PHYSICAL EXAM:
You will be expected to write up your response as follows:
List of Differential Diagnoses [rank ordered]
A. Congestive Heart Failure
B. Angina
C. Hypercholesterolemia
D. Myocardial Infarction
E. Diabetes Mellitus
F. with Grade II diastolic heart failure.
G. Hypertriglyceridemia
H. GERD
I.
J. Hypertension
Leading hypothesis : Congestive Heart Failure
Active Alternative hypotheses
Must not miss diagnoses [critical rule outs]
Congestive Heart Failure
Angina
Hypertriglyceridemia
Hypercholesterolemia
Most common diagnoses [reasonable alternatives]
GERD
Hypertension
Diabetes Mellitus
Presumptive Diagnosis [assumption]
Congestive Heart Failure
Treatment Plan
Non-pharmacologic / lifestyle interventions (provide rationale)
• Modify Diet.
- Advance to a low-sodium, low-cholesterol, low-fat, solid diet as tolerated R: to minimize metabolic demands and decrease fluid retention and subsequently the workload of the heart.
- Increase fiber intake R: to decrease the cholesterol level and prevent constipation
- Emphasize fruits, vegetables, whole grains and low-fat dairy foods. Encourage potassium in diet. R : can help prevent and control high blood pressure.
-Encourage adequate fluid intake. R: to prevent dehydration
-Reinforce to continue with smoking cessation R: to prevent exacerbation of heart problems and prevent cancer
-Inform client to avoid alcoholic drinks and caffeinated, acidic drinks. R: Alcohol often precipitates heartburn, by compromising the lower esophaegeal sphincter, irritating the esophagus, and by stimulating stomach acid production. R: aggravate symptoms by irritating the esophagus or stimulating stomach acid production.
Encourage patient to participate in a regular exercise program
Avoid any strenuous activity R: causes chest pain, shortness of breath or undue fatigue
Instruct client/ SO(s) in monitoring response to activity and recognizing signs and symptoms R: This indicates need to alter activity level of patient.
Plan for progressive increase of activity level as tolerated by client R: Both activity tolerance and health status may improve with progressive training.
Plan care to carefully balance rest periods with activities R: to reduce fatigue
Assist client in learning and demonstrating appropriate safety measures R: to prevent injuries
Encourage client to maintain positive attitude; suggest use of relaxation techniques R: to enhance sense of well-being
Teach home monitoring of weight, pulse, and or BP as appropriate R: to detect change and allow for timely intervention.
Instruct in stress management techniques, as indicated R: to promote wellness
5. Pharmacologic interventions [drug, dose, route, frequency (specific schedule), duration, refills, rationale for selection]
Toprol XL 50 mg QD – Toprol is a beta blocker antihypertensive. The client should take the medication in 50 mg dosage, once a day, orally. Take metoprolol at the same time every day. Metoprolol should be taken with food or just after a meal. Metoprolol is only part of a complete program of treatment for hypertension. Toprol XL doses can be adjusted for CHF, diabetes, liver or kidney disease ("Nursing Central | metoprolol", n.d.).
Lotensin 10 mg BID – Lotensin (benazepril) is an ACE (Angiotensin converting enzyme) inhibitor. It is used to treat hypertension, CHF and heart attacks. This should be taken in 10 mg dose, twice a day, orally. You may take Lotensin with or without food. Drink plenty of water every day while on this medication ("Lotensin: Uses, Dosage & Side Effects - Drugs.com", n.d.).
Glucophage 500 mg BID – Glucophage is an oral antihyperglycemic drug used in treatment of Type 2 diabetes. Should be given in 500 mg dose, twice a day, orally. Glucophage should be given in divided doses with meals. This decreases hepaticglucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization ("Glucophage", n.d.).
Plavix 75 mg QD – Plavix (Clopidogrel Bisulfate) is an anti-platelet medication. It is used to prevent blood clots. Blood clots can form in blood after heart or blood vessel conditions. Should be given in 75 mg, once a day, orally (Karabin, 2016).
Cimetidine 200 mg BID prn – Cimetidine is a histamine H2-receptor antagonist. It is used for treatment in GERD. It blocks histamine which stimulates the release of acid into the stomach. This reduces acidity in the stomach. It must be taken in 200 mg doses, twice a day, as needed ("Cimetidine: Indications, Side Effects, Warnings - Drugs.com", 2016).
SL Nitroglycerin prn – Nitroglycerin is a nitrate that works by relaxing and widening the blood vessels of the heart. It is used to treat angina pectoris. This drug is taken sublingually. If the chest pain has not improved after 5 minutes, emergency help should be called. Five minutes after the second dose, if chest pain has not subsided, take another dose. Do not use more than three doses ("Nitroglycerin sublingual", 2016).
Bactrim (rash) – Bactrim is an antibiotic, a combination of sulfamethoxazole and trimethoprim. The recommended dosage for prophylaxis in adults is 1 Bactrim DS (double strength) tablet daily ("Bactrim (Trimethoprim and Sulfamethoxazole)", 2016).
