Capella FPX 4015 Assessment 5

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

Initial Introduction and Clinical Overview

Hello, I’m Lori. This comprehensive health assessment is based on the Sentinel U. case scenario involving the patient Aiyana Tehanata. The primary concerns include tingling in the feet, moderate pain rated 5 out of 10, and elevated blood glucose levels. During this full-body evaluation, I will describe each step while sharing findings and education with Aiyana to promote her understanding and involvement in her care.

Systematic Physical Examination

General Observations and Vital Signs

Upon initiating the exam, I observed that Aiyana maintains a tripod position and demonstrates labored breathing following physical exertion. This posture may indicate compromised respiratory function possibly linked to reduced oxygenation due to cardiac dysfunction. A general examination reveals pale skin and cold extremities, suggestive of poor perfusion. Her legs display mild swelling, likely due to peripheral edema commonly seen in coronary heart disease (CHD) because of venous congestion.

Her vital signs reveal a temperature of 98.4°F, within the normal range. Her heart rate stands at 96 beats per minute, indicating an increased workload on the heart. Blood pressure measures at 140/88 mmHg, a reading that points toward hypertension often associated with CHD. A respiratory rate of 22 breaths per minute is slightly elevated, possibly due to dyspnea resulting from ischemia. Oxygen saturation is recorded at 94%, slightly below the norm, requiring ongoing monitoring for hypoxia or worsening ischemia (Bhutta et al., 2024).

Neurological and HEENT Evaluation

For the neurological review, Aiyana correctly identifies herself, the current date, and location, which reflects intact cognitive function. Pupil inspection reveals symmetry, roundness, and proper light reactivity. No signs of stroke or transient ischemic attacks are present. Although speech is slightly slowed, motor coordination remains intact based on the finger-to-nose and alternating hand movement tests.

The HEENT assessment shows a normal head shape. Eye inspection reveals mild scleral pallor, possibly due to anemia, a known CHD comorbidity. Ears and nasal passages appear normal with no hearing loss or congestion. Slight dryness in oral mucosa suggests mild dehydration likely caused by diuretic usage. No lesions were found in the oral cavity, affirming generally healthy HEENT status (Mayo Clinic, 2024).

Cardiac and Pulmonary Findings

Auscultation of the heart reveals an S4 sound, typically associated with left ventricular hypertrophy and reduced compliance seen in CHD. Irregularities in the apical pulse could suggest atrial fibrillation. Weak radial and dorsalis pedis pulses point to diminished peripheral circulation, likely due to atherosclerotic narrowing of vessels.

Respiratory auscultation does not detect crackles or wheezing. Breathing remains shallow and quick, possibly due to low cardiac output. Orthopnea is present, indicating breathing is easier in an upright position.

Gastrointestinal, Musculoskeletal, and Skin Examination

Abdominal assessment shows no distension and normal bowel sounds throughout. Mild tenderness in the right upper quadrant occurs without evidence of hepatomegaly or ascites, ruling out signs of right-sided heart failure (NIH, 2023).

Musculoskeletal assessment reveals reduced hand grip and minor weakness in leg muscles, possibly from poor perfusion and reduced mobility rather than fluid retention. There is no joint deformity or contracture. Muscle wasting in the lower limbs may result from inactivity and disease progression.

Skin appears pale and cool, with no rashes or lesions. The shiny, taut appearance of the skin over the legs hints at past fluid accumulation. Capillary refill is delayed, reflecting poor arterial circulation, which aligns with symptoms of CHD-related arterial insufficiency.

Analysis of Diagnostic Findings

Based on the overall assessment, Aiyana shows signs of coronary heart disease, likely influenced by her medical history of hypertension and hyperlipidemia. Diminished oxygen delivery increases myocardial workload, contributing to elevated heart rate and arrhythmias. Symptoms such as tingling in the feet and dizziness support a diagnosis of poor systemic perfusion commonly associated with CHD.

Persistent hypertension and increased heart rate burden the cardiac muscle, while narrowed arteries compromise blood ejection efficiency (NIH, 2023). These insights will guide the provider in selecting appropriate interventions to enhance cardiac function and overall patient well-being.

