Description
Respond to your peers by extending, refuting/correcting, or adding additional nuance to their posts. Each reply must be at least 150 words and contain at least one reference from an academic journal. All replies must be constructive and include at least two references.
Unformatted Attachment Preview
Week 6 Clinical Experience
Tana M Kahn
St. Thomas University
NUR-612CL-AP2: Advanced FNP Clinical IV
Dr. Nancy C. Woelki
September 28, 2023
Week 6 Clinical Experience
Challenges or Success
The sixth clinical week was very interesting. I learned to actively listen to patients. This
enabled me to communicate better with them and capture all relevant details required for making
assessments and diagnoses.
Patient Assessment
J.K., a 70-year-old Asian American female, came into the clinic looking worried. She said,
“I started having chest pain while I walked up the staircase today. What could be the problem?”
Subjective Data
J.K. admitted that the chest pain started in the morning when she was walking up a staircase.
She admitted that the pain was localized in her chest. She admitted that the pain lasted as long as
she was climbing the staircase. She described the pain as aching and pressing. She admitted that
the pain is aggravated by physical activity, specifically walking up the staircase. She denied any
factors that relieved the symptoms. She rates the pain at 7 out of 10. She admits that she has a
history of hypertension and hyperlipidemia well-managed using amlodipine and atorvastatin,
respectively. She admitted that she has a family history of coronary artery disease. She admits
that she is a non-smoker, consumes alcohol occasionally, is retired, and lives independently. She
denied having shortness of breath.
Objective Data
She had a blood pressure of 132/80, a heart rate of 80 bpm, a respiratory rate of 16 breaths
per minute, and a temperature of 98.6 °F. She appeared comfortable and in no acute distress. She
had regular heart sounds with no murmurs or extra sounds. She had clear bilateral breath sounds
and no chest wall tenderness on palpation. An electrocardiogram (ECG) of the CAD indicated
ST-segment depression and inverted T-waves. She also had elevated troponin levels.
Assessment
The primary diagnosis for this patient is coronary artery disease (CAD) (ICD-10: I25.10).
Additional differential diagnoses to consider include acute myocardial infarction (ICD-10:
I21.9), angina pectoris (ICD-10: I20.9), and gastroesophageal reflux disease (GERD) (ICD-10:
K21.9).
CAD (I25.10)
This condition is also known as atherosclerotic heart disease. It occurs when coronary
arteries become narrowed or blocked due to the buildup of plaque. It begins with the
development of atherosclerosis, plaque formation, ischemia, chest pain, and, in severe cases, a
myocardial infarction (Liu et al., 2020). This diagnosis is supported by the presentation of chest
pain, risk factors for hypertension and hyperlipidemia, and a family history of coronary artery
disease. She also has pain on exertion, which is a hallmark of CAD (McConaghy et al., 2020).
The ECG and troponin levels confirm this diagnosis.
Acute Myocardial Infarction (I21.9)
This is also called a heart attack. It is caused by a sudden and complete blockage of one or
more coronary arteries, resulting in the death of heart muscle tissue due to a lack of blood supply
(Tayyeb et al., 2022). It occurs due to the rupture of an atherosclerotic plaque and subsequent
clot formation, which causes chest pain.
Angina Pectoris (I20.9)
This is chest discomfort caused by reduced blood flow to the heart muscle due to coronary
artery narrowing or spasms (Caceres et al., 2021). It is often triggered by physical exertion or
emotional stress. This diagnosis was ruled out due to a conclusive diagnosis of CAD.
GERD (K21.9)
This is a chronic condition where stomach acid backs up into the esophagus (Howden et al.,
2021). It results in heartburn, chest pain, and regurgitation. This diagnosis was ruled out since
the clinical presentations were inconsistent with GERD.
Plan of Care
I prescribed the patient to take aspirin 81 mg orally every four hours as needed for pain. I
advised her to visit a cardiologist for a comprehensive cardiovascular risk assessment. I
scheduled a follow-up appointment after two weeks to assess disease progression and make
necessary adjustments to the care plan.
