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
Upon greeting Aiyana Tehanata, the assessment begins with an introduction and confirmation of consent. She has reported tingling in her feet for two months, described as severe, stinging pain rated 5/10 on the pain scale. She also has a medical history of hypertension and currently exhibits elevated blood glucose levels. The assessment incorporates inspection, palpation, percussion, and auscultation to evaluate her systemic health with specific attention to cardiovascular, respiratory, and neurological functioning.
Aiyana was made comfortable and informed about each step to ensure cooperation and clarity. Her general appearance showed alertness and orientation to person, place, and time, though mild fatigue was noted. The skin inspection revealed pallor and dryness in the lower extremities with mild erythema. Delayed capillary refill of over 3 seconds in both big toes pointed to compromised peripheral perfusion (McGuire et al., 2023). Her pupils were reactive and extraocular movements intact. Oral mucosa appeared dry, likely associated with hyperglycemia (Kumar et al., 2024).
A cardiovascular exam revealed an S4 heart sound, a sign suggestive of hypertensive heart disease and reduced ventricular compliance (Tackling & Borhade, 2025). Peripheral pulses in the dorsalis pedis and posterior tibial arteries were faint bilaterally, confirming vascular insufficiency. Auscultation of the lungs yielded clear breath sounds with no adventitious sounds, though she reported exertional dyspnea—an indicator of underlying coronary heart disease (CHD) (Turaman, 2022).
Neurologically, cranial nerves II through XII were intact. However, sensory testing using a monofilament revealed reduced sensation across several foot regions. Aiyana reported tingling and burning, consistent with diabetic peripheral neuropathy (DPN) (Bodman & Varacallo, 2024). Musculoskeletal evaluation showed slight gait unsteadiness, reduced hand grip, and lower limb strength graded at 4/5. No joint swelling or deformities were observed. Gastrointestinal examination was normal, and the abdomen was soft and non-tender with active bowel sounds. Genitourinary findings included increased thirst and urination, symptoms commonly linked to hyperglycemia. No bladder distention was present.
Analysis of Diagnosis and Findings
The assessment findings offer a comprehensive understanding of Aiyana’s symptoms and underlying diagnoses. Her foot tingling and dryness, coupled with delayed capillary refill and diminished pedal pulses, indicate poor peripheral circulation, commonly seen in diabetes mellitus. Sensory testing confirmed neuropathy, and vascular signs confirmed the systemic implications of both CHD and diabetes (McGuire et al., 2023; Bodman & Varacallo, 2024).
The presence of an S4 heart sound during cardiac auscultation aligns with decreased ventricular compliance, often resulting from chronic hypertension. Coupled with her reported dyspnea and elevated blood pressure, these findings are supportive of a CHD diagnosis. Her muscular weakness, especially in the lower limbs, likely stems from both poor circulation and nerve dysfunction, exacerbated by hyperglycemia and reduced physical activity. Importantly, no visible joint abnormalities or edema were identified, but reduced strength and mobility underscore the functional decline related to both conditions.
Together, these symptoms support a primary diagnosis of CHD with a secondary complication of Type 2 Diabetes accompanied by peripheral neuropathy. Early intervention and appropriate management are essential to avoid progression to more severe complications, such as ulcerations, infections, or cardiovascular events.
Comprehension of Pharmacological Requirements
Pharmacologic Management Summary
| Condition | Drug Class | Examples | Purpose | Considerations |
|---|---|---|---|---|
| CHD | Beta-blockers | Metoprolol | Reduce heart rate and BP | Monitor for bradycardia, fatigue |
| Diuretics | Chlorthalidone | Reduce fluid volume and BP | Risk of electrolyte imbalance | |
| Antiplatelets | Aspirin | Prevent thrombosis | Watch for GI bleeding | |
| Statins | Atorvastatin | Manage cholesterol | Monitor liver function |
| Condition | Drug Class | Examples | Purpose | Considerations |
|---|---|---|---|---|
| DPN | Antidiabetics | Metformin | Control blood sugar | Low risk of hypoglycemia |
| SGLT2 inhibitors | Empagliflozin | Cardiovascular protection, glucose reduction | Risk of dehydration, UTIs | |
| Anticonvulsants | Gabapentin, Pregabalin | Neuropathic pain relief | Monitor for dizziness, sedation |
Medications for CHD focus on optimizing cardiac efficiency and reducing systemic blood pressure, while diabetic management emphasizes glycemic control and symptom relief. Aiyana’s low cholesterol levels may influence decisions regarding statin therapy. Neuropathic agents like pregabalin can help mitigate burning and tingling sensations, while glucose-lowering agents such as SGLT2 inhibitors provide dual benefits for glucose and cardiovascular health (Mayoral et al., 2025; Choi et al., 2022).
Lifestyle adjustments and patient education are critical to ensure adherence and mitigate adverse effects. Monitoring vitals, reporting new symptoms, and avoiding abrupt posture changes are key safety measures. Integrated care involving medication, nutrition, and activity can help stabilize her condition and prevent progression.
Understanding of Pathophysiology
CHD is characterized by atherosclerosis—a process wherein fatty plaques build up within coronary arteries, restricting blood flow to the myocardium. This reduced oxygen supply forces the heart to work harder, particularly during physical exertion, often resulting in symptoms like fatigue, angina, and breathlessness (Turaman, 2022). Aiyana’s exertional dyspnea, S4 heart sound, and elevated blood pressure reflect these pathophysiological changes.