Understanding Pharmacological Management

Treating CHD in Aiyana involves medications designed to reduce cardiac strain and fluid buildup. Drugs like Furosemide and Methotrexate manage fluid retention and inflammation. Metoprolol helps lower heart rate and myocardial stress. Lisinopril reduces blood pressure by relaxing vascular walls but may cause a dry cough, requiring patient communication. Spironolactone is used to stabilize fluid levels and manage hypertension.

Due to the risk of hypoglycemia from beta-blockers, blood glucose monitoring is essential. NSAIDs should be avoided as they can cause fluid retention (American Heart Association, 2023). Patients are encouraged to report side effects such as dizziness or swelling promptly for timely evaluation and medication adjustments.

Pathophysiology of Coronary Heart Disease

CHD originates from atherosclerotic plaque accumulation that narrows coronary arteries, limiting oxygen and nutrient supply to cardiac muscle. This causes ischemic pain (angina), dyspnea, and may lead to myocardial infarction. Additionally, hepatic and pulmonary congestion may develop in advanced cases due to reduced cardiac output.

Symptoms such as fatigue, dizziness, and irregular heartbeat arise from poor perfusion. Monitoring symptoms and clinical markers like blood pressure, cholesterol, and oxygen saturation is critical to prevent complications (Schwinger, 2021).

Critical Thinking and Decision-Making Strategies

The reduced oxygen delivery due to coronary blockage increases the risk of angina, foot numbness, and potential infarction. Antiplatelet agents like aspirin or clopidogrel reduce clot formation. Statins such as atorvastatin manage cholesterol. Nitroglycerin helps relieve angina by vasodilation. Beta-blockers and ACE inhibitors control blood pressure and improve perfusion (Kim & Schaller, 2023).

Medical management also includes interventions like angioplasty or bypass surgery in severe cases. Routine monitoring and tailored medication adjustments ensure optimal results. Lifestyle modifications, including dietary changes, smoking cessation, and physical activity, form the cornerstone of long-term CHD management. Patient education on symptom recognition enables timely intervention (Diab et al., 2023).

Summary of Findings and Interventions

Assessment Area	Findings	Interpretation/Diagnosis	Intervention/Recommendation
General Appearance	Pale skin, tripod position, cool extremities	Possible poor perfusion due to CHD	Monitor oxygenation, educate on CHD signs
Vital Signs	HR 96, BP 140/88, RR 22, SpO₂ 94%	Hypertension, mild hypoxia	Cardiac monitoring, possible beta-blockers
Neurological Status	Alert, oriented, slow speech, intact coordination	Intact cognition, early fatigue	Neurological monitoring, increase oxygen supply
HEENT	Mild scleral pallor, dry mucosa	Anemia, dehydration	Assess hemoglobin, monitor hydration
Cardiac Exam	S4, irregular apical pulse, weak peripheral pulses	Atrial fibrillation, left ventricular hypertrophy	ECG, possible anticoagulants
Respiratory	Clear breath sounds, rapid shallow breathing	Orthopnea due to CHF	Encourage upright sleeping, evaluate for CHF
Gastrointestinal	RUQ tenderness, normal bowel sounds	Possible hepatic strain, no CHF	Monitor LFTs, evaluate medication effects
Musculoskeletal	Weak grip and leg strength, muscle wasting	Circulatory insufficiency	Physiotherapy, mobility support
Skin	Pale, shiny legs, delayed capillary refill	Arterial insufficiency	Compression stockings, vascular assessment
Medications	Furosemide, Metoprolol, Lisinopril, Spironolactone	CHD treatment regimen	Educate on adherence, monitor side effects
Pathophysiology	Atherosclerosis, ischemia	CHD, risk of MI and arrhythmia	Lipid management, lifestyle changes
Decision-Making	Risk of MI, need for intervention	Plaque and clot prevention	Statins, antiplatelets, possible revascularization

References

American Heart Association. (2023). Heart failure: Symptoms, diagnosis, and treatment. https://www.heart.org

Bhutta, Z. A., Salam, R. A., Lassi, Z. S., & Das, J. K. (2024). Clinical guidelines for the evaluation of cardiac patients. World Health Organization.

Diab, L., Al-Mallah, M. H., & Kalra, A. (2023). Lifestyle modifications for the prevention of cardiovascular disease. Current Cardiology Reports, 25(1), 8–15. https://doi.org/10.1007/s11886-023-01775-3