Question

Mr. Green is a 65 year old male who presented to the emergency department with complaints of weakness and a temperature of 102.4.

Subjective Data:

·       “I feel rotten – I don’t know if my counts are down. I just had chemotherapy 8 days ago”.

·       “I have small cell lung cancer and just received Cis-Platin and Etoposide.

·       “I was hospitalized with SIADH two months ago”.

Objective Data:

              Physical examination

·       Cardiovascular: B/P – 82/62       AP – 118/min    O2 sat – 92%               Temperature - 97.6      

Carotid, radial and femoral pulses palpable but weak and thready.

·       Respirations: 32/minute – labored breathing with respiratory distress noted. Lung sounds diminished anterior and posterior in all lobes.

·       LOC – initially alert and oriented x 4 but became increasingly agitated and confused 30 minutes after arriving to the ER.

Laboratory Values:

·       Hgb – 8.0 grams

·       Hct - 24.0

·       WBC – 1

·       Platelets – 24,000

·       CMP – pending

Diagnostic Studies:

              Portable chest x-ray reveals atelectasis in both lungs

1.           Upon arrival to the emergency room, the triage nurse assesses the situation and deems that this is ______________________________________________. What should the triage nurse do next?

2.           What is the data obtained from the primary assessment?

3.           What is the data that is obtained from the secondary assessment?

4.           What is the diagnosis that the nurse suspects and why does it occur? Interpret and explain all the data presented and its significance.

5.           What are some other causes of this diagnosis and what is your role in preventing it in other patients?

6.           What are the initial nursing responsibilities?

7.           What nursing assessments are essential and at what frequency should they be performed?

8.           List and prioritize three nursing diagnoses for this patient.

9.           What are some other collaborative problems that may occur?

10.         Document your findings on the flow sheet and also document your findings using narrative format.

Answer 1

Ans.1) Upon arrival to the emergency room, the triage nurse assesses the situation and deems that this is the case of Leukemia (Blood Cancer).

At first, the triage nurse should assist in the evaluation of symptoms and initiation of interventions. Then access the subjective and objective data, including information about the last chemotherapy treatment and knowledge of the patient's history, guide the nurse in determining the patient's disposition and treatment.

2.) The primary data includes the subjective and objective data, including information about the last chemotherapy treatment and knowledge of the patient's history, guide the nurse in determining the patient's disposition and treatment.

3.) The secondary data basically includes the side effects of last chemotherapy session and the history of medication related to it.

4.) The diagnosis that the nurse suspects are that Mr. Green have small cell lung cancer and had chemotherapy just 8 days ago.

The given laboratory values also indicates that there is some discrepncy in the normal value of these test.

Laboratory Values:

·       Hgb – 8.0 grams

·       Hct - 24.0

·       WBC – 1

·       Platelets – 24,000

6.) The the initial nursing responsibilities includes observing and monitoring patients' conditions, administering medications, managing intravenous lines, maintaining records and communicating with doctors.