Capella FPX 4015 Assessment 5

Capella FPX 4015 Assessment 5

Student Name

Capella University

NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care

Prof. Name:

Date

Comprehensive Head-to-Toe Assessment

Hello, my name is ________, and I will be performing a full head-to-toe assessment today to evaluate your overall health. This thorough examination will give us a clearer picture of your condition and help us determine the best plan of care moving forward. If you experience any discomfort or need to pause at any point, please do not hesitate to let me know. Are you ready to begin?

Comprehensive and Professional Assessment

Hello, and thank you for coming in today. I will be conducting a full head-to-toe assessment, and I will walk you through each step as we go. If you feel uncomfortable at any time or have questions, please do not hesitate to let me know. To begin, can you tell me what brings you in today? Okay, so you are here for a follow-up on your lab results and blood pressure, and you  have also been experiencing some tingling in your feet. Thank you for sharing that with me. Can you describe the tingling a bit more? You mentioned it started about two months ago and that the pain feels sharp, burning, and stinging, happening at any time with no clear triggers. You  have rated the pain as a five out of ten, and it stays localized in your feet, not radiating into your legs. That information is very helpful.

Have you had any other symptoms, like chest pain, shortness of breath, or lightheadedness? I see you have not had chest pain, but you have felt lightheaded and dizzy sometimes, possibly related to long work hours. It is great that you  have increased your water intake again by using a large daily water jug. Staying hydrated is very important, especially with the other symptoms you are experiencing. Let us talk a little more about your medical history. You mentioned you have been diagnosed with hypertension and hyperlipidemia, and you were once told you had hyperglycemia. Have you had any surgeries in the past? No surgeries, that is good to know. What medications are you currently taking? You are on metoprolol 50 mg twice a day and atorvastatin 80 mg daily. Thank you. Do you take any herbal or holistic remedies? Interesting, you use Tung seed for hair growth and to relieve occasional constipation. I appreciate you sharing that.

How about your menstrual history? You said you have not had a regular cycle for about a year, and your last period was about six months ago. That is good information to have. When was your last wellness exam? You have been consistent with your appointments and had a mammogram and pap smear 10 months ago. That is excellent preventive care. Now, let us go over your family history. Your mother and maternal grandparents had a history of alcoholism, cholesterol problems, and diabetes. Your father and sister also have hypertension, and your paternal grandfather had type 2 diabetes with complications that led to an amputation. That is a significant family history and something we will definitely keep in mind when evaluating your current symptoms.

Capella FPX 4015 Assessment 5

Now tell me a bit about your lifestyle. How is your sleep and diet? You get about eight hours of sleep each night, which is great. You try to eat healthy, though sometimes the cost is a barrier. Using canned vegetables and growing your own in containers on the patio is a great way to maintain nutrition on a budget. Eating fast food once a month is reasonable, and it is good that you are mindful of that. You also mentioned walking for 30 minutes on weekends with your husband, which is great for cardiovascular health. Where do you live, and who lives with you? You and your husband live in an apartment together. And what do you do for work?

You are a cashier at a retail store. That can definitely be stressful at times. It is important to recognize that stress can have physical effects on our health. You mentioned that sometimes you cope with stress by eating ice cream—thank you for being honest about that. That insight can help us discuss balanced ways to manage stress moving forward. Do you drink alcohol, use tobacco, or recreational drugs? No? That is excellent, especially considering your family has a history with alcohol. Your choices here definitely support your health.Alright, now I will begin your physical exam. Please let me know if you feel uncomfortable at any point. First, I am observing your general appearance. You appear alert, well-groomed, and in no acute distress—good. Let us check your vital signs now. Your temperature is within normal limits.

Capella FPX 4015 Assessment 5

Your blood pressure is elevated at 142/88 mmHg. Heart rate is 84 beats per minute and regular. Respiratory rate is 18 breaths per minute, and your oxygen saturation is 98% on room air. Your fasting blood glucose is 168 mg/dL, which is higher than the normal range. We will want to monitor this closely. Next, I will listen to your heart. Your heart sounds are regular, and I do not hear any murmurs. Now I will listen to your lungs. Your breath sounds are clear on both sides, with no wheezes or crackles. Moving on to your abdomen, I am inspecting and palpating now. It feels soft, non-tender, and there is no distension. Since you have mentioned tingling in your feet, I want to assess for signs of peripheral neuropathy. First, I will take a close look at your feet; they show some dryness and slight redness, but I do not see any open wounds or ulcers. I am going to palpate now, your pedal pulses are present but slightly diminished, and your capillary refill is a bit delayed. Now I will use a monofilament to test the sensation in your feet. Please let me know when you feel it… Okay, it seems like you are experiencing reduced sensation, which could be a sign of diabetic neuropathy

Your skin overall is intact, with no lesions or rashes. Muscle strength is equal on both sides, and I do not notice any joint deformities or swelling. Based on today’s assessment, it looks like your elevated blood sugar levels may be contributing to nerve damage in your feet. This condition is called diabetic peripheral neuropathy. The good news is that with proper management, we can prevent it from getting worse. I will recommend that you follow up with your primary care provider to reevaluate your diabetes management plan. In the meantime, controlling your blood sugar tightly and practicing daily foot care will be very important. I can provide some educational materials on foot hygiene, signs to watch for, and tips for preventing injury. Do you have any questions about what we have gone over today?

