FINAL CASE STUDY

Mrs. y Is 49 year old female who has been married for 28 years, she has 6 children between the ages
of 10 and 25- year old. She enjoys knitting and sewing, Mrs. y also work 34 hours each week as a
sales clerk manager a department store acts as Girl Scout troop leader, and leads and educational
course at her catholic church.
Her family history is positive for a grandmother, who had default walking the las 10 years of her
life. a diagnosis by a physical was never made for her grandmother. Mrs., Y reports headaches for
the last four months, which are only relived with cutting off the lights and resting for approximately
4-6 hours. She also occasionally feels as though she may fall when walking, but it only happens
every few weeks. She has fallen three times spraining her right ankle once, she also occasionally
experiences diplopia which resolves within 2-3 week
Her last physical exam was I year ago, Ms. Ys blood pressure is 136/78, pulse 70, respirations 28
per minute, and temperature 98.8. She is very health conscious and watches what she eats and feeds
for family. She is 56 tall and 127 lbs. she tries to exercise 2-3x per week but gets most her
exercise from chasing behind her children, she is allergic to both penicillin and shellfish (Iodine),
she also has hypercholesterolemia, which she manages with diet and exercise. Mrs. Y had a breast
cyst removed in 2005. She takes a multi vitamin once a day. Her parents are both alive without any
remarkable health issues, a
Often come over for family excursion

(1) What assessment tools are needed for the physical assessment?
Clean gloves
paper and pencil
scale with height attachment
Thermometer
watch
stethoscope
pulse oximeter
lounge depressor
Penlight
Otoscope

(2) What other question should be essential to ask the patient?

When was the las time youre taken your medication?

How often do you exercise?

What makes you feel that you feel that you dont need to continue the
medication?
Do you have any family member whos had a history of CHF?
Have you noticed any change in the abdomen with tenderness after
discontinuation of the Lasix?
Are you having episodes of blur vision, dizziness or weakness?
How often did you smoke?
When did you discontinue smoking?
 Are you allergic to any medications?
For how long were you a smoker?
When have you notified shortness breath?

3. Why is it important to obtain a thorough medical history for this patient?

The patient medical history is necessary due to the fact that she has a very serious condition called
hypercholesterolemia, this condition can lead to serious heart problems, it can also affect her daily
activities such as walking jogging or running.
4. Create a problems list from the data provided.

Brain stroke
Temporary loss of vision
dizziness
impairment of balance
difficulty speaking
weakness or numbness or tingling, usually on one side of the body.
chest pain
ischemia of the eye may manifest as transient visual loss in one eye
Some types of hypercholesterolemia lead to specific physical findings. For example, familial
hypercholesterolemia (Type II hyperlipoproteinemia) may be associated with xanthelasma
palpebrarum (yellowish patches underneath the skin around the eyelids), arcus senilis (white or gray
discoloration of the peripheral cornea), and xanthomata (deposition of yellowish cholesterol-rich
material) of the tendons, especially of the fingers. Type III hyperlipidemia may be associated with
xanthomata of the palms, knees and elbows.

(5) Nursing Diagnosis: 3 actual, 1 Risk & 1 Wellness

Actual nursing Diagnoses
Domain 4. Activity/Rest Class 2. Activity/Exercise 00088
Impaired walking related to impaired vision evidenced by recent falls.
(1998, 2006; LOE 2.1)
Definition: Limitation of independent movement within the environment on foot.
Defining Characteristics: Impaired ability to climb stairs, impaired ability to navigate
curbs, impaired ability to walk on decline, impaired ability to walk on incline, impaired
ability to walk on uneven surface, impaired ability to walk required distance.
Related Factors: Alteration in cognitive functioning, alteration in mood, decrease in
endurance, environmental barrier (e.g., stairs, inclines, uneven surfaces, obstacles, distance,
lack of assistive device), fear of falling, impaired balance, impaired vision, insufficient
knowledge of mobility strategies, insufficient muscle strength, musculoskeletal impairment,
neuromuscular impairment, obesity, pain, and physical deconditioning.

Domain 12. Comfort Class 1. Physical Comfort 00214

Impaired comfort related to illness-related symptoms evidenced by headaches for the
last 4 months and feeling like falling while walking.
(2008, 2010; LOE 2.1)
Definition: Perceived lack of ease, relief, and transcendence in physical, psychospiritual,
environmental, cultural, and/or social dimensions.
Defining Characteristics: Alteration in sleep pattern, anxiety, crying, discontent with
situation, distressing symptoms, fear, feeling cold, feeling hot, feeling of discomfort,
feeling of hunger, inability to relax, irritability, itching, moaning, restlessness, sighing, and
uneasy in situation.
Related Factors: Illness-related symptoms, insufficient environmental control, insufficient
privacy, insufficient resources (e.g., financial, social, knowledge), insufficient situational
control noxious environmental stimuli, and treatment regimen.

