Capella FPX 4015 Assessment 5

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

Good day, Ms. Tehanata. I am Harry, and I will perform a head-to-toe assessment today to check on your overall health and well-being. This evaluation will guide us in creating a care plan that best fits your needs. If you feel uneasy or need a break, please let me know. We’ll get started now.

Comprehensive and Professional Assessment

I begin by observing your general appearance. You appear alert and oriented to person, place, and time. There is no acute distress, though I do notice some shortness of breath while you speak, which is common in heart failure. As I check your vital signs, I note a blood pressure of 148/90 mmHg, a heart rate of 92 beats per minute, a respiratory rate of 22 breaths per minute, and an oxygen saturation of 94% on room air. Your temperature is within the normal range at 98.7°F. These findings indicate slightly elevated blood pressure and heart rate, consistent with your condition.

Next, I assess your head and neck. Your pupils are equal and reactive to light, and no jugular vein distention is observed at a 45-degree angle. I palpate your carotid arteries, which feel strong and equal bilaterally. Moving on to your heart, I auscultate and hear a regular rhythm with the presence of a soft S3 sound, often associated with fluid overload in congestive heart failure. I then listen to your lungs and note diminished breath sounds at the bases with fine crackles, suggesting fluid accumulation or pulmonary congestion.

As I examine your abdomen, I see it is soft, non-tender, and slightly distended, possibly due to fluid retention. Bowel sounds are present in all four quadrants. When I assess your extremities, I observe 2+ pitting edema in both lower legs and ankles, pointing to fluid retention. Your peripheral pulses are present but slightly diminished. Your skin is warm to the touch but pale, with a capillary refill time of about three seconds, which may suggest delayed peripheral perfusion. Lastly, I check your neurological status. You’re able to follow commands easily, and your speech is clear. Your grip strength is strong bilaterally, and you can lift your legs with no difficulty, indicating intact motor function and no immediate neurological concerns.

Discussion of Diagnosis and Findings

Ms. Tehanata, based on the head-to-toe assessment, several findings suggest you may be experiencing symptoms consistent with congestive heart failure. You presented with noticeable shortness of breath, bilateral lower extremity edema, elevated blood pressure, and lung auscultation revealed crackles, particularly in the lower lobes. These symptoms typically point to fluid overload, which occurs when the heart is not effectively pumping blood, causing fluid to back up in the lungs and extremities (Builder, 2021). Additionally, I detected an S3 heart sound, which often indicates volume overload and is commonly heard in patients with heart failure (Williams et al., 2023). Although your oxygen saturation remains stable, these clinical findings highlight a need for further evaluation and potential adjustments in your treatment regimen, such as optimizing your diuretic therapy to reduce fluid retention (Suri & Pamboukian, 2021).

I want to ensure you understand how these findings relate to your condition. The fluid in your lungs is why you feel breathless, and the leg swelling comes from the same process — your heart is struggling to keep up with circulating blood, and fluid leaks into surrounding tissues (Kim, 2022). Monitoring your daily weight, reducing sodium intake, and reporting any worsening symptoms are essential steps you can take to manage your condition. Do you have any questions about what I found or how it relates to your heart health?

Understanding of Pharmacological Needs

Aiyana, based on what we found during your physical assessment—like the swelling in your legs, shortness of breath, and the sounds in your lungs—we’re seeing signs that your heart isn’t pumping as strongly as it should. This condition is called congestive heart failure. Don’t worry, you’re not alone in this—many people live well with this condition when it is managed carefully with the right medications and daily habits. To help your heart work more efficiently and reduce the extra fluid in your body, we’ll likely start or continue a diuretic, which is often called a “water pill.” This will help your body eliminate the extra fluid, making you feel bloated and short of breath. You may notice you go to the bathroom more often, and I’ll need you to watch for any dizziness or signs of dehydration.

You may also be prescribed medications like ACE inhibitors (for example, lisinopril) to help lower your blood pressure and ease the workload on your heart, and beta-blockers (like carvedilol) to slow your heart rate and protect your heart over time. Both long-term treatments have been shown to improve heart function and help people with heart failure live longer and feel better (Strauss et al., 2021). We must look at your full health history before finalizing your medications. If you have kidney issues or are taking other prescriptions, we may need to adjust your doses or monitor certain blood levels, like potassium. Some drugs can interact with others or cause side effects, so we want to make sure we are choosing the safest and most effective plan just for you.

Also, I want to remind you to avoid using over-the-counter pain relievers like ibuprofen, unless we’ve cleared them. These can worsen heart failure by causing your body to hold onto salt and water. We will review each medication together, and I will give you printed instructions too, so you feel confident and informed. Your care will include regular checkups and lab tests to ensure everything works as it should. I am here to answer your questions and help you feel supported every step of the way.

Understanding of Pathophysiology

Aiyana, I want to explain what is going on in your body with congestive heart failure so that you can better understand how it affects you and what to watch for. Your heart’s main job is to pump blood, carrying oxygen and nutrients to all body parts. In heart failure, your heart becomes weaker and can’t pump blood as effectively. This leads to blood and fluid backing up, especially in the lungs, legs, and other tissues (Kim, 2022). The condition mainly affects your cardiovascular system but also your respiratory system, which is why you might feel short of breath or wheeze, especially when lying down.

That happens because the fluid backs up into your lungs. You may also notice swelling in your legs or feet, called edema, which occurs because fluid builds up in your lower body. You might feel more tired than usual or like everyday tasks take more energy. This happens because your body is not getting as much oxygen-rich blood as it needs (Builder, 2021). If heart failure gets worse and isn’t managed well, the symptoms usually become more noticeable. You might feel more breathless, even at rest.

