determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Topic: W2 A 2
Order Description
Assignment Assignment 2: Case Study Analysis and Care Plan Creation
Click here to download and analyze the case study for this week. Create a wholistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
•Search term page to identify the codes applicable to the care plan. https://www.cms.gov/Medicare/Coding/ICD10/index.html
•This link will lead to an excel version of the latest codes: https://www.cms.gov/Medicare/Coding/ICD10ProviderDiagnosticCodes/codes.html
Click here to download the care plan template to help you design a holistic patient care plan. The care plan example provided here is meant only as a frame of reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.
Format
Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be 2 to 4 pages double-spaced and in 12pt font.
Name your document: SU_NSG6001_W2A2_LastName_FirstInitial.doc.
Submit your document to the W2 Assignment 2 Dropbox by Saturday, September 26, 2015.
Grading Criteria
Maximum Points
Care plan demonstrated involvement of the client in the process of recognition, planning, and resolution of the problem.
15
Care plan included effective nursing interventions that are customized for the client and appropriate to the goal.
15
Care plan included diagnostic work-up, medications, conservative measures, and follow-up plan.
15
Care plan provided rationale for choosing a particular treatment modality.
15
Care plan demonstrated logical diagnosis that was substantiated with relevant evidence.
10
Care plan focused on patient education and maintained a fine balance between major and minor health issues of the patient.
10
Care plan included nursing interventions that are specific, appropriate, and free of essential omissions.
10
Used APA standards consistently and accurately.
10
Total
100
THIS IS THE CASE OF STUDY FOR THIS WEEK
Pulmonology Case Study
HPI
A 65-year-old Caucasian female presents with a chief complaint of cough for two weeks. She has been complaining of dry cough since the past two weeks and low grade fever that started two days ago, and was as high as 101 orally. She has had a decreased appetite but no nausea and vomiting. The cough occurs during the night and she needs to sit up in a chair to be able to breathe easier. The cough is mainly dry, rarely productive.
She had been prescribed inhalers in the past; they have been helpful but she does not use them on a routine basis. She has been prescribed antibiotics in the past as well and that seems to help when she is acutely ill. She has been suffering from shortness of breath for the past two weeks following any kind of activity mainly because of the dry cough. She thinks it’s possible that there’s some problem with her “heart.” She is also complaining of slight sore throat, especially in the morning and feels she may have lung cancer.
The patient’s symptoms have been worsening over the past two days.
She has had similar episodes in the past. The last was three months ago when she had to go to the emergency room and they told her that she needed to be hospitalized. She declined hospitalization at that time and was treated and released. She says they gave her antibiotics and an inhaler before discharging her. She mentioned that though it took some time to feel better, there was gradual improvement in her condition following that treatment. According to her, this is the worst episode that she can remember. She’s very concerned today that she could have pneumonia and might require hospitalization.
She is seeking medical attention today because of the fever and prolonged nature of her illness.
PMH
Though she has been treated for this problem in the past with antibiotics and inhalers, she has not been hospitalized. The patient had a chest investigation the last time she had this problem. She states that she did not have pneumonia but did have “emphysema.” The healthcare professionals wanted to do pulmonary function tests, but she declined.
X-ray report:
X-ray results: Hyperinflation of both lungs with an increased AP diameter. There is evidence of emphysema. .
She states that she had asthma as a child and is a cigarette smoker. She also had a hysterectomy way back in 1970s. Besides these, she has no known chronic medical problems.
ROS
Shortness of breath with activity. No diaphoresis. She has had a fever. No nausea and vomiting. Denies chest pressure sensation with physical activity. No palpitations.
MEDICATIONS
The patient does not take any prescription medicines. She takes occasional over-the- counter Tylenol for pain.
Tylenol 650 mg, 2 PO as needed.
ALLERGIES/REACTIONS
She is allergic to sulfa drugs that cause a rash.
SOCIAL HISTORY
The patient has been widowed for 20 years. She is receiving an annual pension of
$40,000.00 and has some money that she has saved in the bank. She has a high school diploma and owns her house. Though she has little disposable income, her finances are essentially stable. She has little knowledge of community resources that are at her disposal.
She has a primary care provider, whom she sees three to four times every year for a physical examination. The physician is very busy and does not spend much time with her. She has insurance but it does not cover all her prescription medications. She relies on a lot on samples.
