Advanced Nursing Practice

1. review the care plan of two of your peers and provide constructive feedback. Peer # 1 Erin
Care Plan Week 1: Cardiology Clinical Case
Patient Initials: Unknown Age: 52 Sex: Male
Subjective Data:
Client Complaints:
Denies symptoms at this time. Concerned about recurrence of angina. Recheck post cardiac catheterization to assess and discuss risk factors.
HPI (History of Present Illness):
Admitted to hospital with complaints of angina for four hours. Symptoms consisted of substernal, crushing chest pain radiating to neck and jaw with dyspnea on exertion and diaphoresis. Patient had been suffering from similar symptoms for six months prior to seeking medical treatment. Denies symptoms since cardiac catheterization.
PMH (Past Medical History?include current medications, any known allergies, any history of surgery or hospitalizations):
No known allergies. Previous noncompliance with medical treatments, hypertension, high cholesterol, smoker, cardiac catheterization with stent placement, and cholecystectomy. Hospitalized for cholecystectomy and post cardiac catheterization with stent placement. Currently taking the following medications since discharge from catheterization: Tenormin XL 50 mg po qd, Lipitor 10 mg po qd, Glucophage 500 mg po bid, and baby aspirin po qd .
Significant Family History:
Two brothers currently being treated for hypertension and type 2 diabetes since their early forties . Father deceased from heart disease, and mother deceased from breast cancer.
Social/Personal History (occupation, lifestyle?diet, exercise, substance use)
High school graduate that works as a carpenter. Reports no hobbies except reading at home. Lives a sedentary lifestyle, and the only physical activity he participates in is when working as a carpenter. Denies alcohol or street drug use but has smoked one pack of cigarettes daily for 30 years.
Description of Client?s Support System:
Married and lives with disabled spouse in an apartment. Has three children who are grown and do not live near home. Patient does not mention relationship with children or spouse. Patient mentioned having two brothers but does not discuss relationship with them. Parents are deceased . Patient has limited access to local community for support. Patient lacks adequate support systems.
Behavioral or Nonverbal Messages:
Appears anxious, stressed, and displays symptoms of depression. Patient is primary caregiver for disabled spouse, and he is the provider for his family. Patient smokes daily and has inappropriate diet and eating habits. Depressive symptoms displayed by client consist of excessive tiredness and overeating.
Client Awareness of Abilities, Disease Process, Health Care Needs:
Patient does not appear to be knowledgeable about disease process, importance of compliance with improving current health status, and necessity to obtain a primary care provider to appropriately follow the success of treatments.
Objective Data:
Vital Signs including BMI:
BP: 160/92 left arm sitting P: 60 R: 16 T: 98 Wt: 220 Ht: 70? BMI: 31.5
Physical Assessment:
Lymph nodes: none
Lungs: Decreased breath sounds. No adventitious sounds.
Heart: RRR without murmur
Carotids: Right bruit
Abdomen: Android obesity, WC=44 inches
Rectum: Not examined
Genital/Pelvic: NA
Extremities, including pulses: Decreased pedal pulses BL with lower leg edema that extends from ankle to mid-calf.
Neurologic: Not examined.
EKG: Unchanged from baseline.
Lab Tests and Results:
EKG: No change from baseline.
CXR: Hyperinflation of lungs. No infiltrates.
Total cholesterol: 210 LDL: 200 HDL: 25 Triglycerides: 250 Fasting blood sugar: 140
HgbA1C: 7.5
Client?s Support System:
Disabled spouse and estranged children.
Client?s Locus of Control and Readiness to Learn:
Patient appears concerned about risk factors and recurrence of angina; however, patient believes as a man he should not suffer from illnesses and should be able to provide and care for his family . Patient also believes the exercise he obtains while working as a carpenter is sufficient to remain healthy.