Health Promotion Intervention
I educated the patient to engage in lifestyle modifications such as dietary changes to lower
cholesterol and sodium intake. I also recommended regular exercise within the patient’s
tolerance. I recommended that she engage in stress management techniques.
Lessons Learned
This clinical week taught me to effectively use patient history in making diagnoses. This
became helpful in narrowing down the diagnoses and addressing the condition.
References
Caceres, J., Atal, P., Arora, R., & Yee, D. (2021). Enhanced external counterpulsation: A unique
treatment for the “no‐option” refractory angina patient. Journal of Clinical Pharmacy and
Therapeutics. https://doi.org/10.1111/jcpt.13330
Howden, C. W., Manuel, M., Taylor, D., Jariwala-Parikh, K., & Tkacz, J. (2021). Estimate of
refractory reflux disease in the United States. Journal of Clinical Gastroenterology, Publish
Ahead of Print. https://doi.org/10.1097/mcg.0000000000001518
Liu, Y., Neogi, A., & Mani, A. (2020). The role of Wnt signalling in development of coronary artery
disease and its risk factors. Open Biology, 10(10), 200128. https://doi.org/10.1098/rsob.200128
McConaghy, J. R., Sharma, M., & Patel, H. (2020). Acute chest pain in adults: Outpatient
evaluation. American Family Physician, 102(12), 721–727.
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
Tayyeb, M., Mughal, M. S., Mirza, H., Asif, M., Fatima, S., Ghani, A., Waqar, F., Mughal, W. A., &
Wasty, N. (2022). Abstract 13029: Acute myocardial infarction – mortality trends in the United
States. Circulation, 146(Suppl_1). https://doi.org/10.1161/circ.146.suppl_1.13029
Mejia, Valentina
YesterdaySep 28 at 11:57am
Manage Discussion Entry
1.) Did you face any challenges, any success? If so, what were they?
This week I believe was successful me and my preceptor have good teamwork going on when
seeing our patients. The medical assistant is also very helpful as well, we work together to finish
in a timely manner. I saw some interesting patients this week including one patient that had
Raynaud’s disease, and also systemic lupus erythematosus, which was interesting because it was
my first time seeing it.
2.) Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment,
plan of care, and at least 3 possible differential diagnosis with rationales.
Patient T.S is 65 years old. Patient states she felt she had some abnormal rashes and skin
ulcerations for a while now and some alopecia as well, and a lot more joint stiffness in the
morning. Upon assessment of the patient, she has some pallor, generalized erythema, generalized
bruising, she also had an erythematous elevated lesion which is the classic butterfly rash. Based
on plan of care because of the s/s it would be, instructing the patient to keep skin clean and dry
as well as moisturizing the skin using warm water, to maintain skin integrity. I would also
recommend the patient to avoid contact with harsh chemicals to prevent condition from
aggravating. I would also include teaching on wearing protective eyewear, as well as SPF 15 or
above and to avoid ultraviolet rays of light. Since the client is complaining of pain, I would
advise her to avoid prolonged periods of inactivity as this can increase stiffness in the joints, as
well as ROM exercises after shower and bath. Corticosteroids could be prescribed to help with
inflammation as well as immunosuppressant can also be given to suppress the activity of the
immune system specially during severe flares within the CNS and the renal system.
Antimalarials can also be prescribed to this patient for effective management of skin lesions as
they are present in this patient. Patient should also be tested and monitored with laboratory tests
like, ANA test, Anti-double standard antibody test, CBC, as well as kidney function tests. To
identify specific organ involvement patient might need to get a CT scan or an X-ray. Some of the
differential diagnosis used can be but are not limited to; discoid skin lesions this includes round
coin shaped lesions in the skin that develop in the scalp and face as well as other parts in the
body. Erythematous papules involve abnormal redness of the skin. Systemic sclerosis involves
symptoms of decreased joint movement and skin induration with lesions.
3.) Mention the health promotion intervention for this patient.
I have already mentioned some of the health promotion for this patient in this last question, but I
can add more, this includes reinforcing energy conservation tips like the following. Adequate
rest periods, pacing of activities with alternating rest, proper use of assistive adaptive devices,
avoiding stimulating foods like caffeine, encouraging warm baths before bedtime, encouraging
gentle range of motion exercises after a shower or bath. It can also be useful to take an antiinflammatory drug to help decrease pain and help with rest.
