WEEK 5 CASE STUDY NR 601-1, Exams of Nursing

Download WEEK 5 CASE STUDY NR 601-1 and more Exams Nursing in PDF only on Docsity! 1 WEEK 5 CASE STUDY Week 5 Case Study Sara Martinez Chamberlain College of Nursing NR 601: Primary Care of the Maturing and Aged Family 2 WEEK 5 CASE STUDY Week 5 Case Study The purpose of this case study is to present Mrs. R., a 56- year old Hispanic female, follow up visit in the clinic with the chief complaint of fatigue and weight gain. The onset of Mrs. R’s symptoms began three months ago. She reports going to the gym and exercising twice a week, at the gym she walks on the treadmill for 30 minutes in the effort of losing weight in which she has not lost any weight. The purpose of this case study is the analysis of objective and subjective findings in order to diagnose and construct a plan of management of Mrs. R’s chief complaint. To include the National Diabetes Guidelines which will be applied to the patient’s management plan. This paper will comprise of primary diagnosis, secondary diagnosis and differential diagnosis for Mrs. R, along with a plan for management and treatment of the primary diagnosis, secondary diagnosis, and the differential diagnosis. Involving diagnostics, medications, education, referrals and follow-up care. Furthermore, this paper will include the discussion of medication cost of all prescribed and ( OTC) over- the- counter medications. Assessment The following information provided by Mrs. R., reports does not understand why she has weight gain despite working out twice a week on the treadmill for 30 minutes each time, fatigue, increased thirst, hunger, and urination. She is 5’2.5, and 165 pounds according to the Center for Disease Control and Prevention BMI calculator (CDC) (2015), Mrs. R’s BMI is 29.7indicating she is overweight for her height of 5’2.5. The outcome of her urinalysis indicated 1+ glucose and a small amount of protein. Fasting glucose 126 mg/dl and HgbA1C 6.9%, according to the American Diabetes Association (ADA) (2018), meets the criteria for a primary diagnosis of 5 WEEK 5 CASE STUDY There other factors that cause hyperlipidemia such as obesity, diabetes, nephrotic syndrome, end state renal failure, hypothyroidism, estrogen administration, Cushing’s syndrome, and glycogen storage disease remain secondary causes of dyslipidemia ( Dunphy et al., 2015). The causes that are secondary to hyperlipidemia need to be assessed preceding in the initiation of treatment because most often in treating the primary disorder often corrects dyslipidemia (Dunphy et al., 2015). Pertinent positives are elevated triglycerides at 232mg/dl, LDL 144mg/dl, and Total Cholesterol 230mng/dl; decreased HDL 38mg/dl, family history, gender, ethnicity, fatigue, weight gain, increase in hunger, new diagnosis of diabetes mellitus type 2. In the past Mrs. R’s reports weight gain, increase in hunger and thirst in which may indicate a progression of diabetes, in turn, slowing down the bodies function and metabolism. Pertinent negatives no symptoms of hyperlipidemia upon physical examination such as xanthomas (yellow skin deposits of cholesterol on the eyelids) carotid bruit, hypertension, and coronary artery disease (Dunphy et al., 2015). Rationale Secondary diagnosis of hyperlipidemia due to her chief complaint of increased weight gain in the past three months despite exercise and the outcome of her lipid profile which has shown elevated cholesterol. Hyperlipidemia is a treatable disorder and also can be allocated as primary and secondary. Gender, ethnicity, elevated lipid panel and symptoms all play a factor to considering the diagnosis. Patients with hyperlipidemia develop a greater risk of cardiovascular disease also may develop metabolic syndrome factors such as hypertension, increase in waist circumference and diabetes mellitus (Chaker et al.,2017). Bullock-Palmer ( 2015), states hyperlipidemia for Mrs. R places her at high risk for coronary artery diseases because of her 6 WEEK 5 CASE STUDY ethnicity of Hispanic origin increasing her to as an at-risk female who is a minority. Coronary artery disease and its risk factors have a greatest incidence in those of African American