She has two grown-up daughters who live in the nearby community. They are both in their forties and are alive and well. The patient would like her daughters to be more involved in her life, but she is not sure how to approach them about this. The patient’s perception of self-efficacy has been declining over the past ten years. She feels that she could be feeling depressed because she does not get out of the house very often and this depression is only getting worse with each passing year.
The patient has very low level of day-to-day stress. However, she realizes that her depressive symptoms may be causing some of her physical symptoms.
She goes to church and has some contacts there. She sees her daughters once a month. These people are her support system, but she has no one to talk to on a routine basis.
HABITS
• Diet habits
She has a healthy diet and her dietary intake is adequate. The patient has positive health beliefs and knows that she should be doing more to maintain a healthy lifestyle. She does not get adequate exercise because of her shortness of breath. She enjoys visiting her physician.
Smoking: She has smoked one pack per day for 40 years. Alcohol: She denies alcohol use
Substance Use: She denies any street drug use
WORK HABITS
She has always been a hairdresser; is retired now. She goes to church and occasionally attends some of their functions. Her hobbies include sewing. She is from the United States and lives in a suburban setting. Crime rate in her locality is low with easy access
to public transportation. There are a variety of community groups, but she is not aware of these resources.
FAMILY HISTORY
Her two older sisters are alive and well, one with osteoporosis and one with breast cancer. Her 75-year-old sister was diagnosed with osteoporosis at the age of 55. Her 72- year-old sister was diagnosed with breast cancer at 60 years of age.
PHYSICAL EXAMINATION
Vital Signs: BP: 130/72 left arm sitting regular cuff; T: 101 po; P: 100 and regular; R: 20, non-labored; Wt: 130#; Ht: 55”.
HEENT: White material on the buccal mucosa; does not wipe off with tongue blade. Lymph Nodes: None
Lungs: Decreased breath sounds, dull to percussion right lower lobe. End expiratory wheeze in right lower lobe. No rales or rhonchi. Increased anterior-posterior diameter to chest wall.
Heart: RRR without murmur Carotids: No bruits Abdomen: Benign
Rectum: Not examined
Genital/Pelvic: Not examined
Extremities, Including Pulses: 2+ pulses throughout, no edema
Neurologic: Not examined
LAB RESULTS/RADIOLOGICAL STUDIES/EKG INTERPRETATION
CBC- WBCs 15, 000 with + left shift
Pulse oximeter reading: SAO2: 98%
Radiological Studies
CXR – Same as X-ray
EKG
Normal sinus rhythm
THIS IS THE EXAMPLE of my first week THAT YOU HAVE TO FOLLOW TO DO THIS Cardiology Case Study
Name
Date
Professor:
South University
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 2
Care Plan
Patient Initials: A.H. Age: 52 Sex: M
Subjective Data
A.H. is being seen here today for a follow up visit following stent placement.
Patient had stent placed on previous admission and is concern that he will have continued
episodes of angina, even with having stents placed. Patient is seeking information on his
risk factors associated with angina (Week 1: Cardiology Clinical Case, 2015).
Client Complaints
Patient is asymptomatic and has no new complaints at this time. Patient is being
seen for follow up treatment status post stent placement. Patient is seeking education on
his risk factors for angina following stent placement (Week 1: Cardiology Clinical Case,
History of Present Illness
Patient presented to the emergency department with four hour of chest pain. The
patient when presented complained of shortness of breath with exertion and he was
diaphoretic. The patient states that the pain in his chest was crushing, substernal, and
radiated to his neck and jaw. Patient had these episodes for four days and was fearful to
go to the hospital to seek help. Patient stated that the pain was worse today and he could
not resolve with rest. Patient states that he has been having similar episodes for over six
months but he just thought the episodes were due to him being out of shape. Patient
stated that he normally could resolve his angina episodes by rest prior to his visit to the
emergency room. The patient was admitted to the hospital, transferred to the cardiac
floor, and a catheterization was scheduled. Prior to transfer the patient symptoms were
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 3
relieved by the emergency room with medication. The patient was hospitalized for four
days and had stents placed during this admission. The patient is seeking advice regarding
his concern of future angina attacks (Week 1: Cardiology Clinical Case, 2015).
