Student Name
Capella University
NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care
Prof. Name
Date
Comprehensive Head-To-Toe Assessment
Hello, my name is ________. Today, I will perform a detailed head-to-toe assessment on my patient, Aiyana Tehanata, from the Sentinel U case study. Her primary concern is tingling in her feet, accompanied by a pain level of 5/10 and elevated blood glucose levels. This assessment will systematically cover all major body systems, highlighting key findings related to her condition. I will explain each step of the assessment verbally and provide patient education to ensure understanding.
Comprehensive and Professional Assessment
As a first step, I am evaluating your overall appearance. You demonstrate signs of fatigue and exhibit labored breathing, particularly during activity, while assuming a tripod position. This posture suggests increased respiratory effort due to reduced oxygen delivery to the heart. Your temperature, pale skin, and mild leg swelling further indicate possible circulatory compromise. Peripheral edema, observed in your lower legs, may be associated with venous congestion often seen in patients with coronary heart disease (CHD) (Alevroudis et al., 2024).
Vital Signs
| Vital Sign | Observation | Clinical Interpretation |
|---|---|---|
| Temperature | 98.4 °F | Within normal range |
| Heart Rate | 96 bpm | Elevated, suggesting increased cardiac workload |
| Blood Pressure | 140/88 mmHg | Indicates hypertension and increased cardiovascular strain |
| Respiratory Rate | 22 breaths/min | Mild tachypnea; may reflect reduced cardiac output |
| Oxygen Saturation | 94% | Slightly low, requires monitoring for hypoxia |
These values suggest that your heart is working harder to maintain adequate perfusion, and careful monitoring is required to prevent further cardiac compromise.
Neurological Assessment
Please state your name, current location, and the present date. You demonstrate full orientation to person, place, and time. Pupils are equal, round, and reactive to light. There are no focal neurological deficits, transient ischemic attacks, or stroke indicators. Your speech is slightly slowed, likely due to increased cardiac workload. Coordination tests, including finger-to-nose and rapid alternating movements, show no abnormalities.
Head, Eyes, Ears, Nose, and Throat (HEENT)
- Head: Normal shape, no irregularities.
- Eyes: Mild pallor of sclera, suggestive of anemia (Siddiqui et al., 2022); no jaundice.
- Ears: Normal structure and hearing.
- Nose: Patent, no congestion or flaring.
- Mouth: Dry mucous membranes indicate mild dehydration, potentially exacerbated by diuretics; oral cavity shows no lesions.
Cardiovascular Assessment
- Heart Sounds: Presence of S4, consistent with left ventricular hypertrophy in CHD (Pechetty & Nemani, 2020).
- Rhythm: Irregular apical pulse suggests possible atrial fibrillation.
- Peripheral Pulses: Radial and dorsalis pedis pulses are weak, indicating restricted blood flow.
- Edema: Low-grade dependent edema observed; likely due to vascular compromise rather than fluid overload.
- Jugular Vein Assessment: No significant distension at 45° angle, ruling out right-sided heart failure.
Table: Cardiovascular Findings and Interpretation
| Finding | Observation | Clinical Significance |
|---|---|---|
| S4 heart sound | Present | Left ventricular hypertrophy |
| Apical pulse | Irregular | Possible atrial fibrillation |
| Radial/Dorsalis pedis pulses | Weak | Peripheral arterial disease, poor circulation |
| Edema | Mild | Chronic vascular changes rather than fluid overload |
| Jugular veins | Normal | No right-sided heart failure |
Peripheral arterial disease may explain your tingling feet due to reduced blood flow and oxygen delivery to the lower extremities (NHLBI, 2024).
Respiratory Assessment
Breath sounds are clear with no crackles or wheezing. Your respiratory rate is slightly elevated, likely a compensatory response to decreased cardiac output. You exhibit orthopnea, breathing more comfortably in a seated position (Mukerji, n.d.).
Abdominal Assessment
Inspection reveals no visible abdominal distension. Bowel sounds are present in all four quadrants. Mild discomfort is noted in the right upper quadrant, but there is no evidence of hepatomegaly or ascites, distinguishing this from right-sided heart failure.
Musculoskeletal Assessment
- Upper Limbs: Hand grip strength is mildly reduced, likely due to fatigue.
- Lower Limbs: Weakness observed during foot resistance tests; may reflect reduced circulation and physical inactivity.
- Joints: No deformities or contractures noted.
- Muscle Wasting: Mild lower limb atrophy, possibly due to chronic illness and limited mobility.
Skin Assessment
- Color & Temperature: Skin is pale and slightly cool, indicating circulatory insufficiency.
- Lesions/Rashes: None observed.
- Lower Legs: Shiny skin without pitting, suggestive of prolonged edema.
- Capillary Refill: Light blood flow restriction consistent with arterial insufficiency (McGuire et al., 2023).
Discussion of Diagnosis and Findings
Your assessment indicates insufficient coronary blood flow, consistent with coronary heart disease. Factors such as hypertension and hypercholesterolemia increase your risk. Symptoms like dizziness and foot tingling likely arise from impaired circulation.
Your elevated blood pressure and heart rate signify cardiac overwork, leading to reduced cardiac efficiency. A combination of medication, diet, and activity modifications can optimize heart function and minimize complications (Gaudel et al., 2022).
