Module Three Case Study

Type: Case Study

Subject: Advanced Health and Literacy Assessment

Subject area: Nursing

Education Level: Undergraduate/College

Length: 3 pages

Referencing style: APA

Preferred English: US English

Spacing Option: Double

Title: Case Study: PV System and Health Promotion Tools

Instructions: in this brief case study, you will summarize the client's history of present illness, plan a focused assessment, interpret the data, provide diagnosis, and plan of care. in addition, you will research a health promotion tool for the client. please follow the attached rubric

Case Study: PV System and Health Promotion Tools

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Case Study: PV System and Health Promotion Tools

Subjective

The patient presents himself with the bilateral lower leg pain in the hospital. He is an average understudy who answers all regarding his health. He states that the pain started this week, and it has been continuous for a while. He claims that the pain is 5-6 on the scale, and he feels typical pain during morning hours. In addition, he claims that pain arises while sitting. Therefore, he says he prefers to remain active, but the pain has limited his activities. He claims the past medical history includes hyperlipidemia, hypertension, and type two diabetes (Mutlak, Aslam, & Standfield, 2019). 

Objective

Mr. Garcia is a Hispanic male adult of 67 years of age. He remains alert and oriented at the presentation in the hospital. His speech remains clear and maintains eye contact in the clinic. His current medication includes Lipitor, Bystolic, and baby aspirin. His current vital signs and symptoms are high blood pressure of 154/94, high heart rate, and respiratory rate of 20(Mutlak, Aslam, & Standfield, 2019). On carrying out an assessment, the following findings are made; the bilateral lower extremities seem to have been slightly blushed color, there were signs of visible varicosities, skin temperature was high, and the patient had strong peripheral pulses.

Focused assessment

 The first assessment to be done is to establish a verbal relationship with the patient in order to begin the assessment on the client's peripheral vascular system. Next will be to focus on the step by step to determine why there is an increase in blood pressure and diagnose both hyperlipidemia and diabetes II. The vascular assessment includes overall upper and lower extremities, which include inspection and palpation. Both the legs and feet will be observed for color, temperature, size, shape, pulses, and capillary refill (Mutlak, Aslam, & Standfield, 2019). This will be done to ensure it is filled within 3 seconds. In addition, the carotid pulses will be checked too.

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 Documentation on the characteristics of the arterial pulses and the ulnar pulses is also recorded. The peripheral pulses will be compared with the opposite to get any kind of discrepancies. Both the femoral and abdominal aorta will also be assessed (Wang, 2018). Allen's test is finished to decide the patency of both the ulnar and outspread supply routes. The fringe heartbeats will be contrasted with the contrary side for any disparities. Next, the femoral and stomach aorta will be evaluated for bruits. Palpitation and manual pressure are then used to decide the length of the varicose veins and structure of the valves. So as to decide there is no aneurysm, palpated beats incorporate the aorta, femoral, popliteal, dorsalis pedis and back tibial. On vision, the visual inspection for color and any peripheral edema will be checked. Hydration status is also checked by measuring the skin turgor.

Differential diagnoses

A diagnosis of the data collected is made. The diagnosis should not be limited to arterial insufficiency, venous insufficiency, peripheral insufficiency, and deep vein thrombosis (DVT). On treatment, it is focused on reducing the blood cells. The procedure will involve drawing blood out of the vein through the process called phlebotomy. This is usually the initial treatment.

Plan of care

         The plan of care for venous insufficiency (VI) is determined after the completion of the assessment. VI is felt like heaviness or cramps in the legs. It can also be felt like tingling in the legs. People affected with VI feel it more at lower extremities and it can easily rise up to other parts of the body.  To control VI, the patient is asked to keep track of books on how much time is spent on his feet, time spent on sleeping, and time spent on sitting. In addition, the patient will be asked to dictate his pain level (Mutlak, Aslam, & Standfield, 2019).

Mr. Garcia is also instructed to report in the hospital in case of signs and symptoms or pain level increases (Welch, Allen, Zagarins, Stamp, Bursell, & Kedziora, 2011). He is also asked to keep an eye on his legs for any wounds or ulcers and report immediately to the clinic in case of any occurrence.  He is also asked to wear compression socks for feet comfortability and to prevent any serious medical conditions.  They also help to lower the chances of getting deep vein thrombosis (DVT).

Basically, the compression socks help to improve the blood flow in the body. Another order is also placed on him to be receiving an ultrasound to see his blood flow and rule out any sign of blood clot. In addition, he is ordered to place the AIC lab value to check ad see how Mr. Garcia is maintaining his blood sugar level or if he needs to be placed on any medication, which will help to manage his diabetes level too. Finally, a referral is also made on the dietician will make sure that Mr. Garcia is eating the right foods (Roder, Strotmann, Fox, Bitter, Horstkotte, & Oldenburg, 2018).  Using the right skin lotion helps to maintain its balance.

When the skin is too dry, common skin problems start to pop up. Therefore, the patient is advised to use skin lotion to prevent skin dryness. Most importantly, patient education will be given to Mr. Garcia and the VI ways, which aims at increasing the blood flow in the legs. Mr. Garcia will also be asked to return to the clinic for checkup monthly to review the entire test carried out on him and review his journal and possibly make any of the modifications required, as described above in the care plan. 

References

1. Mutlak, O., Aslam, M., and Standfield, N. J. (2019). Chronic venous insufficiency: a new concept to understand pathophysiology at the microvascular level - a pilot study. Perfusion, 34(1), 84–89.
2. Welch, G., Allen, N. A., Zagarins, S. E., Stamp, K. D., Bursell, S.-E., and Kedziora, R. J. (2011). Comprehensive Diabetes Management Program for Poorly Controlled Hispanic Type 2 Patients at a Community Health Center.
3. Dantes, R. B., Zheng, S., Lu, J. J., Beckman, M. G., Krishnaswamy, A., Richardson, L. C., ... and Wang, F. (2018). Improved Identification of Venous Thromboembolism From Electronic Medical Records Using a Novel Information Extraction Software Platform. Medical care, 56(9), e54-e60.
4. Roder, F., Strotmann, J., Fox, H., Bitter, T., Horstkotte, D., and Oldenburg, O. (2018). Interactions of Sleep Apnea, the Autonomic Nervous System, and Its Impact on Cardiac Arrhythmias. Current Sleep Medicine Reports, 4(2), 160-169.