Explaining Diagnosis and Findings to the Patient

Thank you again for coming in today and for sharing so openly with me. I would like to take a moment to go over everything we found during your assessment, explain what it all means, and help you understand the next steps for your health. You mentioned feeling a tingling sensation in your feet, and I really appreciate the way you described it in detail—that it feels sharp and burning, comes and goes without a clear pattern, and has been happening for the past couple of months. That information helped me narrow down possible causes as we moved through your evaluation.

As we talked more, you shared your medical history, including hypertension, hyperlipidemia, and a past diagnosis of hyperglycemia. We also discussed your current medications, your diet, your sleep, and how you manage stress. All of that gave me important context for understanding your overall health. After gathering your history, I checked your vital signs. Your temperature, heart rate, respiratory rate, and oxygen saturation were all in normal ranges, which is a good sign. However, your blood pressure was slightly elevated at 142/88 mmHg, and your fasting blood sugar was 168 mg/dL. That fasting glucose level is higher than what we consider normal, which ideally should be below 100 mg/dL. This elevated blood sugar could be a key factor contributing to the tingling you are feeling in your feet.

Capella FPX 4015 Assessment 5

During the physical assessment, I listened to your heart and lungs. I was glad to hear a regular heart rhythm and clear breath sounds, which are both positive findings. When I examined your abdomen, there was no tenderness or swelling, and everything felt soft and normal. That too is reassuring. Because you specifically mentioned issues in your feet, I did a more focused evaluation of your lower extremities. I observed that the skin on your feet was slightly dry and a bit red, but I did not see any open sores or ulcers, which is very encouraging. I checked the circulation in your feet by feeling for pedal pulses. They were present but a little weaker than expected, and the capillary refill in your toes, how quickly blood returns after applying pressure, was slightly delayed. This tells me that the blood flow in your feet may be somewhat reduced.

Next, I used a monofilament tool to test the nerve sensation in your feet. This tool applies gentle pressure to specific areas, helping us determine whether the nerves are sending signals properly. Based on your responses, your sensation in some areas was diminished. Combined with your elevated blood sugar, this leads me to believe that you can be experiencing diabetic peripheral neuropathy (Zhu et al., 2024). This is a common condition in people with diabetes, where high blood sugar over time damages the nerves, especially in the hands and feet. The tingling you feel is one of the classic symptoms. I want you to know that this condition is manageable, and the sooner we act, the better we can protect your long-term health. The most important step is improving your blood sugar control. Keeping your glucose levels in a healthy range can help slow or even stop further nerve damage. In addition, caring for your feet every day is essential. Because you may not always feel injuries, I recommend checking your feet daily, moisturizing them to prevent cracks, wearing comfortable, well-fitting shoes, and avoiding walking barefoot.

I also encourage you to follow up with your primary care provider soon. They may want to reassess your diabetes management plan and might suggest changes to your medication, diet, or physical activity. If you ever feel unsure about anything or have questions, please ask. You are not alone in this—we are here to support you, and I want you to feel informed and confident about what we found today and how we will move forward together.

Pharmacological Discussion with the Patient

Now that we have completed your assessment and reviewed your current condition, I would like to take a few minutes to go over your medications and how they relate to what we are seeing with your health. You are currently taking Metoprolol and Atorvastatin, and both of these medications are very important in managing your blood pressure, cholesterol levels, and now, the signs of diabetic peripheral neuropathy that we observed during your exam.

Let us start with Metoprolol. This is a beta-blocker that helps lower your blood pressure by slowing your heart rate and reducing the force with which your heart pumps. This reduces the overall strain on your cardiovascular system (MedlinePlus, 2023). Since we noticed that your blood pressure was slightly elevated today, and because poor circulation can worsen the symptoms of diabetic neuropathy, it is important that you continue taking Metoprolol as prescribed. Keeping your blood pressure under control will help protect the small blood vessels in your feet and reduce further nerve damage.

However, it is also important to be aware of some potential side effects of Metoprolol. These can include feeling tired, dizziness, or having cold hands and feet. Given that you are already experiencing some circulation issues and reduced sensation in your feet, I want you to be especially alert to any changes like increased numbness, tingling, or a colder feeling in your extremities. If any of these symptoms worsen or if you feel extremely fatigued, please contact us. It might be necessary to adjust the dosage or evaluate other options, depending on how you are doing.