4.) What did you learn from this week’s clinical experience that can beneficial for you as an
advanced practice nurse?
Some of the stuff that I learned this week involves, the evaluation and important laboratory tests
needed for patients with suspected SLE. I also learned the treatment options for this patient
pharmacological as well as therapeutical. I also got to see how the butterfly rash looks on the
patient as well as other representations of the disease on the patient’s skin.
5.) Support your plan of care with the current peer-reviewed research guideline.
The efficacy of glucocorticoids in the control of SLE is well established, and the use of highdose or “pulsed” GCs to rapidly ablate the autoimmune response in organ-threatening
manifestations is an important component of SLE treatment regimens (Schwarting A, 2020). It
was stated in this article that glucocorticoids were started to be given to patients in the 1950s and
it has greatly increased the survival rates of these patients. Antimalarials are among the oldest
drugs used to treat SLE, but they are still rightfully considered to be the cornerstone of SLE
therapy (Daikh D, 2019).
References
Basta F, Fasola F, Triantafyllias K, Schwarting A. Systemic Lupus Erythematosus (SLE)
Therapy: The Old and the New. Rheumatol Ther. 2020 Sep;7(3):433-446. doi: 10.1007/s40744020-00212-9. Epub 2020 Jun 2. PMID: 32488652; PMCID: PMC7410873.
Aringer M, Costenbader K, Daikh D, et al. 2019 European League Against
Rheumatism/American College of Rheumatology classification criteria for systemic lupus
erythematosus. Ann Rheum Dis. 2019;78:1151–1159.
Discussion 6
Selvia Beshay
NUR-612-AP1
St. Thomas University
Dr. Nancy Woelki
Additional Subjective Data
Besides the patient’s complaint of reduced vision and bothersome glare, I will interview the
patient for past medical history and gather information about any pre-existing eye conditions
they may have including chronic illnesses and previous surgeries. I will also ask the patient about
any medications they are currently taking since certain drugs can affect vision. It will be essential
to inquire about the patient’s history of trauma and injuries as well as the patient’s overall health,
lifestyle changes, and any change in social or personal circumstances since they moved to
Florida.
Additional Objective Data
Some of the objective data that I will look out for include the visual acuity test, which will
be performed using the Snellen chart. In addition, a physical examination of the eyes would be
conducted to check for signs of cataracts and other abnormalities and this may involve looking
for cloudiness or the opacity of the eye lens as well as assessing for pupillary response and eye
movements and checking for intraocular pressure. Besides, a test will be carried out to evaluate
the patient’s visual field so as to identify loss in peripheral vision or any blind spots.
Differential Diagnoses
Based on symptoms presented by the patient, the three possible differential diagnoses
include; first, cataracts, which is the gradual opacification of the usually clear lens of the eye that
obscures the passage of light, which leads to the individual having blurry vision, difficulty in
reading in dim light, poor visibility especially at night, occasional double vision, and glare and
halos around lights. The second possible diagnosis is age-related macular degeneration, which is
a condition that is acquired through the degeneration of the retina and leads to significant central
visual impairment. This happens through a combination of non-vascular such as the drusen and
the retinal pigment epithelium abnormalities, and the neo-vascular derangement that includes the
choroidal neo-vascular membrane formation (Thomas et al., 2021). The third possible diagnosis
for this patient is diabetic retinopathy, which is a common cause of gradual visual loss in older
people where photocoagulation and vitreous surgery may be used to restore vision.
Laboratory Tests
The lab tests that will help me rule out some of the differential diagnoses include blood
tests, especially if the client has a history of diabetes, to check for blood sugar levels and to
assess the kidneys and liver function. Similarly, if the patient is taking certain medications that
may affect their vision like steroids, then blood tests would help monitor the effects of the drugs
(Gaballa et al., 2021). Besides blood tests, there are no specific lab tests that are typically ordered
for diagnosis of cataracts, although if the provider suspects that the patient has an underlying
condition that is affecting their vision, then additional tests may be necessary. In other words, the
need for additional lab tests is dependent on the patient’s medical history and the provider’s
clinical judgment.
