Running head: CASE ASSESSMENT

Case Study Assessment NURS 600 Advanced Health Assessment Linda Ngameduru C !!in State University Helen "uld Sch l # Nursing

N vem$er %&' (0%()

CASE ASSESSMENT ( Identifying Information: Ms) *) C is a 6& years ld A#rican+American #emale !resented t the St) ,ude H s!ital- emergency r m n N vem$er .' (0%() She is & #t) 6 in tall and /eighs (0( l$)

She /as a$le t give /ell detailed medical hist ry) Chief Concern: 0"eeling lightheaded # r the !ast /ee1)2 History of the present Illness The !atient is 6& years #emale /ith a hist ry # an em$ lic str 1e # r /hich he is n antic agulati n /h !resents #r m the C umadin Clinic # r 3NR 4)&) She has $een n C umadin since ,une and her last # ll /+u! visit /ith her !rimary !hysician # r an 3NR chec1 /as ()( t/ /ee1s ag ) 5n 6uesti ning' the !atient admits t di77iness' descri$ed as #eeling lightheaded' ver the !ast /ee1) She re! rts dar1 tarry st ls since 8 days ag and diarrhea this m rning) Ms) *) C denies any chest !ain' !al!itati n' /eight l ss' a$d minal !ain r nausea9v miting) Ms) *) C states that she had n rmal c l n sc !y a$ ut ( years ag at St) , hn-s h s!ital and hem gl $in :H;<= ne m nth ag /as 4)() She had $een eating less green lea#y vegeta$les recently :Seidel et al)' (0%%=) Past Medical History
1. Hy!ertensi n > diagn sed in (00%' n medicati n since (00% and admitted ta1ing

medicati ns as directed until the !ast ( years)

2. Atrial #i$rillati n > diagn sed in (0%() 3. Em$ lic Str 1e > diagn sed in ,une (0%(' n C umadin and Li!it r since discharged

#r m the h s!ital)

CASE ASSESSMENT ?
4. N n+ST elevati n M3 > diagn sed in ,une (0%(' /as treated and /as advised t reduce

/eight)
5. Asthma > diagn sed since childh

d' ta1es singular daily and Al$uter l inhaler as

needed)
6. ;astr es !hageal re#lu@ disease :;ERA= > diagn sed in %440' ta1es Bantac daily) 7. Aia$etes Mellitus Ty!e 33 :AM= > diagn sed in %44&' tried c ntr lling it /ith dieting $ut

/as unsuccess#ul' then started n ral medicati n since (00& and AM has $een under c ntr l)
8. Alc h l a$use > She /as admitted # r alc h l /ithdra/al in (004) Started drin1ing

$ecause # her marital !r $lems $ut currently drin1 ccasi nal)

9. Cigarette sm 1er > A sm 1er since the age # (&' sm 1e ne !ac1 in ? days) Last

cigarette sm 1e /as $e# re her arrival in the emergency r in the !ast /ith the sm 1ing !atch' /as unsuccess#ul) Surgical History: N ne stated)

m) Having attem!ted t 6uit

Immunizations: She had her he!atitis <' ATC' 3CD' MMR' Daricella' Cneum c ccal ,une' (0%( during h s!itali7ati n and #lu vaccine received n 5ct $er' (0%( at her d ct r-s ##ice) Hospitalizations: She /as h s!itali7ed # r Asthma in (0%0' alc h l a$use in May' (004' and CDA in ,une' (0%() Drug Allergies/Nature of reaction: She stated n 1n /n drug allergy)

