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Client Complaints
The patient has complained of crushing chest pain accompanied by shortness of breath and exertion and diaphoretic. Four days of lasting symptoms that have been recurring in the last 6 months. A lack of activeness following the angina symptoms with substernal pain and crushing and recitation of neck and jaw is also part of the complaints by the patient.
HPI (History of Present Illness)
The patient has been discharged following a percutaneous coronary intervention procedure and admitted in the urgent situation with chest pain symptoms. The patient complained about discomforting chest pain with shortness of breath and symptoms similar relevant for a heart attack. The symptoms have been recurring during the last 6 months. The situation seems to deteriorate when he was admitted to the hospital, but relieved with medication and cardiac interventions. The patient is also not active following the symptoms related to pain in the chest.
PMH (Past Medical History – include current medications, any known allergies, any history of surgery or hospitalizations)
The client has not had cases of hospitalization previously even though previous treatments have been about high cholesterol and hypertension. This treatment was stopped without the recommendation or advice from the doctor. There are no records of significant illnesses in the past. The EKG was described as a baseline during the prescription for medication on blood pressure, but with no history of heart diseases or the level checks for cholesterol.
Significant Family History
The patient comes from a family with a history of chronic diseases as evidenced by the medical history of his parents and brothers. The older brothers have been treated for high blood pressure as well as type 2 diabetes; these ailments were diagnosed in their forties. There is a need to determine if the patient is also following the pattern of his elder brothers. This circumstance will be essential in providing health promotion services, including preparing the patient to handle the emergent illness rather than dismissing it as an issue that will just disappear on its own. The fact that the father died from heart disease and the mother from breast cancer should alter the practitioner to examine if there are symptoms pointing to these diseases.
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Social/Personal History (Occupation, lifestyle-diet, exercise, substance use)
The patient works as a carpenter to provide for his family. Whatever he earns from the carpentry work is not sufficient in order to cater to the needs of the family, and each day, he is apprehensive to report back at the place of work. To address this problem, the health care practitioner will require identifying alternative sources of income which can help the patient and avoid him having to go to work on a daily basis. The patient will also need to get counseling to improve his self-efficacy and take care of the sick wife. Additionally, the situation requires involving mature children to assist their parents. The patient should also be encouraged to participate in physical activities, eat healthy food, and develop a consistent eating pattern (Gulanick & Myers, 2010). By integrating into the society, the patient and his wife will have emotional and social support since at the moment they deeply lack such support. The patient needs activities that will relieve them of stress to ensure that they have enough sleep and that they are not overeating. Moreover, the patients need to have access to health insurance services that can cover their full medical prescriptions and enable them to lead a normal life. They must also have access to primary health care on a regular basis to advice what to do whenever they see a certain symptom.
Description of Client’s Support System
The patient’s support system is very poor. First, the wife is also sick: namely, she cannot support him, but instead, he is the one supporting her. The patient is also not engaged with the community, and the family is living in isolation of the rest of the community. What is more, the adult children are not accessible and not helping the aging couple. This issue is likely to contribute to their stress and poor health condition. The patient’s access to insurance services is also not stable as the available insurance cannot cover for all prescribed medication.
Behavioral or Nonverbal Messages
Heavy smoking, though no alcohol or drug abuse.
Client Awareness of Abilities, Disease Process, and Health Care Needs
The client is poorly informed about disease and necessary health care needs.
Objective Data
Vital Signs
BP: 160/92 left are sitting; P: 60; R: 16; T: 98; Wt: 220#; Ht: – 70.
Physical Assessment Findings
Total cholesterol – 210, LDL- 200, HDL- 25, triglycerides – 250, fasting blood sugar – 140, HgbA1c – 7.5
Lab Tests and Results
Tenormin XL 50 mg QD, Lipitor 10 mg QD, Glucophage – 500mg BID, Baby ASA QD. The patient should take the prescribed medication and seek a recommendation from a medical practitioner. The patient stopped previous medication without the approval of the physician.
Client’s Support System
The patient has a poor support system following the years of intensive work and smoking which has affected the immune system.
Client’s Locus of Control and Readiness to Learn
Willing to learn but unable to find time; there is a need to help the client to learn some of the health practices.
ICD-10 Diagnoses/Client Problems
Episodes of angina symptoms, hypertension and high cholesterol, high blood pressure, hypercholesterolemia, and type 2 diabetes.
Advanced Practice Nursing Intervention Plan
There is a need to start a program for multidisciplinary intervention engaging community health workers, nurses, and counselors. The reason for involvement is because the patient indicates the symptoms of different illnesses, he is a chain smoker, has an ailing wife at home, and is also neglected by his children. A collaboration of all these professionals will help to deal with every aspect related to the health of the patient. For example, counselors will help to deal with stress and anxiety about work; community health workers/officers will help to integrate the patient into community health services whereas currently, the patient is isolated. The patient also needs support from his adult children and the community as a whole. Children must help to take care of the man and his wife (Nolte & McKee, 2013).
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The rationale for the Inclusion of the Evidence in the Care Plan
Given the profile of the patient, in this case, the chronic diseases are likely to manifest complications following the pre-existing conditions, long latency, prolonged affliction, and vague beginnings (Gulanick & Myers, 2010). As a result, the patient experience impairments in normal functioning, sleep patterns, eating habits, and also the emergence of emotional or mental disorders being a characteristic of anxiety and withdrawal from the general population (Loretz, 2012).
Conclusion
To control chronic diseases that must come to a person whose lifestyle encourages such occurrence, well-organized healthcare management is required. The proposed care plan will be effective in health promotion for the patient exhibiting the stated conditions. There is a need for the health professionals to work together with the client and other related parties to bring quality and effective medical services to the client before the disease is completely addressed.
