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UNIVERSITY OF MASSACHUSETTS DARTMOUTH COLLEGE OF NURSING abdominal pain

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UNIVERSITY OF MASSACHUSETTS DARTMOUTH COLLEGE OF NURSING abdominal pain

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									                                                                                                      NUR 451 Care Plan
                UNIVERSITY OF MASSACHUSETTS DARTMOUTH ~ COLLEGE OF NURSING
                              Clinical Data Analysis Tool and Linking Map
                                               NUR 451

                              Student’s Name:_____        _________________          Date: _________

                                                       *Assignment Prep
Background Data
Pt’s Initials : _CS_   Rm #: 4015 Age: 52 Gender: F Code Status:             F   Advanced Direct ive: __Husband____
Allergies: __iodinated contrast media__Date Admitted: _         Ad mitted fro m:__Ho me________
Admitt ing Dx (s): _dehydration, R Leg cellulitis ___________________________
Presenting Sx/Sx: __fatigue, fever, SOB, nausea, RLE pain________________________________________________________
PMHx (dates): __hypothryoid, meningitis as a baby, lung cancer, liver cancer, spleen cancer, hip bone cancer bilaterally, DVT,
bilateral PE__________________________________________________________________________________________
SurgHx (dates): cholecystectomy, C-section, partial thyroidectomy, IVC filter,____________________________________
Special Considerations/Precautions: __reverse precautions, impaired coag_____________________________________________
Plans for D/C__none_________________Baseline VS: __98.3, 112, 103/ 74, 99% on NC 2 liters _________________________
Diet :_na_____ Activity Order:_ OOB TID_ Oxygen Therapy: _2-3L/ min_______ IV Fluids: __DC’ed____________



                                        *General Information Related to Admitting Dx(s)
Pathophysiology of        Lung cancer: cancer cells arise from bronchial epitheliu m and grows slowly occurs mostly in the
Admitting Dx(s)
                          segmental bronchi and tend to be in upper lobes
Definition(s)
                          -non-specific in flammatory changes and hypersecretion of mucus, desquamation of cells, reactive
                          hyperplasia of basal cells, metaplasia of normal respiratory epitheliu m to stratified squamous cells




Signs & Symptoms          Persistent and productive cough that may or may not be blood tinged
Often seen with Dx(s)
                          Chest pain
                          Dyspnea, ausculatory wheeze
                          Anorexia, fatigue, weight loss, nausea, vomiting, hoarseness, dysphagia, pericardial effusion, cardiac
                          tamponade, dysrhythmias
Diagnostic Tests          Chest x-ray
Used to confirm Dx(s)
                          CT-most effective noninvasive way to evaluate for lung Ca
                          MRI, PET, sputum culture, bronchoscopy, med iastinoscopy, VAT
                          Biopsy-gold standard

Treatment Opti ons        Surgical resection, pneumonectomy, lobectomy, surgery to remove tumor, radiat ion, chemotherapy,
Available for Dx(s)
                          targeted therapy




                                                                                                                                  1
                                                                                                     NUR 451 Care Plan

                                                *Plan for the Day
                                        (For discussion in pre-conference)
Upon initial data collection, what would you identify as key areas to focus on with your patient?
Skin care
Teaching/answering ques tions regarding chemotherapy regimen and its effects on the body
Management of high levels of pain patient has been experiencing associated with her terminal illness
Coping evaluation and emotional support

What will be the focus of your shift assessment? (and why)
Monitor breath sounds, respiratory rate and rhythm, O2 sat, activity tolerance
Monitor cardiovascular system for any dysrhythmias, cardiac tamponade, pericardial effusion
Monitor for fever/signs of infection
Monitor labs
What are the 3 Priority Nursing Diagnoses (in order of importance)
(Note: After caring for patient, nursing diagnoses may need to be reprioritized)
Acute pain related to pressure of tumor, erosion of tissues, skin infection
Fluid volume alteration due to decreased fluid intake, chemotherapy regimen, pleural effusion
Altered skin integrity due to chemotherapy and disease process
Risk for altered nutrition