ICD-9 Diagnoses/Client Problems according to the Centers for Medicare and Medicaid Services (2014):
V15.81 Personal history of noncompliance with medical treatment presenting hazards to health
459.39 Chronic venous hypertension with other complications
278 Obesity unspecified
278.02 Overweight
V15.82 Personal history of tobacco use
790.21 Impaired fasting glucose
250.92 Diabetes with unspecified complication, type 2 or unspecified type, uncontrolled
308.3 Other acute reactions to stress
V79.0 Screening for depression
V69.1 Inappropriate diet and eating habit
V17.3 Family history of ischemic heart disease
V18.0 Family history of diabetes mellitus
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
1. High blood pressure
Systolic and diastolic hypertension are present. May be related to anxiety form initial visit and stress. Edema present to lower extremities bilaterally. Hypertension can lead to coronary artery disease, heart failure, stroke, kidney failure, and other disease processes (National Institutes of Health, 2012). Discuss importance of incorporating a healthier lifestyle and follow treatment regimen with Tenormin XL in order to reduce health related problems associated with hypertension because this patient is currently being treated for stage 2 hypertension (National Institutes of Health, 2012). Discuss criteria for evaluating blood pressure (Bickley, 2013, p. 36). Smoking cessation is essential for blood pressure management as well as limiting salt intake to one teaspoon (1500 mg) a day while working to maintain a healthy weight and remaining physically active (Bickley, 2013, p. 36; Centers for disease control and Prevention, 2013; National Institutes of Health, 2012). Schedule carotid duplex ultrasonography due to presence of right carotid bruit on assessment which can indicate atherosclerosis (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013, p. 512).
2. Hypercholesterolemia
Patient has elevated total cholesterol, LDL, and triglycerides with a low HDL level. Patient?s poor diet habits, lack of exercise, obesity, and smoking negatively impact cholesterol levels and blood pressure. Schedule appointment with dietician to educate patient on importance of eating a balanced diet, avoiding saturated fats, trans fats, dietary cholesterol, and limiting carbohydrate intake in order to raise HDL levels while decreasing LDL, triglycerides, and total cholesterol levels (Centers for Disease Control and Prevention, 2013). Patient should continue taking Lipitor daily as prescribed and incorporate necessary lifestyle modifications because they are as important as taking medications (Centers for Disease Control and Prevention, 2013).
3. Type 2 diabetes
Patient has elevated fasting glucose and hgbA1C values. Type 2 diabetes is associated with obesity, increased age, physical inactivity, family history, and impaired glucose metabolism, and research has discovered that lifestyle interventions are more cost-effective than medications (Centers for Disease Control and Prevention, 2014). Encourage patient to modify lifestyle by increasing physical activity, losing weight, smoking cessation, and eating a healthy, balanced diet along with taking Glucophage daily in order to control his type 2 diabetes, especially since he is experiencing financial difficulties (Centers for Disease Control and Prevention, 2014. Discuss the chronic disease process of type 2 diabetes. Provide education about necessary lifelong management of this disease process in order to prevent damage to organs, nerves, blood vessels, and decrease risk of heart disease (Centers for Disease Control and Prevention, 2014). Provide self-management training in order to improve health outcomes and quality of life (Centers for Disease Control and Prevention, 2014). Schedule appointments with a diabetes educator and a dietician in order to increase knowledge and obtain coping skills that are necessary to manage this disease process successfully, and his excessive sleepiness can be also be attributed to uncontrolled diabetes (Centers for Disease Control and Prevention, 2014). Coping skills are essential for this patient to obtain in order to help reduce emotional eating in response to increased stress and anxiety (Adariaanse, Ridder, & Evers, 2011, p. 23.