Now, regarding Atorvastatin, this medication is used to help manage your cholesterol. It works by blocking an enzyme that your body uses to produce cholesterol, which helps lower your LDL or “bad” cholesterol while increasing your HDL or “good” cholesterol (Cleveland Clinic, 2024). This is especially important for you because high cholesterol combined with high blood sugar increases your risk for heart disease, stroke, and poor circulation. Atorvastatin not only lowers cholesterol but also helps reduce inflammation in your blood vessels, which adds another layer of protection for your heart and vascular health.

Capella FPX 4015 Assessment 5

Like any medication, Atorvastatin can have side effects. A common one is muscle pain or weakness. If you ever notice unexplained muscle aches, particularly in your legs, or dark-colored urine, it is very important to tell your provider right away. These symptoms could indicate a rare condition called rhabdomyolysis. Additionally, please avoid grapefruit and grapefruit juice, as they can interfere with how Atorvastatin is broken down in your body and increase your risk of side effects. Regular blood tests to monitor liver function are also necessary while you are taking this medication, so we will keep up with that as part of your ongoing care.

Because you are starting to show signs of diabetic peripheral neuropathy, we may need to consider adding a medication for nerve pain in the future if your symptoms get worse. Medications like gabapentin or duloxetine are commonly used to help manage nerve-related discomfort (Zhu et al., 2024). That said, we must be cautious about introducing new medications, especially those that affect your nervous system or blood pressure, given your current prescription for Metoprolol. Drug interactions can increase the risk of dizziness, drowsiness, or dangerously low blood pressure. This is why I encourage you to keep communicating with us about any new symptoms or medications you are considering, including over-the-counter drugs or herbal supplements.

Moving forward, the goal will be to continue with Metoprolol and Atorvastatin, while also improving your blood sugar control through adjustments in diet, exercise, and possibly your diabetes medications. You are taking a great step by being engaged and informed, and I want you to know that we will work together closely to monitor your progress and make sure your treatment plan is working well for you. Do you have any questions about your medications or what we just talked about? I want to make sure you feel confident and supported in understanding how everything fits together.

Explaining the Pathophysiology to the Patient

Thank you for taking the time to talk with me a little more about what is going on in your body and how it connects to the symptoms you have been feeling, especially that tingling and reduced sensation in your feet. I believe that when you understand what is happening inside your body, it can help you feel more empowered and involved in managing your health. This is not just about treating symptoms. It is about understanding the root cause and working together to protect your long-term health. From your medical history and the blood glucose reading we took, it looks like you may be dealing with something called diabetic peripheral neuropathy. This is a common complication of diabetes, especially when blood sugar levels stay too high for too long. When that happens, those high sugar levels start damaging the small blood vessels and the nerves, particularly the ones in your hands and feet.

Let me explain how this works. Your nerves function kind of like electrical wires, carrying signals between your brain and different parts of your body. These signals tell you how things feel—whether something is hot, cold, sharp, or painful- and they also help control your movement and coordination. When blood sugar is not well controlled, it starts damaging those nerves and the tiny blood vessels that feed and nourish them. When the nerves do not get the oxygen and nutrients they need, they start to malfunction or die off (Chu et al., 2022). That is what causes the sensations you are feeling, tingling, burning, or even complete numbness in your feet. The specific nerves being affected here are called peripheral nerves. These are located outside the brain and spinal cord and help with sensation and motor control in your limbs. As these nerves become more damaged, you might experience muscle weakness, difficulty balancing, and even trouble walking if the condition gets worse. One of the big concerns is that if your feet go numb, you might not feel a small injury, like a blister or cut. If unnoticed, that small issue can turn into an ulcer or serious infection, especially if your immune system is also weakened from diabetes.

Capella FPX 4015 Assessment 5

If we do not take steps to manage this condition, it can get progressively worse. Many patients describe the sensation as feeling like they are wearing socks when they are not, or they feel a constant buzzing or pricking, especially when they are trying to rest at night. What may have started out as a mild tingling can become sharp pain, intense burning, or eventually a total loss of feeling. This is why foot care and close monitoring are so important. And it is not just about your nervous system, this condition can also impact your balance and coordination, making you more likely to fall or get injured. It can even affect how your body interprets temperature, which means you might not notice if something is too hot or too cold, potentially leading to burns or frostbite. Some patients tell me it feels like “pins and needles,” or they experience pain out of nowhere that makes it hard to sleep.

