patient teach plan paper - case study 3

Running head: CASE STUDY 3 – PATIENT TEACHING PLAN 1

Case Study 3 - Patient Teaching Plan

0253173

Technical College of the Lowcountry

CASE STUDY 3 - PATIENT TEACHING PLAN 2

Introduction

Stephen Prileau is a 68 year old African American male experiencing reoccurring pain in his

right calf known as intermittent claudication (Ignatavicius & Workman, 2013). Claudication is

indicative of ischemia consequential to poorly managed Peripheral Artery Disease and

precipitated by systemic atherosclerosis. (Linden, 2013) “PAD is as common as heart disease

and cancer and one of the fastest-growing diseases of our time, affecting an estimated 4 million

people in the UK, and 27 million individuals in Europe and North America.” (Smith, Fox, &

Seriki, 2014) A substantial growth in the prevalence of type 2 diabetes, in conjunction with

diabetes being one of the top factors for developing critical limb ischemia, correlates

considerably with the increase in PAD and other coronary complications. (Smith, Fox, & Seriki,

2014) When PAD and ischemia are left undetected, considerable tissue damage of the extremity

can result. (Ignatavicius & Workman, 2013) Depending on the amount of tissue damage,

presence of infection, and type of ulcers, emergent care may be required. (Smith, Fox, & Seriki,

2014) Emergency care admissions have an increased likelihood of extremity amputation,

especially in diabetic patients. (Smith, Fox, & Seriki, 2014) By managing the patient’s care

through a holistic, collaborative approach, thorough implementation of the nursing process,

patients’ with PAD can have decreased compilations and an improved quality of life.

Assessment

The patient is a 68 year old African American male who came to the hospital emergency room

today experiencing pain in his right lower extremity, which he states initially began 2 years ago.

The patient states the pain has become increasingly worse over the last four months, is triggered

by only a limited amount of exercise and is relieved with rest. The patient admits to a smoking

habit of 2-3 packs of cigarettes per day with a 45 year history of tobacco use. He admits he lives


a sedentary lifestyle, has a medical history of peripheral artery disease, hypertension, coronary

artery disease, osteoarthritis. He denies any history of diabetes. The patient states he does not

always take his medications every day as they are prescribed and has not complied with the

exercise regimen his cardiologist prescribed after his quadruple coronary artery bypass graft that

was done 3 years ago. His only other surgical history is an open reduction and internal fixation

of the right femur that was done 20 years ago after he had fallen off a ladder on the job, causing

the fracture.

Patient is alert and orient but appears much older than his stated age. Vital signs: blood pressure

of 163/91 mm Hg, heart rate of 82 beats per minute, respirations of 16 breaths per minute,

oxygen saturation of 95% on room air, temperature of 98.1 F, and is absent of pain at this time.

His Patient has unequal bilateral pulse rates upon palpation of the posterior tibial arteries. His

right posterior tibial pulse is notably more diminished than on the left. The patient’s skin was

cold and dry, the toe nails appeared to be thick and brittle, especially on the right lower

extremity. No skin discoloration nor peripheral edema present.

Patient has an elevated cholesterol of 239 mg/dL, and is 5’10 weighing 261 lbs. equaling a body

mass index of 37.4. He denies having any allergies and is currently prescribed 20 mg of Vasotec

daily, 50 mg of Lopressor daily, 325 mg of aspirin daily, and 40 mg of simvastatin daily. Fasting

lipids are LDL 181 mg/dL, HDL 28 mg/dL, cholesterol 239, and triglyceride 150 mg/dL. The

patient is a retired painter who has just recently relocated from Cleveland, Ohio to the Beaufort

area. He is a widower who lives alone but has a daughter and two granddaughters who live

nearby in Beaufort.