and Hispanic, also as a female in the United States have elevated cholesterol <200 mg/dl is 40% to 50 % (Bullock- Palmer, 2015). Differential Diagnosis Overweight and Obesity (E66) Dunphy et al (2015) states body mass index of 30kg/ m2 Indicates obesity is described as excess of body fat. AACE/ACE (2017) states, BMI of ≥ 30/m2 is classified as obese, where as a BMI is 25-29 kg is considered overweight and with co-morbidities should be treated as obesity. The occurrence of obesity in the United States is greater with African American and Hispanic females as compared to Caucasian females, with CVD being the greatest risk in females rises uniformly with the increase in BMI (Bullock- Palmer, 2015). Rationale Mrs. R’s is calculated BMI- 29.7 in which places her as overweight for her height. Most common and often present symptoms for obesity are as follows shortness of breath, decreased energy, fatigue, weakness, joint pain, depression, and increased daytime sleepiness (Dunphy et al., 2015). According to Cafalu et al ( 2015) treatment includes lifestyle and behavioral modification. Mrs. R’s symptoms include fatigue, a decrease in energy, weakness, still continuing to gain weight despite exercise on the treadmill twice a week at the gym for 30 min, with exercise making an increase in hunger and thirst . Management Plan Diagnostics Repeat HgbA1c and Fasting glucose while her HgbA1c is currently at 6.9% and FBG is 126 a repeat of either HgbA1C or FBG and a two-hour glucose tolerance test would be 7 WEEK 5 CASE STUDY considered appropriate for the progression of determining a diagnosis of Diabetes Mellitus Type 2. The recommendation made by the ADA (2018) a second test is essential in the diagnosis confirmation, except in the event of a hyperglycemic crisis or random plasma glucose of ≥ 200mg/dl. Furthermore, the ADA (2018) mentions a repeat in the same test or a different test drawn without delay with the use of a new blood sample to verify the diagnosis of DM2. The Hgb A1c also will continue throughout treatment will be obtained every three months after the repeat HgbA1c (ADA, 2018). With the confirmation of DM2, Mrs. R’s plan for management would include medication to control her blood glucose and HgbA1c levels. Vitamin D levels. With a deficiency of these levels can cause chronic non-specific musculoskeletal pain, weakness ,and fatigue that is non-specific to age, mobility, gender or ethnic group (Rose, 2013). Mrs. R has symptoms of fatigue, and increased tiredness. If Vitamin D levels are low the plan for management would include sun exposure and dietary foods enriched with Vitamin D. Serum B12. With the diagnosis of Diabetes Mellitus Type 2, initial serum B12 levels would be drawn due to Metformin can cause a decrease in serum B12 concentration (Gorroll & Mulley, 2014; Kennedy-Malone et al., 2014). Vitamin B 12 along with other Vitamin B’s such as B6 may affect, mood, and other brain functions also linked to depression (Ng, C. et al., 2016). Mrs. R is recently separated also reports fatigue and tiredness. If Vitamin B 12 level is low the plan for management would be dietary foods rich in vitamins and minerals. Folate levels. Low levels of folate have been associated with higher risk of cardiovascular disease and fatigue. The new diagnosis of Diabetes Type 2 and hyperlipidemia indication for the folate level would be obtained. Mrs. R’s current elevated lipid panel and family 10 WEEK 5 CASE STUDY healthy diet to include fresh fruits and vegetables with limited sodium intake may help reduce the risk for a cardiovascular event any benefit to balance the glycemic index (ADA, 2018). The monitoring of blood sugars daily is recommended as well to keep a blood sugar level between 70-130mg/dl prior to meals and before meals, a blood sugar of < 180mg/dl for management of diabetes (AACE/ACE, 2017; ADA, 2018). Education Diagnosis Mrs. R we will need to educate you on the management and possible complications associated with your new diagnosis of Diabetes Mellitus Type 2, hyperlipidemia and obesity is not managed correctly (Redmon et al., 2014). What is diabetes, it is when there is not a sufficient amount of insulin that is produced in