4. Android obesity
Discuss diet history, and ask patient to keep a diary of food intake (Bickley, 2013, p. 36). It is essential to prevent further disease complications by controlling blood glucose levels, blood pressure, and lipids while continuing to participate in preventative care practices (Centers for Disease Control and Prevention, 2014). Provide education in relation to the importance of incorporating adequate dietary habits and regular physical activity. Patient weight loss goals should be established (Bickley, 2013, p. 36). Patient is classified as obese based on his BMI with a high disease risk due to a large waist circumference (National Institutes of Health, 2012). Encourage patient to aim for an initial goal of at least a 10% reduction in weight in order to lower risk of disease (National Institutes of Health, 2012). Schedule visit with a dietician, and discuss exercise program (Bickley, 2013, p. 36). Arrange meeting with social worker to evaluate community resources. Exercise can incorporated by taking the stairs and performing exercises indoors within his apartment complex while determining community programs that are available for assistance. Encourage patient to start slowly with exercise and increase as tolerable due to the fact he has not exercised regularly since he was younger. Gradually increase to incorporating 30 to 60 minutes of exercise for at least three to four days a week (Buttaro et al., 2013, p. 131).
5. Cigarette smoker
Patient has smoked one pack of cigarettes daily for the past 30 years. Perform spirometry testing (Bickley, 2013, p. 36). Offer warning against smoking and discuss effects of smoking (Bickley, 2013, p. 36). Smoking cessation will help to reduce the risk of recurring angina (Buttaro et al., 2013, p. 519). Counseling, nicotine products, medications, and referral to smoking cessation program may be needed to aid in smoking cessation (Bickley, 2013, p. 36; Buttaro et al., 2013, p. 517).
6. Family stress
Patient is primary care provider for family and caregiver for disabled spouse. Explore patient?s opinions on stress coping strategies (Bickley, 2013, p. 36). Determine additional sources of support and possible financial counseling for patient (Bickley, 2013, p. 36). Referral and collaboration with a social worker and case management should be performed in order to determine available assistance for patient and spouse as well as community resources. Patient?s spouse may be able to obtain disability assistance, and the patient may qualify for government or community assistance programs. Discuss coping mechanisms in order to improve stress, decrease anxiety, improve sleep, and reduce emotional eating (Adariaanse et al., 2011, p. 23. Continue to monitor patient for depression (Bickley, 2013, p. 36).
7. Hyperinflation of lungs
It is essential to detect chronic obstructive pulmonary disease (COPD) early in order to decrease morbidity and mortality associated with this disease process (Buttaro et al., 2013, p. 447). Perform spirometry testing to assess COPD because late stages of COPD may include hyperinflation of lungs (Buttaro et al., 2013, p. 447). Encourage smoking cessation.
Patient goals consist of smoking cessation, blood pressure control, reduction of lipids, decreased hemoglobin A1C, reduced fasting glucose, salt restriction, healthy diet with fruits, vegetables and low-fat dairy products, weight management, and incorporating a minimum of 30 minutes of moderately intense physical activity three days a week (Buttaro et al., 2013, p. 519). Continue current medications. Patient should be scheduled to be re-evaluated in three months. Recheck height, weight, waist circumference, blood pressure, hemoglobin A1C, lipid profile, and fasting glucose to determine efficiency of modifications and treatment regimen. Check creatinine clearance because patient is taking Metformin daily (Buttaro et al., 2013, p. 1071).
Adriaanse, M. A., Ridder, D., & Evers, C. (2011, January). Emotional eating: Eating when emotional or emotional about eating? Psychology and Health, 26(1), 23-39. doi:0887-0446print/ISSN1476-
Bickley, L. S. (2013). Guide to physical examination and history taking (11th ed.). Rochester, NY: Lippincott Williams and Wilkins, WoltsKluwer Health.
Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice. St. Louis, MO: Mosby.
Centers for Disease Control and Prevention. (2014). 2011 National diabetes fact sheet. Retrieved from
Centers for Disease Control and Prevention. (2013). Nutrition and physical activity and obesity program. Retrieved from
Centers for Medicare and Medicaid Services. (2014). ICD-9 code lookup. Retrieved from
National Institutes of Health. (2012). Blood pressure numbers. Retrieved from
National Institutes of Health. (2012). Weigh your patient?s health risks. Retrieved from
U. S. Food and Drug Administration. (2010). High cholesterol: Medicines to help you. Retrieved from PEER # 2 Kathleen
Week 1: Cardiology Clinical Case
Patient Initials: NA Age: 52 Sex: Male
Subjective Data:
Chief Complaints: Client presents to clinic for post-op visit after stent placement. Client is currently asymptomatic. Education today will include risk factors associated with cardiovascular disease.