Analysis


Considering the patient’s history of peripheral artery disease, long term smoking habit, sedentary

lifestyle, and lack of compliance with taking his cardiac medications; in conjunction with the

assessment findings of decreased posterior tibial pulses, cold and dry skin, thick and brittle toe

nails, point to an arterial problem such as intermittent claudication. (Ignatavicius & Workman,

2013) The gradual onset of pain over 2 years indicates a chronic issue decreasing the possibility

of DVT. The absence of edema and discoloration of the skin rule venous disease. (Ignatavicius &

Workman, 2013) The patient’s heavy use of tobacco not only causes arterial constriction, it has

a negative impact upon his fasting lipid levels further increasing his heart disease risks and

atherosclerosis throughout his body. (Gulanick & Myers, 2014) Lack of exercise and a BMI of

37.4 also are significant factors in decreased tissue perfusion, regular exercise will enhance his

circulation. (Gulanick & Myers, 2014) A BMI 30 or greater falls under the category of obesity.

His obesity maybe caused by an unhealthy diet relating to African American cultural, cuisine

options that can include an increased amount of starch, sodium, and fat. Being a widower who

lives alone may factor into being overweight if he chooses fast, processed foods as convenience

to not having to cook for himself. An unhealthy diet and lack of medication compliance,

otherwise, poorly managed hypertension is another contributing threat that is damaging his

cardiovascular system and effecting proper tissue perfusion. (Gulanick & Myers, 2014) Elevated

lipid levels as stated previously, increase atherosclerosis and progression of PAD. (Ignatavicius

& Workman, 2013) Medication compliance in general to all his prescribed medications is

another priority problem that need to be addressed combination with, psychosocial interventions

to determine the patient’s overall mental health since the loss of his wife.

Cultural Learning Needs


Lifestyle changes for Mr. Prileau need to be realistic and must obviously work within his

cultural, developmental, socioeconomic, and psychosocial learning needs in order for adherence

to occur.

Evaluating Mr. Prileau’s psychosocial learning needs are priority because his needs are likely

precipitating from depression brought on by the loss of his wife and the aging process.

Furthermore, his sedentary lifestyle and poor diet are counterproductive in dealing with

depression which initiated in and commonly occurs in cities such as, Cleveland. His

psychosocial needs, once met may have a favorable influence on his affective domain and

change his indifference about his health. A therapeutic dialogue about dietary changes that will

balance both his cultural and medical need will be a necessary part in managing his HTN and

well as a discussion on smoking cessation. Mr. Prileau is at a pivotal point within the

developmental stage of Integrity vs. Despair. If Mr. Prileau can turn around his health, not cause

any further damage to his right limb, and reconnect relationships with his family he may

withstand the conflict of despair. (Chang, Nead, Olin, Cooke, & Leeper, 2014)

Realistic Patient Outcomes

Stephen Prileau will demonstrate an affective learning domain as evidenced by a request of

information on medication options available that assist with smoking cessation by the time of

discharge.

Stephen Prileau will express positive expectations about his future as evidenced by his interest in

finding a church in Beaufort to attend with his family after he is discharged from the hospital.


Stephen Prileau verbalizes motivation to learn better nutritional options for decreasing his high

blood pressure and cholesterol as evidenced by his interest in speaking with dietary personnel

prior to discharge.

Learning/Teaching Principles

After determining through assessment that visual learning style works best for Mr. Prileau,

patient information material was accessed and printed for him including with detailed

explanations of the disease processes, ways to optimally manage one’s health, and why health

management is important. The primary risk factors relevant to Mr. Prileau are smoking, lack of

exercise, uncontrolled hypertension and usage of medication inconsistent with how it is to be

prescribe. (Linden, 2013) By Mr. Prileau quitting smoking, he can reduces the progression of

peripheral artery disease. Smoking damages the endothelial lining of the arteries and cause

atherosclerotic plaque buildup. (Gulanick & Myers, 2014) Lack of exercise increases vascular

resistance therefore not improving hypertension nor tissue perfusion through the body’s

extremities. (Gulanick & Myers, 2014) Intermittent claudication symptoms will decrease as

tissue perfusion improves from proper medication usage and light physical therapy to promote

tissue regrowth. (Gulanick & Myers, 2014) Uncontrolled hypertension leaves unnecessary

pressure upon an already fragile cardiovascular system, which left untreated can cause further

cardiovascular events such as MI or stroke (Linden, 2013). Education of how specific

medications help treat the disease process is an important learning process for the patient in order

to promote compliance. If the patient doesn’t understand how each medication effects their body

nor the life threating side effect that can occur, the ultimate goal of health promotion will be left

unachieved.

