Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions
Patient Objective Data Collection: 2 of 2 (100%)
Inspected Ankles
1 of 1 point
Right Ankle (1/2 point)
– No visible abnormal findings
– Swelling
– Visible mass
– Irregular alignment
– Discoloration
– Joint deformity
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Left Ankle (1/2 point)
– No visible abnormal findings
– Swelling
– Visible mass
– Irregular alignment
– Discoloration
– Joint deformity
Palpated Ankles
0.75 of 1 point
Left Ankle Palpation (1/4 point)
– No abnormal findings
– Tenderness
– Warmth
– Erythema
– Edema
Right Ankle Palpation (1/4 point)
– No abnormal findings
– Tenderness
– Warmth
– Erythema
– Edema
Left Ankle Pitting Test (1/4 point)
– No pitting
– 1+ Slight pitting
– 2+ Deeper pit, disappears in 10-15 seconds
– 3+ Noticeably deep pit that lasts for more than a minute
– 4+ Very deep pit that lasts 2 to 5 minutes
Right Ankle Pitting Test (1/4 point)
– No pitting
– 1+ Slight Pitting
– 2+ Deeper pit, disappears in 10-15 seconds
– 3+ Noticeably deep pit that lasts for more than a minute
– 4+ Very deep pit that lasts 2 to 5 minutes
Education & Empathy
During the patient interview, several opportunities arose to provide patient education and empathy. Nursing experts identified specific opportunities crucial to this patient. Model statements are presented as examples of appropriate responses to each opportunity.
Opportunities:
1. Swelling and Weight Gain
Followed Up
Model Statement: “You should be aware of what signs and symptoms may indicate worsening heart failure so that you can react appropriately if they arise. For example, the rapid weight gain you experienced over the last 24 hours or the swelling you are exhibiting in your lower extremities indicates a fluid volume overload in your body, and that your congestive heart failure is worsening. Paying attention to these signs and symptoms can help you determine if you need to take your diuretic. However, if you have continued swelling and weight gain, you should contact your provider and seek emergency hospital care, as they are indications of a CHF exacerbation.”
2. Taking Diuretics
Not Encountered
Model Statement: “You should take your furosemide 20 mg and potassium chloride tablet 10 mEq as needed when you exhibit abnormal signs and symptoms, like swelling and weight gain. Even though the swelling you are experiencing in your lower extremities is minor, it can still have a great effect on your cardiovascular functioning. Taking the furosemide and potassium chloride tablets upon the onset of swelling will help control this symptom and maintain your cardiovascular health. However, if your symptoms worsen or do not resolve, you should contact your provider and seek emergency hospital care.”
3. Diet Adherence
Not Encountered
Model Statement: “It can be hard to adhere to your low-sodium diet all the time, especially in social situations. However, nonadherence to your typical low-sodium diet can have negative effects on your cardiovascular health and exacerbate your congestive heart failure. The large quantity of high-sodium foods you ate at the recent party led to a fluid volume overload and resulted in your rapid weight gain and the swelling in your extremities. Adhering to your diet will help prevent fluctuations in your cardiovascular health and reduce the risk of exacerbating your CHF.”
4. Waking Up at Night
Not Followed Up
Model Statement: “I’m sorry to hear your sleep has been disrupted by having to wake up frequently to use the bathroom. Having a restful, uninterrupted sleep is important for your physical and emotional health, and disruptions to this can be very irritating. If you need to take your diuretic, do so in the morning if appropriate to avoid triggering nocturia. If your nocturia worsens, follow-up with your provider as it may be an indication of an underlying or worsening condition.”
Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions
Patient Objective Data Collection: 2 of 2 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- No visible abnormal findings
- Swelling
- Visible mass
- Irregular alignment
- Discoloration
- Joint deformity
- No visible abnormal findings
- Swelling
- Visible mass
- Irregular alignment
- Discoloration
- Joint deformity
- No abnormal findings
- Tenderness
- Warmth
- Erythema
- Edema
- No abnormal findings
- Tenderness
- Warmth
- Erythema
- Edema
ORDER SHADOW HEALTH HELP HERE
- No pitting
- 1+ Slight pitting
- 2+ Deeper pit, disappears in 10-15 seconds
- 3+ Noticeably deep pit that lasts for more than a minute
- 4+ Very deep pit that lasts 2 to 5 minutes
- No pitting
- 1+ Slight Pitting
- 2+ Deeper pit, disappears in 10-15 seconds
- 3+ Noticeably deep pit that lasts for more than a minute
- 4+ Very deep pit that lasts 2 to 5 minutes
Education & Empathy
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
- Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
- Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
- Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
- Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection
|
Description: Mr. Fitzgerald is experiencing swelling and rapid weight gain. |
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 |
Any weight issues? (Clarified to: Have you lost weight?) |
Question |
|
No, I’ve actually gained some. (Clarified to: if I have lost weight) |
|
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Gaining weight will only worsen your heart problems |
Educate |
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Got it. Thanks. |
|
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Model Statement: “You should be aware of what signs and symptoms may indicate worsening heart failure so that you can react appropriately if they arise. For example, the rapid weight gain you experienced over the last 24 hours, or the swelling you are exhibiting in your lower extremities, indicates a fluid volume overload in your body and that your congestive heart failure is worsening. Paying attention to these signs and symptoms can help you determine if you need to take your diuretic. However, if you have continued swelling and weight gain, you should contact your provider and seek emergency hospital care, as they are indications of a CHF exacerbation.” |
|
Description: Mr. Fitzgerald has experienced signs and symptoms that indicate he should use his as needed medications, furosemide and potassium chloride. |
||
|
Model Statement: “You should take your furosemide 20 mg and potassium chloride tablet 10 mEq as needed when you exhibit abnormal signs and symptoms, like swelling and weight gain. Even though the swelling you are experiencing in your lower extremities is minor, it can still have a great affect on your cardiovascular functioning. Taking the furosemide and potassium chloride tablets upon the onset of swelling will help control this symptom and maintain your cardiovascular health. However, if your symptoms worsen or do not resolve, you should contact your provider and seek emergency hospital care.” Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection |
|
Description: Mr. Fitzgerald recently consumed a meal of high-sodium foods at his grandson’s party. |
||
|
Model Statement: “It can be hard to adhere to your low-sodium diet all the time, especially in social situations. However, nonadherence to your typical low-sodium diet can have negative effects for your cardiovascular health and exacerbate your congestive heart failure. The large quantity of high-sodium foods you ate at the recent party lead to a fluid volume overload and resulted in your rapid weight gain and the swelling in your extremities. Adhering to your diet will help prevent fluctuations in your cardiovascular health and reduce the risk of exacerbating your CHF.” |
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Description: Mr. Fitzgerald has been experiencing nocturia four to five nights a week. |
||
|
Any urination issues? |
Question |
|
No issues with going to the bathroom, but I do wake up needing to pee at night. |
|
|
Any weakness? |
Question |
|
I’m no Thor, but I can still open pickle jars when needed. |
|
|
Any breathing problems? |
Question |
|
I haven’t had any issues with my breathing. |
|
|
Model Statement: “I’m sorry to hear your sleep has been disrupted by having to wake up frequently to use the bathroom. Having a restful, uninterrupted sleep is important for your physical and emotional health, and disruptions to this can be very irritating. If you need to take your diuretic, do so in the morning if appropriate to avoid triggering nocturia. If your nocturia worsens, follow-up with your provider as it may be an indication of an underlying or worsening condition.” Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |