Priority Nursing Diagnoses - Case Study Example

CASE STUDY ASSIGNMENT 3: NURSING ASSESSMENT: Identify 3 priority nursing diagnoses/problems This health assessment centres on a patient with peripheral arterial disease or PAD. It will try to identify the specific nursing diagnosis for the patient’s health problems. Peripheral arterial disease (PAD) is a chronic obstruction of blood flow into the arterial system that carries blood to vital organs of the body, especially in the lower extremities and is common in old age. Approximately 8 million Americans are affected by PAD and is consider a major cause of disability, loss of work and lifestyle changes in the United States (Tran and Anand, 2004). PAD can come with intermittent claudication or other leg pain and in addition, the symptomatic and asymptomatic PAD is associated with cardiovascular disease including stroke and a risk of functional decline (McDermott, 2004). Atherosclerosis is the principal cause of PAD and develops in the same way as in coronary artery disease (CAD), The risk factors associated with PAD are irreversible and reversible. According to Lewis (2001) the Irreversible risk factors are advanced age, male gender and family history (Insert Patrick data) and the Reversible risk factors include smoking, diabetes, hypertension and hyperlipidemia (insert partrick data) (Lewis, 2001). The natural history of PAD is slow progression of symptoms over time, in most cases the disease progression is benign and the majority of patients remain an asymptomatic or with fairly stable symptoms (Schmieder, 2001). Many patients will have to adjust or adapt their lifestyles in connection with their symptomatic limbs. The 2007-2008 North American Nursing Diagnostic Association or NANDA will be used to recognize diagnoses. NANDA is the Approved Nursing Diagnosis list. NANDA defines nursing diagnosis as “ a clinical judgment about individual, family or community responses to actual or potential health problems or life processes which provides the basis for selection of nursing interventions to achieve outcomes” (NANDA 2008, 1) By using specific diagnoses, evidence-based assessment determines the proper interventions for best health results for client. The patient in this case study is Charles Patrick, 66 years old, a white male and suffering from pain in both legs. The pain has been progressing for worse during the last three months. His pain experience cited includes the need to rest in a 100-metre walk such as when going to a shop or grocery. Due to pain, Mr. Patrick would need to rest for about 5 minutes halfway due to pain, until the pain subsides. The pains have been described as dull ache and not sharp all the time until he sits and rests. He used to play golf of 9 holes, about 2-3 times a week. But he no longer can play after he experienced the pains. His feet become redder during pain. On a scale of 10, it is 3-4 but sometimes reaches 6-7. He has not experienced pain in other areas. After detailed examination, Mr. Patrick seemed to have five major nursing diagnoses issues relating to peripheral arterial disease as well as management of his health condition. These are activity intolerance relating to impaired physical mobility; impaired skin integrity, and pain in the legs. This paper shall discuss three nursing diagnoses in more detail relating to peripheral arterial disease of Mr. Patrick’s condition. Mr. Patrick’s nursing diagnosis related to pain in the legs PAD diagnosis should be considered on patients reporting muscular pain in legs. This is most especially for high-risk groups of people older than 65 years, African Americans, smokers, and those with hyperlipidemia. This is applicable in the case of Mr. Patrick who complained of pain in both legs (calf area) which is progressively getting worse when he walks. He noticed the pain three months ago and is still present especially after walking about 100 metres. He claimed the need to rest halfway for about five minutes before the pain subside. Most patients remain asymptomatic for many years. The symptom of PAD starts when there is > 50% narrowing of the artery lumen. If untreated and undiagnosed, PAD can progress to critical limb ischaemia (CLI). The dull ache pain experienced by Mr. Patrick all the time till he sits and rests is due to CLI which is ischemic pain at rest and may be associated with tissue loss. Condition improves when the leg is in a dependent position. It worsens when it is elevated. The patient goes on to develop CLI will also more likely to develop multi-vessel disease (Sieggreen, 2006). Mr. Patrick noticed that his feet get redder when the pain is happening. The rationale is that any noticeable sluggish return of capillary refill indicates reduced arterial pressure. Elevating an ischemic limb causes it to become pale, and when lowered below heart