McGuire et al., 2023).

Diagnostic Summary and Plan

Aiyana appears to be experiencing manifestations of CHD, including poor circulation, high blood pressure, and arrhythmias. Tingling in the feet and fatigue likely stem from inadequate oxygenation and nutrient delivery. Interventions may involve adjusting current medications, emphasizing a cardiac-friendly diet, and increasing physical activity. Findings will be shared with her provider to optimize care (Gaudel et al., 2022).

Pharmacological Considerations

Treatment may include medications such as:

• Furosemide (Lasix): Reduces fluid overload.
• Metoprolol: A beta-blocker that lowers heart rate and strain.
• Lisinopril: An ACE inhibitor that relaxes vessels and controls blood pressure. Monitor for dry cough (Marti et al., 2020).
• Spironolactone: Manages fluid retention and supports blood pressure control.

Patients with diabetes should be cautious, as beta-blockers can influence glucose levels. NSAIDs like ibuprofen must be avoided to prevent fluid retention (Bindu et al., 2020). Close monitoring of symptoms and side effects is critical.

Pathophysiology of CHD

CHD develops due to plaque accumulation in coronary arteries, impairing oxygen and nutrient supply to heart tissue. This condition results in angina, dyspnea, and fatigue, and may eventually cause heart attacks or heart failure. Systemic effects extend to hepatic circulation, exacerbating oxygen deficits (Shahjehan & Bhutta, 2024). Routine monitoring and early detection of symptoms like chest pain or swelling are vital.

Clinical Reasoning and Care Priorities

Improving Blood Flow: Use of antiplatelets (aspirin, clopidogrel) and statins (atorvastatin) to reduce clotting and cholesterol. Nitroglycerin helps relieve angina. Lifestyle changes are also crucial.

Enhancing Heart Function: Medications such as beta-blockers and ACE inhibitors regulate heart function. Monitoring BP and heart rate ensures therapeutic effectiveness.

Preventing Complications: Advanced CHD may necessitate angioplasty or bypass surgery. Regular diagnostics help identify risks early.

Promoting Self-Care: Educating patients about nutrition, exercise, and smoking cessation is essential. Patients should be empowered to recognize early warning signs and seek timely care.

References

Alevroudis, I., Kotoulas, S.-C., Tzikas, S., & Vassilikos, V. (2024). Congestion in heart failure: From the secret of a mummy to today’s novel diagnostic and therapeutic approaches: A comprehensive review. Journal of Clinical Medicine, 13(1), 12. https://doi.org/10.3390/jcm13010012

Bindu, S., Mazumder, S., & Bandyopadhyay, U. (2020). Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochemical Pharmacology, 180(1), 114147. https://doi.org/10.1016/j.bcp.2020.114147

Capella 4015 Assessment 5

Gaudel, P., Neupane, S., Koivisto, A., Kaunonen, M., & Rantanen, A. (2022). Effects of Intervention on Lifestyle Changes among Coronary Artery Disease Patients: A 6‐month Follow‐up Study. Nursing Open, 9(4). https://doi.org/10.1002/nop2.1212

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., & Milano, C. A. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063

Marti, C. N., Fonarow, G. C., Anker, S. D., Yancy, C., Vaduganathan, M., Greene, S. J., Ahmed, A., Januzzi, J. L., Gheorghiade, M., Filippatos, G., & Butler, J. (2020). Medication dosing for heart failure with reduced ejection fraction — opportunities and challenges. European Journal of Heart Failure, 21(3), 286–296. https://doi.org/10.1002/ejhf.1351

McGuire, D., Gotlib, A., & King, J. (2023). Capillary Refill Time. PubMed Central. https://www.ncbi.nlm.nih.gov/books/NBK557753/

Mukerji, V. (n.d.). Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea. Nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK213/

Capella 4015 Assessment 5

NHLBI. (2024, October 28). Atherosclerosis – What Is Atherosclerosis? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/atherosclerosis

Pechetty, R., & Nemani, L. (2020). Additional Heart Sounds—Part 1 (Third and Fourth Heart Sounds). Indian Journal of Cardiovascular Disease in Women WINCARS, 5(02), 155–164. https://doi.org/10.1055/s-0040-1713828

Shahjehan, R. D., & Bhutta, B. S. (2024, October 9). Coronary artery disease. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK564304/

Siddiqui, S. W., Ashok, T., Patni, N., Fatima, M., Lamis, A., & Anne, K. K. (2022). Anemia and heart failure: A narrative review. Cureus, 14(7). https://doi.org/10.7759/cureus.27167