                                        Review of Abnormal Lab Results & Diagnostic Data
  Abnormal Lab                        Trending of Results to Date                Why is each lab result abnormal for your
  Test/Result on                                                                                 patient?
  Admission or in
   last 72 hours
Na                           11/ 15            11/16          11/17       Patient presented dehydrated, affects electrolytes
135-145 mEq/ L               132 (L)          132 (L)        132 (L)
Cl                           11/ 15           11/ 16          11/17       Patient presented dehydrated, affects electrolytes
98-106 mEq/ L                94 (L)          94 (L)           96 (N)
Glucose                      11/ 15           11/ 16          11/17       Glucose can be increased by chemotherapy
70-100 mh/d L                103 (H)          101 (H)        103 (H)      Stress, and break down of cells.
Alk phos                     11/ 15          11/16           11/ 17       Patient’s cancer has spread to liver
45-125                       218 (H)         179 (H)          ND
WBC                          11/ 15          11/16           11/17        Chemotherapy reduces the total WBC count in the body
4500-10000                   1.4 (L)         1.3 (L)         5.8 (N)      eliminating defenses
Plt                          11/ 15          11/16           11/17        Anemia induced by chemotherapy
150-450                      6 (L)           26 (L)           13 (L)
Hgb                          11/ 15          11/16           11/ 17       Chemotherapy reduces level of all cells in the blood
12-16 g m/d L                9.5 (L)         7.8 (L)         9.5 (L)


                                                                                                                                 2
                                                                                                     NUR 451 Care Plan

                                                *Medications (Daily and PRNs)


Patient’s Initials: CS     Room #:_4015__             Allergies: __iodinated contrast media__________


 Med. Name     Drug              Dose            Why is Pt         Major Side Effects &            Contraindications         Ti me(s)
 (Brand &      Classification    Route           Taking This       Nursing Considerati ons                                   Due
 Generic)      & Suggested       Frequency       Medication?
               Dose for Pt’s
               Age
               Anti-infective    1000 mg         Treat ment of     Nephrotoxicity, phleb itis,     Hypersensitivity,         0000
               1 gram q 12       IV              cellu lit is      nausea/vomit ing,               renal impairment          1200
 Vancomycin    hrs               Every 12 hrs    infection;        hypotension, rashes
 (Vancocin)                                      prevention of
                                                 further
                                                 infection (very
                                                 low W BC)
               Anti-infective    2000 mg         Emp iric          Seizures,                       Hepatic dysfunction/      0600
 Cefep ime     2 g every 8 hrs   IV              treatment of      pseudomemb ranous colitis,      poor nutritional status   1400
 HCl                             Every 8 hrs     neutropenia       rashes, phlebitis at IV site,                             2200
 (Maxipime)                                                        anaphylaxis



               Laxative          100 mg          Prevention of     Throat irritation, mild         Hypersensitivity,         0900
 Docusate      50-400 mg in      PO              constipation      cramps, rashes                  nausea, vomit ing
 Sodiu m       1-4 div ided      Once Daily      associated
 (Co lace)     doses                             with
                                                 dehydration
                                                 and poor PO
                                                 intake
               Hormone           0.1 mg          Hormone           Nervousness, arrhythmias,       Hypersensitivity          0600
               75-125            PO              replacement       cramps, diarrhea, vomiting,
 Levothyroxi   mcg/day           Once daily      since thyroid     headache, insomnia,
 ne                                              was removed       irritability
 (Synthroid)


               Opiod             0.25 mcg        To treat          Confusion, sedation,            Hypothyroidism,           Q3
               Analgesic         Topical         chronic pain      weakness, anorexia,             hepatic disease, fever    days
 Fentanyl      25 mcg/hr         Patch           associated        constipation, dry mouth,
 (Duragesic)                     Change          with terminal     nausea, vomit ing, sweating
                                 every 3 days    lung Ca


               Colony-           215 mcg         Management        Pain, redness at S.C. site,     Hypersensitivity          PRN
               stimulat ing      S.C.            of neutropenia    excessive leukocytosis                                    until
 Filgrastim    factor            Once Daily      caused by                                                                   ANC=
 (Neupogen)    5 mcg/kg/day                      chemotherapy                                                                greater
                                                                                                                             than
                                                                                                                             100




                                                                                                                                    3
                                                                                               NUR 451 Care Plan
              Antianemic     5 grams       Treat ment/Pre    Hypotension, nausea,            Hepatic impairment,     0900
              120-240        PO            vention of        constipation, diarrhea,         CV disease              2100
Ferrous       mg/day         Twice Daily   anemia            epigastric pain, GI b leeding
Sulfate                                    induced by
(Feosol)                                   chemotherapy


              Antianemic     1 mg          Treat ment/Pre    Rashes, irritability,           na                      0900
              1 mg/day       PO            vention of        confusion, malaise, fever
Folic Acid                   Once Daily    anemia
(Folv ite)                                 induced by
                                           chemotherapy


