Case Plan Synthesis- Atrial Fibrilation
The care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of
care from specialty organizations and other research based resources.
In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan.
Your paper should
adhere to APA format for title page, headings, citations, and references and be less than 20% according to Turn it in.com
Care Plan Synthesis
1) Design a comprehensive and holistic recognition and planning for the disorder.
2)Addresses how the patient’s socio-cultural background can potentially impact optimal
management and outcomes.
3) Demonstrate an evidence-based approach to address key issues identified in the case study.
4) Formulate a comprehensive but tailored approach to disorder management.
Case Study-Atrial fibrillation
Mrs. A is a 75 y/o white female who you have been following in the clinic for HTN/ Obesity/
DM II/ and Osteoporosis. She normally runs a BP of 144/ 86 and admits to occasionally
forgetting to take her BP med Zestoretic (Lisinopril/HCTZ) 10mg/12.5mg – one tab qd. Since
her last visit her DM II is under good control, as she finally agreed to see the registered dietician.
For the last 3 months, she has been following a 2GM NA 1800 Cal ADA low cholesterol, low fat
diet and has lost 8 lbs since her last visit. She is taking metformin 500mg bid and Amaryl 2mg
daily for her DM. She also has started a walking program in the last 3 weeks as advised and is up
to 15 minutes a day 3x/ week.
The client called yesterday to make an appointment for episodes of “feeling funny- like her heart
was racing” over the past 3 weeks. She is not sure how long she has been having these episodes,
but has not mentioned this before as it “only happened once or twice” this year and she attributed
it to doing more activity than usual on those occasions. She would just sit and rest and within a
few minutes her symptoms would resolve. Also, she does not have a supplemental insurance as
is “worried about running up big bills”.
Mrs. A. reports that the racing heart began again this am while she was in the bathroom washing
her face and brushing her teeth and lasted for about an hour despite her sitting down and resting.
She denies dizziness or faint-like feelings, SOB, chest pain, nausea, diaphoresis or anxiety.
Past Medical History: As above
Family History: Pt adopted and family history is unknown.
Social History: Happily married x 45 years. Husband is 76, healthy and active. They have 2 adult
children who have families of their own and live out of state. They are close with their children
and grandchildren and visit at least 2x/ year with each family. Mrs. A. smoked from age 21-40, 1
pack every week. She drinks 1- 4 ounce glass of wine 2x/ week when they go out for dinner with
friends.
Allergies: NKDA, no food allergies.
Meds: As above and Fosamax 70 mg 1x/ week.
ROS: Negative except for cardiac complaints as above.
PE: BP 140/80 mmHg (took her BP med this am); T: 98.6; P: 105, irregular; R: 20, O2 Sat 93%
FBS: 110
BMI: 32
PE WNL except for:
HEENT: Bilateral xanthelasma
Heart: Irregularly, irregular rate, systolic murmur 2/6 best at the apex. PMI diffuse.
Extremities: Trace bilateral pretibial edema.
RUBRIC ( Create Care Plan for this Patient)
1) Design a comprehensive and holistic recognition and planning for the disorder.
2) Address how the patient’s socioculturalbackground can potentiallyimpact optimal management andoutcomes.
3) Demonstrate an evidence-basedapproach to address key issuesidentified in the case study.
4) Formulate a comprehensive buttailored approach to disordermanagement.
5) Your care plan should be based on current best practicesand supported with citations from current literature (nursing associations, ebsco host with peer reviews etc), such as systematic reviews, published practice guidelines, standards ofcare from specialty organizations and other research based resources. In addition, you will provide adetailed scientific rationalethat justifies the inclusion of this evidence in your plan. Your paper shouldadhere to APA format for title page, headings, in text citations, and references.