Additional Diagnostic Studies
In this case, the additional diagnostic study that I may order is the optical coherence
tomography (OCT) test which may be used to evaluate the structure of the optic nerve and retina
(Bekollari et al., 2023). The OCT will help in identifying any abnormalities that are associated
with certain illnesses such as macular degeneration. Also, a slit-lamp exam may be ordered to
assess the interior segment of the eye such as the cornea and the lens.
Treatment
For this patient, if they are diagnosed with cataracts, then the treatment would likely be a
cataract surgery. In this procedure, the surgeon will remove the cloudy lens in the eyes and
replace it with an artificial lens or the intraocular lens implant (IOL) (Lapp et al., 2023). Before
the surgical procedure, the patient will be educated about the benefits as well as the eminent risks
involved. In particular, the provider should explain to the patient the pre-and post-operative
instructions that include any necessary preparations and the potential complications.
Potential Complications
The treatment ordered in this patient’s case is cataract surgery. Some of the expected
complications from this procedure would include increased intraocular pressure, infection,
bleeding, and swelling (Grzybowski et al., 2019). There is no risk of retinal detachment or an
endophthalmitis and hence, it is crucial for the patient to be educated about such potential
complications and advised appropriately on how to seek immediate medical attention if they
experience adverse symptoms.
Additional Laboratory tests
Some additional la tests in this case would include; a comprehensive metabolic panel, a
complete blood count (CBC), a lipid profile, and a thyroid function test. The additional tests
would help provide information about the patient’s general health and any underlying condition
that could be contributing to their loss of vision. Note that, age is a factor in loss of vision as
many of the elderly people, like the patient in this case, usually lose their eyesight as they
advance in age. Hence, aging will also be a factor to consider when ordering additional tests.
Additional Patient Teachings
The patient may need additional education and teachings especially about the importance of
carrying out a regular eye exam, especially as they age. It is also essential to discuss the
strategies for managing glare such as wearing sunglasses and using anti-glare filters on the
screens. Further, the patient should be taught about considering changing their lifestyle such as a
modification in nutrition and lifestyle activities, to help prevent and manage conditions such as
debates which may cause vision problems.
Consultation
In this case, consultation with a specialist will be necessary. A referral to an ophthalmologist
for a comprehensive eye examination and surgical intervention may be necessary and
appropriate. The ophthalmologist would offer their expertise in diagnosing and treating eye
conditions, and this includes cataracts.
References
Bekollari, M., Dettoraki, M., Stavrou, V., Skouroliakou, A., & Liaparinos, P. (2023). Investigating
the structural and functional changes in the optic nerve in patients with early glaucoma using the
Optical Coherence Tomography (OCT) and RETeval System. Sensors, 23(9), 4504.
https://doi.org/10.3390/s23094504
Gaballa, S. A., Kompella, U. B., Elgarhy, O., Alqahtani, A. M., Pierscionek, B., Alany, R. G., &
Abdelkader, H. (2021). Corticosteroids in ophthalmology: Drug delivery innovations,
pharmacology, clinical applications, and future perspectives. Drug Delivery and Translational
Research, 11, 866-893. https://doi.org/10.1007/s13346-020-00843-z
Grzybowski, A., Kanclerz, P., Huerva, V., Ascaso, F. J., & Tuuminen, R. (2019). Diabetes and
phacoemulsification cataract surgery: Difficulties, risks and potential complications. Journal of
Clinical Medicine, 8(5), 716. https://doi.org/10.3390/jcm8050716
Lapp, T., Wacker, K., Heinz, C., Maier, P., Eberwein, P., & Reinhard, T. (2023). Cataract surgery—
Indications, techniques, and intraocular lens selection. Deutsches Ärzteblatt
International, 120(21-22), 377. https://doi.org/10.3238/arztebl.m2023.0028
Thomas, C. J., Mirza, R. G., & Gill, M. K. (2021). Age-related macular degeneration. Medical
Clinics, 105(3), 473-491. https://doi.org/10.1016/j.mcna.2021.01.003
Purchase answer to see full
attachment
