Apa Case Study Cardiovascular Disease
West Virginia University at Parkersburg
Nursing 131 – Physical Assessment
Case Study – Cardiovascular Disease
Nancy Riverhawk is a 75-year-old woman who presents to the provider’s office with fatigue.
Subjective Data
PMH: HTN, hyperlipidemia, MI 3 years ago
Fatigue started about 1 month ago, getting worse
Relieved with rest, exacerbated with activity
Denies pain chest
Ankles swollen
Objective Data
Vital signs: T 37, P 112, R 18, BP 110/54
Lungs: bilateral lower lobe crackles
O2 sat: 94%
Skin: cool to touch
CV: heart rate regular, positive peripheral pulses
ECG: no changes
+2 edema bilateral ankles
Medications: metoprolol 20 mg per day, aspirin 325 mg per day
Answer the questions and submit via Dropbox …show more content…
chronic
Is there a simple reason for the fatigue-such as boredom, extra activity, no sleep, etc.…
What is the quality of your sleep?
Have you had any recent illnesses or change in medications OTC or prescribed?
Any new stressors in your life? - Such as family/health /financial/emotional/physical etc..
What does your diet consist of on a daily basis, is this new? - Also does it include alcohol/caffeine/smoking if so how much?
2. What other assessments would be for this patient?
Full head to toe neuro/skin/lungs/heart/pulses/skin turgor/percussion/BP/temp, etc.…
Maybe some tests such as; ECG, EKG, stress test, sleep test/observation, etc.…
Lab tests such as CBC w/ diff, TSH, LFP, cholesterol, A1C, serum glucose, fasting glucose, U/A, CMP, B12, ECT…
Review of medications, past medical history, vaccination records, environmental factors, family history
Assessment of other current problems or symptoms.
Weight
3. What are some causes of …show more content…
Develop a problem list from objective and subjective data.
Problem list:
Pain, HTN, Hyperlipidemia, edema of lower extremities, elevated HR, decreased BP, fatigue, bil lung adventicous sounds
5. What should be included in the plan of care?
Teaching – diet/meds/exercise/when to seek medical attention/ reduce risk factors
Monitor- Strict I&O, Freq. VSs, monitor cardiac rhythm, edema-TED/SCD/elevate, lung sounds, o2 saturation, skin integrity, neuro checks, pain, pulses, lab values, s/e of current medication, daily weight.
Encourage- compliance with diet, medication regimen, exercise program, and overall health maintenance.
6. Based on the readings, what is the most likely cause of fatigue for this patient?
CHF
HR- 112 - Heart pumps harder in attempt to get more blood to the body.
Fatigue- Due to less blood and oxygen to vital organs.
Edema- Due to the weakness of the heart pumping less fluid to the kidneys. Kidneys release renin, angiotensin, and aldosterone which holds on to sodium and attracts fluid into the vascular system.
Lung crackles: The weak heart contractions cause fluid to build up in
Nursing 131 – Physical Assessment
Case Study – Cardiovascular Disease
Nancy Riverhawk is a 75-year-old woman who presents to the provider’s office with fatigue.
Subjective Data
PMH: HTN, hyperlipidemia, MI 3 years ago
Fatigue started about 1 month ago, getting worse
Relieved with rest, exacerbated with activity
Denies pain chest
Ankles swollen
Objective Data
Vital signs: T 37, P 112, R 18, BP 110/54
Lungs: bilateral lower lobe crackles
O2 sat: 94%
Skin: cool to touch
CV: heart rate regular, positive peripheral pulses
ECG: no changes
+2 edema bilateral ankles
Medications: metoprolol 20 mg per day, aspirin 325 mg per day
Answer the questions and submit via Dropbox …show more content…
chronic
Is there a simple reason for the fatigue-such as boredom, extra activity, no sleep, etc.…
What is the quality of your sleep?
Have you had any recent illnesses or change in medications OTC or prescribed?
Any new stressors in your life? - Such as family/health /financial/emotional/physical etc..
What does your diet consist of on a daily basis, is this new? - Also does it include alcohol/caffeine/smoking if so how much?
2. What other assessments would be for this patient?
Full head to toe neuro/skin/lungs/heart/pulses/skin turgor/percussion/BP/temp, etc.…
Maybe some tests such as; ECG, EKG, stress test, sleep test/observation, etc.…
Lab tests such as CBC w/ diff, TSH, LFP, cholesterol, A1C, serum glucose, fasting glucose, U/A, CMP, B12, ECT…
Review of medications, past medical history, vaccination records, environmental factors, family history
Assessment of other current problems or symptoms.
Weight
3. What are some causes of …show more content…
Develop a problem list from objective and subjective data.
Problem list:
Pain, HTN, Hyperlipidemia, edema of lower extremities, elevated HR, decreased BP, fatigue, bil lung adventicous sounds
5. What should be included in the plan of care?
Teaching – diet/meds/exercise/when to seek medical attention/ reduce risk factors
Monitor- Strict I&O, Freq. VSs, monitor cardiac rhythm, edema-TED/SCD/elevate, lung sounds, o2 saturation, skin integrity, neuro checks, pain, pulses, lab values, s/e of current medication, daily weight.
Encourage- compliance with diet, medication regimen, exercise program, and overall health maintenance.
6. Based on the readings, what is the most likely cause of fatigue for this patient?
CHF
HR- 112 - Heart pumps harder in attempt to get more blood to the body.
Fatigue- Due to less blood and oxygen to vital organs.
Edema- Due to the weakness of the heart pumping less fluid to the kidneys. Kidneys release renin, angiotensin, and aldosterone which holds on to sodium and attracts fluid into the vascular system.
Lung crackles: The weak heart contractions cause fluid to build up in