But here is the good news: by keeping your blood sugar in a healthy range, checking your feet every day, wearing shoes that protect you properly, and using medications or therapy when necessary, we can slow down or even ease some of these symptoms. It takes teamwork, and your role is just as important as ours. Every step you take to monitor your health matters. What you are feeling is your body’s way of telling you that it needs help. But with awareness, the right tools, and consistent care, we can absolutely manage this together. Do you have any questions about what is happening or how you can help keep things from getting worse? I am here for you every step of the way.

Synthesis of Findings and Care Priorities for the Patient

Based on everything we have discussed today and the findings from your physical assessment, I want to walk you through the most important priorities in your care going forward. The tingling and decreased sensation in your feet, along with your elevated fasting blood glucose levels and the results from the monofilament test, strongly suggest that you are dealing with diabetic peripheral neuropathy. This condition arises when high blood sugar levels over time begin to damage the peripheral nerves, especially in your feet. It is a common but serious complication of diabetes, and we want to make sure we are addressing it thoroughly.

One of the main concerns we identified during the assessment was your blood pressure reading, which was 142 over 88. That is higher than we would like it to be, especially considering your history of diabetes. You are currently taking Metoprolol, which is a beta-blocker that helps manage blood pressure, and Atorvastatin, which helps control your cholesterol levels. These medications are part of a standard and effective approach for reducing cardiovascular risk in people with diabetes, as supported by the American Diabetes Association (Cleveland Clinic, 2024).

The first and most urgent priority in your care is getting your blood sugar under tighter control. Sustained high glucose levels are the root cause of the nerve damage you are experiencing, so bringing those levels down can help slow the progression of the neuropathy and may even improve your symptoms over time. We might need to review your current diabetes treatment plan to see if adjustments are necessary; this could involve changes to your medications, a closer look at your diet, or increasing physical activity. These are all strategies recommended in the ADA guidelines for managing diabetes effectively. I will also encourage you to monitor your blood sugar regularly and might refer you to a diabetes educator or an endocrinologist for more specialized guidance.

Capella FPX 4015 Assessment 5

Another top priority is protecting your feet from injury. Because your sensation is reduced, there is a greater chance that you might not notice cuts, blisters, or pressure sores, which can lead to serious infections if not caught early. According to the Centers for Disease Control and Prevention, practices like inspecting your feet daily, keeping your skin moisturized, and wearing well-fitting shoes are essential preventive steps. I will work with you to build this into your daily routine and may recommend a referral to a podiatrist for additional evaluation and support. We also need to focus on managing your cardiovascular health. Your current medications (Metoprolol and Atorvastatin) are evidence-based treatments that help lower your risk of heart attack and stroke, especially given your history of both hypertension and diabetes (MedlinePlus, 2023). I will continue to monitor your blood pressure during our visits and make sure you are not experiencing any side effects such as fatigue or dizziness. If needed, we can explore other medication options or dosage adjustments.

Finally, education and regular follow-up are essential to your care. It is important for you to recognize the signs of worsening neuropathy, such as increasing numbness or burning pain, and to know when to contact your healthcare provider. Staying consistent with your medications, attending your follow-up appointments, and reaching out if anything changes will all play a part in keeping you healthy and avoiding complications. So, as your nurse, I want you to know that we are going to take a proactive, team-based approach to your care. By working together, managing your blood sugar, protecting your feet, supporting your cardiovascular health, and ensuring you are fully informed, you can take control of your condition and maintain a high quality of life. Do you have any questions or concerns about the steps we will be taking? I am here to support you. 

Conclusion

Today’s assessment showed that your blood sugar is too high and is likely causing nerve damage in your feet. This is called diabetic neuropathy. It is important to keep your blood sugar under control and take good care of your feet every day. We will work with your provider to make a plan that helps you feel better. You are not alone—we are here to help you every step of the way.

References

Chu, X.-L., Song, X.-Z., Li, Q., Li, Y.-R., He, F., Gu, X.-S., & Ming, D. (2022). Basic mechanisms of peripheral nerve injury and treatment via electrical stimulation. Neural Regeneration Research, 17(10), 2185–2193. https://doi.org/10.4103/1673-5374.335823 

Cleveland Clinic. (2024). Atorvastatin: Treatment for high cholesterol. Cleveland Clinic. https://my.clevelandclinic.org/health/drugs/19081-atorvastatin-tablets 

MedlinePlus. (2023). Metoprolol: MedlinePlus drug information. Medlineplus.gov. https://medlineplus.gov/druginfo/meds/a682864.html 

Zhu, J., Hu, Z., Luo, Y., Liu, Y., Luo, W., Du, X., Luo, Z., Hu, J., & Peng, S. (2024). Diabetic peripheral neuropathy: Pathogenetic mechanisms and treatment. Frontiers in Endocrinology, 14(14). https://doi.org/10.3389/fendo.2023.1265372