level, the limb becomes dark with rubor (Sieggreen, 2006). Mr Patrick’s pain is 3-4 on scale of 10. Sometimes it reaches the 6-7 scale. Pain intensity is evaluated using the visual analogue scale or VAS, 0 (no pain) to 10 (most intense pain). According to Hirsch (2001), objectives of pain management are to maintain pain intensity within VASs ≥ 3 and VASd ≥4. The rationale is that chronic severe pain limits physical activity, affects sleep and sexual activities, and leads to changes in mood, reduced self-esteem and negative feelings, such as despair. Pain also alters patients’ family, work and leisure relationships. Pain may serve as a protective indicator, but intensity and frequency may seriously compromise the quality of life of individuals (Hirsch, 2001). It is the major objectives of pain treatment to prevent ischaemic attacks and to improve quality of life. The nursing diagnosis of Mr. Patrick relating to activity intolerance The most prominent sign of PAD is walking impairment due to claudication. As in the case of Mr. Patrick who complained of leg pain, Hirsch (2001) emphasized that ability of walking deteriorates due to a chain of events resulting in further functional decline, eventual physical disability, loss of independence, and finally impaired quality of life. Intermittent claudication or IC is defined as fatigue, discomfort, or pain. It involves specific limb muscle groups during exertion due to exercise-induced ischemia (Hirsch, 2001). IC also involves functional decline - pain occurs earlier or is more severe with the same activity during disease progression. A number of factors relate to this problem were identified during Mr. Patrick’s examination. Mohler (2003) suggested that the development of atherosclerosis can lead to peripheral arterial disease. It has been manifested in this case as peripheral pain during walking when the muscles demand more oxygen but deprived due to obstruction in the circulation. There are a number of factors that relate to this problem, and that were identified during Mr. Patrick’s examination. Mr. Patrick is smoking 1-1.5 packets a day since the age of 18. Smoking is the greatest modifiable risk factor for PAD. Longitudinal population studies indicated that 80% of persons having primary symptom of intermittent claudication smoked. Smoking increases the risk of PAD and accelerates the onset of symptoms specifically intermittent claudication by almost 10 years. Smokers also have poorer survival rates than non-smokers. They are twice as likely to develop critical limb ischemia leading to amputation as compared to non-smokers (Bartholomew, 2006). Barhtolomew (2006) also found that smoking increases the atherosclerosis process by reducing the effect of NO vasodilatation. Tobacco cessation retards the progression of PAD in CLI. Death risk due to vascular causes is also decreased. Multiple modalities of behavioural therapy, nicotine replacement, and medications are effective as compared to a single modality. Tobacco cessation may not increase walking distance but reduces the risk of cardiovascular events and reduces the risk of CLI progression (Bartholomew, 2006). Mr. Patrick had a history of hypertension for 10 years. Angiotensin-converting enzyme (ACE) inhibitors have an important role in management of hypertension in patients with PAD. Evidence also showed that ACE inhibition may increase pain-free and maximum walking time in patients with symptomatic PAD (Ahimastos, 2006). ß-adrenergic blockers were endorsed for use amongst patients with cardiovascular disease. Ahimastos, (2006) recommended that blood pressure goal for patients with PAD should be less than 140/90 mm Hg. Mr. Patrick has a history of high level of cholesterol. According to Levy (2002), hyperlipidemia is an abnormal increase in level of cholesterol and is associated with a 2-fold increase in risk for intermittent claudication. Arterial disease is a strong predictor of systemic atherosclerosis and is considered a CAD risk equivalent (Mohler, 2003). It is necessary for Mr. Patrick to target for low-density lipoprotein cholesterol less than 100 mg/dL. Aggressive lipid lowering improves cardiovascular outcomes in patients with atherosclerotic vascular disease and improves pain-free walking distance and community-based physical activity in patients with IC (Mohler, 2003). The National Health and Nutrition Examination Survey (NHANES) suggested that more than 60% of individuals with PAD also had elevated cholesterol (NHANES, 2008). Bartholomew (2006) suggested that every 10mg/dL increase in total cholesterol, the likelihood of developing PAD increases by 10%. Studies indicated that exercise is an important element in managing PAD. The pain of intermittent claudication usually makes many individuals reduce physical activity as indicated in the study of Watson (2006). The study