Past Medical History
The patient has been diagnosed with hypertension and high cholesterol; however,
he is not compliant with his medications, and he stopped taking them. The only surgery
that the patient has had in the past before the stent placement was a cholecystectomy and
that was over ten years ago. The patient denies any allergies and the only other
hospitalization was for his cholecystectomy. The patient had an EKG on file at his PCP
office from when he was prescribed his hypertensive medications. The patient did have
his cholesterol level periodically checked. The patient was prescribed daily medications
on discharge from the hospital, and has been complaint with his discharge regimen, and
the medication list is as follows:
? Tenormin XL 50 mg daily
? Lipitor 10 mg daily
? Glucophage 500 mg BID
? Baby Aspirin 81 mg daily
(Week 1: Cardiology Clinical Case, 2015)
Significant Family History
The patient has two older brothers that are currently being treated for
hypertension and type two diabetes. The brothers were diagnosed in their forties with
these disorders. Both the patient parents are deceased. The patient father dies from heart
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 4
disease and his mother dies from breast cancer (Week 1: Cardiology Clinical Case,
Social and Personal History
The patient is a carpenter and makes about 50,000.00 dollars a year. He is a high
graduate. The patient lives with his wife in a one bedroom apartment in the inner city that
has a high crime rating. They live pay check to pay check and his spouse is disabled.
They have three grown children that do not live in the area. He does not participate in any
physical activity. They have limited community involvement and do not have any family
in the area. He lacks social and emotional support. The patient has limited health
insurance coverage and uses the local clinic as his PCP. The patient prescriptions are not
covered by his current health care plan (Week 1: Cardiology Clinical Case, 2015).
The patient eats one large meal a day after work and does not eat breakfast. The
patient when he does eat lunch consist of fast food. The patient eats limited fruits and
vegetables and mostly eats pasta and meat when he meals at home. The patient smokes a
pack a day for over thirty years. The patient does not drink and does not use any illegal
drugs. The patient does not have any hobbies outside the home and will read when he at
home. The patient states that the exercise that he receives as a carpenter is enough
physical exercise for him to be healthy and feels like he got enough exercise when he was
younger (Week 1: Cardiology Clinical Case, 2015).
Client’s Support System
The patient is married to a disabled spouse from uncontrolled diabetes type two.
He lacks any family support and is isolated from the community. The patient uses the
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 5
local clinic as a primary care source, so he never sees the same practitioner (Week 1:
Cardiology Clinical Case, 2015).
Behavioral or Nonverbal Messages
The patient has anxiety regarding returning to work. The patient is scared that he
will be unable to care for his spouse, due to his recent illnesses. The patient has high
stressed levels and is worried over his finances. The patient has a strong family sense and
believes that as a real man he should be able to care for his family and should be strong
enough not to suffer from any diseases. The patient suffers from depression. He is dealing
with his depression by over eating and sleeping excessively (Week 1: Cardiology Clinical
Client Awareness of Abilities, Disease Process, and Health Care Needs
Patient is fearful of being able to continue to financially take care of his spouse
and himself. The patient is seeking advice on the risk factors for angina. The patient
needs education on the causes of angina and his risk of heart disease. The patient also
needs assistance with his medications due to lack of insurance coverage for medication.
The patient has limited knowledge on his disease process and the reason for stent
placement (Week 1: Cardiology Clinical Case, 2015).
Objective Data
The patient’s objective data is as follows:
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 6
? WT- 220 POUNDS
? HT- 70 INCHES
? BMI- 31.6 (Calculate Your Body Mass Index, n.d.)
Physical Assessment Findings:
? LYMPH NODES- None
? LUNGS- Decreased breath sounds throughout no adventitious sounds
? HEART- RRR without murmurs noted
? CAROTIDS- Right Bruit
? ABDOMEN- Obesity
? RECTUM- Not Examined
? GENTITAL/PELVIC – NA
? EXTREMITIES WITH PULSES- Decreased pedal pulses BL with lower
leg edema from ankle to mid-calf
? NEUROLOGIC- Not Examined
? EKG- No changes from baseline
? TOTAL CHOLESTEROL- 210
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 7
? TRIGLYCERIDES- 250
? FASTING BLOOD SUGAR- 140
? CXR- Hyperinflation of the lungs without infiltrates noted
? EKG- No change noted from previous
Client’s Support System: Disabled Spouse
Client’s Locus of Control and Readiness to Learn: Patient is showing his wiliness to learn
by coming to follow up appointment and seeking advice on risk factors for angina. He
has been following his discharge planning and taking his medications as prescribed
(Week 1: Cardiology Clinical Case, 2015).