HPI: Client presented to the ER with symptoms of angina (crushing chest pain, short of breath with exertion, diaphoretic). Client stated these symptoms had been going on for the past four days, however now he thought he was having a heart attack. Client stating he has had similar symptoms within the last 6 months, which had resolved with rest.
PMI: Client has a past history of hypertension and hypercholesterolemia for which he was placed on medication, however was noncompliant. Client states he had a baseline EKG and has had his cholesterol levels checked at his doctor?s office. No other history of cardiovascular testing completed. Hospitalizations include: cardiac catheterization with stent placement four days ago and cholecystectomy ten years ago w/o complications. All other systems are negative at this time.
This client has no known drug allergies. Present medications include: Tenormin XL 50 mg QD, Lipitor 10 mg QD, Glucophage 500 mg BID, and Baby ASA QD.
Significant Family History: Both parents are deceased. Father died from heart disease and mother died from breast cancer. Client states he has two older brothers who are currently being treated for high blood pressure and Type II diabetes. Both siblings were diagnosed in their early forties.
Social/Personal History: Client states he is a high school graduate. He currently works as a licensed carpenter and is the sole bread winner of the family. He is married and has three grown children who are living on their own. His wife is disabled with uncontrolled type 2 diabetes. This gentleman currently does not eat breakfast, frequently consumes fast food for lunch, and eats pasta and meat for dinner. He currently does not exercise. Client has been a 1 pack per day smoker for the last 30 years. Client denies alcohol consumption. Client denies the use of street drugs. Client denies hobbies though he does state he reads at home.
Description of Client?s Support System: Client is married to a spouse who is disabled and counts on him for care. His parents are deceased. He has two brothers and three children who do not live in the area. Client does not socialize with his neighbors and is isolated from his community. Emotional and social support are lacking at this time.
Behavioral or Nonverbal Messages: Pt appears anxious, stressed, and depressed. Client reports he is feeling excessively tired and over eating. Unhealthy behaviors include: smoking cigarettes daily and unhealthy eating habits.
Client Awareness of Abilities, Disease Process, and Health Care Needs: Due to past medical history, it would appear that this gentleman is uncomfortable seeking medical care and that he does not fully understand his disease process or the necessity to follow medical treatment.
Objective Data:
Physical Findings include:
Vital Signs including BMI: B/P 160/92 left arm sitting; P: 60; R: 16; T: 98; Wt.: 220#; Ht. 70?
Physical Assessment Findings: Lymph Nodes: none; Lungs: decreased breath sounds throughout, no adventitious sounds; Heart: RRR without murmur; Carotids: right bruit; Abdomen: android obesity, WC= 44?; Rectum: not examined; Genital/Pelvic: NA; Extremities, including Pulses: decreased pedal pulses BL with lower leg edema from ankle to mid-calf; Neurologic: Not examined
Lab Test and Results: EKG: no change from baseline, Total cholesterol: 210; LDL: 200; HDL: 25; Triglycerides: 250; Fasting blood sugar: 140; HgbA1c: 7.5; and CXR: hyperinflation of the lungs, no filtrates.
Client?s Support System: Client has a limited support system, disabled spouse and family not living near him, as well as no community support at this time.
Client?s Locus of Control and Readiness to Learn: Client?s locus of control is diminished. Client states he is not sure he will be able to care for his disabled wife now that he is ill, this conflicts with his belief system, that a man does not suffer from illness, it is his responsibility to care for his family. Client appears to be ready to learn. He has voiced an interest in avoiding further symptoms of angina. Client has been compliant with medications prescribed post-op and has returned as recommended for follow-up.