CASE ASSESSMENT 8 Medications/Doses: As!irin ?(& mg C5 daily' C umadin & mg C5 daily' C tassium ;luc nate (0 mE6 C5 t/ice !er day' and E@# rge &9%609%()& mg ( ta$lets C5 daily :e@# rge is a c m$inati n drug # aml di!ine+valsartan+hydr chl r thia7ide=' ;luc !hage &00 mg C5 daily' (Al$uter l inhaler ( !u##s every 8 h urs as needed # r S5<9/hee7ing' Singular & mg C daily' Li!it r 80 mg C5 daily' ;luc !hage &00 mg C5 daily) She denies any her$al r c m!limentary thera!ies) ransfusions: N ne !motional Status: N ne "amily History The !atient denies any #amily hist ry # str 1e' C r nary artery disease :CAA=' cancer' renal disease' mental illness' alc h lism' dia$etes' tu$ercul sis :T<=' and thyr id disease) Ms) *) C stated that her m ther has asthma and hy!ertensi n and she died at the age # .( # c m!licati ns # hy!ertensi n) Her #ather died at the age # 8E #r m a car accident) She has t/ si$lings' a $r ther /h is 60 years ld in g d health and a sister 6E years ld has dia$etes

mellitus ty!e 33) The !atient has t/ daughters) He #irst daughter is age 8? has a hist ry # asthma' and her sec nd daughter is 80 years ld and she is in g Personal and psychosocial history Ms) *) C /as $ rn in <altim re' Maryland) She c m!leted her c llege educati n and she / r1s as an acc untant) She is div rced) She stated that she l ves her F $' l ve travelling' and / uld li1e t #ind a g d man s meday t remarry) She denies any slee!ing !r $lem) She currently d health)

lives /ith her sister /h d es n t li1e her sm 1ing ha$its) She had made a !r mised t her sister

CASE ASSESSMENT & that she /ill 6uit sm 1ing' have cut d /n #r m % !ac19day cigarette t hal# !ac19day and ta1es a glass # /ine ccasi nal) Her last alc h l inta1e /as n her $irthday /hich /as t/ m nths ag ) She ta1es a $rie# /al1 /ith her sister at least nce !er /ee1) #e$ie% of systems Ms) *) C denies any recent unintenti nal /eight gain r l ss' int lerance t c ld r heat :,arvis' (00E=) She denies any #ever' Chills' $leeding r s/eats e@ce!t her c m!laint # di77iness times ne /ee1 as stated !revi usly) She has a mild le#t sided /ea1ness # leg and arm) There are n a$n rmal hairs r nails c l r r te@ture' n s re' and rashes n ted) She denies headache' $lurring visi n' rhin rrhea' e!ista@is' n redness' n !ain r $structi n' n l ss # sense # smell r taste' s re thr at' h arseness' gum !r $lem' n earring l ss' n tinnitus r discharge) N enlargement r tenderness # lym!h n des n ted) Ms) *) C denies any sh rtness # $reath' !ain#ul $reathing' dys!nea' /hee7ing' and c ugh) She denies any chest !ain' !al!itati n' rth !nea' leg !ains9edema' varic se veins' and e@ercise int lerance) She denies any a$d minal !ain' nausea and v miting' $ /el irregularity' hem rrh ids' and decrease a!!etite) Ms) *) C denies any di##iculty urinating' dysuria' r hematuria) Physical !&amination General Appearance: This is an educated middle adult / man l 1ing much y unger than her stated age' /ith n $reathing !r $lem at !resent) She is alert' riented' and c !erative /ith care) Vital Signs: Measured rth static $l d !ressure :lying' sitting' and standing= 4&96(' %069.0' and %%(9 .E mm Hg :right arm=' heart rate %%( !er minute' tem!erature ?6)6 C' res!irat ry rate %6 !er minute' 5( saturati n 40G n r m air and 46G n (l nasal cannula :McCance' Huether'

<rashers and R te' (0%0=' and /eight (0? l$)

