Question

Please use this Case Study to complete the questions below.

KP – 68-year-old male

Dx – Colon Cancer – 5 days post-chemotherapy – 5FU and Leucovorin every 3 weeks.

Presents to the clinic today c/o of cough SOB, temp 100.5.

APN – determines the patient needs to be admitted. Direct admission to the oncology unit.

Past Medical History –

HTN

Elevated Cholesterol Levels

Depression

Asthma

A-Fib

Admitting Orders

1. Admit to Oncology Unit
2. R/O Infection
3. PIV – 1 Liter of D5 ½ NS at 75 cc/hr
4. Stat CXR
   1. EKG
   2. Blood Cultures
   3. CBC
   4. Chem Screen
   5. Lactic Acid Levels
5. Regular Diet
6. OOB with assistance
7. O2 at 3 Liters via NC

Med

Tylenol 650mg PO every 4 hours prn temp above 101

Hydrochlorothiazide 12.5 mg PO daily

Lipitor 20 mg PO daily

Lexapro 10 mg PO BID

Singular 10 mg PO daily

Ceftriaxone 1 gram in 100 cc of NS IVSS every 12 hours

Proventil 2.5 mg via Nebulizer every 4 hours as needed.

Questions

1. Physical Assessment findings:

-Neurological

-Cardiovascular

-Respiratory

-Gastrointestinal

-Musculoskeletal

-Genitourinary

-Skin

2. Identify 2 major nursing diagnoses for this patient.

i.

a. Nursing Diagnosis

b. Goal outcome/Criteria

c. Nursing Interventions: (Include rationale)

d. Variance/Evaluation

ii.

a. Nursing Diagnosis

b. Goal outcome/Criteria

c. Nursing Interventions: (Include rationale)

d. Variance/Evaluation

Answer 1

1. Nursing assessment

Skin

The nurse assesses the patient’s skin and oropharyngeal mucosaregularly when radiation therapy is directed to these areas, and also the nutritional status and general well-being should be assessed.

Genitourinary

Assess renal function test,urine analysis, color of the urine, amount of the urine should be assessed for patient with chemotherapy

Neurological assessment

Peripheral neuropathies are a common side effect of chemotherapy, particularly for platinum-containing agents such as cisplatin and oxaliplatin. Assessment involves check numbness and paresthesias that start at the edges of the fingers and toes and spreads inwards.

Cardiovascular assessment

Check the blood pressure abd and signs of transient heart dysfunction. EKG and echocardiography is always recomended before each cycle and every 4 – 12 weeks after the cycle an during the chemotherapy

Respiratory assessment

Pulmonary complications can begin with the first dose of chemotherapy assess rate and rhythms of Respiration,check the signs and symptoms of respiratory infections, oxygen saturation

Gastrointestinal assessment

Chemotherapy-induced abdominal pain, cramping and flatulence: Chemotherapy can cause both increased and decreased motility of the intestines. ... Steroids and other immunosuppressive medications may increase the probability of ulcers or other potentially serious abdominal complications such as perforation check the signs and symptoms kf above all

Muskuloskeletal assessment

Assess the strength and mobility of the muscles, assess for pain and check the signs of joint inflammation

2.Nursing diagnosis

• Hyperthermia related to

Infection

Dehydration

Exposure to hot environment

Illness or trauma

Inability to perspire

Increased metabolic rate

Medications

Vigorous activity

Goals

• Patient maintains body temperature below 39° C (102.2° F).
• Patient maintains BP and HR within normal limits.

Nursing intervention

• Identify the triggering factors.
• Monitor the patient’s HR, BP, and especially the tympanic or rectal temperature
• Monitor fluid intake and urine output. If the patient is unconscious, central venous pressure or pulmonary artery pressure should be measured to monitor fluid status.
• Give antipyretic medications as prescribed.
• Provide chlorpromazine (Thorazine) and diazepam (Valium) when excessive shivering occurs.
• Educate patient and family members about the signs and symptoms of hyperthermia and help in identifying factors related to occurrence of fever

Ineffective Breathing Pattern related to

Alteration of patient’s usual O2/CO2 ratio

Decreased energy

Decreased lung expansion

Fatigue

Hypoxia

Inflammatory process: viral or bacterial

Neuromuscular dysfunction

Pain

As evidenced by shortness of breath

Goals

• Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea and shortness of breath
• Patient’s respiratory rate remains within established limits.

Interventions

• Place patient with proper body alignment for maximum breathing pattern.
• Using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation
• Utilizing incentive spirometer
• Encourage diaphragmatic breathing for patients with chronic disease. This method relaxes muscles and increases the patient’s oxygen level.
• Evaluate the appropriateness of inspiratory muscle training. This training improves conscious control of respiratory muscles and inspiratory muscle strength.
• Provide respiratory medications and oxygen, per doctor’s orders. Beta-adrenergic agonist medications relax airway smooth muscles and cause bronchodilation to open air passages.
• Avoid high concentration of oxygen in patients with COPD. Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When administering oxygen, close monitoring is very important to avoid uncertain risings in the patient’s PaO2, which could lead to apnea.
• Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing. This facilitates adequate clearance of secretions.
• Suction secretions, as necessary. This is to clear blockage in airway.
• Stay with the patient during acute episodes of respiratory distress. This will reduce the patient’s anxiety, thereby reducing oxygen demand.
• Educate patient or significant other proper breathing, coughing, and splinting methods. These allow sufficient mobilization of secretions.