Capella 4015 Assessment 5

Capella 4015 Assessment 5

Student 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 today I will perform a comprehensive head-to-toe assessment on Aiyana Tehanata, a patient featured in the Sentinel U case study. Her primary complaints include tingling in the feet, a self-reported pain score of 5/10, and elevated blood glucose levels. This evaluation involves a complete review of all major bodily systems to determine clinical findings relevant to her symptoms. I will provide clear verbal communication throughout the process to ensure both transparency and patient education.

Comprehensive and Professional Assessment

The general survey begins with observation of the patient’s physical appearance and demeanor. Aiyana exhibits fatigue, labored breathing especially with activity, and assumes a tripod position, suggesting compromised oxygen delivery. Her skin appears pale, and mild swelling is noted in the lower extremities. Peripheral edema may be indicative of venous congestion, a common feature of coronary heart disease (CHD) (Alevroudis et al., 2024).

Vital Signs: Her temperature registers at 98.4°F, which is within normal limits. The heart rate is elevated at 96 bpm, and blood pressure is 140/88 mmHg, indicating potential hypertension and increased cardiac workload. A respiratory rate of 22 breaths per minute suggests dyspnea, possibly resulting from myocardial ischemia. Oxygen saturation stands at 94% on room air, a borderline value warranting close observation for potential hypoxia.

Neurological Assessment: Aiyana is alert and oriented to person, place, and time. Pupillary assessment reveals equal, round pupils reactive to light. No focal neurological deficits or signs of TIA or stroke are present. Although her speech is slightly slowed, there are no issues with coordination, as evidenced by intact fine motor testing.

HEENT Examination: Her skull is normocephalic with no deformities. Mild scleral pallor is evident, suggesting anemia, a frequent coexisting condition in CHD (Siddiqui et al., 2022). There are no signs of jaundice, and ear and nasal assessments are unremarkable. The oral mucosa is dry, indicating possible dehydration due to diuretic use. No lesions are noted in the oral cavity.

Cardiovascular Examination: Auscultation detects an S4 heart sound, typically associated with left ventricular hypertrophy in CHD (Pechetty & Nemani, 2020). The apical pulse is irregular, hinting at possible atrial fibrillation. Peripheral pulses are diminished, particularly in the radial and dorsalis pedis regions, suggesting peripheral arterial disease (PAD), which can cause foot tingling (NHLBI, 2024). Jugular venous distention is absent, and there is mild dependent edema without pitting, likely due to vessel damage.

Respiratory Assessment: Breath sounds are clear without adventitious noises. However, tachypnea is observed, possibly due to exertional dyspnea from poor cardiac output. The patient exhibits orthopnea, preferring an upright position for breathing comfort (Mukerji, n.d.).

Abdominal Examination: Inspection reveals no distention, and bowel sounds are present in all quadrants. Mild tenderness is noted in the right upper quadrant, but without signs of hepatomegaly or ascites. These findings argue against significant right-sided heart failure.

Musculoskeletal Assessment: Hand grip strength is reduced, and lower extremity motor strength is slightly impaired, likely from deconditioning and poor perfusion. No joint deformities or contractures are observed. Mild muscle atrophy in the lower limbs may reflect chronic illness and decreased mobility.

Skin Assessment: The patient’s skin is pale and cool, indicative of impaired circulation. There are no rashes or lesions, but the lower legs exhibit shiny, stretched skin consistent with chronic edema. Capillary refill is delayed, supporting a diagnosis of arterial insufficiency (McGuire et al., 2023).

Discussion of Diagnosis and Findings

Based on the assessment, Aiyana demonstrates multiple signs of coronary heart disease. Her elevated heart rate and blood pressure, along with irregular pulse and lower extremity tingling, suggest impaired perfusion. These issues arise from atherosclerotic changes and arterial narrowing that reduce cardiac efficiency. The observed symptoms, including dyspnea and orthopnea, further support this diagnosis. Intervention may include medication adjustments, dietary modifications, and physical activity to improve cardiac function (Gaudel et al., 2022).

Understanding of Pharmacological Needs

CHD management includes several pharmacologic interventions. Diuretics such as Furosemide help prevent fluid overload. Beta-blockers like metoprolol reduce heart rate and myocardial workload, although initial fatigue may occur (Marti et al., 2020). Lisinopril, an ACE inhibitor, promotes vasodilation and reduces afterload, though it may cause a dry cough. Spironolactone helps regulate fluid balance and blood pressure. Given Aiyana’s diabetes, careful monitoring is essential, as beta-blockers may mask hypoglycemia. NSAIDs should be avoided due to the risk of fluid retention and cardiovascular strain (Bindu et al., 2020).

Understanding of Pathophysiology

CHD occurs when atherosclerosis leads to plaque buildup within coronary arteries, restricting blood and oxygen supply to the myocardium. This impairs the heart’s ability to function efficiently, resulting in symptoms such as chest pain, fatigue, and dyspnea. When untreated, it may progress to myocardial infarction or heart failure. Compromised systemic and hepatic perfusion may also occur, causing multi-organ impact. Recognizing early warning signs like chest discomfort or swelling is critical for timely intervention (Shahjehan & Bhutta, 2024).

Critical Thinking and Clinical Reasoning

Care Priorities for the Patient with CHF

Care Priority	Description
Enhancing Cardiac Perfusion	Aspirin, clopidogrel, and statins help prevent clot formation and reduce cholesterol levels.
Improving Heart Function	Beta-blockers and ACE inhibitors manage heart rate and blood pressure, enhancing overall cardiac output.
Preventing Complications	Monitoring and intervention prevent stroke, arrhythmias, and potential heart failure.
Patient Education	Promoting lifestyle changes such as low-fat diets, regular exercise, and smoking cessation is essential.

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

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

Capella 4015 Assessment 5

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/

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

Capella 4015 Assessment 5

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