In terms of chest pain and breathing difficulties, the best approach is to assume that it is heart-related. When performing a focused assessment of the heart, several different elements can be considered and will help to make a formal diagnosis of the patient. The first task is to determine how long the shortness of breath has lasted and to take a brief history of the patient. It is also important to understand the nature of the shortness of breath, and the client can be asked to describe how it feels and what (if any) pain is experienced with the symptom (Weber & Kelley, 2013). Aggravating factors should also be considered, and in this case Norma states that simply walking between rooms aggravates her shortness of breath and that any task that requires little exertion makes the symptom worse.

Alleviating factors are also important, and the patient should be asked to describe what makes her symptom better. In this case, she states that sitting down helps her shortness of breath, but nothing appears to alleviate her ankle swelling. Taking an overall history can also help highlight some of the factors that may be causing this shortness of breath, as well as identifying any medications that the patient is on. In this case, stage II heart failure is a likely diagnosis based on the symptoms, but also due to the fact that the patient has a number of the risk factors for heart failure, including type 2 diabetes, hypertension, atrial fibrillation, and stroke in the past, as well as her age (Olson, 2014). The assessment findings also support this diagnosis, as there is an irregular heartbeat and low respirations. Also of concern with this diagnosis is the fact that Norma has type II diabetes, and the high blood glucose level suggests that this is not well-controlled (Olson, 2014). This can be improved by ensuring that Norma follows recommendations for diabetes control (Davis, 2004).

The findings should be documented simply and clearly in the medical record. It should also be combined with the patient’s past medical history to give an overview of how the current symptoms are related to the problems that the patient has had in the past. Each element of the assessment should be summarized briefly to ensure that it can be easily understood in future.

The main nursing diagnosis in this case is stage II heart failure. One intervention that can be made by nurses here is to suggest changes in lifestyle factors that will help the patient. This includes quitting smoking (if relevant), ensuring that the patient is exercising more, and losing weight (Weber & Kelley, 2013). Nurses should also monitor the blood pressure of the patient over time. An inspection of the skin for cyanosis and pallor is also important as it can indicate that there is a diminished level of peripheral perfusion (Olson, 2014). Palpitating peripheral pulses can also be a good indicator of decreased cardiac output which will give more information about the level of heart failure that the patient is experiencing and the best elements to include in the care plan.

As noted above, the patient should be aware that several lifestyle factors have an impact on their care. The primary thing to include in patient education for Norma is how to control her type 2 diabetes, as the high level of blood glucose indicates that it is not controlled (Olson, 2014). This should be done by following a diet and exercise plan and regularly checking blood glucose levels. Doing this will likely improve Norma’s health overall. These lifestyle factors, when changed, can also be beneficial when trying to protect the patient from heart failure. Norma should also be educated on the importance of taking medications regularly, as not doing so can put her health at significant risk.