Cardiac issues /care plan/diagnoses

Cardiac issues /care plan/diagnoses
Analyze the case study assigned to you at the outpatient clinic. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-9 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
•Search term page to identify the codes applicable to the care plan. http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx
•This link will lead to an excel version of the latest codes: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
HPI
A 52-year-old Irish American male is discharged from the hospital. He was hospitalized for four days after a stent placement, following admission from the emergency room with angina symptoms. This patient presented to the emergency room with four hours of crushing chest pain. He was short of breath with exertion and diaphoretic. The patient thought he was having a heart attack and was afraid to come to the hospital. The symptoms lasted for four days before the patient sought help. The patient had been suffering from similar symptoms for the past six months but thought that he just out of shape. It was worse upon admission to the hospital. Prior to this, the symptoms disappeared with rest.
His symptoms were relieved in the emergency department with medication and he was transferred to the cardiac floor for catheterization.
The patient’s symptoms were highly debilitating upon his admission to the emergency department.
Prior to his admission to the hospital for this event, the patient was not very active because of his angina symptoms. The pain that he had was substernal and crushing and radiated to his neck and jaw. His symptoms resolve with rest only. He has not sought any therapeutic maneuvers.
He is currently asymptomatic and is here for a follow-up visit from his hospitalization to discuss his risk factors. The patient is still concerned that he may have other episodes of angina, even after the stent placement.
PMH
The patient has not sought care for his problems in the past. He had been treated for hypertension and high cholesterol in the past but stopped medication on his own. Besides that, he has had no other significant illnesses.
He was hospitalized for a cholecysectomy ten years ago
This patient had a baseline EKG at his doctor’s office when he was first prescribed his blood pressure medication. Otherwise he’s had no other investigations for heart disease besides his cholesterol levels checks.
Results of Laboratory Investigations Following Hospitalization
Total cholesterol – 210
LDL- 200
HDL- 25
Triglycerides – 250
Fasting blood sugar – 140
HgbA1c – 7.5
CXR – hyperinflation of the lungs – no infiltrate
EKG – no change from baseline.
Risk Factors:
• High blood pressure
• Hypercholesterolemia
• Type 2 diabetes
• Android obesity
• Cigarette smoker
• Positive family history
Past surgical history of Cholecysectomy, almost 10 years age without any complications.
ROS
Review of systems is otherwise negative
DISCHARGE MEDICATIONS
Tenormin XL 50 mg QD
Lipitor 10 mg QD
Glucophage – 500mg BID
Baby ASA QD
Patient is now compliant with the prescribed regimen, but wasn’t in the past. The medicines were prescribed by the physician who discharged him from the coronary care unit.
ALLERGIES/REACTIONS
Patient has no known drug allergies
SOCIAL HISTORY
The patient is a high school graduate and a licensed carpenter and is anxious to get back to work because of finances. His income is around $50,000.00 per year. His wife is currently disabled with uncontrolled type 2 diabetes. The patient has disrupted self-efficacy because he is not sure whether he can care for his wife, who needs his help, now that he is sick. They live paycheck to paycheck and cannot afford a vacation. They have three grown-up children who have left home and do not live in the area. The patient has lived in the same city all his life. He does not participate in sports or any other physical activity. The streets of his neighborhood are not safe for exercising; the crime rate is high. There is little community socialization and most people are at the poverty level.
He is the sole bread winner in the family. His stress level is very high because of the impending bills that he needs to pay while he is not able to work. He believes that a man should be able to care for his family and be strong enough not to suffer from any illnesses himself.
The patient and his wife live in a one-bedroom apartment in an inner city, quite isolated from their community. They do not have any relatives living in the area nor do they socialize with neighbors. He has little emotional or social support. He is stressed most of the time and is now suffering from depressive symptoms such as sleeping excessively and over eating.
This patient has health insurance through the union to which he belongs, but it does not offer complete coverage of all his prescription medications. Though he goes to a clinic that is associated with the hospital, he does not always see the same primary care provider.
HABITS
• Diet Habits
The patient usually eats one large meal a day after work. He skips breakfast most of the times and eats fast food for lunch. He eats few fruits and vegetables; mostly pasta and meat at home.
He feels that he got all the exercise he needed when he was a young man, and the exercise he gets as a carpenter now is sufficient to keep him healthy.
Smoking: He smokes 1 pack per day from the past 30 years
Alcohol: Does not drink
Substance Use: Denies street drug use
• WORK HABITS
He’s always been a carpenter; has no hobbies and reads at home.
FAMILY HISTORY
He has two older brothers who are being treated for high blood pressure and type 2 diabetes. Both brothers were diagnosed with these disorders in their early forties.
Both parents are deceased; father from heart disease, and mother from breast cancer.
7. PHYSICAL EXAMINTAION
Vital Signs: BP: 160/92 left are sitting; P:60 ; R: 16; T: 98; Wt: 220#; Ht:– 70”
HEENT: WNL
Lymph Nodes: None
Lungs: Decreased breath sounds throughout, no adventitious sounds
Heart: RRR without murmur
Carotids: Right bruit
Abdomen: Android obesity, WC = 44 inches
Rectum: Not examined
Genital/Pelvic: NA
Extremities, Including Pulses:
Decreased pedal pulses BL with lower leg edema from ankle to mid calf.
Neurologic: Not examined
EKG: No change from baseline
Care Plan Template
Patient Initials: ______ Age: _______________ Sex: ___________
Subjective Data:
Client Complaints:
HPI (History of Present Illness):
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
Significant Family History:
Social/Personal History (occupation, lifestyle—diet, exercise, substance use)
Description of Client’s Support System:
Behavioral or Nonverbal Messages:
Client Awareness of Abilities, Disease Process, Health Care Needs:
Objective Data:
Vital Signs including BMI:
Physical Assessment Findings:
Lab Tests and Results:
Client’s Support System:
Client’s Locus of Control and Readiness to Learn:
ICD-9 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
References