NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System

NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System

NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System

SUBJECTIVE DATA:

Chief Complaint (CC): ‘I have been experiencing troubling chest pains for the last one month.’

History of Present Illness (HPI): Brian Foster is a 58-year-old patient that came to the clinic with complains of experiencing troubling chest pains over the past one month. The patient reports that the chest pains last few minutes. Initially, he thought the chest pain was due to heartburns but have been worsening in nature. He describes the chest pain to be tight and unconformable located in the middle of the chest. Brian denies radiating, arm, crushing, or burning chest pain. He has experienced three episodes over the last month, which last for a few minutes. The patient currently reports no pain (0/10). The patient rated pain severity at its worst at 5/10 According to him, laying down with brief rest alleviate the chest pain. The onset of the chest pain was when he engaged in physical activity while doing yard work. The second episode was while taking stairs t work. His medications are current.

Medications: Brian is currently using the following medications:

Metoprolol 100 mg one po 1 day

Atorvastatin 20 mg po 1 day

Omega-3 fish oils 1200 mg on po q day last dose Thursday 8 am

Tylenol or Motrin when having a headache

Allergies: Brian reports that he is allergic to codeine, which causes nausea and vomiting when he uses it.

Past Medical History (PMH):the patient has hypertension and hyperlipidemia, which were diagnosed a year ago. He denies any history of surgeries.

Past Surgical History (PSH): Include dates, indications, and types of operations.

The patient denes any history of surgeries.

Sexual/Reproductive History: Non contributory

Personal/Social History: Brian denies any history of illicit drug use or tobacco use. He drinks 2-3 alcoholic beverages per week. He only drinks during the weekends. He denies stress. He does not engage in regular exercises, with the last time being two years ago. His diet comprises granola bars, turkey subs and grilled meat and vegetables. He is unsure of his salt intake amount. He drinks four glasses of water a day. He drinks two cups of coffee a day. He does not frequently monitor his blood pressure at home.

Immunization History: His influenza vaccination record is up to date. TDAP was given last 10/2014.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Brian’s deceased father was hypertensive with hyperlipidemia, obesity and colon cancer. His mother has type 2 diabetes mellitus and hypertension at 80years. His sister aged 52 has type 2 diabetes mellitus and hypertension. His maternal grandfather died at 54 years due to heart attack while maternal grandmother died of cancer at the age of 65 years. His paternal grandmother died of pneumonia at 78 years while his daughter has asthma at the age of 19 years.

Review of Systems

General: the patient denies any fatigue, increased sweating, fever, chills, weight loss, or recent illness.

                Cardiovascular/Peripheral Vascular:He denies palpitations, angina, edema, circulation problems, blood clots, murmurs, or cyanosis,

                Respiratory: The patient denies sore throat, difficult in swallowing, cough, difficulty in breathing, shortness of breath, or shortness of breath.

Integumentary: The patient denies rashes, lesions or skin changes

OBJECTIVE DATA:

                Physical Exam:

Vital signs:BP 146/88 mm Hg, MAP 109 mmhG, HR 104 bpm, RR 19, O2 saturation 98% room air, Temperature 36.7C (98F)

General: The patient is well groomed with no visible abnormal findings. He is alert, oriented, with clear speech and in no acute distress.

Cardiovascular/Peripheral Vascular: Jugular venous assessment shows its height of venous pressure to be less than 4 cm above the sternal angle. The chest is symmetrical with no visible abnormal findings. Presence of S1, S2, and S3 heart sounds on auscultation. There is also audible gallop. Absence of abdominal and lower extremity arteries bruit. Presence of a thrill and increased amplitude on palpating right carotid artery. The PMI is displaced laterally with brisk and tapping amplitude. Absence of thrill and abnormal amplitudes in brachial arteries. There are no thrills in popliteal, tibial, and dorsalis pedis arteries except diminished amplitudes. EKG reveals regular sinus rhythm with no ST elevation.

Respiratory: Patient breaths quietly, unlabored with clear breath sounds present in all the lung areas. Adventitious sounds heard to the lower posterior right and fine crackles and rales in the left posterior bases.

Gastrointestinal:The abdomen is symmetrical with no rash, distention, or bruising. Absence of bruits in abdominal aorta. Bowel sounds are normoactive. The abdomen is non-tender on palpation with not palpable mass or organomegaly. There is tympany on spleen, with liver span being 6-12 cm.

Neurological:Alert and oriented, follows commands, and moves all the extremities. 

Skin:capillary refill of less than 3 seconds, skin is warm, pink, dry, and intact without tenting, edema, and rashes.

Diagnostic Test/Labs:

Several diagnostic investigations are needed to develop an accurate diagnosis for the client. One of them is echocardiogram. An echocardiogram will provide accurate insight into the blood circulation through the heart valves and heart. An exercise stress test may also be essential for this patient. The test will enable the determination of cardiac functioning when the patient engages in his daily routines. A nuclear stress tests may also be needed.

