Assessment Task 1B Case studies

Assessment Task 1B Case studies

 

Part 1of the Case Studies

Physical activity places a lot of demand on the cardiovascular and respiratory systems. Strength, endurance, dexterity, and alertness depend on adequate respiratory and cardiovascular function. Reduced cardiovascular function, for instance, from myocardial ischemia, or from mechanical dysfunction like reduced peripheral perfusion or valve defects can affect the person’s strength, endurance, dexterity, strength, and alertness.  The assessment of job requirements relevant to the cardiovascular system requires information about critical the person’s performance level is and the effects of worsening of and cardiovascular disorders.  The cardiovascular history offers psychological and physiological information that guides physical assessment, the laboratory tests and the mode of treatment. The nurse asks about the past heath history, presenting symptoms, current health status, family history, risk factors, and personal and social history. During the history, the nurse also asks about behaviors that jeopardize or promote cardiovascular health and they use the information in directing health teaching. During the procedure of performing a physical examination and taking a through history, the nurse has the chance to establish rapport with the patient and to evaluate the general emotional status of the patient.

Subjective Data

Question 1: Are you currently in any pain?

Nurses begin the history through investigating the chief complaints of the patient. In the case study on Mr. Richard Kleinfelt (DOB: 12.03.1962) UR 768953; 41 Williams Road, I will ask him to describe in his own words the reason for seeking care. I will ask Kleinfelt about any associated symptoms like chest pain, edema of ankles or feet, dyspnea, palpitations and syncope, hemoptysis and cough.  Chest pain is the most common symptom of people with cardiovascular ailments. Thus, it entails an important component of the assessment interview. The patient may be hesitant to start a conversation about chest pain because the pain is mainly a frightening or even disturbing experience. Therefore, it is important to ask the patient to talk about any pain they are experiencing. In case the patient reports any chest pain symptoms, I will ask him about the onset of the symptoms and whether the onset was gradual or sudden.

Question 2: Have you had any heart surgeries in the past?

As part of taking past history from the client, I will inquire about past  cardiovascular surgeries like valve replacement, coronary artery bypass grafting, peripheral vascular procedures and any other health problems.

Question 3:  Are they taking any medications or supplements for these symptoms?

As part of the heath history, I will query the Mr. Mr. Richard Kleinfelt about the use of prescription or over-the-counter drugs, herbs and vitamins. Additionally, I will ask him about food allergies, drug allergies or any previous allergic reactions to drug of food agents.

Question 4: Do you smoke or use alcohol or other drugs?

I will also ask Mr. Richard Kleinfelt about use of alcohol and tobacco. Tobacco smoking raise the risk of myocardial infarction to more than twice that if nonsmokers. Drinking too much alcohol can raise the blood pressure, lead to stroke, cause heart failure and contribute to obesity and high triglycerides.

Question 5: Describe your typical day, whether at work or doing other activities.

Assessment of cardiovascular disease risk factors is a crucial element of the history.  Risk factors are grouped into major risk factors that can be treated; uncontrollable risk factors and contributing risk factors. Major uncontrollable risk factors include heredity, age, gender and race. Major risk factors that be controlled include tobacco smoking, hypertension, High blood cholesterol, obesity, diabetes mellitus and physical activity. Other contributing factors include stress, birth control, sex hormones, excessive use of alcohol and Homocysteine levels.

Question 6: How often do you exercise?

Since obesity is a major risk factor that can be modified or controlled, it is important to ask about the patient’s exercise regime. An association exists between obesity and an increased rate of mortality from stroke and coronary artery disease.

Question 7: How would you describe your stress level over the previous year?

An individual’s response to stress may be a contributing factor to cardiovascular disease. For instance, people under stress may smoke, overeat, and not exercise.

Question 8: Describe what you typically eat for breakfast, lunch and dinner.

