Nursing Case Study discussions

Nursing Case Study discussions
Discussion #1
1. Discuss the history of the present illness that you would take on this patient in preparation for the clinic visit. Include questions regarding Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, and Severity (OLDCARTS).
HPI:
Ms. Susan Johnston is a 60-year-old female that presented to the clinic with complaints of intermittent chest pain that has been occurring for the last 3 months on exertion. She has a history of hyperlipidemia, hypertension, and a family history of Diabetes and cardiac disease. At the present time, she is non-compliant with her current medication regime of lisinopril 20mg, hydrochlorothiazide 25mg, and occasional aspirin.
Nursing Case Study discussions
Ms. Johnston states that her chest pain is in the “middle of her chest” and says her pain level can be 6/10 on the pain scale at its worst. She states that the discomfort occurs when she is “active” climbing stairs and is relieved by rest. Ms. Johnston describes her pain as “burning at times and sometimes tingling” but also stated, “it always goes away”. She did state that she has some shortness of breath with the occurrence. She denies any symptoms of dizziness or passing out. Also denies any radiation of pain to the neck, jaw, or arm. She has not been woken by the pain and has no nausea or vomiting during or after the pain onset.
Describe the physical exam and diagnostic tools to be used for Ms. Johnston. Are there any additional you would have liked to be included that were not?
The physical exam to be used on Ms. Johnston includes a full head-to-toe assessment which showed no abnormalities besides obesity and hypertension.  An EKG was also completed which
showed normal sinus rhythm. Labs were drawing including a CBC, TSH, basic metabolic panel, and
a fasting lipid panel. CBC allows us to get a foundation of the hemodynamics of her system and
check for signs of ischemia. By drawing a TSH we can check for possible thyroid dysfunctions that
may be contributing to her ailments such as her weight gain. With the lipid panel we can assess
the risk to Ms. Johnston for coronary artery disease

After receiving the Lab results back it was noted that her ASCVD score was at a 7.2% which
increases her risk for a cardiac event. A chest x-ray was completed and Ms. Johnston was sent
for a stress test and a cardiac Cath procedure where a stent was placed.
I feel that all the diagnostics and labs performed were appropriate. If we were to add anything
possibly dopplers to make sure there are no other signs of lack of perfusion to the peripherals as
well. What plan of care will Ms. Johnston be given at this visit; what is the patient education and
follow-up?
During the follow-up visit, we would like to gauge Ms. Johnston’s compliance with her medications.
Set up an appointment for 6-12 weeks to redraw the lipid panel to check for compliance (University of Michigan Medicine, 2014). We will discuss possible diet changes and safe physical activities for her to complete in order to better her health and weight.

Nursing Case Study discussions Discussion #2
Ms. Johnston, a 60-year-old patient presented with a complaint of non-radiating midline chest pain, onset about 3 months ago, intermittent in nature, and lasting 2-3 minutes after the onset, described as burning with occasional tingling sensations.
The patient is not endorsing any aggravating factors, associated with the complaint of this chest
pain. The patient didn’t identify any specific relieving factors, stating that the chest pain is self-resolving with the worst exacerbation’s pain score of 6/10.

The patient's initial vital signs are within defined limits, with exception of blood pressure of 138/78, and 136/82 thereafter. A review of medications was performed in order to connect the findings from the physical exam to the medication efficacy. The patient endorses taking lisinopril and hydrochlorothiazide, although is still hypertensive.
Family history was obtained, which helps identify the risk factors, as related to the genetic pre-
disposition. Paternal family history of a heart attack at age 57, which poses a risk factor when looking comprehensively at findings. Social history was obtained and the patient is a non-smoker, which decreases her associated cardiovascular risk.
Also, the dietary habits were assessed with the patient shown to be obese with a BMI of 35.5 and
denying following healthy diet habits. This finding created a need for associated education and
dietary intervention plan. Overall, the physical assessment was within defined limits. I think that
additionally, an EKG should be a standard tool for gathering data when related to any patients with complaints of chest pain, arrhythmia, and/or shortness of breath. In this particular case with Ms.Johnson, she also presents with multiple risk factors that just amplify the need for EKG testing.

This patient should be given a thorough education about the need for lifestyle modifications. The patient needs to follow a heart-healthy diet that will help her heart function and also potentially
reduce excess weight. The patient also will need to be instructed that she may benefit from an
individually tailored physical activity program and refer her to the resources available. The patient
had been started on new medications, so thorough teaching on medication regimens and
medication side effects is warranted. Medication compatibility needs to be assured. The patient will benefit from a referral to cardiology for follow-up, so a new evaluation, later on, can be conducted and see if the further need for intervention is warranted. The patient needs to be given education on signs and symptoms of worsening condition, therefore prompting the patient to seek further medical care.
It is important to understand that the patient will feel comfortable in receiving information and navigating it accordingly. Increasing healthcare literacy is paramount. Physicians must promote patient education and engagement through improvement in patients' health literacy. Health literacy is defined as the capacity to seek, understand, and act on health information. The presumption has been that low health literacy means that physician communication is poorly understood, leading to incomplete self-health management and responsibility and incomplete healthcare utilization. It is the responsibility of physicians to proactively enable patients to have more accessible interactions and situations that promote health and well-being (Patrick, Patel, Tajik, & Chandrasekaran, 2017).

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