The nuclear stress tests will add the benefit of generating images of the ECG recordings while the patient engages in physical activity. A CT scan may also be prescribed. The test will enable the visualization of abnormalities such as the presence of calcification of the arteries. Lastly, cardiac catheterization may be done(Joshi & de Lemos, 2021). This will provide direct visualization of the blood vessels and presence of any blockages.

ASSESSMENT: Stable angina is the client’s primary diagnosis. Stable angina or angina pectoris is a cardiac condition that is characterized by inadequate cardiac tissue perfusion due to occlusion of blood flow. The occlusion impairs blood and oxygen supply to a specific region of the heart muscle, leading to tissue ischemia. Patients with stable angina experience symptoms such as chest pain, fatigue, dizziness, nausea, and shortness of breath when they engage in active physical activities that increase oxygen supply to the cardiac muscles(Ferraro et al., 2020; Joshi & de Lemos, 2021). Brian has symptoms that align with those seen in stable angina. He reports that the symptoms that include chest pain and fatigue develop when he engages in active physical activity. The symptoms also have the same duration and character whenever he experiences them, hence, the diagnosis of stable angina.

One of the differential diagnoses that should be considered in Brian’s case is myocardial infarction. Myocardial infarction occurs when there is complete or partial cessation of blood flow to the coronary artery. This causes damage to the heart muscle. Patients often experience symptoms such as chest pain, nausea, sweating, and chest pain referred to the neck or shoulders(Vogel et al., 2019; Zhang et al., 2022). These characteristics lack in Brian’s case study, hence, myocardial infarction is the least cause. The other differential diagnosis that should be considered in the case study is congestive heart failure.

Congestive heart failure is a heart disorder that is characterized by the heart’s inability to pump blood throughout the body organs and tissues.  Patients can suffer from either right-sided or left-sided hear failure. Depending on the type, patients experience symptoms that include weight gain, chest pain, cough, edema, and jugular venous distention(Groenewegen et al., 2020; Palo & Barone, 2020; Slivnick& Lampert, 2019). Brian lacks these symptoms, making it the least likely cause of his health problem.

The other differential diagnosis that should be considered is aortic aneurysm. Aortic aneurysm is a disorder that develops following the weakening of the walls of the aorta. This causes budging and an increased risk of rupture if not treated on time. Patients experience symptoms such as sudden, sharp, crushing chest and back pain, rapid heart rate, and dizziness. The last differential diagnosis is pericarditis. Pericarditis refers to the inflammation of the pericardium due to causes such as infections. Patients experience symptoms such as chest pain and fever, which are not evidence in Brian’s case(Chiabrando et al., 2020). Therefore, additional diagnostic investigations should be undertaken to guide the diagnosis and treatment plan.

References

Chiabrando, J. G., Bonaventura, A., Vecchi,  é A., Wohlford, G. F., Mauro, A. G., Jordan, J. H., Grizzard, J. D., Montecucco, F., Berrocal, D. H., Brucato, A., Imazio, M., & Abbate, A. (2020). Management of Acute and Recurrent Pericarditis. Journal of the American College of Cardiology, 75(1), 76–92. https://doi.org/10.1016/j.jacc.2019.11.021

Ferraro, R., Latina, J. M., Alfaddagh, A., Michos, E. D., Blaha, M. J., Jones, S. R., Sharma, G., Trost, J. C., Boden, W. E., Weintraub, W. S., Lima, J. A. C., Blumenthal, R. S., Fuster, V., & Arbab, -Zadeh Armin. (2020). Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm. Journal of the American College of Cardiology, 76(19), 2252–2266. https://doi.org/10.1016/j.jacc.2020.08.078

Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European Journal of Heart Failure, 22(8), 1342–1356. https://doi.org/10.1002/ejhf.1858

Joshi, P. H., & de Lemos, J. A. (2021). Diagnosis and Management of Stable Angina: A Review. JAMA, 325(17), 1765–1778. https://doi.org/10.1001/jama.2021.1527

Palo, K. E. D., & Barone, N. J. (2020). Hypertension and Heart Failure: Prevention, Targets, and Treatment. Heart Failure Clinics, 16(1), 99–106. https://doi.org/10.1016/j.hfc.2019.09.001

Slivnick, J., & Lampert, B. C. (2019). Hypertension and Heart Failure. Heart Failure Clinics, 15(4), 531–541. https://doi.org/10.1016/j.hfc.2019.06.007

Vogel, B., Claessen, B. E., Arnold, S. V., Chan, D., Cohen, D. J., Giannitsis, E., Gibson, C. M., Goto, S., Katus, H. A., Kerneis, M., Kimura, T., Kunadian, V., Pinto, D. S., Shiomi, H., Spertus, J. A., Steg, P. G., & Mehran, R. (2019). ST-segment elevation myocardial infarction. Nature Reviews Disease Primers, 5(1), Article 1. https://doi.org/10.1038/s41572-019-0090-3

Zhang, Q., Wang, L., Wang, S., Cheng, H., Xu, L., Pei, G., Wang, Y., Fu, C., Jiang, Y., He, C., & Wei, Q. (2022). Signaling pathways and targeted therapy for myocardial infarction. Signal Transduction and Targeted Therapy, 7(1), Article 1. https://doi.org/10.1038/s41392-022-00925-z

Diagnostic Test/Labs

An electrocardiogram is required as the clinical manifestations displayed lead to the patient potentially suffering from a cardiovascular condition. A chest x-ray is required to reveal any abnormalities in the chest region and in the underlying organs of the chest region that could be causing the symptoms. Lab values on CBC are also required to determine the WBC if it’s a bacterial or viral condition causing the symptoms.