found that walking increases collateral circulation. In the case of Mr. Patrick, he has been taking ½ of aspirin per day. According to Watson (2006), a dose of 81 mg to 325 mg of aspirin is effective in reducing ischemic events in persons with vascular disease. During the physical examination of Mr. Patrick’s extremities which is appropriate for the diagnosis of PAD, he stated that he is experiencing impaired skin integrity which is evident by the changes in skin colour in his lower limb. Atherosclerosis is the primary disease process that leads to PAD and affects the lower extremities circulation that results from chronic reduction in the diameter of the lumen of lower extremity arteries (Bartholomew, 2006). Mr. Patrick reported about the change in colour of his skin in his lower limbs coinciding with the pain he is experiencing. In the case of Mr. Patrick, he claimed his feet become redder during pain. PAD results from disruption of blood flow in the circulatory system. When circulation is restricted, cells are deprived of oxygen. If circulation cannot meet tissues’ oxygen demand, then ischemia develops. Sieggreen (2006) suggested that sluggish return of capillary refill indicates reduced arterial pressure and when elevating an ischemic limb causes it to become pale, and when lowered below heart level, the limb becomes dark with rubor (Sieggreen 2006). During the examination of Mr. Patrick, it was noted that changes such as hair loss, thin skin, thick nails, tapering toes and skin breakdown are present. These are signs of prolonged ischemia (Sieggreen 2006). Conclusion PAD adversely affects the lives of affected patients and their families. Diagnosis of Mr. Patrick’s health problem can help improve his condition through non-invasive methods. His physical activities as well as decrease his pain. It is important for Mr. Patrick to become fully prepared to understand his health condition and the need to change some aspects of his lifestyle such as smoking, exercises, diet, and other daily activities that could help improve his health condition. In addressing his condition, significant benefits of reduced risks may provide him 75% more chance of living better. Proper and increased awareness through health screening coupled with early treatment, may mean for Mr. Patrick a better quality of life, decreased morbidity and mortality associated with PAD. Reference: Ahimastos AA. Lawler A. Reid CM. Blombery PA. Kingwell BA. 2006. Brief communication: ramipril markedly improves walking ability in patients with peripheral arterial disease: a randomized trial. Ann Intern Med. 144(9): 660-664. Bartholomew JR, Olin JW. 2006. Pathophysiology of peripheral arterial disease and risk factors for its development. Cleve Clin J Med73 (Suppl). Hirsch AT, Criqui MH. Trat-Jacobson D. et al. 2001. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 286. Lewis CD. Peripheral arterial disease of the lower extremity. 2001. J Cardiovasc Nurs 15:45-63. Levy, P.J. 2002 Epidemiology and pathophysiology of peripheral arterial disease. Clinical Cornerstone Peripheral Arterial Disease 4: 1–13. McDermott MM, Liu K, Greenland P et al. 2004 Functional decline in peripheral arterial disease: Associations with the ankle brachial index and leg symptoms. JAMA 292:453–461. NHANES report. 2008. Accessed at: www.cdc.gov/nchs/nhanes.htm. November 5, 2008. Schmieder FA, Comerota AJ. 2001. Intermittent claudication: magnitude of the problem, patient evaluation and therapeutic strategies. Am J Cardiol.. Sieggreen M. 2006. A contemporary approach to peripheral arterial disease. Nurse Pract 31:14-25. Tran H, Anand SS. 2004. Oral antiplatelet therapy in cerebrovascular disease, coronary artery disease and peripheral arterial disease. AMA 292. Watson K, Watson BD, Pater KS. 2006. Peripheral arterial disease: A review of disease awareness and management. Am J Geriatr Pharmacother 4:4. Reference: Ahimastos AA. Lawler A. Reid CM. Blombery PA. Kingwell BA. 2006. Brief communication: ramipril markedly improves walking ability in patients with peripheral arterial disease: a randomized trial. Ann Intern Med. 144(9): 660-664. Bartholomew JR, Olin JW. 2006. Pathophysiology of peripheral arterial disease and risk factors for its development. Cleve Clin J Med73 (Suppl). Hirsch AT, Criqui MH. Trat-Jacobson D. et al. 2001. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 286. Mohler ER III. Hiatt WR. Creager MA. 2003. Cholesterol reduction with atorvastatin improves walking distance in patients with periphera arterial disease. Circulation. Sep 23; 108(12):l481-1486. Epub Sep 2. Sieggreen M. 2006. A contemporary approach to peripheral arterial disease. Nurse Pract 31:14-25. Tran H, Anand SS. 2004. Oral antiplatelet therapy in cerebrovascular disease, coronary artery disease and peripheral arterial disease. JAMA 292, October 20, Read More