CASE ASSESSMENT 6 HEENT: Head is n rm ce!halic /ith n scal! r #acial tenderness) Eyes: Cu!ils sluggishly reactive t light and e6ual si7e at 8 mm) Cale c nFunctivae' n Faundice r hem rrhages n ted) Ears: Tym!anic mem$rane has range c l r' n erythema' and hearing is intact) N se: N nasal deviati n' discharge r #laring n ted) 5r !haryn@: a m ist muc us mem$rane' n denture r missing t th) Nec1: Trachea is in midline' n thyr id enlargement' n Fugular ven us distenti n n ted) Car tid u!str 1es n le#t and right sides are str ng /ith n $ruit) Chest: N chest /all de# rmities r chest tenderness n ted) Has symmetric chest e@!ansi n' lungs clear at all $ases' n $r nch !h ny' and eg !h ny r tactile #remitus n ted) Heart: Regular rate and rhythm' the ! int # ma@imal im!ulses n ted) The S% and S( n rmal' 3393D $l /ing' syst lic murmur le#t sternal $ rder) Breast: Ae#erred assessment) Abdomen: A$d men is s #t' n n+distended' n n+tender' n mass' r re$ und9guarding) Has a hy! active $ /el s unds) Rectal: A ! sitive guaiac st l !er e@am) Genitalia/Pel ic: Ae#erred assessment) E!tremities: N edema' cyan sis r clu$$ing n ted) <ilateral d rsal !edals and ! steri r ti$ia !ulses /ere str ng) "#sc#los$eletal/%oints: N $vi us F int /all de# rmities' n redness r tenderness n ted) There

is a decreased range # m ti n n the le#t arm and the le#t leg $ut n t n ticea$le) S$in: S1in is /arm' dry' intact' n rashes r scar)

CASE ASSESSMENT . Neurology !&am

1. "ental Stat#s: Catient is a/a1e' alert and riented t sel#' !lace' and time) N #lat a##ect'

slurred s!eech r th ught dis rder n ted :assessing # r c gnitive im!airment due t l ss # @ygen t the $rain=' :Aldridge' (0%0=)
2. Cranial Ner es: 33 > H33 intact) 3. "otor: 89& strength n le#t arm and leg) 4. Sensor&: Catient res! nse t !ain' and a light t uch) 5. Re'le!es: Negative <a$ins1i re#le@) 6. Coordination/gait: Steady gait)

Assessment Ms) *) C 6& years ld / man /ith a hist ry # multi!le # ci # in#arcti n in ,une (0%(' th ught t $e em$ lic' n / n C umadin' /h !resents /ith a critical elevated 3NR level 4)& and melena) 0" r /ar#arin+treated !atients' the ris1 # $leeding increases as the 3NR rises' !articularly i# the 3NR e@ceeds 82 :;arcia' Regan' Cr /ther and Hyle1' (006' !) E08=) She c m!lains # di77iness # ne /ee1 durati n' and dar1 tarry st ls # r 8 days) Ms) *) C !hysical assessment indicates a syst lic murmur le#t sterna $ rder /hich is as a result # her !ast medical hist ry # CDA) She is signi#icant # r di77iness' l / S<C 40 > %%( and tachycardia) Mild hy! tensi n li1ely related t ;3 $leed causing v lume de!leti n) *ill give 3D hydrati n /ith N rmal saline' and h ld h me antihy!ertensive medicati n) Differential diagnosis

CASE ASSESSMENT E S#pra(therape#tic )NR: The eti l gy # the high 3NR level is unclear) Her vitamin I inta1e may $e varia$le' $ut her c nsum!ti n # vitamin I c ntaining # d !r duce /as l /er than usual

ver the !ast /ee1' / uld e@!ect high thera!eutic 3NR /ith l / r n vitamin I c nsum!ti n) 3n the study c nducted $y Miesner and Sullivan :(0%%= c n#irms that eliminati n # vitamin I su!!lement in a !atient receiving /ar#arin c ntri$utes t a critically high 3NR level' $ut /ith the l /+d se vitamin I su!!lement ()& mg and /ithh ld # /ar#arin # r ( days' a !atient /ith an 3NR # E)&) The 3NR level reduced t ()4 and !atient /as maintained n /ar#arin . mg9/ee1 and l /+d se # vitamin I su!!lement) There# re' /ill h ld C umadin' and re!eat CT93NR level daily' give vitamin I & mg SJ nce' and ! ssi$ly trans#use ne unit # "resh #r 7en !lasma i# need $e) Acc rding t the study c nducted $y ;arcia' Regan' Cr /ther and Hyle1' :(006= n the ris1 # a hem rrhage /ith the !atients that /ere ta1en /ar#arin /ith elevated an 3NR level K& suggested that /ith the use # c nservative management and /ithh lding /ar#arin d ses # r at least 8 +& days /ill reduce their 3NR level t ()0 r less :!) E0&=) G) bleed: Ms) *) C 3NR level 4)&' as!irin c nsum!ti n' and hist ry # ;ERA may have dis! siti n her t internal $leeding) 3nternal $leeding can result in ir n+de#iciency anemia $ecause /hen y u l se $l d' y u l st ir n :Nati nal Aigestive Aisease 3n# rmati n Clearingh use LNAA3CM' (00.=) Ms) *) C sh /s s me signs and sym!t ms # a !ers n e@!eriencing a ;3 $leed dis rderN such as di77iness' ! sitive rth static $l d !ressure' ra!id !ulse' dar1 tarry st ls' and !ale !u!ils) Catient /ith a hist ry # ;ERA /ill start n Cr t ni@ 80 mg 3D <3A' es!ecially given evidence # ! ssi$le ;3 $leed) Aue t the !atient-s hist ry # str 1e' h lding C umadin and as!irin as a$ ve' /ill m nit r # r neur l gical de#icits) "inal diagnoses