Understanding of Pharmacological Needs
Patients with CHD often require medications to improve heart pumping efficiency and prevent fluid overload. Medications may include:
| Medication | Purpose | Key Considerations |
|---|---|---|
| Furosemide (Lasix) | Diuretic; reduces fluid retention | Monitor electrolytes and hydration |
| Metoprolol (Beta-blocker) | Slows heart rate; reduces cardiac workload | Initial fatigue may occur (Marti et al., 2020) |
| Lisinopril (ACE inhibitor) | Lowers blood pressure; improves cardiac output | Monitor for dry cough |
| Spironolactone | Aldosterone antagonist; reduces fluid & blood pressure | Monitor potassium levels |
| Avoid NSAIDs | Prevent fluid retention | Can worsen symptoms (Bindu et al., 2020) |
Regular monitoring of blood sugar is critical due to potential interactions with beta-blockers in diabetic patients. Any side effects such as dizziness or swelling must be promptly reported.
Understanding of Pathophysiology
Coronary heart disease arises when atherosclerotic plaques narrow coronary arteries, reducing oxygen and nutrient delivery to cardiac tissue. This leads to angina, fatigue, shortness of breath, and, in severe cases, myocardial infarction (Shahjehan & Bhutta, 2024). Secondary effects may include fluid accumulation, arrhythmias, and organ hypoperfusion. Daily monitoring of blood pressure, cholesterol, and symptoms is crucial for early detection and management.
Critical Thinking and Clinical Reasoning
Care Priorities for the Patient with CHF
- Improving Blood Flow: Use of antiplatelet agents (aspirin, clopidogrel), statins (atorvastatin), and nitroglycerin, alongside lifestyle interventions, improves circulation and relieves angina.
- Optimizing Heart Function: Beta-blockers and ACE inhibitors support cardiac output and regulate blood pressure. Regular monitoring ensures treatment efficacy.
- Preventing Complications: Blood-thinning agents, angioplasty, or bypass surgery may be indicated for advanced CHD to prevent myocardial infarction, stroke, or arrhythmias.
- Lifestyle and Self-Care Education: Low-fat, low-sodium diet, regular physical activity, smoking cessation, and symptom awareness help prevent disease progression (Gaudel et al., 2022).
Evidence-Based Practices Supporting These Priorities
The American Heart Association (AHA) and American College of Cardiology (ACC) recommend combining pharmacological treatment, lifestyle modifications, and continuous monitoring for optimal CHD management. Research confirms that controlling blood pressure, blood sugar, and cholesterol significantly reduces cardiovascular events and enhances long-term outcomes (Heidenreich et al., 2022).
Conclusion
This comprehensive assessment of Aiyana Tehanata highlights her coronary heart disease and associated complications. Thorough evaluation identified concerns in circulation, respiratory function, and musculoskeletal health. Effective management will require medication adherence, lifestyle changes, and ongoing monitoring to improve overall health outcomes.
NURS FPX 4015 Assessment 5 Comprehensive Head-to-Toe Assessment
References
Alevroudis, I., Kotoulas, S.-C., Tzikas, S., & Vassilikos, V. (2024). Congestion in heart failure: From the secret of a mummy to today’s novel diagnostic and therapeutic approaches: A comprehensive review. Journal of Clinical Medicine, 13(1), 12. https://doi.org/10.3390/jcm13010012
Bindu, S., Mazumder, S., & Bandyopadhyay, U. (2020). Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochemical Pharmacology, 180(1), 114147. https://doi.org/10.1016/j.bcp.2020.114147
Gaudel, P., Neupane, S., Koivisto, A., Kaunonen, M., & Rantanen, A. (2022). Effects of Intervention on Lifestyle Changes among Coronary Artery Disease Patients: A 6‐month Follow‐up Study. Nursing Open, 9(4). https://doi.org/10.1002/nop2.1212
Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., … & Milano, C. A. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063
Marti, C. N., Fonarow, G. C., Anker, S. D., Yancy, C., Vaduganathan, M., Greene, S. J., … & Butler, J. (2020). Medication dosing for heart failure with reduced ejection fraction — opportunities and challenges. European Journal of Heart Failure, 21(3), 286–296. https://doi.org/10.1002/ejhf.1351
McGuire, D., Gotlib, A., & King, J. (2023). Capillary Refill Time. PubMed Central. https://www.ncbi.nlm.nih.gov/books/NBK557753/
Mukerji, V. (n.d.). Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea. Nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK213/
NHLBI. (2024, October 28). Atherosclerosis – What Is Atherosclerosis? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/atherosclerosis
NURS FPX 4015 Assessment 5 Comprehensive Head-to-Toe Assessment
Pechetty, R., & Nemani, L. (2020). Additional Heart Sounds—Part 1 (Third and Fourth Heart Sounds). Indian Journal of Cardiovascular Disease in Women WINCARS, 5(02), 155–164. https://doi.org/10.1055/s-0040-1713828
Shahjehan, R. D., & Bhutta, B. S. (2024, October 9). Coronary artery disease. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK564304/
Siddiqui, S. W., Ashok, T., Patni, N., Fatima, M., Lamis, A., & Anne, K. K. (2022). Anemia and heart failure: A narrative review. Cureus, 14(7). https://doi.org/10.7759/cureus.27167