Nursing Case Analysis custom essay

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Case Study Scenarios 1
You are managing a 67-year-old female with lower extremity swelling, history of CHF, and doing well by following a low sodium diet. She presents to your clinic with mild lower extremity swelling, BP 175/78, and mild shortness of breath. She denies chest pain, diaphoresis, or nausea /vomiting. She is on no medications and has no allergies. You have opted to try outpatient management with close follow-up.
What would your clinical management plan include?
Management of C HF begins with an accurate assessment of the etiology and severity of the disease. This is followed by a therapeutic regimen aimed at the following factors: Correction of systemic factors (e.g. hypertension, diabetics, infection). The clinical treatment plan for this patient will be pharmacology and non-pharmacologic plan.
The non-pharmacologic treatment
Dietary advice: Provide advice on sodium intake. Patients with obesity, diabetes, and dyslipidemia should be given instructions on carbohydrate and caloric restriction
Sodium restriction: Dietary sodium intake should be restricted to 2 to 3 g daily for patients with clinical heart failure, irrespective of left ventricular ejection fraction (LVEF). Restriction to less than 2 g daily may be required
Restricted fluid intake: Restriction of daily fluid intake to less than 2 L is recommended in patients with severe hyponatremia (serum sodium less than 130 mEq/L). It should be considered for all patients with fluid retention that is poorly responsive to high doses of diuretic and sodium restriction
Caloric supplementation: A dietician consult and caloric supplementation should be provided for patients with advanced heart failure and unintentional weight loss or muscle loss (cardiac cachexia)
Multivitamin supplementation: Patients with heart failure should be considered for daily multivitamin-mineral supplementation, especially if on diuretic therapy and restricted diets
Home-based exercise programs may result in reduced hospitalization rates, and supervised interval training may improve functional capacity and quality of life
Avoid products containing ephedra (ma huang) or ephedrine
Patients with heart failure should received pneumococcal vaccination and annual influenza vaccination unless contraindicated
The Pharmacology management
Loop diuretics are introduced first for fluid control in patients in overt HF. The goal is relief of signs or symptoms of volume overload, such as dyspnea and peripheral edema.
ACE inhibitors, or if not tolerated, angiotensin II receptor blockers (ARBs) are typically initiated during or after the optimization of diuretic therapy. These drugs are usually started at low doses and then titrated to goals based upon trial data.
Beta blockers are initiated after the patient is stable on ACE inhibitors, again beginning at low doses with titration to trial goals as tolerated.
What pharmaceutical agents would you treat with, if at all?
Will start patient on 5 mg of lisinopril once daily, the starting dose, will dispense 14 tablets with no refill, and will reevaluate in 2 weeks.

What do the evidence-based guidelines say about management in this scenario?
Clinical practice guideline recommends that A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of CHF. Initial examination of patients presenting with CHF should include assessment of the patient’s volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index.
Clinical practice guideline recommends that All patients with asymptomatic or symptomatic left ventricular dysfunction should be started on an ACE inhibitor. Beginning therapy with low doses (eg, 2.5 mg of enalapril twice daily, 6.25 mg of captopril three times daily, or 5 mg of lisinopril once daily) will reduce the likelihood of hypotension and azotemia . If initial therapy is tolerated, the dose is then gradually increased at one to two week intervals to, if tolerated, a target dose of 20 mg twice daily of enalapril, 50 mg three times daily of captopril, or up to 40 mg/day of lisinopril or quinapril. Blood should be obtained in all patients one to two weeks after starting or changing a dose and periodically thereafter to assess the plasma potassium concentration and renal function.

You are being consulted by a 15-year-old healthy female on the best choices for oral contraceptives. This patient is without medical problems, on no meds, has regular monthly periods every 30 days, lasting 5 days without change in that regimen for 2 years. There is no dysmenorrhea or other complaints. She is sexually active and has been using condoms. She presents to your clinic alone and requests that her parents (who she lives with) not be made aware of this visit or of your treatment.

Advise to a 15-year-old Minor about Contraceptive
This patient wil be advised about the consequences of sexual activity, including pregnancy and STDs. she will also be informed that oral contraceptive will not prevent STDs. comprehensive sexuality education and services will be offered to this patient including education on sexual abstinence, correct use of condoms, . Prescribing of contraception to a 15-year-old Minor without parental consent depends on the local laws in the state or country the minor is residing or the therapy is taking place. Most states in the U.S. allow for prescribing of medications to prevent pregnancy without parental consent as long as the healthcare provider believes that the therapy is in the best interest of the minor and the minor is capable of given informed consent. Confidentiality is also important. Based on the Mature minor rule, a minor does not need a parental consent for contraceptives or pregnancy tests as long as the healthcare provider believes that the therapy is in the best interest of the minor and the minor must be capable of providing informed consent. Before making a decision to prescribe contraceptive it important to obtain through history and physical. it is important to find out the minors though thoughts on contraceptives and how she would handle the discussion of sexual activity and contraception with her parent.
Clinical Management Plan
Choice of contraceptive method should involve factors such as efficacy, safety, noncontraceptive benefits, cost, and personal considerations. Oral contraceptives are the choice of most American women who use birth control; combined monophasic oral contraceptive with low estrogen is considered the first choice therapy for birth control pills. Initial examination should include eliciting history such as menstrual history, past medical history, sexual history and risk factors for sexually transmitted diseases, family history and history of any health problems that may be contraindications for use of the pill.
Physical examination should include weight and blood pressure measurements, abdominal examination, and breast examination before starting the pill. Pelvic examination and thyroid examination may be obtained 3-6 months at a minimum after stating the pill. It is important to check Pap smear and screening for Chlamydia. Patient education and counseling is very essential. once therapy is initiated, follow up will be at 1 month and again at 3 months after and then every 6 months. Blood pressure will be checked at 3 months and breast and pelvic examination will be done every 12 months. Annual screening for chlamydia will also be done. the American Academy of Pediatrics recommends standard 28-day pack of pills (21 days of hormone and 7 days of placebo) for adolescents because it promotes daily compliance.