ICD-9 Diagnosis/Client Problems:
According to (Centers for Medicare & Medicaid Services, 2014), the following apply:
V45.09 Other Specified Cardiac Device in Situ
277.7 Metabolic Syndrome
272.0 Pure Hypercholesterolemia
401.9 Unspecified Essential Hypertension
250.92 Diabetes with Unspecified Complication, Type II, uncontrolled
V18.0 Family History of Diabetes Mellitus
V69.1 Inappropriate Diet and Eating Habits
V15.82 Personal History of Tobacco Use
790.21 Impaired Fasting Glucose
429.2 Cardiovascular Disease Unspecified
V17.49 Family History of Other Cardiovascular Diseases
V79.0 Screening for Depression
300.00 Anxiety State Unspecified
517.8 Lung Involvement in Other Diseases Classified Elsewhere
V16.3 Family History of Malignant Neoplasm of the Breast
Advanced Practice Nursing Intervention Plan
Consultations may include:
? Cardiologists for further evaluation of the heart following diagnosis of angina and stent placement.
? Pulmonologist for symptoms of hyperinflation of the lungs noted on CXR.
? Endocrinologist for uncontrolled diabetes mellitus and cholesterol disorder.
? Dietician to formulate healthy eating plan related to diabetes mellitus, obesity, and hypertension.
? Social Worker to assist the family with resources focusing on finances, assistance with spouse, and support.
Appropriate community resources for support, exercise, and smoking cessation will be included.
Optimal Goal: Remain healthy through lifestyle changes and medication. Client will maintain a blood pressure below 120/80, cholesterol levels to be maintained within normal limits, there will be stabilization of client?s blood glucose level, client will reduce weight, and the client will quit smoking.
1) Educate client on the importance of maintaining a blood pressure in order to prevent or delay cardiovascular disease. High blood pressure has already caused atherosclerosis, resulting in plague build up, requiring a stent. Uncontrolled high blood pressure causes the heart to work harder, which is responsible for left ventricular hypertrophy. Left ventricular hypertrophy increases the risk of cardiovascular diseases such as: ?coronary heart disease, cardiac dysrhythmias, sudden death, and congestive heart failure? (Porth & Matfin, 2009, p. 514-515). Weekly self- monitoring of blood pressure is necessary. Provide education on the use of proper placement of blood pressure device. The use of a sphygmomanometer and stethoscope is preferred. Encourage the client to keep a diary of readings to monitor fluctuations as well as time of day (American Heart Association, n.d., p. 1).
2) Follow a healthy diet which is low in glycemic value, high in fruit, vegetables, and fiber (American Diabetes Association, n.d., p. 1); low in saturated fats (no more than 25 to 35 percent of the diet); contains lean protein; and limit the amount of sodium per day to less than 6 g per day (Porth & Matfin, 2009, p. 514), while allowing the client to manage their diet using personal preferences. A healthy diet will also assist in decreasing of LDL, increasing of HDL, the decreasing of triglycerides, therefor reducing cholesterol level, and will assist in the management of weight loss and diabetes (Porth & Matfin, 2009, p. 514).
3) Target a healthy weight loss of approximately 1 pound per week by consuming, between 1200-1600 calories day (National Institute of Health, n.d., p. 1).
4) Increase physical activity by encouraging aerobic and isometric exercises (Porth & Matfin, 2009, p. 232).
5) Encourage the client to attend smoking cessation classes. Provide websites such as ?Quit Guide? (Centers for Disease Control and Prevention, n.d., p. 1) and phone numbers of agencies which offer help and support, as well as prescribe nicotine replacement therapy to aid in the reduction of nicotine cravings.
6) Decreasing stress through strategies such as: attending stress reduction workshops, which provide coping skills; using biofeedback techniques, imagery, and relaxation (Porth & Matfin, 2009, pp. 210-211).
7) Continue with all medications prescribed at discharge. No changes noted at this time.
American Diabetes Association. (n.d.).
American Heart Association. (n.d.).
Centers for Disease Control and Prevention. (n.d.).
Centers for Medicare & Medicaid Services. (2014).
National Institute of Health. (n.d.). Retrieved from
Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of altered health states (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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