ICD-9 Diagnoses/Client Problems
? 413.9- OTHER AND UNSPECIFIED ANGINA PECTORIS
? 401.9- UNSPECIFIED ESSENTIAL HYPERTENSION
? 272.4- OTHER AND UNSPECIFIED HYPERLIPIDEMA
? 250.02- DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,
TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
? 278.00- OBESITY UNSPECIFIED
? V79.0- SCREENING FOR DEPRESSION
? 309.28- ADJUSTMENT DOSORDER WITH MIXED ANXIETY AND
? V15.82- PERSONAL HISTORY OF TOBACCO USE
? 786.59- OTHER CHEST PAIN
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 8
Advanced Practice Nursing Intervention Plan
Coronary artery disease is the primary cause of death for both men and women in
the United States. CAD includes acute MI, angina pectoris, atherosclerotic cardiovascular
disease, and any chronic ischemic heart disease. There are modifiable and nonmodifiable
risk factors that lead to heart disease. The factors that the patient cannot control is his
family history, his age, and gender. The modifiable risk factors that the patient has
control over is his smoking, lack of physical exercise, diet, obesity, and stress level
(Buttaro, Terry, Trybulski, Bailey, & Cook, 2013 pg. 518-519).
Stable angina is precipitated by exertion and is typically relieved by rest. The
demand or reduction in myocardial oxygen supply are the factors that cause coronary
ischemia. There is three factors that determine the amount of oxygen needed; the heart
rate, systemic blood pressure, and left ventricular wall tension. The heart rate and blood
pressure influence the oxygen requirements because both determine the myocardial
workload. Activities and increased metabolic demands that increase the workload of the
heart increases that oxygen requirements and causes angina and ischemia (Buttaro, Terry,
Trybulski, Bailey, & Cook, 2013 pg. 520).
A.H. condition is complicated because he has comorbid diseases that will require
him to be followed by a cardiologist. The amount of follow up visits will be determined
by the cardiologist. The clinic that the patient uses as primary care will follow the
cardiologist recommendations. The patient will require management of his disease
processes and medications which the clinic is able to provide. A.H. will be provided with
nitroglycerin tablets and education will be provided on the use of these tablets. On the
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 9
visit the patient will be asked about the frequency of his episodes, the severity of pain,
and if he is using his nitro tablets. The patient will receive education on angina and the
warning signs of a heart attack (Buttaro, Terry, Trybulski, Bailey, & Cook, 2013).
The patient will continue with his prescribed medications because the use of
calcium channel blockers, beta blockers, and nitroglycerin help reduce the episodes of
chest pain (Alaeddini, 2014). This assigned treatment plan will also benefit the patient is
his management of hypertension. The patient will be provided with information and help
from the CDC website on smoking cessation. The patient primary care physician will
focus on diet, exercise, smoking, and management of his present illnesses. The patient
will receive lab work at his appointment to assess cholesterol levels, and diabetes control
(Alaeddini, 2014). The patient was provided with resources in his community that will
help him with his medication cost, diet planning, and exercise (Buttaro, Terry, Trybulski,
ADVANCED PRACTICE NURSING CASE STUDY WEEK ONE 10
References
Alaeddini, J. (2014, March 27). Angina Pectoris Follow-up. Retrieved from
https://emedicine.medscape.com/article/150215-followup
Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, and Joanne Sandberg-Cook. Primary
Care, 4th Edition. Mosby, 2013. VitalBook file. Retrieved from
https://digitalbookshelf.southuniversity.edu/books/978-0-323-07501-
5/id/B9780323075015001208_s0340
Calculate Your Body Mass Index. (n.d.). Retrieved from
https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
ICD-9 Code Lookup. (n.d.). Retrieved from https://www.cms.gov/medicare-coverage-
database/staticpages/icd-9-code-lookup.aspx
Week 1: Cardiology Clinical Case. (2015). Retrieved from
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