Implementation


Maintain adequate fluid intake to prevent increased blood viscosity, therefore promoting

effective circulation. (Gulanick & Myers, 2014)

Instruct patient to avoid crossing the legs, due to further impairment of circulation. (Gulanick &

Myers, 2014)

Educate patient to avoid use of heating pads, wear protective footwear and avoid injury to the

skin. The rationale is that the skin has poor circulation and is subject to injury ulcerations of the

extremities. (Gulanick & Myers, 2014)

Assess patient’s extremities for the pain, pallor, paresthesia, poikolthermia, pulse and paralysis.

Learning the patient’s baseline circulatory grade is helpful for any changes that may occur

requiring more invasive interventions. (Gulanick & Myers, 2014)

Assess patient for pain, quality of pain, time of onset, duration, relieving factors, numbness, and

tingling. Intermittent claudication is the most common symptom of PAD and is located in the

calf muscles or buttocks. If pain occurs while the patient is at rest a more extensive occlusion of

the artery may exist needing immediate care. Tingling and numbness represents lack of

circulation to the nerve cell tissue. (Gulanick & Myers, 2014)

Assess the patient’s ankle-brachial index. Knowledge of baseline circulation status is important

and is diagnostic of PAD as well as the severity of the disease. (Rac-Albu, Iliuta, & Maria,

2014)

Provide medication therapy as prescribed by the provider, educate the patient about such

medications which usually include antiplatelet drugs and lipid-lowering medications.

Antiplatelet medications reduce platelet build up, decrease pain, and stronger medications can

cause arterial dilation. Antiplatelet medications such as Cilostazol shouldn’t be use in patients


with heart failure or prescribed with aspirin. These medications create a risk for bleeding and the

patient should monitor for signs or symptoms such as unusual bleeding , dark and tarry stools,

and nosebleeds. (Gulanick & Myers, 2014)

Conclusion

Top risks factors for developing claudication are smoking, hypertension, and hyperlipidemia and

is the most common symptom of peripheral vascular disease. (Ignatavicius & Workman, 2013)

Prevention of further progression of PAD include smoking cessation, dietary modification, and

hypertension management. (Gulanick & Myers, 2014) Smoking is the “most commonly

implicated in the PAD and is said to triple the risk for developing claudication.” (Gulanick &

Myers, 2014) Repetitive exercise regimen is crucial treatment for PAD and for claudication due

to benefits such as enhancing collateral circulation and increasing walking ability. (Linden,

2013) Early assessment and education of claudication especially in diabetics and PAD patients

is fundamental in reducing complications that lead to ulceration, gangrene and ultimate

amputation of the extremities. (Smith, Fox, & Seriki, 2014)


ReferencesChang, P., Nead, K., Olin, J., Cooke, J., & Leeper, N. (2014). Clinical and socioeconomic factors associated

with unrecognized peripheral artery disease. Vascular Medicine, 19(4), 289-296.

Gulanick, M., & Myers, J. L. (2014). Nursing Care Plans (8th ed.). Philadelphia: Elsevier.

Ignatavicius, D. D., & Workman, M. L. (2013). Medical-Surgical Nursing: Patient-Centered Collaborative Care (7th ed.). St. Louis, Missouri: Elsevier Saunders.

Linden, B. (2013, March). Lower limb peripheral artery disease. British Journal of Cardiac Nursing, 8(3), 112-113.

Rac-Albu, M., Iliuta, L., & Maria, S. G. (2014). The Role of Ankle-Brachial Index for Predicting Peripheral Arterial. MAEDICA – a Journal of Clinical Medicine, 9(3), 295-302.

Smith, L., Fox, M., & Seriki, D. (2014, June). The role of the community clinician in early detection, referral and treatment of critical limb ischaemias. British Journal of Community Nursing, Vol 19(No 6), 266-272.

patient teach plan paper - case study 3

Documents