You may gain weight quickly from fluid retention or feel a tight, heavy feeling in your chest. Sometimes people even hear themselves wheezing or feel gasping for air during sleep. These are all signs that we need to adjust treatment or seek help right away. Knowing what to look and listen for in your body will help us catch problems early and stay in control of your health. You’re not alone in this, and we’ll manage it step by step together.

Critical Thinking and Clinical Reasoning 

Aiyana, based on the findings from your assessment and our understanding of congestive heart failure (CHF), we need to prioritize several aspects of care to manage your condition effectively and prevent further complications. The priority is managing fluid retention. CHF can cause fluid to accumulate in the body, leading to symptoms such as swelling in the legs or fluid buildup in the lungs, which can affect your breathing. We will focus on diuretics, such as furosemide, to help your body remove excess fluid. Regularly monitoring your weight and observing any changes in swelling or difficulty breathing will be important in managing this issue (Abassi et al., 2022).

Another key area is optimizing heart function. Since CHF affects the heart’s ability to pump blood effectively, we will use medications like ACE inhibitors (e.g., enalapril) or ARBs (e.g., losartan) to help reduce the strain on your heart. These medications have been shown to prevent further damage to the heart muscle and improve overall heart function. Additionally, we may consider beta-blockers, such as metoprolol, to lower the heart’s oxygen demand and help improve its efficiency (Wołowiec et al., 2023). These treatments are supported by strong clinical evidence demonstrating their ability to improve outcomes, reduce hospitalizations, and increase survival rates in patients with CHF.

Capella FPX 4015 Assessment 5

A third priority is to monitor and address arrhythmias. Since CHF can increase the risk of abnormal heart rhythms, we will closely monitor your heart rhythm. If necessary, we will use medications like amiodarone to help regulate your heart rhythm and reduce the risk of complications (Pannone et al., 2021). Finally, we will emphasize patient education. You need to understand how to manage your condition at home.

This includes dietary modifications, such as reducing sodium intake, and daily weight tracking to monitor any sudden increases in fluid retention (Podvorica et al., 2021). By actively managing your health in this way, you can reduce the risk of complications and hospitalizations. These priorities are grounded in best practices and evidence-based guidelines emphasizing a comprehensive approach to managing CHF. By combining the insights from your assessment with knowledge of pharmacology and pathophysiology, we ensure that your care is effective and personalized to meet your needs. 

Conclusion

I appreciate your time and cooperation today, Ms. Tehanata, during this assessment. Your health is my top concern, and I am committed to providing you with the best care possible. We will closely monitor your condition, make any necessary changes, and work together to ensure the best results for your health. Please feel free to reach out if you have any questions or require additional support. I’m here to assist you throughout this process.

References

Abassi, Z., Khoury, E. E., Karram, T., & Aronson, D. (2022). Edema formation in congestive heart failure and the underlying mechanisms. Frontiers in Cardiovascular Medicine, 9(933215). https://doi.org/10.3389/fcvm.2022.933215 

Builder, V. (2021). Mosby’s pathology for massage professionals – e-book. Google Books. https://books.google.com/books?hl=en&lr=&id=KT1BEAAAQBAJ&oi=fnd&pg=PA234&dq=+symptoms+typically+point+to+fluid+overload 

Capella FPX 4015 Assessment 5

Kim, J. H. (2022). Heart and circulatory system. In Recent Advancements in Microbial Diversity (pp. 229–254). Academic Press. https://doi.org/10.1016/B978-0-12-822368-0.00010-4

Kim, J.-H. (2022, January 1). Chapter 11 – heart and circulatory system (J. Y. Cho, Ed.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128223680000104 

Pannone, L., D’Angelo, G., Gulletta, S., Falasconi, G., Brugliera, L., Frontera, A., Cianfanelli, L., Baldetti, L., Ossola, P., Melillo, F., De Blasi, G., Malatino, L., Landoni, G., Margonato, A., Della Bella, P., Zacchetti, D., & Vergara, P. (2021). Amiodarone in ventricular arrhythmias: still a valuable resource? Reviews in Cardiovascular Medicine, 22(4), 1383. https://doi.org/10.31083/j.rcm2204143 

Podvorica, E., Bekteshi, T., Oruqi, M., & Kalo, I. (2021). Education of the patients living with heart disease. Materia Socio Medica, 33(1), 10. https://doi.org/10.5455/msm.2021.33.10-15 

Strauss, M. H., Hall, A. S., & Narkiewicz, K. (2021). The combination of beta-blockers and ACE inhibitors across the spectrum of cardiovascular diseases. Cardiovascular Drugs and Therapy, 37(4), 757–770. https://doi.org/10.1007/s10557-021-07248-1 

Suri, S. S., & Pamboukian, S. V. (2021). Optimal diuretic strategies in heart failure. Annals of Translational Medicine, 9(6), 517–517. https://doi.org/10.21037/atm-20-4600 

Capella FPX 4015 Assessment 5

Williams, J. B., Harmon, D., & Lindenfeld, J. (2023). Physical exam for the presence and severity of heart failure. Managing Heart Failure in Primary Care: A Case Study Approach, 35–53. https://doi.org/10.1007/978-3-031-20193-6_4 

Wołowiec, Ł., Grześk, G., Osiak, J., Wijata, A., Mędlewska, M., Gaborek, P., Banach, J., Wołowiec, A., & Głowacka, M. (2023). Beta-blockers in cardiac arrhythmias–Clinical pharmacologist’s point of view. Frontiers in Pharmacology, 13(13). https://doi.org/10.3389/fphar.2022.1043714 

 

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