Advanced Practice Nursing: Case Study Analysis and Care Plan Creation Client Complaints:

This case study involves a patient with symptoms for the past 24 hours and the patient expresses pain as ten on a scale of one to ten in the past 24-hour however, it is presently stated at seven. This patient is being treated for hypercholesterolemia, hypertension and gout. The patient tested positive for H. pylori.

History of Present Illness:

The patient has had incidents of stomach problems in the past however, this incident appears to be more severe in nature and to have lasted longer than in the past.

Past Medical History:

The patient is Italian and this is important because of the choice of foods of this patient. In addition, the patient is found to be H. pylori positive. H. pylori is a spiral-shaped bacterium commonly found in the stomach with a shape and movement that enables them to penetrate the protective mucous lining of the stomach. These bacteria are reported to produce substances that serve to weaken the lining of the stomach making it more susceptible to gastric acid damage. Additionally these bacteria attach to the stomach cells and this may cause inflammation of the stomach known as gastritis resulting in the simulation of the production of an excess amount of stomach acid. The risk of stomach cancer increases across time when infected with H. pylori. The patient exhibits symptoms of this infection. In addition, the patient has Gout, Hypercholesterolemia and Hypertension. A high level of uric acid in the individual's system results from consuming purine containing foods and the increase in uric acid results in its accumulation causing gouty arthritis. Bacon is reported as a good source of urine which breaks into uric acid. Foods to avoid include alcohol and bread. Gout destroys the joints causing renal damage. According to the University of California San Francisco Medical Center "The hallmark symptom of gout is a sudden, severe attack of pain, redness, swelling and tenderness in a joint, often the first toe. Inflammation also can occur in the knee, ankle, foot, hand, wrist and elbow. Gout typically occurs quickly in only one joint at a time, but symptoms may occur in two or three joints simultaneously. Deposits of uric acid, called tophi, can appear as lumps under the skin around the joints and at the rim of the ear. Occasionally, uric acid collects in the kidneys and forms stones." (2014, p. 1) Hypertension is reported to be defined as "a sustained blood pressure of 140 mmHG or greater systole, and/or 90 mmHg or greater diastole." (Hypertension Care Plan Guidelines, nd, p. 1) It is reported that 50% of individuals who have their first heart attack and two-thirds of those who have a stroke have a blood pressure reading higher than 160/95 mm Hg. In addition, it is reported that hypertension "precedes the development of congestive heart failure in 91% of the cases and elevated blood pressure is associated with 2-3 times higher risk for developing congestive heart failure." (Peters Institute of Pharmaceutical Care, nd, p. 1) The patient additionally has Hypercholesterolemia. Hypercholesterolemia is commonly known as high cholesterol. It is reported that fats in the blood are "called lipids" and that hyperlipidemia is defined "as an elevation of one of more of the following: cholesterol, cholesterol esterse, phospholipids, or triglycerides" (Peters Institute of Pharmaceutical Care, nd, p. 1)

Significant Family History:

The patient is married and his wife tries to get him to eat healthier foods. The patient has two brothers and both have high cholesterol, high blood pressure and developed gout in their early fifties. Gout is predominant in this family.

Treatment Plan:

Treatment is aimed at pain reduction, prevention of attacks in the future and avoidance of tophi and kidney stone development. Drug therapy reported is as follows:

"Nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroids, which are either taken orally or injected into the affected joint, are two of the most common treatments for acute attacks of gout. NSAIDs and corticosteroids reduce the inflammation caused by deposits of uric...

Patients often begin to improve within a few hours of treatment, and the attack usually goes away completely within a week or so." (University of California San Francisco Medical Center, 2014, p. 1)
The patient's care plan will involve instructions on the recommended diet for this patient. Management of Gout requires that the patient adhere to a specialized dietary intake and that they avoid certain foods. Medicines to help with gout are reported to include Bromelain, black cherry juice and celery seed extract for providing relief from uric acid increase and inflammation. Celery seed is also beneficial for hypertension and high blood cholesterol. In addition, maintenance of weight plays a critical role in treating gout, hypertension and hypercholesterolemia. In addition, a diet that is balanced and rich in complex carbohydrates assists in treating these three conditions and a low fat diet with dietary fiber is reported as beneficial. Recommendations are stated for small amounts of polyunsaturated fats as well as vegetable oils including sunflower oil, groundnut, soy and flaxseed oil.

Unsaturated fats should be avoided and there should be no intake of deep fried foods. Processed foods containing high sodium levels and trans fats should be avoided by those with high blood pressure. Foods containing complex carbohydrates including whole grains, vegetables, cereals, legumes, fruits and pulses are recommended for those with high blood pressure. Oatmeal and fruits including apple and guava make provision of soluble fiber and reduce cholesterol levels.

Ten glasses of water is reported to be assistive in flushing off the toxins and diluting the uric acid. Acidic food intake should be avoided as well as pastries, black tea, chocolate, white flour, pasta, turkey, artificial sweeteners, white rice, salt, sweet bread, beef, anchovies, herring, mackerel, game meat and scallops. Regular physical activity is critical in treating hypertension and hypercholesterolemia. The patient will be instructed to avoid fast foods that he is reported to eat quite regularly.

Initial treatment for most patients for hypertension is reported to be "either diuretics alone or in conjunction with another class of antihypertensives." (Peters Institute of Pharmaceutical Care, nd, p. 1) This patient should monitor their blood pressure regularly and should be instructed in relaxation techniques that will serve to lower their blood pressure. (Nurselabs.com, 2014, p. 1) The patient's response to drug therapy will be monitored in a regular basis. A great deal of the patient's stomach pain is related to the presence of H. pylori which will be treated. It is reported that according to the Food and Drug Administration that several regimens have been approved for the treatment of H. pylori infection and specifically reported for patients with peptic ulcer disease are what are known as triple therapies with cure rates stated at 85 to 90%. The triple therapies are administered for 10 to 14 days and include omeprazole, amoxicillin and clarithomycin (OAC) for ten days and bismuth subsalicylate, metronidazole, and tetracycline (BMT) for 14 days; and lansoprazole, amoxicillin, and clarithromycin (LAC), which has been approved for either 10 days or 14 days of treatment" (Santacroce and Katz, 2014, p. 1)

The long-term goals or therapy for hyperlipidemia are the reduction of coronary heart diseases and reduction of risk for stroke as well as to slow the development of coronary atherosclerosis and the prevention of pancreatitis. Therapeutic alternatives reported include drug therapy reported to be "often initiated with a statin (HMG-CoA redutase inhibitor" which is reported to be convenient in use due to the single daily dose taken orally.

Finally, the patient should be instructed as to compliance with the medication regimen as prescribed because all of these conditions could worsen and result in other health problems for the patient.

III. ICD-9 Classification Diagnoses

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) classifications for the patient in…