your pancreas to break down the sugar that is produced in your body and transform it to energy (ADA,2018). I would like to discuss the signs and symptoms of hypoglycemia and hyperglycemia as well as when to seek medical attention. Hypoglycemia is called low blood sugar below 70mg/dl and is opposite of hyperglycemia which is high blood sugar above 180 mg/dl. Hypoglycemia or low blood sugar means you do not have enough glucose (body fuel) and symptoms include irregular heart rate, shaky, sweating, hunger, irritable, fatigue and pale or clammy skin (Redmon et al., 2014). An in hyperglycemia or high blood sugar you have too much glucose (body fuel), and you will have symptoms such as fatigue, hunger, increased thirst, headaches, and urine frequency as you are probably feeling right now because that is why you are at the clinic. (Redmon et al., 2014). Now you will have to check your blood sugars with the glucometer I have prescribed and keep a log of your readings, and at 11 WEEK 5 CASE STUDY your next visit you will bring both the glucometer and journal with you, so we can evaluate the trend of your blood sugars and adjust plan accordingly (Redmon et al., 2014). Let’s talk about your lab work your lab work reveals elevated cholesterol levels, and HgbA1C with elevated blood glucose indicating Diabetes and hyperlipidemia placing you at risk for coronary artery disease (ADA, 2018). Elevated cholesterol levels increase your risk for heart disease, which is the buildup of cholesterol ( a fat-like substance) in the walls of your heart and arteries with time it can cause your arteries to harden and decrease the blood flow in your body (ADA, 2018). The HgbA1c (hemoglobin A1C) shows us the average blood sugar levels over the past two to three months, this test measures the hemoglobin which is a protein in your blood in your red blood cells that carry oxygen is coated with glycate (sugar) (ADA, 2018). The fasting blood glucose is a measurement of sugar in your blood after fasting for at least 8 hours (ADA,2018). This all can be managed with a heart-healthy diet, a 2000 calorie diabetic diet, exercise, changes to lifestyle, and weight loss. Medication We will need to prescribe you medications to manage your diabetes and cholesterol. I will place you on Metformin for the management of diabetes (ADA, 2018). Metformin is the preferred choice according to the ADA (2018) for treatment of Diabetes Mellitus Type 2, also has potential for weight loss of course with diet and exercise because you should not rely on the Metformin for weight loss. Has the potential benefit for lowing your risk for a cardiovascular event. The potential side effects according to the ADA (2018), diarrhea, nausea, and a potential B12 deficiency so we will monitor your B12 levels every time we perform your labs this will be included. To include checking your blood sugar twice daily before breakfast and before dinner. 12 WEEK 5 CASE STUDY Along with the Metformin you will also be taking Simvastatin to help lower your cholesterol levels by at least 50 % because this is a high-intensity therapy due to your cholesterol levels, but it is not without diet and exercise as well. We will recheck your cholesterol levels approximately 4-12 weeks after initial medication start (ADA, 2018). Common side effects according to the ADA (2018) are diarrhea, nausea, abdominal pain, flatulence, elevated liver enzymes. Do not drink grapefruit while on this medication. We will monitor your liver enzymes when you come in for your other lab work. Last medication would be Aspirin due to your diabetes and hyperlipidemia placing you at higher risk for a cardiovascular event (ADA, 2018). Aspirin will aid in slowing down the development of platelets in your blood to help reduce your risk of a blood clot (ADA, 2018). Diet Your diet will need to be modified to a heart-healthy diabetic diet in order to achieve weight loss also to manage your diabetes and cholesterol. The recommendations by the ADA (2018) does not recommend a super strict diet but more of a low calorie, low saturated fats with come complex carbohydrate. Eating in small portions, limiting your simple carbohydrates such as fruit and fruit