NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum

NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum Complete your Week 8 Discussion prompt. This week you will complete a Case Study prompt and a Reflection prompt. Select one of the following case studies to discuss: A 42 year old patient is 3 days postoperative from an abdominal cholecystectomy. She is currently only taking antibiotics and hydrocodone. Today she complains of pain in her left calf just below the knee and says it is swollen, hot and painful to the touch. She denies other symptoms, significant history or allergies. A 66-year-old woman complains of shortness of breath, numbness and heaviness in her arms as she walks up the hill to her house. The pain lessens when she stops to rest. For the case you have chosen, post in the discussion: Discuss the questions you would ask the patient, the physical exam items you would include, and any additional tests you would like to have performed. In SOAP format, list: Relevant positive and negative information Differential and working diagnosis Treatment plan, including: pharmacotherapy with complementary and over-the-counter therapy, diagnoses (labs and tests), health education and mode changes life, age-appropriate preventive care and follow-up at this visit. Use at least one scientific source other than your textbook to link your response to national guidelines and evidence-based research supporting your ideas. In your peer responses, please respond to at least one peer who chose another case study. Reflect on what you have learned in this lesson: Example of solution The patient is a 42 year old female, three days post cholecystectomy, currently reporting development of lower extremity pain, warmth and swelling left. Negative for any other symptoms, relevant medical history and allergies. Currently taking antibiotics and hydrocodone. Questions for the patient Considering that the symptoms can be attributed to several diagnoses, the basic information about the patient being three days after the operation indicates the possibility of a common post-surgical complication in the form of a clot (Evans & Ratchford, 2018). The questions I would like to ask the patient begin with the mnemonic OLDCART as it would be prudent to know the onset or when the patient noticed the swelling, redness and pain. Likewise, the degree of pain when attempting extremity displacement, reliving factors and characteristics. I would also like to know if the patient is receiving thromboembolic therapy in the sense of compression stockings or sequential compression devices, pharmacological therapy such as subcutaneous heparin or enoxaparin. Also, I would like to know if the hydrocodone she is taking is effective, if she has had a fever, chills or malaise. Additionally, I would ask the patient if she has a history of scratching or injury to the lower extremities, or a history of bleeding disorders, and whether the patient was taking any contraceptive medications. Finally, I would like to know if the patient has started to walk since the operation. Review of objective data Patient is on day 3 postoperatively for cholecystectomy Redness and swelling in left lower limb; measure the circumference of both lower limbs to compare the size difference. NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum On ABx post-op; afebrile. Possible positive Homan test (if performed on assessment) Differential Diagnoses Working Diagnosis: Deep Vein Thrombosis Pos Relevant: Postoperative redness, pain and swelling of the posterior part of the calf within 3 days of abdominal surgery, patient possibly immobile after surgery operation. Neg Relevant: Not known for vascular lesions or hypercoagulability. In the case of deep vein thrombosis, post-surgical venous stasis is a very common etiology for the formation of a deep vein clot in the lower limbs (Stone et al., 2017). Considering all the subjective and objective data so far, it would not be unreasonable to suspect DVT as the primary and functional diagnosis for this development. Signs and symptoms of DVT coincide with the presentation shown above with redness, swelling and pain in the posterior part of the calf just below the knee (Stone et al., 2017). There are a number of factors involved in the potential formation of a DVT beginning with venous stasis and extending to hypercoagulability, and in the case of this patient, venous stasis is the most likely culprit when recovery from extensive surgery, which can be considered a form of trauma. Generally, the formation of a DVT is within the time window of 3 days of bed rest or hospitalization (Evans & Ratchford, 2018). Differential diagnosis 1: Superficial thrombophlebitis Pos Relevant: Postoperative redness, pain and swelling of the posterior part of the calf within 3 days of surgery. Neg Relevant: No recent history of trauma to extremities, no varicose veins reported/assessed. Although diagnoses of DVT are more likely, it is also very likely to indicate the formation of a superficial venous thrombus, as symptoms of pain, redness, and swelling coincide with symptoms of a DVT (Evans & Ratchford , 2018). As mentioned above, timeline, triggers, and objective and subjective data also contribute to whether this is plausible. However, given the patient’s age and lack of relevant medical history, as well as other unknown factors apart from the surgery and the time since, it would not be unreasonable to consider this situation like a TVP vs TVS scenario. Differential diagnosis 2: Cellulitis Pos Relevant: Swelling, pain and redness of the lower limb. Neg Relevant: Afebrile, no knowledge of high white blood cell count. Cellulitis is a fairly common bacterial infection of the skin and subcutaneous tissue, and can erupt from isolated dormant structures in the tissues during events where the immune system is weakened following traumatic events or a pathological process (Collazos et al., 2018). The case study patient had just undergone surgery which may explain the weakened immune system, but in light of the relevant negatives, this can be ruled out by the diagnosis. The patient is already on antibiotics and afebrile as far as we know, so this is more of an early presentation of cellulitis with a non-systemic effect at this time. Although the previously discussed diagnoses are more likely, redness, swelling, and pain are also possible symptoms of cellulitis. Treatment plan Initial planning will involve diagnostics to confirm or rule out DVT. The prevalent diagnoses for this case would be venous ultrasound to visualize the thrombus, PT/INR and DDimer to assess coagulability, possibly CT scan and/or contrast venography if available (Stone et al., 2017). Medical management will include anticoagulant treatment with UFH or LMWH with a possible evolution towards an oral anticoagulant. It is also possible to plan in advance the placement of a vena cava filter as a preventive measure against progression to a pulmonary embolism (Stone et al., 2017). In addition, the patient’s diet will need to be modified and ensure a decrease in vitamin K intake. Once the patient can be cleared, physical therapy should be initiated to get him up. Education will focus on prevention of venous stasis and adherence to medication regimen, as well as possible complications of DVT such as progression to PE. References: Collazos, J., de la Fuente, B., García, A., Gómez, H., Menéndez, C., Enríquez, H., Sánchez, P., Alonso, M., López-Cruz, I. , Martín-Regidor, M., Martínez-Alonso, A., Guerra, J., Artero, A., Blanes, M., de la Fuente, J., & Asensi, V. (2018). Cellulitis in adults: A large prospective, multicenter, observational study of 606 episodes and analysis of factors related to treatment response. PLOS ONE, 13(9). https://doi.org/10.1371/journal.pone.0204036 Evans, NS and Ratchford, EV (2018). Superficial vein thrombosis. Vascular Medicine, 23(2), 187–189. https://doi.org/10.1177/1358863×18755928 Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, MG, Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: pathogenesis, diagnosis and medical management. Cardiovascular Diagnosis and Therapy, 7(S3). https://doi.org/10.21037/cdt.2017.09.01 Part 2 – Reflection This course helped me develop more advanced research skills in terms of evaluating appropriate interventions for diagnoses and supporting relevant data positive and negative. Also, this course helped me to understand the process of writing a progress note as well as its objectives. The process of collecting information from patients in the subjective and objective sense was a challenge, but the process of learning how to do it was also very helpful in understanding how to synthesize the collected information into an action plan. Get 10% Off Order Over $100 Use Coupon Code: ORDER NOW