CASE ASSESSMENT 4 "inal diagn ses is an ir n+de#iciency anemia given the !atient-s descri!ti n # dar1 tarry st ls # r 8 days' a H;< level # 4)( ne m nth ag ' a !ale c nFunctivae' and sluggish !u!ils reacti ns) Anemia is a c nditi n that is characteri7ed $y a decrease in the num$er # red $l d cells) Ms) *) C has an ir n+de#iciency anemia $ecause she is e@!eriencing light+headedness' di77iness' and l / $l d !ressure indicating a reducti n in hem gl $in a$ility t carries @ygen #r m the lungs t the rest # the $ dy :Nati nal Heart Lung and <l d 3nstitute LNHL<3M' (0%%=) Ms) *) C-s ir n+de#iciency anemia might $e sec ndary t ! r diet /ith ir n rich dar1 green lea#y

vegeta$les and as!irin /hich reduce acid in the st mach and there$y inter#ere /ith ir n a$s r!ti n) Her c m!laint # a dar1 tarry st ls is an additi nal signs and sym!t ms # ir n+ de#iciency anemia) Chec1 # r a ! sitive #ecal ccult $l d test' C<C /ith manual di##erential' ir n studies' # lic acid' thiamine' Ditamin <%(' #erritin level' Ty!e O screen' and a ! ssi$le trans#usi n # !ac1ed Red <l d Cells) C nsider the # ll /ing rec rds # !ri r C l n sc !y d ne t/ years ag at St) , hn-s h s!ital and ;3 c nsultati n # r ! ssi$le re!eat c l n sc !y i# needed) Plan
1. Cardiac: A c m!lete $l

d c unt /ith manual di##erential' ir n studies' # lic acid' vitamin

<%(' serum #erritin level' CT93NR' reticul cyte c unt' !eri!heral smear' <l d ty!ing' Screening' and Rh #act r' and a c m!lete meta$ lic !anel)
-

Culse @imetry and give @ygen (l9min via nasal cannula t 1ee! @ygen level a$ ve K 4(G :NHL<3' (0%%=)

M nit r daily /eight' inta1e and ut!ut)

CASE ASSESSMENT %0
-

EC; Chest H+Ray A$d minal9Celvic CT Scan r ultras und imaging test: Use t evaluate the liver' s!leen' and lym!h n des # r enlargement may $e a sign # $l d cancer) 3t can als $e used t l 1 at the 1idneys and the $ nes in the arms and hands' /hich are s metimes a$n rmal in y ung !e !le /ith a!lastic anemia :NHL<3' (0%%=)

Need an ir n su!!lements)

2. End crine: M nit r #inger stic1 t/ice !er day' chec1 hem gl $in A%C' and thyr id

stimulating h rm nes) C ntinue n ral hy! glycemia medicati n :/ill h ld met# rmin 8E h ur !ri r t and a#ter CT scan /ith c ntrast t av id 1idney damage= :Le/is' Air1sen' Heit1em!er' <usher and Camera' (0%%=)
3. Neur l gy: Cer# rm neur l gical assessment every 8 h urs' !lace n a #all !recauti n

given her c m!laint # di77iness' l / $l d !ressure' sluggish !u!ils- reacti n' and !ale c nFunctivae)
4. Health !r m ti n: -