Patient Education
Focus areas: intended use & expected action, potential interactions (drug-drug, with/without specific foods), storage/preparation/administration, side effects/adverse reactions (what to do), missed dose (what to do), special precautions (e.g., no driving)
Web sites for patients wishing to access health education information (disease and treatment)
http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.jsp
http://www.healthline.com/health/familial-hypercholesterolemia
Plan for Follow-up
Alarm symptoms to notify office or seek emergent care, if present
Symptoms of a heart attack, such as chest pain or pressure, shortness of breath, and nausea.
Fainting
Rash, itching/swelling (especially of the face/tongue/throat),
Severe dizziness,
Trouble breathing
Follow-up / Return for appointment
Persistent high blood pressure
Persistent chest pain
Lipid blood tests
Treatment cost
Toprol XL 50 mg QD - $15.47
Lotensin 10 mg BID - $3.90
Glucophage 500 mg BID - $3.60
Plavix 75 mg QD - $10.08
Cimetidine 200 mg BID prn -$ 15.99
SL Nitroglycerine prn -$ 9.87
Bactrim - $ 4.08
Answers to Case Questions
Are there other laboratory or diagnostic tests that would be important to obtain prior to treatment? Briefly describe these tests and why you think they are important. What information would they provide and how would this information guide your choice of treatment?
a. Chest radiograph – uses x-ray to view the chest and its contents. This would reveal cardiomegaly and vascular congestion of lung fields.
b. Electrocardiogram- checks the electrical activity of the heart. This identifies hypertrophy or myocardial damage.
c. Serum enzyme studies reveal elevated levels of creatinine phosphokinase, lactate dehydrogenase nd troponin.
d. CBC or complete blood count evaluate overall health and detect a wide range of disorders.
Are there any drug interactions of concern? Briefly explain your answer. What teaching is important with regard to potential interactions with over-the-counter medications?
The drug interaction that causes concern is the drug interaction between Plavix and Cimetidine (Tagamet). Tagamet could reduce the effectiveness of Plavix Over-the-counter drug Ibuprofen increases the risk of GI bleeding when used with Plavix.. The interaction between nitroglycerin and Toprol XL can also cause hypotension. With these potential drug interactions, it is the priority of the nurse to monitor any unwanted effects.
It is important to inform the client that before he uses over-the-counter drugs, he must first consult with his physician.
What health risks are posed by his occupation? What role might occupation play in management of his health? How does his alcohol consumption likely affect his medication regimen?
As a truck driver, he spends most of his day sitting and driving not being able to do physical activities. Since his condition has much to do with lifestyle choices, considering he has heart problems and diabetes, physical activity is very much recommended. He says he has occasional alcohol consumption which is not acceptable since he is taking medications that have proven to have interactions with alcohol.
Should you be concerned about the laboratory results for kidney function? Briefly explain your answer.
Yes, the results of kidney laboratory results are concerning. The BUN is above the normal range (30 mg/dL. The creatinine is also slightly above the normal range (1.8 mg/dL). Although generally, elevated values could mean damage with the kidneys, these could indicate CHF and gastrointestinal bleeding.
What concerns do you have for this patient’s long-term prognosis? What history & physical exam findings lead you to these conclusions? How will you communicate your concerns to the patient?
If the patient does not comply with the treatment regimen both with the medications and lifestyle changes, the patient’s prognosis could be bad. Based on the assessment, the patient has heredofamilial tendency for diabetes and other cardiovascular diseases. His lab results such as his lipid exams, glycated hemoglobin, kidney function tests are above the normal range. In the lung assessment, fine crackles are already heard. With his heart assessment, S3 sound was auscultated. Pitting edema was also found in his physical exam. First of all, establishing trust and rapports is the important. Proper health teachings on prevention and lifestyle and diet changes should be done in a manner that the patient will understand. Do not give huge amounts of information all at once and consider the pace and learning style of the patient.
References
Bactrim (Trimethoprim and Sulfamethoxazole). (2016). RxList. Retrieved 23 March 2016, from http://www.rxlist.com/bactrim-drug/indications-dosage.htm
Cimetidine: Indications, Side Effects, Warnings - Drugs.com. (2016). Drugs.com. Retrieved 23 March 2016, from http://www.drugs.com/cdi/cimetidine.html
Doenges, M., Moorhouse, M., & Murr, A. (2006). Nurse's pocket guide (11th ed.). Philadelphia: F.A. Davis.
Glucophage, Glucophage XR (Metformin Hcl) Drug Information: Clinical Pharmacology - Prescribing Information at RxList. RxList. Retrieved 23 March 2016, from http://www.rxlist.com/glucophage-drug/clinical-pharmacology.htm
Karabin, S. (2016). Plavix (Clopidogrel) - Side Effects, Dosage, Interactions | Everyday Health. Everydayhealth.com. Retrieved 23 March 2016, from http://www.everydayhealth.com/drugs/plavix
Lotensin: Uses, Dosage & Side Effects - Drugs.com. Drugs.com. Retrieved 23 March 2016, from http://www.drugs.com/lotensin.html
Nitroglycerin sublingual. (2016). WebMD. Retrieved 23 March 2016, from http://www.webmd.com/drugs/2/drug-6928/nitroglycerin-sublingual/details
Nursing Central | metoprolol. Nursing.unboundmedicine.com. Retrieved 23 March 2016, from http://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/51497/all/metoprolol
