Free case study on care plan template

[Institution Title]

Patient Initials: _N/A___Age: ___52 years old_____Sex: __Male______
Subjective Data:
Patient has been complaining of chest pain. Manifested signed of labored breathing and excessing perspiration suggesting signs of exertion. Chest pains also seems to radiate to neck as it intensifies.

HPI (History of Present Illness):

Patient has reported to have experienced angina symptoms four days prior to hospitalization. Patient defers seeking medical attention in the belief that the physical symptoms were simply the result of stress and would eventually be relieved after bed rest. Patient was not active as a result of non-activity particularly relating to work.

PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):

Patient has no known allergies. Patient was previously prescribed with medications for hypertension. However, patient did not adhere to the prescription and stopped. Ten years prior to hospitalization, patient was hospitalized for cholecystectomy for which he received a stent placement.

Significant Family History:

Patient’s wife is currently sick with uncontrolled Type 2 Diabetes Mellitus. Siblings, both older brothers have hypertension and type 2 diabetes mellitus who were both diagnosed in their forties. Patient’s parents are bot dead—patient’s father died from heart disease and mother dies from breast cancer.

Social/Personal History (occupation, lifestyle—diet, exercise, substance use)

Patient used to work as a carpenter before his wife got sick. This prompted the patient to stop work and stay at home to care for ailing wife. Patient admitted that he does not engage in any physical activities because his neighborhood is not conducive for outdoor activities since crime rates are very high. Patient also admitted to smoking one pack of cigarette a day. Patients does not drink nor use street drugs. Patient’s diet involved mostly pasta and meat. Does not eat breakfast and eats lunch quickly because of work.

Description of Client’s Support System:

Patient has a wife he live with but is currently ill with uncontrolled Type 2 Diabetes. His children are all grown and lived very far from them. In addition, patient’s parents are both dead and nothing was mentioned in reference to the patient’s siblings aside from their medical conditions.

Behavioral or Nonverbal Messages:

Patient refuses to seek medical attention unless very necessary or unless the symptoms becomes intolerable. Patient also refuses to ask help from his children in caring for his wife as he believes that it is a man’s obligation to take care of the needs of his family.
Patient has knowledge of the risk factors that he experiences given his medical condition. In addition, patient is aware of the physical symptoms being associated with his existing medical condition. However, still refuses to check-in with the doctors out of fear of additional expenses. Thus, patient refuses to seek medical treatment despite necessity.

Objective Data:

Vital Signs including BMI:
Patient’s blood pressure shows abnormal findings. BP is very high at 160/92. Pulse is normal at 60bpm. Respiratory rate is also normal at 16bpm. Temperature is also normal at 98°F. According to patient’s weight and height patient is obese with BMI of 31. 6 .

Physical Assessment Findings:

Physical assessment revealed significant findings for abdomen measurement WC= 44 which indicates android obesity. In addition abnormal heart sound documented on the right side.

Lab Tests and Results:

Lab test and results show high level of cholesterol and high blood sugar level. Patient’s cholesterol level is very high especially that he has existing heart condition. 200 is the ideal level but for people with heart problems it should even be lower than 200 .
Considering the case of both himself and his wife, patient has been able to process his need to comply with the medications and adhere to a healthier lifestyle. Nevertheless, he’s present situation of being out of work greatly causes him stress that is resulting to added pressure to his heart ailment. Patient should be able to verbalize his condition and his wife-s condition to his children for appropriate support.

ICD-9 Diagnoses/Client Problems:

According to ICD- 9 patient is diagnosed with 401. 0 Malignant Essential Hypertension and Z83. 3 Family history of diabetes mellitus

Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):

Nursing intervention requires patient to adhere to a strict low-cholesterol diet. This means that patient will need to decrease his total cholesterol level to below 200 to make it ideal considering that he has an existing medical condition. This would also require patient to stop smoking altogether. Patient is advised to perform physical activity and lower down his weight to an ideal level. In addition, patient needs rest and be relieved from stress as much as possible to relieve the pressure from his heart. He would necessarily have to call in his children as seek for their help both financially and looking after him and his wife while they are sick. Patient needs to see a cardiologist to check up on the condition of his stent placement. Specifically, the patient is to follow the guide below:
– Lifestyle Modification
Objective: Change the patient’s lifestyle, i. e. smoking, sedentary lifestyle non-compliance to medical advice.
Rationale: This will help prevent the symptoms from manifesting again and allow the client to go back to his previous daily activities before his symptoms started manifesting.
Nursing Action: Patient currently is adhering to everything that he should not be doing given his existing medical condition. In lieu with this, patient should stop smoking. He should engage in physical workout exercises and turn his back on his sedentary lifestyle. Patient is also advice to eat a regular and healthy diet. Avoid foods that are oily and sweet.
– Adhere to Health Practices and Medical Advise
Objective: Change patient’s current unhealthy health patterns, i. e. ignoring symptoms and delay seeking medical attention.

Rationale: Consulting the doctor immediately once symptoms start manifesting can prevent getting the situation from progressing and creating complications.

Nursing Action: Patient should always consult a doctor immediately if he feels something different and should not ignore his symptoms. Patient is also advice to see a doctor or a regular monthly check-up to follow-up his condition.
– Strict Medication and Treatment Compliance

Objective: Patient should religiously follow the prescription.

Rationale: This can help the patient with his symptoms and condition. While hypertension and type 2 diabetes mellitus are irreversible medical conditions, they can still be managed given patient’s strict compliance to medication and treatment. Blood pressure and blood sugar level can be managed and regulated if compliance if maintained.
Nursing Action: Patient must immediately consult his attending physician immediately at the onset of experiencing any symptoms. It should not be deferred at under any condition. Patient should follow his medication according to the instructions given by the doctor.

References

Durstine, L., Moore, G., Painter, P., & Roberts, S. (2009). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities-3rd Edition. Champaign, Illinois: Human Kinetics Publishing.
National Health, Lungs and Blood Institute. (2014, November 5). Aim for a Healthy Weight. Retrieved from National Health, Lungs and Blood Institute Website: http://www. nhlbi. nih. gov/health/educational/lose_wt/BMI/bmicalc. htm