What a person eats may contribute to progression of other conditions like high blood cholesterol. Increased levels of blood cholesterol raise the risk of coronary heart disease. I will pay special attention to diets rich in sugar, salt and fat.

Question 9: Does anyone in your family (who is living) have heart disease or any other cardiovascular issues?

I will ask about the health and age of close family members including grandparents, children, siblings, parents and grandchildren.

Question 10: Has anyone in your family passed away from cardiovascular disease?

Family history plays a significant role in a patient’s wellbeing and cardiovascular health. By asking the question, I can get a good sense of Mr. Richard Kleinfelt’s risk factors for cardiovascular disease like coronary artery disease and blood clots.

Objective Data

In the assessment of Mr. Richard Kleinfelt’s cardiovascular system, I will evaluate the adequacy of cardiac output which includes

1. General Appearance

I will inspect Mr. Richard Kleinfelt as soon as we interact. I will take note of his posture, gait and musculoskeletal coordination.

2. Jugular Venous Distension

Any pressure in the jugular vein would reflect right arterial pressure thus providing me with and indication of hemodynamics plus cardiac function. The height of the blood level in the jugular vein indicates right atrial pressure since there are no obstructions or nerves between the right atrium and the vein. The pulsation of a normal jugular vein should not exceed three centimeters above the angle of Louis.

3. Color of Mucous Membranes & Skin

Cyanosis may indicate inadequate oxygenation

4. Temperatureof Extremities

Cold skin may a sign of existing or new circulatory system issues. Hot skin may indicate fever and it needs a follow up with a complete vital signs. Closely inspecting a patient’s extremities can also offer clues about cardiovascular wellbeing. I will examine the extremities for ulcerations, lesions, unhealed sores and varicose veins. Additionally, I will inspect the distribution of hair on the extremities. A lack of normal distribution of hair on the extremities may be a sign of diminished arterial blood flow to the extremities.

5. 5. Heart Rate, Blood Pressure, SpO2

Baseline vital signs are paramount in any assessment. They should be compared to Mr. Richard Kleinfelt’s normal values. Trends and patterns out of the normal range will be reported to the relevant person.

6. 6. Capillary Refill

I will press on the toe nail beds/ or fingers until there is blanching, I will then release the pressure and count the seconds it took for the patient’s full color to return.  A delayed cap refill of greater than three seconds may suggest respiratory or cardiovascular dysfunction and it will be followed up with a focused assessment.

7. Edema

I will compare limbs simultaneously to compare. I will also ask Mr. Richard Kleinfelt if it is normal for them to have any swollen areas. Unilateral edema of the leg may be an indication of deep vein thrombosis (DVT).

8. Palpate extremities to assess warmth, color, movement and sensation

Warmth and color offer information about perfusion. Movement offers an overview of the musculoskeletal activity of extremities which is affected by circulation.  Sensation can be assessed by asking Mr. Richard Kleinfelt if has a tingling in extremities or numbness which will give me a brief overview of his baseline. Altered sensation may be due to impaired perfusion or neurological function.

9. Auscultate: Apical Heart Rate for Rate and Rhythm

I will assess apical pulses by placing the stethoscope on the patient’s 4^th to 5th intercostal space of the midclavicular line on the left side. For accurate auscultation I will ensure that the patient is well relaxed and comfortable, in a warm, quiet environment with adequate lighting.

10. Clubbing of Nails

Clubbing of nails may indicate underlying cardio pulmonary disease.

 

 

References

Dharwadkar, P.S., 2018. PATIENT SAFETY IN TERMS OF QUALITY CARE AND DOCUMENTATION. LIFE SCIENCE EDGE, 5(1), p.79.

Antniemi-Mouchette, A.L., 2019. How does the nursing summary tool support professional nurse competences?.

Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The differential diagnosis of dyspnea. Deutsches Ärzteblatt International, 113(49), 834.

Ranson, M., & Braithwaite, W. (2017). Cardiovascular assessment. Clinical Examination Skills for Healthcare Professionals.