Lipid profile test is also required since the patient was diagnosed with high cholesterol it would determine if the levels could be causing the symptoms. Echocardiogram could be required to determine if there could be an observable abnormality in the heart causing the symptoms. An exercise stress test is required as the patient reported symptoms are aggravated when conducting physical activity.

Pharmacology: diltiazem 30mg 6 hourly prescription is required as it would help manage his hypertension and also angina that the patient could be suffering from until the angina is controlled. Nitroglycerin when needed should also be added. The patient should also continue with previous prescriptions. Patient education: Patient should also undergo health education on diet modification and importance of a healthy diet. Referrals: patient should also consult with a vascular surgeon to see deliberate on potential interventions.

ASSESSMENT

Differential diagnosis

1. Coronary artery disease: this is due presence of a damage in the major blood vessels of the heart could be caused by occurrence of a plaque that narrows the vessels and limits blood flow to the heart. This is a potential diagnosis as the patient present with chest pain and the lifestyle patient has reported such as eating red meat are in line in what is found in patient with this condition (Hinkle & Cheever, 2014).
2. Pericarditis: this is a condition that occurs due to swelling and irritation of the structure that surrounds the heart the pericardium. It could be due to a viral infection and manifests with a sharp chest pain hence it being a potential diagnosis as the patient presents with the same (McCance & Huether, 2019).
3. Congestive heart failure: this is whereby the heart is unable to pump enough blood to the organs that require it. The clinical manifestations include pain in the chest area and probable weight gain hence placing it as a potential diagnosis as the patient also presented with this (Hinkle & Cheever, 2014).
4. Hypertension: this is a possible differential diagnosis since the patient was previously diagnosed with it whereby his blood pressure was higher than normal and if there was poor management of the condition it could lead to the clinical manifestations the patient presented with (McCance & Huether, 2019).
5. Hypercholesterolemia: the patient was previously diagnosed with this whereby his cholesterol levels were higher than normal hence if this condition complicated it could have led to cholesterol accumulating in the blood and limiting blood flow which could have then affected the heart and causing the symptoms the patient presented with such as chest pain (Hinkle & Cheever, 2014).

Priority diagnosis: coronary artery disease.

References

McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology:    The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical          nursing (Edition 13.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 800,000

deaths annually, CVD frequently goes unnoticed until it is too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax, or chest area.

This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.

Learning Objectives

Students will:

• Evaluate abnormal cardiac and respiratory findings
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system

Photo Credit: ANDRZEJ WOJCICKI/Science Photo Library/Getty Images

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Learning Resources

Required Readings

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

• • Chapter 13, “Chest and Lungs” (pp. 260-293)This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.

• • Chapter 14, “Heart” (pp. 294-331)The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.

• Chapter 15, “Blood Vessels” (pp. 332-349)This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

• • Chapter 8, “Chest Pain” (pp. 81–96)This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.

• • Chapter 11, “Cough” (pp. 118-147)A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough through asking questions and performing a physical exam.

• • Chapter 14, “Dyspnea” (pp. 159–173)The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.

• • Chapter 26, “Palpitations” (pp. 310-317)This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.

• Chapter 33, “Syncope” (pp. 390-397)This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• Chapter 8, “Outpatient Charting and Communications” (pp. 173-188)

Note: Download these Adult Examination Checklists and Physical Exam Summaries to use during your practice cardiac and respiratory examination.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Blood vessels. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. This Blood Vessels Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for cardiovascular assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Cardiovascular Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for chest and lung assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Chest and Lung Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Chest and lungs. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. This Chest and Lungs Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Heart. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. This Heart Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of respiratory disease part 1. Practice Nurse, 40(1), 35–41.Retrieved from the Walden Library databases. This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.

McCabe, C., & Wiggins, J. (2010b). Differential diagnosis of respiratory diseases part 2. Practice Nurse, 40(2), 33–41. Retrieved from the Walden Library databases. The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.

SkillStat Learning, Inc. (2014). The 6 second ECG. Retrieved from http://www.skillstat.com/tools/ecg-simulator#/-home. This interactive website allows you to explore common cardiac rhythms. It also offers the Six Second ECG game so you can practice identifying rhythms.

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html. This website provides an introduction to radiology and imaging. For this week, focus on cardiac radiography and chest radiology.

Required Media

Laureate Education. (Producer). (2012). Advanced health assessment and diagnostic reasoning. Baltimore, MD: Author. Note: You will use the case studies presented in the media, Advanced Health Assessment and Diagnostic Reasoning, to complete this week’s Discussion.

Online media for Seidel’s Guide to Physical Examination

In addition to this week’s media, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 13, 14, and 15 that relate to the assessment of the heart, lungs, and peripheral vascular system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

• Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The