Focused assessment of heart

Review the case scenario. Norma James is a 69-year-old white female. She presents to the clinic today with worsening shortness of breath. She has a history of type 2 diabetes, hypertension, atrial fibrillation, and stroke. You perform the following assessment: Onset: You asked when she first noticed her shortness of breath, and Norma stated that it seems like it comes and goes and has been getting worse over the past four months. When asked if she has experienced any other new problems, Norma tells you her ankles have been swelling a lot more lately, and she has been unable to walk to the senior center. You ask her how controlled her blood sugars have been over the past several weeks. She ran out of testing supplies and has been unable to test her blood sugar at home. She has been going to the senior center to get tested, but now she is unable to walk there. Duration: You ask her how long she has been experiencing shortness of breath. She tells you she has had intermittent shortness of breath for a few years, but it has become almost constant in the past four months. The episodes start with activity, and it takes her up to an hour after she stops activity for her breathing to get better. When asked about the edema, she tells you it has gotten worse in the past two months, and she is unable to get the swelling down when she elevates her legs. She has always had some swelling, but it seems like it is worse now. Characteristics: You ask her to describe her shortness of breath, and she tells you it feels like she can’t get enough air in her lungs. When asked about her swelling in her legs, she tells you they are swollen mostly around the ankles; some days she can’t get her shoes on. She also tells you she has gained 10 lbs recently, according the nurse at the senior center. Aggravating factors: You ask her what makes her shortness of breath worse, and she tells you that anytime she walks from one room to another room in her house, she has a hard time breathing. When she gets dressed in the morning, and when she is doing any kind of activity like cooking or doing dishes, she has a harder time breathing. When asked what makes her leg swelling worse, she tells you that they are not too swollen in the morning, but by the time she finishes getting bathed and dressed, on the mornings she is able to bathe, her ankles are starting to swell. Alleviating factors: When you ask her what helps her shortness of breath, she tells that she sits down when it gets bad, and eventually it gets easier to breathe. You ask her if anything helps her ankle swelling, and she tells you she has tried soaking them in cold water, but it doesn’t seem to really help. Her neighbor told her to wear tight socks, but she doesn’t have any, so she hasn’t tried that yet. Other background information: Norma is a widow who lives alone with her six cats. She has two grown sons, with whom she has limited contact with one son, but recently her other son stayed with her after her stroke. She has a long history of type 2 diabetes. She had a foot ulcer two years ago that was successfully treated. She has chronic atrial-fibrillation, and last year she suffered a mild stroke and initially had affective aphasia, right-sided weakness, and difficulty swallowing. She spent several weeks in a rehab unit but has since returned home, and is once again independent in her own care. She has a history of seeing multiple physicians for her health care needs. Norma has a known drug allergy to penicillin. She is currently on the following medications: Glucotrol, 10 mg twice a day Captopril, 50 mg twice a day Digoxin, 125 mcg once a day Coumadin, 5 mg once a day You perform the following assessment: Heart: Her rhythm is irregular and rapid; she has normal S1S2. Lungs: She is clear in the upper lobes and has crackles in the lung bases. Peripheral Vascular: She has 2+ radial pulses bilaterally and 1+ pedal pulses. She has 3+ pitting edema in both legs from ankle to mid-calf. She also has jugular vein distention. Capillary refill is < 2 sec. Other vital signs and findings: Her blood pressure is 140/92, her heart rate is irregular and 112, her respirations are 24, and her blood glucose is 140. Diagnosis and treatment: Norma is sent for several tests, including an x-ray, EKG, and echocardiogram. She is diagnosed with Class II heart failure. Her physician prescribes the following additional medications: Lasix and a potassium supplement. Step 2 Write a 3-page (750 word) paper using APA 7.0 format style and address the information below. You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items: Write a detailed explanation describing what you would say to the student, explaining the assessment conducted and the findings. Discuss the heart assessment you performed and any additional assessments you would perform. What are other factors related to the probable diagnosis you would be concerned about with this client? Explain how you would document your findings in the medical record. Develop your plan of care. Identify two nursing diagnoses and one to two nursing interventions related to those diagnoses. The interventions need to be evidence based. Cite the references used in your plan in correct format. Identify what client education should be done for Norma, given her background and presenting illness. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention. Appropriately cite and reference all resources used to complete this assignment in APA 7.0 format style. The course textbook and any article you are asked to read should be used as evidence, the next level of evidence you may use would be peer reviewed articles after that well known web sites for example CDC or the AHA. Objectives Develop a plan of care for the heart and vascular system Demonstrate documentation of the heart and vascular assessment findings Explain how to conduct a physical assessment of the heart and vascular system Assignment Overview In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client. The rubric used to grade this assignment is attached below the assignment description. Deliverables Write a 3-page (750 word) paper using APA 7.0 format style. The minimum page count does not include the required cover page or the reference list. The required course textbook and any article you are asked to read should be used as evidence. The next level of evidence you could utilize would be peer reviewed articles; after that well known web sites for example CDC or the AHA. Avoid blogs, continuing education articles, non-healthcare websites, or obscure web sites. Never cite or reference Wikipedia in formal writing. avoid use Wikipedia as a resource to complete any assignment or discussion in this program.