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Care Map Clinical 10/13 92yo Female Patient - Coggle Diagram
Care Map Clinical 10/13 92yo Female Patient
Coronary Artery Disease
Pathology
Narrowing or coronary arteries due to plaque buildup
Clinical Findings
Physical Assessment
Subjective: "I feel short of breath"
Objective: elevated BP, elevated HR
Risk Factors
Modifiable: obesity, high cholesterol, exercise
Non modifiable: age, gender, family history
Treatments
Pharm: Atorvastatin
Non Pharm: exercise, lowering blood pressure, increase fluids
Lab and Test Results
Elevated HR, elevated BP
Aortic Stenosis
Pathology
Narrowing of aorta due to fibrosis and calcification of valve
Clinical Findings
Physical Assessment
Subjective: "My legs feel heavy
Objective: high blood pressure, pitting edema in lower extremities
Risk Factors
Non modifiable: >60 years old, chronic kidney disease
Modifiable: obesity, high cholesterol
Lab and Test Results
High LDL
Treatments
Pharm: Heparin, Atorvastatin
Non Pharm: exercise, lowering blood pressure
Mitral Stenosis
Pathology
Narrowing of mitral valve
Clinical Findings
Physical Assessment
Objective: high blood pressure, diminished pulses in lower extremities
Subjective: "My legs feel so swollen"
Risk factors
Modifiable: obesity, high cholesterol
Non modifiable: >60 years of age, rheumatic fever
Treatments
Pharm: Heparin, Atorvastatin
Non pharm: exercise, lowering blood pressure
Lab and Test Results
High LDL
Peripheral Vascular Disease
Pathology
Buildup of plaque on arterial wall
Clinical Findings
Physical Assessment
Subjective: "My legs feel so cold"
Objective: diminished pedal pulses, lack of color in the toes
Risk Factors
Modifiable: diabetes, smoking, obesity
Non modifiable: age, gender, family history
Treatments
Pharm: Atorvastatin
Non Pharm: increase fluids, increase physical activity
Lab and Test Results
Elevated resting HR, elevated BP
Hypertension
Pathology
Excess sodium intake, sodium retention, increased fluid volume, increased preload, which increases contractibility
Clinical Findings
Physical Assessment
Subjective: "I have a headache"
Objective: dizziness upon movement
Risk Factors
Modifiable: smoking, stress, agitation, salt intake, water intake
Non modifiable: >60 years of age, family history
Treatments
Pharm: Meoprolol
Non Pharm: reduced salt intake, increase water intake, promote low stress
Lab and Test Results
BP 172/90
Hyperlipidemia
Pathology
Excess lipid or fat buildup in bloodstream
Clinical Findings
Physical Assessment
Subjective: "I don't do as many exercises as I used to or walk around nearly as much"
Objective: slight weight gain, more sedentary
Risk Factors
Non modifiable: family inheritance
Modifiable: obesity, saturated fact intake, cholesterol, diabetes
Treatments
Pharm: Atorvastatin
Non Pharm: increase physical activity, eat healthy, quit smoking, lose weight
Lab and Test Results
High HDL
Type II Diabetes
Pathology
Insulin resistance, impaired glucose production
Clinical Findings
Physical Assessment
Subjective: "I'm not hungry - I feel fine"
Objective: increased urine output, lethargic
Risk Factors
Non modifiable: genetics, ethnicity, age
Modifiable: obesity, hypertension, poor diet, lack of exercise
Treatments
Pharm: insulin regular
Non Pharm: low fat/low carb diet, exercise
Lab and Test Results
BS 99
Osteomyelitis
Pathology
Bone infection causing an occlusion of blood vessels causing bone necrosis and spread of infection
Clinical Findings
Physical Assessment
Subjective: "I am missing several toes by the way"
Objective: missing three toes, history of fractures, current sternal fracture
Risk Factors
Modifiable: smoking, diabetes, high blood pressure
Non Modifiable: >60 years of age, kidney problems, immune issues
Treatments
Pharm: n/a
Non Pharm: hyperbaric chamber
Lab and Test Results
Elevated leukocytes, WBC
Chronic Kidney Disease
Pathology
Decreased renal perfusion pressure, inability to maintain fluid and electrolyte balance
Clinical Findings
Physical Assessment
Subjective: "I frequently feel like I have to pee"
Objective: foley in place
Risk Factors
Modifiable: good diet, exercise, high intake of fluids
Non modifiable: age, gender, race, diabetes
Treatments
Pharm: n/a
Non Pharm: increase fluids, reduced sodium diet
Lab and Test Results
BUN 39, Creatinine 1.6
Chronic Anemia
Pathology
Red blood cells do not have enough iron
Clinical Findings
Physical Assessment
Sujective: "I bruise really easy honey be careful"
Objective: bruising, pale cheeks and lips
Risk Factors
Modifiable: diet
Non modifiable: age, family history, menopause
Treatments
Pharm: ferrous sulfate
Non Pharm: fruits, vegetables, teas
Lab and Test Results
Hem 9, Hct 26.2
UTI
Pathology
Bacteria invade urinary epithelium causing irritation and inflammation
Clinical Findings
Physical Assessment
Subjective: "I feel like I have to pee AGAIN" or "It really burns with I urinate"
Objective: foley in place
Risk Factors
Modifiable: wipe front to back, refrain from retaining urine
Non modifiable: females, sexuality, birth control, menopause
Treatments
Pharm: ceftriaxone
Non Pharm: fluids, cranberry juice
Lab and Test Results
Leukocytes in urine, bacteria in urine, blood in urine