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

Hello, my name is __________, and today I will be conducting a detailed head-to-toe evaluation of the patient, Aiyana Tehanata, as presented in the Sentinel U simulation. Aiyana has reported numbness in her feet, a moderate pain level rated 5 out of 10, and elevated blood glucose levels. This examination includes a full-body systems review, proper documentation of clinical findings, and providing health education throughout the process. Each aspect of the assessment is verbally explained to ensure clarity and enhance Aiyana’s understanding of her condition.

Holistic and Structured Assessment

Upon initiating the physical examination, Aiyana’s overall appearance suggests significant fatigue. Her breathing is strained, and she adopts a tripod position—a common indication of respiratory distress, possibly associated with reduced cardiac output. The pallor of her skin and mild lower extremity edema could indicate circulatory inefficiency, potentially a symptom of coronary heart disease (CHD) (Alevroudis et al., 2024).

Table 1: Vital Signs and Physical Observations

Measurement/Observation	Findings	Interpretation
Temperature	98.4°F	Normal body temperature
Heart Rate	96 bpm	Slightly elevated; indicative of increased cardiac activity
Blood Pressure	140/88 mmHg	Elevated; suggestive of potential hypertension
Respiratory Rate	22 breaths/min	Marginally high; may be due to compromised oxygenation
Oxygen Saturation	94% (room air)	Mildly low; requires ongoing observation for hypoxia

Neurological and HEENT Evaluation

The neurological evaluation reveals that Aiyana is alert and oriented to person, place, and time. Her pupils are symmetrical and responsive to light. There are no symptoms suggestive of a transient ischemic attack or stroke. Her speech is somewhat slowed but coherent, which could be secondary to cardiac stress. Coordination remains unaffected. In the HEENT assessment, the skull is of normal contour, while a slight pallor in the conjunctiva suggests anemia (Siddiqui et al., 2022). Ear and nasal assessments are unremarkable. However, the oral mucosa appears dry, which might be a side effect of diuretics prescribed for cardiac conditions.

Cardiovascular, Respiratory, and Abdominal Systems

Cardiac auscultation detects an S4 heart sound—commonly seen in patients with CHD due to stiff ventricular walls (Pechetty & Nemani, 2020). The apical pulse is irregular, possibly pointing to atrial fibrillation. Peripheral pulses are weak, and Aiyana’s complaint of tingling in her feet could be attributed to peripheral arterial disease, a common CHD complication (NHLBI, 2024). Absence of jugular vein distention helps eliminate the possibility of right-sided heart failure. Lung sounds are clear; however, her rapid breathing and use of upright positioning (orthopnea) signal respiratory discomfort (Mukerji, n.d.).

Abdominal examination reveals no visible distension, normal peristalsis, and mild tenderness in the right upper quadrant, with no evidence of liver enlargement or fluid accumulation. These findings do not indicate right-sided heart failure.

Musculoskeletal and Integumentary Examination

The musculoskeletal evaluation shows reduced grip strength and weakness in the lower limbs, which could stem from decreased blood flow and physical inactivity. There is no visible joint deformity or contracture, though minimal muscle wasting is present. The skin is pale and cool to the touch, consistent with impaired vascular supply. The skin on the lower legs is glossy and taut, possibly suggesting chronic edema. Capillary refill is delayed, supporting the diagnosis of poor peripheral perfusion (McGuire et al., 2023).

Diagnostic Summary and Plan

Aiyana exhibits multiple signs indicative of CHD, such as diminished circulation, elevated blood pressure, and irregular heartbeat. Symptoms like numbness and fatigue may arise from suboptimal oxygen delivery. Clinical management may include modifying medications, adopting a heart-healthy diet, and increasing daily physical activity. All examination findings will be reported to her healthcare provider to refine her treatment plan (Gaudel et al., 2022).

Pharmacological Considerations

Medications that may benefit Aiyana include:

• Furosemide (Lasix): Helps relieve fluid retention.
• Metoprolol: A beta-blocker used to reduce cardiac workload.
• Lisinopril: An ACE inhibitor for blood pressure control, with a known side effect of a persistent cough (Marti et al., 2020).
• Spironolactone: Aids in managing hypertension and fluid imbalance.

For diabetic patients, caution is advised when using beta-blockers as they can mask hypoglycemia. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, should be avoided due to their tendency to promote fluid retention (Bindu et al., 2020). Continuous monitoring for adverse drug reactions is essential.

Pathophysiology of CHD

Coronary heart disease is characterized by atherosclerosis, where plaque builds up inside coronary arteries, restricting blood flow to myocardial tissues. The limited oxygen supply can cause symptoms such as chest pain, breathlessness, and fatigue. If left untreated, CHD may progress to myocardial infarction or congestive heart failure. Furthermore, reduced perfusion can impact other organs like the liver, worsening systemic hypoxia (Shahjehan & Bhutta, 2024). Early identification and consistent monitoring of hallmark signs are vital for effective management.

Clinical Reasoning and Care Priorities

Improving Blood Circulation: Use of antiplatelet agents like aspirin or clopidogrel and cholesterol-lowering medications such as atorvastatin is crucial. Nitroglycerin may be administered to relieve angina, while lifestyle changes enhance therapeutic outcomes.

Optimizing Cardiac Function: Medications like beta-blockers and ACE inhibitors regulate heart rhythms and support cardiac output. Blood pressure and heart rate monitoring guide dose adjustments.

Preventing Adverse Outcomes: For advanced CHD, interventions such as coronary angioplasty or bypass surgery might be needed. Routine imaging and lab tests aid in early complication detection.

Fostering Self-Management: Patients should be educated about heart-healthy habits, including nutritious diets, regular physical activity, and avoiding tobacco. Recognizing early warning signs empowers timely intervention and reduces emergency visits.

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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

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

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

Capella 4015 Assessment 5

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