juices, milk or dairy product and sweetened foods such as candy, soda, and most desserts. Complex carbohydrates with lots of fiber such as beans, oatmeal, brown rice, and whole grains. Your plate should be only 9 inches, and half of your plate should contain vegetables, limit the protein and carbohydrates to a ¼ the of the place for each. Sweets and sauces should be used in moderation. This will help with portion control and aid in weight loss. Exercise As discussed earlier exercise plays a significant role in the reduction of weight loss along with diet and also will help your glycemic control (sugar control). ADA (2018) recommends at 15 WEEK 5 CASE STUDY Follow-up. Follow up interval recommended by the ADA (2018) is every 3 to 6 months. For Mrs. R, I will have her follow up in 2 weeks then every 3 months of initial diagnosis for repeat labs, review of her glucose log, review if she had been to the educator for diabetes and dietician along with following up with her eye doctor whom she already sees for contacts. Of course, she may always follow up sooner if needed. I will evaluate her medications, and any possible adverse reaction to her medications and also make sure the medications are cost- effective for her in order to stay on the treatment of medication. Reviewing any other issues if any she may have. Medication Cost The most effective in cost and for travel, you have all in one at Walmart, which has a $4.00 prescription list both her medications Metformin 500mg and Simvastatin 400mg tablets are both on this list with or without insurance. Walmart is a brand that is worldwide and can access a Walmart if she travels. Also noting that Walmart carries Aspirin EC 81mg, along with all the diabetic testing supplies she needs. Walmart (n.d.)states a 30-day supply for Metformin ER 500mg (60 tablets) is $4.00, a 30-day supply for Simvastatin 400mg (30 tablets) is also $4.00. According to Walmart’s(n.d.) website sells the Equate brand OTC of Aspirin EC 81mg (60 tablets) for 98 cents. Mrs. R’s monthly cost for her medication, if she had no insurance, would be a total of $9.98. If she opted for a 90-day supply of Metformin ER 500mg (180 tablets) at $10.00 and Simvastatin 400 mg (90 tablets) at $10.00 and Equate Aspirin EC 81 mg (300 tablets) at $4.00 would cost every 90 days would be $ 24.00 a savings of $5.94 for 90-day supply opposed to 30 days’ supply. 16 WEEK 5 CASE STUDY Glucose monitoring supplies, Walmart also carries all of the supplies she will need such as the glucometer, test strips, lancets and alcohol pads. ReliOn Prime Blood Glucose Monitoring System is the best price at $9.00 (Walmart, n.d.). ReliOn Prime Glucose Test Strips (100 count) priced at $17.88 (Walmart,n.d.), ReliOn 33 Gauge Mirco - Thin Lancets (100 count) $1.48 (Walmart,n.d.) and BD Alcohol Swabs individually wrapped (100 count) $1.98 (Walmart,n.d.). The initial cost of diabetic supplies is $30.34 then will decrease $9.00 after that because you do not have to buy a glucometer each month. The total for medication and glucometer with all the supplies for the first 30-day supply would be $40.32. If she opts for the 90-day supply of medication and adding in the supplies excluding the monitor would be $45.34. Walmart is a great resource especially if the patient has no insurance; I will likely use this medication pricing in my future practice. The number one question any patient always asks me is how much does it cost and if I can rely on that information the patients may become more compliant with medication purchase and use. 17 WEEK 5 CASE STUDY SOAP NOTE Patient Information: Mrs. R., 56-year-old, female, Hispanic S: (Subjective) Chief Complaint: Severe fatigue, polyuria, polydipsia, polyphagia, weight gain despite exercise HPI: Patient present to the clinic for a follow up visit and reports of being very fatigued and have no energy at all. The onset of her symptoms was 3 months ago. She also reports that she gained weight despite her attempts to exercise. She walks on the treadmill for 30 minutes twice per week. Current Medications: Tylenol 500 mg, PO, 2 tabs in AM for left knee pain, daily multivitamin Allergies: NKDA, allergic to cats and pollen. No