*eight c ntr l Educati n n the im! rtance # maintaining m derate vitamin I # d

c ntaining !r ducts /hile n C umadin) The additi n # vitamin C hel!s the $ dy a$s r$ ir n and g d s urces # vitamin C are vegeta$les and #ruits'

CASE ASSESSMENT %% es!ecially citrus #ruits :NHL<' (0%%=) Enc urage !atient t eat # d enriched

ir n' such as liver' /h le+grain $reads and cereals' eggs' and dar1 green vegeta$les :Simm n' (0%0=)
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Cigarette and alc h l cessati n is im! rtant $ecause the use might disru!t the hemat l gic system) Cigarette sm 1ing causes an increase in l /+density li! !r tein :LAL= ch lester l and car$ n di @ide level resulting in hy! @ia' altering the antic agulant !r !erties # the end thelium' and als sm 1ing increases hemat crit' !latelet reactivity' !lasma #i$rin gen' and $l d visc sity :Le/is' Air1sen' Heit1em!er' <usher and Camera' (0%%=) Alc h l use may damage the ;3 tract causing ;3 $leed and reduce the a$s r!ti n # c $alamin and ther nutrients)

CASE ASSESSMENT %(

Re#erences Aldridge' S) :(0%0=) Cum!ing ir n: re!lenish ir n a#ter anemia) HE"A*ARE: The Bleeding +isorders "aga,ine) Retrieved #r m ///)hemi!hilia) rg9st ry9!um!ingir n) ;arcia' A) A)' Regan' S)' Cr /ther' M)' O Hyle1' E) M) :(006=) The ris1 # hem rrhage am ng Catients /ith /ar#arin ass ciated c agul !athy) %o#rnal o' the American College o' Cardiolog&' 8. :8=' E08 > E0E) ,arvis' C) :(00E=) Ph&sical e!amination and health assessment :&th ed)=) St L uis' Miss uri: Saunders Elsevier) Le/is' S) L)' Air1sen' S) R)' Heit1em!er' M) M)' <usher' L)' O Camera' 3) M) :(0%%=) "edical( s#rgical n#rsing: assessment and management o' clinical problems :Eth ed)=) St) L uis' Miss uri: Elsevier+M s$y 3nc) McCance' I) L)' Huether' S) E)' <rashers' D) L)' O R te' N) S) :(0%0=) Pathoph&siolog&: the

CASE ASSESSMENT %? biologic basis 'or diseases in ad#lts and children :6th ed)=) Maryland Heights' Miss uri: Elsevier+M s$y 3nc) Miesner' A) R)' O Sullivan' T) S) :(0%%=) Elevated internati nal n rmali7ed rati n #r m vitamin I su!!lements disc ntinuati n) The Annals o' Pharmacotherap&' 8& :%=' () Nati nal Aigestive Aisease 3n# rmati n Clearingh use :NAA3C=) :(00.=) HeartGastro esophageal re'l#! .GER/- and gastro esophageal re'l#! disease .GER+=) Retrieved N vem$er %0' (0%( #r m htt!:99digestive)nidd1)nih)g v9diseases9!u$s9gerd9gerdP&0E)!d#) Nati nal Heart Lung and <l d 3nstituti n: Nati nal 3nstitute # Heart) :NHL<3=) :(0%%=) E!plore iron(de'icienc& anemia) Retrieved N vem$er %0' (0%( htt!:99///)nhl$i)nih)g v9health9health+t !ics9t !ics9ida9treatment)html) Seidel' H) M)' <all' ,) *)' Aains' ,) E)' "lynn' ,) A)' S l m n' <) S)' O Ste/art' R) *) :(0%%=) "osb&0s g#ide to ph&sical e!amination :.th ed)=) St) L uis' Miss uri: Elsevier+M s$y 3nc) Simm n' S) :(0%0=) Catient educati n series: anemia) N#rsing1231' 80 :6=' ?8)

CASE ASSESSMENT %8