System Findings (normal/abnormal) Equipment needed Laboratory findings
Cardiovascular System Normal findings: Stethoscope - Total cholesterol level: less than 200
- Equal peripheral pulses Sphygmomanometer mg/dL
- No audible heart murmurs or EKG machine - Fasting blood glucose level: less
abnormal heart sounds than 90 mg/dL
Abnormal findings: - Hemoglobin (Hb): 16.2 mg/dL
- Elevated heart rate - White blood cell count (WBC):
- Elevated blood pressure 6,200 cells/mcL
- Moderate chest discomfort - Platelet count: 250,000 cells/mcL
- Pedal edema
Respiratory System Normal findings: Stethoscope - Total cholesterol level: less than 200
- Symmetrical chest rise and fall with mg/dL
each breath - Fasting blood glucose level: less
- Pink, warm, and dry skin without than 90 mg/dL
cyanosis or pallor - Hemoglobin (Hb): 16.2 mg/dL
Abnormal findings: - White blood cell count (WBC):
- Crackles or wheezing are heard 6,200 cells/mcL
throughout the lung fields - Platelet count: 250,000 cells/mcL
- Increased respiratory rate
- Moderate shortness of breath
I performed a head-to-toe assessment on a typical 51-year-old female client who was
experiencing Heart Failure.
Age-specific Risk Reduction Health Screening and Immunizations:
Based on the guidelines provided by the Centers for Disease Control and Prevention (CDC), it is
advised that a 45-year-old male undergo certain health screenings and immunizations. These
include:
Blood pressure screening every 2 years.
Fasting blood glucose screening every 3 years.
cholesterol screening every 4-6 years.
Screening for prostate cancer starting at age 50 (digital rectal exam and PSA blood test).
Colon cancer screening (colonoscopy) every 10 years.
Td or Tdap vaccination every 10 years.
Influenza vaccination annually.
Pneumococcal vaccination at age 65 if not previously vaccinated.
Two Differential Diagnoses:
1. Acute kidney injury (AKI), formerly referred to as acute renal failure, has been described
as a rapid and frequently reversible decline in kidney function, indicated by elevated
creatinine levels or reduced urine volume. Possible inciting factors include diarrhea,
nausea, vomiting, fluid depletion, or the use of nonsteroidal anti-inflammatory drugs
(NSAIDs). Medical history and physical examination are crucial in AKI because
laboratory tests typically fail to provide a definitive explanation for the cause of AKI.
Outlined below are several associations: Oliguria is indicative of anterior kidney injury,
while abrupt anuria implies the presence of acute urinary tract obstruction, acute
glomerulonephritis, or vascular blockage. Polyuria, on the other hand, shows either a
concentrating tubular abnormality, such as acute interstitial nephritis, or post-obstructive
nephropathy (Goyal & Hashmi, 2023).
2. Chronic obstructive pulmonary disease (COPD): This is a chronic inflammatory lung
disease that obstructs airflow, making it difficult to breathe. Symptoms may include
wheezing, shortness of breath, coughing, and chest tightness. Risk factors for COPD
include smoking, exposure to air pollution or irritants, and genetic predisposition
(Agarwal et al., 2023).
Care Plan:
Nursing diagnoses of priority:
Diminished cardiac output associated with impaired cardiac function.
Reduced gas exchange caused by constriction of aerodynamic flow in the lungs.
Interventions:
Provide the client with information on correct drug administration, lifestyle adjustments, and
symptoms that should be reported as red flag events.
Regularly evaluate respiratory conditions, including lung auscultation, oxygen saturation, and
respiratory rate.
Track daily body weights and measurements of fluid consumption and excretion to detect
indications of fluid overload in severe heart failure.
Promote smoking cessation and the prudent avoidance of environmental contaminants.
Administer the prescribed bronchodilators, anti-inflammatory drugs for chronic obstructive
pulmonary disease (COPD), and diuretics and angiotensin-converting enzyme (ACE) inhibitors
for heart failure.
Evaluation:
The client's respiratory and cardiac condition has shown improvement and increased stability.
The client exhibits comprehension of the treatment plan and can effectively control symptoms
and promptly report any newly presented symptoms.
Pharmacological therapies:
Diuretics are used to facilitate the elimination of surplus fluid from the body and lungs and
improve breathing.
Inhaled or oral bronchodilators serve to dilate airway passageways and enhance respiratory
function.
ACE inhibitors are used to enhance cardiac function and reduce the electrical burden on the
heart.
Relevant evidence-based practice strategies for health promotion adapted to specific clients
and age groups:
Advocating for consistent physical activity can enhance pulmonary function and cardiovascular
well-being.
Providing the client with information on appropriate nutrition, namely a low-sodium diet, to
effectively control symptoms associated with heart failure.
Promoting smoking cessation and the avoidance of environmental pollutant exposure to mitigate
additional harm to the respiratory and cardiovascular systems.
Instructing the client on stress management strategies, as stress can exacerbate symptoms of
heart failure.
Promoting compliance with advised health screenings and immunizations to proactively prevent
or detect pre-existing health problems at an early stage.
Reduce the intake of saturated fat and trans-fat, as well as intake of red meat and dairy products
made with whole milk.
Reduce the ingestion of fried foods and cook with healthy oils, such as vegetable oil.
Increase intake of fruits, vegetables, whole grains, poultry, fish, nuts, and non-tropical vegetable
oils.
Reduce sodium, sugary foods, and drinks (Malik et al., 2022).
References
Agarwal, A.K., Raja, A., Brown, B.D. (2023). Chronic Obstructive Pulmonary Disease.
StatPearls [Internet]. Treasure Island: StatPearls Publishing. Located in:
https://www.ncbi.nlm.nih.gov/books/NBK559281
Goyal, A., Hashmi, M.F. (2023). Acute Kidney Injury. StatPearls [Internet]. Treasure Island:
StatPearls Publishing. Located in: https://www.ncbi.nlm.nih.gov/books/NBK441896
Malik, A., Brito, D., Vaqar, S. (2022). Congestive Heart Failure. StatPearls [Internet]. Treasure
Island: StatPearls Publishing. Located in:
https://www.ncbi.nlm.nih.gov/books/NBK430873
