Question

Case Scenario: Task

A patient rushed to ER Dept. with complaint of severe DOB. As independent nursing intervention,

patient was placed on bed safely in high back rest and hooked to O2 inhalation at 5 Lpm via face

mask. Upon assessment, Mrs. Nicole Reyes, a 42-year-old, the Physician noted that there is

swelling on her right breast, discharge and crusting on nipple, v/s BP: 150/90, RR, 40, SPO2: 88%,

Temp. 36.5 C. On examination, the Physician note that her breasts feel nodular but with discrete masses

T-3 >5 cms, N-3, M-1. Other findings include evidence of inflammation, w/ axillary node enlarged.

Thorax assessment as follows: Decreased chest movement, Stone dullness to percussion,

diminished breath sounds, decreased resonance and fremitus, + pleural friction rub and

egophony, In response to questioning, she relates that she is a “heavy coffee drinker” and is

under a great deal of stress in her job, and the mass was noticed 5 years ago with no consultation was made due financial constraint. She reports that a maternal aunt died of breast cancer. She

wants to know if the mass could be cancerous or what can be done to eliminate this breast problem.

The Doctor order for some laboratory examinations and stat CXR. Initial Dx r/o Breast Cancer Stage III,

Pneumonia, Covid 19 Suspect

WHY WAS IT ORDERED? (LEVEL 2)

Associated Concepts:

Infection

The purpose of this activity is to evaluate client orders, determine the relationship to the concept

of infection, and discuss appropriate nursing considerations for each order.

Related Concept Learning Outcomes

1. Describe diagnostic and laboratory tests to determine the individual’s infection status.

2. Compare and contrast independent and collaborative interventions for clients with

infection.

Client Diagnosis:Instructions: Search through the orders in the client’s medical record and identify how each

order is related to the concept of infection. Consider medications, diagnostics, and collaborative

considerations. Identify nursing considerations for each order. Fill out the following table.

order	How is the order related to infection?	Nursing considerations related to each order
Chest X-ray
Thoracentesis (CTT insertion)
Azithromycin 500mg/tab P.O.
Cefuroxime 1.5 gram I.V
N- acetylcysteine P.O.
Na Ascorbate + Zinc tab P.O.
Iron + Folic acid tab P.O.
Multivitamins

Answer 1

I have answered all the parts before client diagnosis in the same question posted previously. I didn't get what was written below client diagnosis, so I didn't answer. Okay let's start.

I will be putting point "i" for how is the order related to infection and "ii" for nursing considerations related to order.

Chest X ray:- I) To look for any haziness in lungs due to pneumonia infection. Ii) Antibiotics will be provided.

Thoracentesis:-I) to drain out eccess pleural fluid. Ii)the procedure is carried out by inserting a needle in between the chest wall and lungs.

Azithromycin:-I) Antibiotic given in pneumonia. Ii) Dose and interval has to be known from the physician. It is usually given once daily after food for 5 days.

Iron and folic acid:- I) Given in covid infection to increase immunity. Ii) give the patient the dose as per order.

Multivitamins:-same answer as above.

Na ascorbate+zinc tablets:- same as above.

Cefuroxime-i) cephalosporin to be given to prevent infection. Ii) provide to the patient as per order.

Acetylcysteine:-I) to prevent paracetamol toxicity. Ii) give as per order.

***P.O. means Orally by mouth.

***I.V. means intravenously.