elderly insomnia

As the Nurse Practitioner for the case study patient, Evaluate the subjective and objective information provided in the case study scenario
below.
The first identify all pertinent positive and, negative information and list the needed missing information.
Then create a differential diagnosis list with at least 3 possibly actual diagnoses based on your findings.
The second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.
Be sure to utilize template, in-text citations, and provide full reference citation at the end of your response.

Case study Information:

C.C. “I can’t sleep.”
HPI: 97 y.o. F presented to HU Clinic for follow-up trouble sleeping. First noticed the sleep dysfunction
when she was hospitalized three months ago with acute exacerbation of heart failure. Since then she
has been waking up frequently at night. She denies trouble lying flat, her weight has been stable, and no
swelling. She denies CP or SOB. She reports not having issues with initiating sleep, but it is maintaining
sleep. She wakes up and lays in bed for hours until she falls back to sleep. She has noticed this causes
her to have increased daytime sleepiness. She is wanting to try something to help her sleep since she is
frustrated at this point and it has never been an issue.
Past medical history: HFpEF, HTN, HLD, CAD
Allergies: Cephalosporin, PCN, Carbapenems.
Medications: Metoprolol Succ 50 mg PO daily. Lasix 40 mg PO daily. Atorvastatin 40 mg PO daily. ASA
81 mg PO daily. Amlodipine 10 mg PO daily. Lisinopril 10 mg PO daily. Tylenol 500 mg PO Q6H as
needed for generalized pain.
Social history: Lives in assisted living. Usually active walking laps around the apartment complex with a rolling
walker. Has four adult children who live close by and visit her weekly. She denies tobacco, alcohol, and
illicit drug use.
Family history: Was adopted does not know biological family.
Health Promotion: UTD on routine screening, prevention, and vaccinations. Last PCP appt 1 month ago
for follow-up after hospitalization: CBC, BMP, TSH, BNP, Lipid panel, EKG check and in normal limits.
Review of system
General – Denies fever, chills or dizziness. She has been sleeping more during the day. Goes to bed
around 8PM without issues, then wakes around 12AM. She lays in bed until around 4AM and usually
falls back to sleep.
Skin – denies rash and skin ulcer
HEENT -denies hearing and vision loss, headache
Neck – denies swelling and stiffness
Cardiovascular – denies chest pain/tightness palpitations, heart racing
Pulmonary – denies shortness of breath, cough
Gastrointestinal – denies abdominal pain, nausea, vomiting, and diarrhea. No change in appetite, weight
gain or loss.
Genitourinary – Reports increase urination in the morning with Lasix but denies burning or blood.
Peripheral vascular – denies discoloration and edema
Musculoskeletal – denies muscle and joint ache
Neurological – denies confusion, memory loss, numbness or tingling. Denies lightheadedness or feeling
of faintness. Psychological – denies anxiety, depression and confusion. Feels stressed from not sleep
because it is affecting her during the day and not walking daily like she typically does. Endocrine: Denies
weight loss or weight gain. Hematologic: Denies bruising or bleeding easily.
Objective Data
Vital signs:.
T- 98.6 F, HR- 59 RR- 19, BP – 132/76 mmHg
Pulse ox – 96%, Wt.: 165 lbs. Ht 62 in
General appearance: No acute distress, well-nourished and cleanly kept.
HEENT: Normocephalic, face symmetrical. PERRLA. Auditory canal intact and clear. Hearing intact. Oral
mucosa moist without ulcerations or lesions. Uvula midline. Dentures. Neck: Non-palpable, non-tender
lymph nodes. Thyroid gland without enlargement or nodules.
CV: Regular rate, rhythm, S1/S2.
Lungs: Bilaterally clear to auscultation, no adventitious sounds. No clubbing noted. Abdomen: Bowel
sounds present in all four quadrants, abdomen is soft and non-tender, no guarding, no rebound, no
enlargement, or organomegaly noted.
Genitourinary: No suprapubic or CVA tenderness.
PV: B/L, equal +2 distal pulses. Capillary refill less than 3 seconds. No swelling, erythema or ulcerations
on exam. No edema.
MSK: Active and passive ROM within normal ranges. Uses rolling walker without issues.
Neuro: Alert and oriented to person, place, date and situation. Appropriate conversation. Strength 5/5
throughout. Cerebellar Rapid alternating movements intact.
Psychiatric: Behavior appropriate for the age. Thoughts are coherent
Neurological: Alert, oriented, cooperative. Speech is clear. Oriented to person, place, and time.

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