NR226 Fundamentals – Patient Care RUA

Assessment

General appearance: J.D., a 45-year-old male, appears visibly fatigued, lethargic, and unwell. He demonstrates signs of distress, with a notable reduction in energy levels and overall alertness.

Vitals:

Blood Pressure: 160/100 mmHg (elevated)

Heart Rate: 90 bpm

Respiratory Rate: 20 breaths per minute

Temperature: 99.5°F (37.5°C)

Neuro: J.D. complains of constant headaches

HEENT:

Head: Reports constant headaches.

Eyes: Visual acuity is normal; fundoscopic examination reveals no abnormalities.

Ears, Nose, Throat: No significant findings.

Cardiac: Regular heart sounds, with no murmurs or abnormal sounds.

Respiratory: Clear breath sounds on auscultation. Oxygen saturation is 96% on room air.

GI: J.D. reports a decreased appetite. Abdominal examination reveals no tenderness, masses, or organomegaly.

GU/Elimination: Normal urinary habits reported. No issues with bowel movements. No signs of urinary or fecal incontinence.

Integumentary: A wound is observed on J.D.’s right leg. The wound is approximately 3 cm in diameter, showing signs of inflammation but no apparent signs of infection.

Musculoskeletal: Limited physical activity was reported. Muscle strength appears diminished, with complaints of weakness in the extremities.

Psychosocial: J.D. expresses sickness, weakness, and frustration due to his health condition.

Labs/Diagnostics:

Blood glucose levels: 280 mg/dL (elevated)

Complete Blood Count (CBC): Normal white blood cell count, hemoglobin, and platelet levels.

Electrolyte panel: Sodium, potassium, and chloride levels within normal range.

Lipid profile: Elevated LDL cholesterol levels.

Imaging of the right leg wound: X-ray shows no underlying bone involvement but signs of cellulitis.

ECG (Electrocardiogram): Normal sinus rhythm with no significant abnormalities.

Renal function tests: Serum creatinine and blood urea nitrogen within normal range.

Pathophysiology

 Diabetes Mellitus:

Initiation: J.D. has a history of diabetes and has discontinued medication.

Functional Changes: Beverly et al. (2020) state that insufficient insulin or insulin resistance leads to elevated blood glucose levels (hyperglycemia).

Processes: Chronic hyperglycemia damages blood vessels and nerves.

Cardiovascular Complications:

Initiation: Uncontrolled diabetes contributes to atherosclerosis.

Functional Changes: According to Sposato et al. (2020), narrowing and hardening of blood vessels leads to increased blood pressure.

Processes: Chronic inflammation, oxidative stress, and endothelial dysfunction contribute to atherosclerosis.

Hypertension:

Initiation: Elevated blood glucose levels and atherosclerosis contribute to increased peripheral resistance.

Functional Changes: Persistent high blood pressure.

Processes: Renin-angiotensin-aldosterone system activation and impaired vasodilation contribute to hypertension (Sposato et al., 2020).

Wound Formation:

Initiation: Impaired blood flow and compromised immune function due to diabetes.

Functional Changes: Wound formation on the right leg, likely complicated by peripheral neuropathy.

Processes: Reduced tissue perfusion, impaired wound healing, and increased infection susceptibility (Lehmann et al., 2020).