Cardiovascular Health Case Study: Tina Jones, Exams of Nursing

Download Cardiovascular Health Case Study: Tina Jones and more Exams Nursing in PDF only on Docsity!

Shadow Health Tina Jones

Cardiovascular LATEST UPDATE WELL

RESERCHED CASE STUDY 2023- 2024

Asked about heart problems - ANSWER>>Denies heart problems Asked about heartbeat - ANSWER>>- reports normal heartbeat

• reports normal heart rate
• denies palpitations
• denies arrhythmia Asked about high blood pressure - ANSWER>>- denies high blood pressure
• reports last blood pressure check Finding:
• reports last blood pressure check 140 over 80 or 90
• reports belief that current blood pressure is on the high side of normal range Asked about heart murmur - ANSWER>>Denies heart murmur Asked about swelling - ANSWER>>Denies swelling other than foot wound Asked about blue skin - ANSWER>>Denies blue skin Asked about cardiac tests - ANSWER>>- Denies having a stress test
• Denies having an echocardiogram
• Denies having a coronary artery CT scan Asked about cardiac surgeries - ANSWER>>- Denies having a heart catheterization
• Denies having angioplasty or stent
• Denies having a pacemaker

Asked about chest pain - ANSWER>>- Denies chest pain

• Denies angina Asked about chest tightness - ANSWER>>- Reports chest tightness during asthma exacerbations
• Denies current chest tightness Asked about breathing problems - ANSWER>>- Reports wheezing
• Reports shortness of breath
• Denies waking at night, unable to breathe
• Denies sleep apnea
• Denies difficulty breathing when lying down
• Denies current breathing problems Followed up on breathing problem triggers - ANSWER>>Reports breathing problems occur during asthma exacerbations Asked about leg cramping - ANSWER>>Denies leg cramping Asked about mobility - ANSWER>>Reports being immobile for past three days Asked about Venous Thrombosis - ANSWER>>- Denies tender or painful areas other than foot wound
• Denies redness other than foot wound
• Denies unusual warmth
  • Denies history of venous thrombosis Asked about cholesterol - ANSWER>>Denies cholesterol problems Asked about dietary habits - ANSWER>>- Reports drinking Diet Coke
• Reports trying to avoid sugar

• Reports not worrying about diet Asked about perceived weight - ANSWER>>- Reports being overweight for whole life
• Reports being satisfied with weight Asked about recent weight change - ANSWER>>- Reports recent weight loss
• Reports losing about 10 lbs Asked about alcohol intake - ANSWER>>- Reports last alcoholic drink was 3 weeks ago
• Reports no more than 2 or 3 alcoholic drinks in one sitting
• Reports no more than 1 or 2 nights a week drinking alcohol Asked about illicit drugs - ANSWER>>- Reports history of smoking recreational marijuana
• Denies current use of recreational marijuana Asked about tobacco use - ANSWER>>- Denies tobacco use
• Denies vaping Asked about secondhand smoke - ANSWER>>Denies exposure to secondhand smoke Asked family history of high blood pressure - ANSWER>>- Reports mother has high blood pressure
• Reports father had high blood pressure
• Reports maternal grandfather had high blood pressure
• Reports paternal grandmother has high blood pressure
• Reports maternal grandmother had high blood pressure
• Reports paternal grandmother has high blood pressure Asked family history of high cholesterol - ANSWER>>- Reports mother has high cholesterol

• Reports father had high cholesterol
• Reports maternal grandfather had high cholesterol
• Reports paternal grandfather had high cholesterol
• Reports maternal grandmother had high cholesterol Asked family history of stroke - ANSWER>>Reports maternal grandmother died of stroke Asked about family history of heart attack - ANSWER>>Reports maternal grandfather died of heart attack Asked about family history of obesity - ANSWER>>Reports some family members are overweight