Pharmaceutical agents, Rx, Sig, Dispensed Amount, and Refills
Evidence-Based Guidelines
The American Academy of Pediatrics recommends that sexual abstinence be be encouraged adolescent patients as part of comprehensive sexuality education and services. they recommended that healthcare provides offer confidential, nonjudgmental education and risk-reduction counseling around issues of sexuality for adolescent patient. adolescent patients should be encouraged to consistently and correctly use condoms with every event of sexual intercourse. according to mature minor rule, a minor does not need a parental consent for contraceptives or pregnancy tests as long as the healthcare provider believes that the therapy is in the best interest of the minor and the minor must be capable of providing informed. Combined monophasic oral contraceptive with low estrogen is considered the first choice therapy for birth control pills. Particularly over the 21 days of hormone-containing pills helps to maximize efficacy and minimize bleeding irregularities and are recommended for adolescent patients

Your patient’s lab work demonstrates TSH 17 milliunits/L and free T4 0.5ng/dl. Clinically, these values support your physical exam and history, and your patient is symptomatic.

Clinical Management Plan
This clinical management plan for this patient will include a detailed medical history, as this will provide clues to suggest the diagnosis of hypothyroidism. Determining the cause of hypothyroidism is essential, as this is important in treatment. Appropriate physical examination will be performed as initial evaluation. This include checking patient’s weight and height, pulse rate and regularity, blood pressure, cardiac examination, thyroid enlargement muscle weakness, eye examination and thorough skin assessment. Diagnostic tests will include TSH assay, Free T4, Thyroid autoantibodies and Thyroid scan or ultrasonography to evaluate suspicious structural thyroid abnormalities. The treatment of primary hypothyroidism is directed toward increasing the serum concentrations of thyroid hormones to reestablish a eumetabolic state. Levothyroxine will be used for the treatment of hypothyroidism in this patient. The recommended dosage of levothyroxine is 1.6 µg/kg of body weight per day. The guideline recommends that patients undergo reassessment in 6 weeks and therapy be titrated after an interval of at least 6 weeks. The serum TSH level and free T4 need to be estimate as well. It is important to include the patient as an active participant in the decision-making process regarding type of therapy. The patient should be educated on the indications and implications of therapy, including risks, benefits, and side effects. Once the TSH level has normalized, a follow-up visit can be conducted in 6 months and then annually.
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Pharmaceutical agents, Rx, Sig, Dispensed Amount, and Refills
Evidence-Based Guidelines
Patients with primary hypothyroidism should undergo assessment for the cause of their hypothyroidism since this is important in determining treatment. Hypothyroidism can result from under secretion of thyroid hormone from the thyroid gland, which can be caused by the most chronic autoimmune thyroiditis (Hashimoto’s disease), tumor such as lymphoma, surgical removal of the thyroid gland, drugs such as lithium or interferon and thyroid gland ablation with radioactive iodine. The practice guideline recommends that consultation with an endocrinologist be done if patient is age 18 years or less, unresponsive to therapy, pregnant, has cardiovascular disorder, and if there is presence of other endocrine disease. TSH assay is as the primary test to establish the diagnosis of primary hypothyroidism. Other tests recommended include Free T4, Thyroid autoantibodies and Thyroid scan or Ultrasonography to evaluate suspicious structural thyroid abnormalities.
AACE recommends the use of a high-quality brand preparation of levothyroxine for the treatment of hypothyroidism. It is advised that patient receive the same brand of levothyroxine throughout treatment. The recommended dosage of levothyroxine is 1.6 µg/kg of body weight per day, appropriate dosage and pace of treatment depends on the duration and severity of the hypothyroidism and presence of other associated medical disorders.
The initial levothyroxine dosage should be based on patient’s age, weight, and cardiac status of
the patient and the severity and duration of the hypothyroidism; it usually 12.5 µg daily.
the guideline recommends that patients undergo reassessment in 6 weeks and therapy be titrated after an interval of at least 6 weeks. The serum TSH level and free T4 need to be estimate as well. Once the TSH level has normalized, a follow-up visit can be conducted in 6 months and then annually. Follow-up assessment should include appropriate interim history physical examination and pertinent laboratory tests. it is also to involve the patient as an active participant in decision making and educate the patient on the indications and implications of therapy, including risks, benefits, and side effects to help improve adherence to recommendations.

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