              Diuret ic      40 mg         Mobilizat ion     Dehydration,                    Electrolyte depletion   0900
              20-80 mg/day   PO            of excess fluid   hypochloremia,                                          1800
Furosemide                   Twice Daily   in leg            hypokalemia, hypovolemia,
(Lasix)                                                      anorexia, constipation



              Antiulcer      40 mg         Ulcer             Headache, abdominal pain,       Hypersensitivity        0900
Pantoprazol   40 mg/day      PO            prevention        diarrhea, flatulence,
e Sodiu m                    Once daily                      hyperglycemia
(Protonix)



Guaifenesin   Expectorant    10 mL         Help              Dizziness, headache,            Hypersensitivity        0000
Codeine       100 mg/ 5 mL   POL           expectorate       nausea, diarrhea, stomach                               0400
                             Every 4 hrs   secretions to     pain, vomiting                                          0800
                                           prevent                                                                   1200
                                           aspiration                                                                1600
                                                                                                                     2000

              Antiemetic     4 mg          Control of        Headache, dizziness,            Liver impairment        PRN
              4-8 mg q six   IV            nausea            constipation, diarrhea,
Ondansetron   hours          Every 6 hrs   associated        abdominal pain, dry mouth,
(Zofran)                     PRN           with post         increased LFTs
                                           chemotherapy


              Opiod          0.5 mg        Treat ment of     Confusion, sedation,            Hypothyroidism          PRN
              analgesic      IV            acute pain        hypotension, constipation,
Dilaudid      1.5 mg every   PRN           associated        blurred vision
(Hyro morph   3-4 hrs                      with cancer
one)



              Antipyretic    650 mg        Use for fever     Hepatic failure,                Hepatic disease         PRN
              325-650 mg q   PO            over 100          hepatotoxicity, neutropenia,
Acetaminop    4-6 hrs        PRN           degrees           rash, urticaria
hen
(Tylenol)




                                                                                                                            4
                                                                               NUR 451 Care Plan
             Opiod           10 mg   Given along    Confusion, sedation,      Hypothyroidism,   PRN
Oxycodone/   analgesic       PO      with 325 mg    constipation, nausea,     hepatic disease
Acetaminop   5-10 mg every   PRN     Tylenol for    vomit ing, dry mouth,
hen          3-4 hrs                 pain control   orthostatic hypotension
(Percocet)




                                                                                                      5
                                                                              NUR 451 Care Plan

FHP                  WNL            Issues of Concern to you with rationale
Health Perception-
Health Management    
Nutrition-                 Altered due to nausea and decreased appetite as a
Metabolic                  result of chemotherapy regimen.


Elimination                Altered due to diarrhea associated with chemotherapy
                           and laxative treatment.


Activity-                  Altered due to impaired physical mobility associated
Exercise                   with chemotherapy and metastatic lung cancer.



Sleep-Rest
                     

Cognitive-
Perceptual
                     

Self-Perception            Altered due to slight depression as evidenced by
Self Concept               patient statement and affect and mood.



Roles and                  Altered due to inability to provide care as a result of
Relationships              debilitating diagnosis of cancer.


Sexuality &                Altered due to impaired physical mobility and
Reproductive               diagnosis of cancer.


Coping and Stress
Tolerance
                          Pt coping relatively well with diagnosis



Values and Beliefs
                      


                                                                                                  6
                                                                                                           NUR 451 Care Plan

                                                           Shift Assessment                                    Changes on Day 2
General        Ill appearing 52 year old female appearing her stated age, in no apparent distress, alert
Survey         and oriented times 3, with thinning hair due to chemo, appearing fatigued


Neurological Alert and oriented times three, speech is clear, ab le to follow conversation and
             commands, purposeful movement


HEENT          Sclera wh ite, conjunctiva pink, hair is thin and shaved due to side effects of
               chemotherapy, nares are patent with no nasal discharge, PERRL, ears clear with slight
               moderate ceru men

Chest &        Lung sounds clear, slightly dimin ished, breathing is slightly labored, respiration rate
Lungs          varying throughout shift fro m 12-24, O2 sat at 98% on 2.5 L, no use of accessory
  Inspect      muscles, dullness on percussion due to pleural effusion; thoracentesis performed at 1230
  Palpate      by MD, removed 500 cc b loody drainage fro m R lung, patient tolerated procedure well
  Auscultate   with improvement in breathing and lung expansion
Heart          0700: 108, 110/65
               1200: 104 106/65
               No extra heart sounds, tachycardic throughout shift, regular rhythm

