Read The Information About The Case Study With The Chart Mat ✓ Solved

Read The Information About The Case Study With The Chart Materials

Read the information about the case study with the chart materials provided or gather the necessary information from one of your patients. Review the patient assessment information. What other assessments might you do in addition to those provided? What findings would you anticipate with this patient?

Develop a care plan (use the template provided) based on the highest priority problem (1 nursing diagnosis, 2 goals, 3 interventions for each goal, 2 rationales for each intervention and evaluation for each goal). Complete an in-depth analysis reflecting your ability to prepare a case study based on principles derived from pharmacology, pathophysiology, psychology, nutrition, and evidence-based nursing practice guidelines. Remember to include an introduction to the patient, pathophysiology, history, nursing assessment (given and any additional), and related treatments.

Include selected references for your case study paper/care plan and use APA format. A specific grading rubric and template are attached. The care plan should also be completed.

Sample Paper For Above instruction

Introduction to the Patient

Mr. John Doe, a 65-year-old male, presented to the clinic with complaints of persistent chest pain, shortness of breath, and fatigue over the past two weeks. His medical history includes hypertension and hyperlipidemia. He has a family history of coronary artery disease. The pathophysiology of his current condition involves atherosclerosis leading to coronary artery narrowing, which impairs blood flow and causes ischemia of the myocardium.

Pathophysiology and History

Coronary artery disease (CAD) results from the buildup of plaques in the coronary arteries, which restricts blood flow and increases the risk of myocardial infarction. Mr. Doe's history of hypertension and hyperlipidemia predisposes him to atherosclerosis. His lifestyle factors include a sedentary lifestyle, high-fat diet, and smoking, further exacerbating his cardiovascular risk factors.

Nursing Assessment (Given and Additional)

  • Vital signs: Elevated blood pressure (150/90 mmHg), heart rate 88 bpm.
  • Physical examination: Mild edema in lower extremities, clear lung sounds.
  • Electrocardiogram (ECG): Shows ST-segment depression suggestive of myocardial ischemia.
  • Laboratory tests: Elevated LDL cholesterol and triglycerides, normal troponin levels.

Additional assessments could include an exercise stress test to evaluate myocardial ischemia, echocardiography to assess cardiac function, and lipid profile testing to monitor cholesterol management effectiveness. Monitoring for signs of angina, heart failure, or arrhythmias would be essential.

Related Treatments

  • Medications: Antihypertensives, statins, aspirin, nitroglycerin for chest pain.
  • Lifestyle modifications: Dietary changes, smoking cessation, exercise program.
  • Patient education on recognizing symptoms of acute coronary syndrome.

Highest Priority Problem and Nursing Diagnosis

Imbalanced tissue perfusion related to myocardial ischemia secondary to coronary artery narrowing.

Nursing Care Plan

Goal 1:

  • Improve myocardial oxygenation and reduce ischemia.
Interventions:
  1. Administer prescribed nitroglycerin and monitor blood pressure regularly.
  2. Assess pain characteristics and use the pain scale to evaluate effectiveness of interventions.
Rationale:
  1. Nitroglycerin promotes vasodilation, reducing myocardial oxygen demand.
  2. Monitoring blood pressure prevents hypotension caused by vasodilation, ensuring adequate tissue perfusion.
Evaluation:

Reduction in chest pain and improved ECG findings indicating decreased ischemia.

Goal 2:

  • Enhance patient understanding of disease process and adherence to treatment plan.
Interventions:
  1. Provide education on medication use, lifestyle changes, and importance of follow-up appointments.
  2. Encourage participation in cardiac rehabilitation programs.
Rationale:
  1. Patient education improves compliance and promotes healthier behaviors.
  2. Rehabilitation supports risk factor management and improves cardiovascular outcomes.
Evaluation:

Patient demonstrates understanding of disease management and adheres to prescribed lifestyle modifications and medications.

References

  • American Heart Association. (2021). Heart Disease and Stroke Statistics. Circulation, 143(8), e254–e743.
  • Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
  • Potter, P. A., & Perry, A. G. (2017). Fundamentals of Nursing. Elsevier.
  • Lehne, R. A. (2018). Pharmacology for Nursing Care. Elsevier.
  • Chobanian, A. V., et al. (2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA, 289(19), 2560–2572.
  • Yancy, C. W., et al. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 Guideline for the Management of Heart Failure. Circulation, 136(6), e137–e161.
  • Freeman, R., et al. (2019). Pathophysiology of Coronary Artery Disease. J Clin Med, 8(10), 1570.
  • Thompson, P. D., et al. (2020). Exercise Standards for Testing and Training: A Scientific Statement From the American Heart Association. Circulation, 141(23), e654–e687.
  • Smith, S. C., et al. (2016). AHA/ACC Guideline for the Management of Patients With Stable Ischemic Heart Disease. Circulation, 134(25), e123–e155.
  • Libby, P. (2019). Pathophysiology of Atherosclerosis. Circ Res, 124(11), 1597–1610.

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