NURS FPX 6008 Assessment 3: Business Case for Change

Marco Mancini is having trouble sleeping and feeling anxious because the nurse starts with a greeting and lets him know what the physical exam is going to assess. When consenting, the nurse reassures the client to communicate any discomfort that occurs. Vital signs are taken and mostly normal, temperature 98.6°F, heart rate 82 beats per minute with a regular rhythm, respiratory rate 16 per minute, and oxygen saturation is 98% on room air. But the blood pressure is high at 148/92 mmHg, which is in line with the client’s known history of hypertension. His height is 5’10”, and his weight is 175 lbs for a BMI of 25.1, considered normal.

Generally, in physical appearance, Marco looks 30 years old and is well-dressed and well-groomed. Slightly anxious about engaging in eye contact, tends to pause when discussing emotionally sensitive things – maintains fair eye contact. Neurological assessment reveals he is alert and oriented (knew his name, place, time, and situation). He has a good memory, but may be a little slower to process questions that are emotional or difficult. Cranial nerves II–XII are grossly normal with good visual acuity and facial symmetry. He says that on a concentration task, like counting backwards by sevens, he can do it, but it takes him longer to process what he is saying, which means that there is mild cognitive strain under stress.

Ahead, eyes, ears, nose, and throat (HEENT) examination is normal, including a normocephalic, atrophic head, pupils equal and reactive to light, and clear tympanic membranes and normal nasal mucosa. The mucous membrane in the oral cavity is moist without lesions. Assessing the skin is done to confirm normal colours, warm and dry texture, good turgor, and no lesions, rashes, or evidence of self-harm observed. Cardiovascular examination reveals normal heart sounds (S1 and S2), regular rate and rhythm, strong peripheral pulses bilaterally, and capillary refill of less than 2 seconds.

Respiratory Exam – clear breath sounds bilaterally, breathing is unlabored and symmetrical. The gastrointestinal examination is unremarkable, the abdomen is soft, flat, and non-tender, bowel sounds are active in all quadrants, and organ palpation shows no enlargement. The client has reported no gastrointestinal complaints (loss of appetite, nausea). Data from the genitourinary system are subjective in that the client reports no urinary symptoms, sexual dysfunction, or history of sexually transmitted infection. MS evaluation demonstrates good ambulation, full range of motion for all extremities, normal muscle strength 5/5 bilaterally, and no joint abnormalities.

Psychiatric evaluation reveals an affect that is restricted but appropriate with a sense of guilt and fear. He reasons and judges in an objective, logical fashion with some goals in mind. He reports no recent or past suicidal or homicidal thoughts. He says he has trouble sleeping from nightmares and flashbacks; however, this doesn’t seem to be a very serious issue. Avoidance behaviors and isolation from others are his coping strategies.

A plan of care is to start Lisinopril for blood pressure and Citalopram 20 mg for symptoms of anxiety and depression. An adult nurse pays attention to orthostasis because of the chance of medication interactions. Individual psychotherapy is offered as a referral, cognitive behavioral therapy, as well as psychoeducation regarding post-traumatic stress disorder, medication side effects, and resources to prevent suicide. Follow-up will be with a psychiatric nurse practitioner in 3 weeks.

The session ends with the nurse praising Marco for his willingness to discuss and discuss the possibilities of further support and partnership in Marco’s recovery from Marco. The nurse tells him that he’s not alone and explains what he should do next: go for therapy and what his medication will look like in the future.