Abdomen        Abdomen is distended, non tender, soft and large mass protruding in left lo wer quadrant
  Inspect      which is nontender to the touch, red, edematous, with no drainage, positive bowel
  Auscultate   sounds in all four quadrants, one bowel movement at 1100, bro wn, liquid, moderate
  Palpate      amount

GU             Urine is clear and amber, patient had sufficient fluid intake (800 cc) wh ich exceeded
               output (500 cc)



Extremities    CSM intact in all ext remities, right leg pitting edema 3+, mob ility decreased due to
    &          activity intolerance associated with shortness of breath, cap refill less than 3 seconds,
Peripheral     skin cool, dry
Vascular
Circulati on

Musculo-       Full ROM independently, hand grasp equal in strength bilaterally, patient is unsteady
skeletal       upon ambulation to commode requiring 1 person assist,


Skin           Cool, dry, intact, erythema on right lo wer extremity due to cellu lit is, edema




Wounds(s) & NA
Dressings




                                                                                                                                  7
                                                                   NUR 451 Care Plan



Presenting Sx/Sx That R/T
   Admitting Diagnoses
SOB                                      PMH that Relates to Admitting Diagnoses
Fatigue                                      (include supporting rationale)
Cough
Diminished Breath Sounds           Stage IV Lung Ca
Tachypnea                          Metastases to liver, spleen, bilateral hip bone




        Alte red FHPs

Mobility
Ineffective Breathing Pattern




    Relevant Medications
 That Effect or Treat the Dx(s)


Dilaudid to help respiratory
                                                  Admitting Diagnoses
slow pattern
                                               Bilateral Pleural
                                               Effusion




      Relevant Labs/Xrays            Medical/Surgical Treatments this Hospitalization
     that Confirm the Dx(s)
 (include supporting rationale)
                                  Bilateral thoracentesis
X-Ray                             Oxygen therapy
CT

                                                                                        8
               Diagnostic Cues
           R/T 1° Nursing Dx (Data)
                                                                    1° Nursing Dx (From List of 3)
   Shortness of breath
   Lung cancer                                               Ineffective breathing pattern as evidenced by
   Bilateral pleural effusions with 1400 cc                  excess fluid in pleural space, dyspnea,
   drainage on thoracentesis                                 increased respiratory rate, decreased breath
   Diminished lung sounds                                    sounds



                                                                   Altered FHP(s) R/T 1° Nursing Dx


                                                             Mobility




                                       3 Outcome Goals (Planning)
              Goal 1                               Goal 2                                Goal 3
                                        Patient will exhibit effective      Provide comfort and alleviating
   Patient will maintain normal         breathing techniques during       factors associated with excess fluid
        respiration status               exacerbations of dyspnea            and altered breathing pattern


          Focus of Care               Focus of Care (Interventions)                 Focus of Care

       -monitor breath sounds               -teach patient relaxation     -instructed patient to ask for PRN
     -monitor O2 sat every 2hrs                   techniques                  medications for anxiety and
  -ensure oxygen therapy is being      -teach patient to deep breathe 5   discomfort associated with pleural
          used by patient               seconds in, 10 seconds out via             effusions/dyspnea
      -monitor respiratory rate                    pursed lip                -remain with patients during
 -monitor for signs and symptoms         -teach patient importance of             periods of dyspnea
  of hypoxia (cyanosis, dizziness,    keeping oxygen in despite drying      -evaluate therapeutic effect of
             confusion)                 effects on mucuos membranes         thoracentesis and monitor any
                                         -teach patient to pace herself       discomfort post procedure
                                         during periods of ambulation




            Evaluation                          Evaluation                            Evaluation




Respiration rate fluctuated                Patient displayed correct      Patient verbalized understanding of
throughout shift, however, O2 sat            breathing techniques,             medication use to help with
remained high at 98% consistently           implemented relaxation            pain/discomfort, no extreme
throughout shift, patient exhibited      techniques, patient remained      episodes of dyspnea experienced
no signs of hypoxia                     consistent with use of oxygen      during shift, patient improvement
                                       throughout shift, patient moved      in breathing and lung expansion
                                           slowly during ambulation                post thoracentesis
                                                                                                                 9
For each intervention, identify its corresponding focus from the following key:
Promoting Health (PH), Guiding Client (GC), Shaping Health Environment (SHE)




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