latex allergy PMHx: She has left knee arthritis. Had mumps as a child All vaccines up to UTD PSHX: none stated Health screening: No hx of abnormal pap smear Soc Hx: Recently separated, works from home part time as a wedding coordinator, non-smoker, occasionally has 1-2 glass of wine on weekends, no illicit drugs use. Fam Hx: Parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol. ROS: General: Denies headache, vision changes, night sweats, fever. She reports difficulty losing weight despite exercising. Respiratory: No SOB, no cough Musculoskeletal: arthritis to left knee O: (Objective) Physical Exam: BP: 118/80; HR 76; RR 16; Hgt: 5'2.5"; Wgt: 165 lbs; BMI: 29.7 (weight gain of 3 lbs within 3 months) General: Obese female. Alert, oriented and cooperative. No acute distress HEENT: Head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Skin: Warm, dry, and intact. No lesions noted. CV: S1/S2, RRR, no murmurs, no rubs Lungs: CTA bilaterally, respirations unlabored. Abdomen: soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT. Diagnostic or Lab results: (Fasting labs) 20 WEEK 5 CASE STUDY References $4 Prescriptions. (n.d.). Retrieved from https://www.walmart.com/cp/$4prescriptions/1078664 American Diabetes Association. (2018). Standards of Medical Care in Diabetes -2018. Diabetes Care, 41 (Suppl. 1), S105-S118. Retrieved from https://doi.org/10.2337/dc18- S010 Body Mass Index (BMI). (2015, May 15). Retrieved from https://www.cdc.gov/healthyweight/assessing/bmi/index.html Bolzetta, F., Veronese, N., De Rui, M., Berton, L., Toffanello, E. D., Carraro, S., … Sergi, G. (2015). Are the Recommended Dietary Allowances for Vitamins Appropriate for Elderly People? Journal of the Academy of Nutrition & Dietetics, 115(11), 1789–1797. Retrieved from https://chamberlainuniversity.idm.oclc.org/login? url=https://search.ebscohost.com/login.aspx? direct=true&db=s3h&AN=110432402&site=eds-live&scope=site Bullock-Palmer, R. P. (2015). Prevention, Detection and Management of Coronary Artery Disease in Minority Females. Ethnicity & Disease, 25(4), 499-506. Chaker, L., Bianco, A., Jonklaas, J., & Peeters, R., Division of Endocrinology, Georgetown University, Washington, DC, USA. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. doi:10.1016/S0140-6736(17)30703-1 Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care:The art and science of advanced practice nursing(4th ed.). Epocrates. (2018). Aspirin. Retrieved from https://online.epocrates.com/drugs/143/aspirin Epocrates (2018) Metformin. Retrieved from https://online.epocrates.com/drugs/3697/Fortamet Epocrates (2018) Simvastatin. Retrieved from https://online.epocrates.com/drugs/879/Lipitor 21 WEEK 5 CASE STUDY Goroll, A. H., Jr., Mulley, A.G.. (2014). Primary Care Medicine: Office evaluation and management of the adult patient, (7th ed.). Retrieved from https://online.vitalsource.com/#/books/9781496309990/ Introduction: Standards of medical care in diabetes 2018. (2018). Diabetes Care, 41, 2. doi:10.2337/dc18-SINT01 Kennedy-Malone, L., Fletcher, K., & Plank, L. (2014). Advanced practice nursing in the care of older adults. Retrieved from https://bookshelf.vitalsource.com Ng, C. M., How, C. H., & Ng, Y. P. (2016). Major depression in primary care: making the diagnosis. Singapore Medical Journal, 57(11), 591-597. doi:10.11622/smedj.2016174 Pippitt, K., Li, M., Gurgle, H. E., (2016) Diabetes mellitus: Screening and diagnosis. American Family Physician. 2016 Jan 15;93(2):103-109. Rose, A. M. (2013). Vitamin D testing: clinical and laboratory considerations. MLO: Medical Laboratory Observer, 45(5), 8. Retrieved from https://chamberlainuniversity.idm.oclc.org/login? url=https://search.ebscohost.com/login.aspx? direct=true&db=mdc&AN=23763042&site=eds-live&scope=site Redmon, B., Caccamo, D., Flavin, P., Michels, R., O’Connor, P., Roberts, J., Smith, S., & Sperl- Hillen, J. (2014). Diagnosis and management of type 2 diabetes mellitus in adults. Retrieved from https://www.icsi.org/_asset/3rrm36/Diabetes.pdf Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., . . . Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 70(6), 776-803. doi:10.1016/j.jacc.2017.04.025 22 WEEK 5 CASE STUDY