DPN, on the other hand, results from chronic hyperglycemia causing damage to microvasculature and peripheral nerves, especially in the lower limbs. Nerve dysfunction manifests as paresthesia, burning, or loss of sensation. The interplay between impaired circulation from CHD and nerve damage from diabetes compounds the risk of complications such as foot ulcers and infections (Bodman & Varacallo, 2024).
The co-existence of these conditions heightens the risk of cardiovascular and neurological deterioration. As the diseases progress, patients like Aiyana may face functional limitations, poor wound healing, and potential cardiovascular events, reinforcing the need for early intervention, consistent monitoring, and multidisciplinary care.
Analytical Thinking and Clinical Decision-Making
Based on clinical findings, Aiyana’s care priorities include stabilizing blood glucose, improving cardiovascular function, relieving neuropathic symptoms, and implementing preventive lifestyle changes. Her weak pulses, diminished foot sensation, and fatigue highlight both diabetic and circulatory complications, while cardiovascular auscultation findings and vital signs reinforce the presence of CHD.
Care Strategy Overview
| Priority | Interventions |
|---|---|
| Glycemic control | Metformin, SGLT2 inhibitors, glucose monitoring |
| Cardiovascular optimization | Beta-blockers, diuretics, statins, BP monitoring |
| Pain management | Gabapentin or pregabalin for neuropathic discomfort |
| Lifestyle modification | DASH diet, regular aerobic exercise, hydration |
| Patient education | Foot care, symptom tracking, medication adherence |
| Emotional well-being | Stress management, psychological support, counseling |
Evidence-based guidelines recommend first-line use of metformin and the inclusion of SGLT2 inhibitors for added cardiovascular benefits (Choi et al., 2022). According to the American Heart Association (Virani et al., 2023), beta-blockers and diuretics are effective in CHD management when combined with lifestyle changes such as a reduced-sodium diet and physical activity.
Routine check-ups and education on early signs of foot complications are essential, as recommended by the CDC (2024). Nutritional and psychological counseling support overall health while ensuring long-term treatment adherence. By integrating diagnostic insight, pharmacology, and lifestyle counseling, the care plan supports holistic management and patient empowerment.
Conclusion
Aiyana Tehanata’s full-body assessment identified hallmark signs of coronary heart disease and diabetic peripheral neuropathy. Her symptoms—tingling in the feet, elevated blood glucose, diminished pulses, and abnormal heart sounds—reflect systemic involvement requiring targeted intervention. The integration of evidence-based pharmacological treatment, patient education, and lifestyle counseling provides a comprehensive approach to managing her conditions. Emphasis on glycemic and cardiovascular control, neuropathic pain relief, and proactive self-care education can significantly improve her quality of life and prevent future complications. Effective clinical reasoning and multidisciplinary planning ensure safe, patient-centered care delivery for chronic disease management.
References
Bodman, M. A., & Varacallo, M. (2024). Diabetic peripheral neuropathy. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK442009/
Centers for Disease Control and Prevention. (2024, May 15). Promoting foot health. Diabetes. https://www.cdc.gov/diabetes/hcp/clinical-guidance/diabetes-podiatrist-health.html
NURS FPX 4015 Assignment 5 Comprehensive Head-to-Toe Assessment
Choi, J. G., Winn, A. N., Skandari, M. R., Franco, M. I., Staab, E. M., Alexander, J., Wan, W., Zhu, M., Huang, E. S., Philipson, L., & Laiteerapong, N. (2022). First-line therapy for type 2 diabetes with sodium–glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Annals of Internal Medicine, 175(10), 1392–1400. https://doi.org/10.7326/m21-2941
Khalil, H., & Zeltser, R. (2023). Antihypertensive medications. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554579/
Kumar, B. A., Shenoy, N., Chandra, K. S., & Shetty, A. (2024). Relationship between glycemic control and oral health status in patients with type 2 diabetes mellitus. Gulhane Medical Journal, 66(3), 133–138. https://doi.org/10.4274/gulhane.galenos.2024.42713
Mayoral, V., Galvez, R., Ferrándiz, M., Vázquez, X. M., Cordero-García, C., Montero, A. A., Pérez, C., & Pérez-Páramo, M. (2025). Pregabalin vs. gabapentin in the treatment of neuropathic pain: A comprehensive systematic review and meta-analysis of effectiveness and safety. Frontiers in Pain Research, 5. https://doi.org/10.3389/fpain.2024.1513597
McGuire, D., Gotlib, A., & King, J. (2023). Capillary refill time. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557753/
Pikula, A., Gulati, M., Bonnet, J. P., Ibrahim, S., Chamoun, S., Freeman, A. M., & Reddy, K. (2024). Promise of lifestyle medicine for heart disease, diabetes mellitus, and cerebrovascular diseases. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 8(2), 151–165. https://doi.org/10.1016/j.mayocpiqo.2023.11.005
Tackling, G., & Borhade, M. B. (2025). Hypertensive heart disease. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539800/
NURS FPX 4015 Assignment 5 Comprehensive Head-to-Toe Assessment
Turaman, C. (2022). Classification of the risk factors of coronary heart disease and their evolutionary origins. Health Sciences Review, 3, 100027. https://doi.org/10.1016/j.hsr.2022.100027
Virani, S. S., Newby, L. K., Arnold, S. V., et al. (2023). 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. Circulation, 148(9), e9–e119. https://doi.org/10.1161/CIR.0000000000001168