Domain 4. Activity/Rest Class 2. Activity/Exercise 00090

Impaired transfer ability related to the occasional diplopia (double vision) evidenced
by the feeling of falling when walking.
(1998, 2006; LOE 2.1)
Definition: Limitation of independent movement between two nearby surfaces.
Defining Characteristics: Impaired ability to transfer between bed and chair, impaired
ability to transfer between bed and standing position, impaired ability to transfer between
car and chair, impaired ability to transfer between chair and floor, impaired ability to
transfer between chair and standing position, impaired ability to transfer between floor and
standing position, impaired ability to transfer between uneven levels, impaired ability to
transfer in or out of bath tub, impaired ability to transfer in or out of shower, impaired
ability to transfer on or off a commode, impaired ability to transfer on or off a toilet.
Related Factors: Alteration in cognitive functioning, environmental barrier (e.g., bed
height, inadequate space, wheelchair type, treatment, equipment, and restraints), impaired
balance, impaired vision, insufficient knowledge of transfer techniques, insufficient muscle
strength, musculoskeletal impairment, neuromuscular impairment, obesity, pain, and
physical deconditioning.
Risk diagnosis
Domain 11. Safety/Protection Class 5. Defensive Processes 00217
Risk for allergy response evidenced by her allergy to shellfish and penicillin.
(2010, 2013; LOE 2.1)
Definition: Vulnerable to an exaggerated immune response or reaction to substances,
which may compromise health.
Risk Factors: Allergy to insect sting, exposure to allergen (e.g., pharmaceutical agent),
exposure to environmental allergen (e.g., dander, dust, mold, pollen), exposure to toxic
chemical, food allergy (e.g., avocado, banana, chestnut, kiwi, peanut, shellfish, mushroom,
tropical fruit). repeated exposure to allergen-producing environmental substance.
Wellness diagnosis
Domain: 9. Coping/Stress Tolerance Class: 2. Coping Responses 00158
Readiness for enhanced coping evidenced by awareness of possible environmental
change.
(2002, 2013; LOE 2.1)
Definition: A pattern of cognitive and behavioral efforts to manage demands related to
well-being, which can be strengthened.
Defining Characteristics: Awareness of possible environmental change, expresses desire
to enhance knowledge of stress management strategies, expresses desire to enhance
management of stressors, expresses desire to enhance social support, expresses desire to
enhance use of emotion-oriented strategies, expresses desire to enhance use of problem-
oriented strategies, enhance use of spiritual resource.

(6) What teaching and nursing interventions should be in included in the plan
of care for this patient.

Maintain a healthy weight. Ask your healthcare provider how much you should
weigh. Ask him or her to help you create a weight loss plan if you are overweight.
Weight loss can decrease your cholesterol and triglyceride levels.
 Exercise as directed. Exercise lowers your cholesterol levels and helps you
maintain a healthy weight. Get 40 minutes or more of moderate exercise 3 to 4 days
each week. You can split your exercise into four 10-minute workouts instead of 40
minutes at one time. Examples of moderate exercises include walking briskly,
swimming, or riding a bike. Work with your healthcare provider to plan the best
exercise program for you.

Do not smoke. Nicotine and other chemicals in cigarettes and cigars can increase
your risk for a heart attack and stroke. Ask your healthcare provider for information
if you currently smoke and need help to quit. E-cigarettes or smokeless tobacco still
contain nicotine. Talk to your healthcare provider before you use these products.

Eat heart-healthy foods. Talk to your dietitian about a heart-healthy diet. The
following will help you manage hyperlipidemia:
o Decrease the total amount of fat you eat. Choose lean meats, fat-free or 1%
fat milk, and low-fat dairy products, such as yogurt and cheese. Limit or do
not eat red meat. Red meats are high in fat and cholesterol.
o Replace unhealthy fats with healthy fats. Unhealthy fats include saturated
fat, trans fat, and cholesterol. Choose soft margarines that are low in saturated
fat and have little or no trans fat. Monounsaturated fats are healthy fats. These
are found in olive oil, canola oil, avocado, and nuts. Polyunsaturated fats are
also healthy. These are found in fish, flaxseed, walnuts, and soybeans.
o Eat fruits and vegetables every day. They are low in calories and fat and a
good source of essential vitamins. Include dark green, red, and orange
vegetables. Examples include spinach, kale, broccoli, and carrots.
o Eat foods high in fiber. Choose whole grain, high-fiber foods. Good choices
include whole-wheat breads or cereals, beans, peas, fruits, and vegetables.

Ask your healthcare provider if it is safe for you to drink alcohol. Alcohol can
increase your cholesterol and triglyceride levels. A drink of alcohol is 12 ounces of
beer, 5 ounces of wine, or 1 ounces of liquor.