Clinical Worksheet: /var/www/apps/conversion/tmp/scratch - 2/182114054

Clinical Worksheet
Student Name: Marie Cho Gregory Demographic Data Client Initials: B.F. Age: 72 Sex: F Admitting Medical/Psychological Diagnosis: Altered mental status, pancytopenia Patients Chief Compliant (What brought them to the hospital): Fatigue Past Medical/Psychological History: DM Type II, proteinuria, cardiomegaly, urge incontinence, essential HTN (benign), dizziness and giddiness, other pulmonary emboli and infarction, arthropathy, DM neuro manifestation Type 2, migraine, pancreatic cancer, chronic constipation, obesity, rash blood transfusion, pneumonia, anemia, AC DVT/embol., MRSA, MDS, CHF, cardiomyopathy Past Surgical History: Cholecystectomy, appendectomy, knee surgery-BTKR, abdominal exploratory surgery Date: April 25, 2013
/var/www/apps/conversion/tmp/scratch_2/182114054.doc
Pancreatic Cancer Pancreatic cancer is defined as a malignant neoplastic disease of the pancreas characterized by anorexia, flatulence, weakness, dramatic weight loss, epigastric or back pain, jaundice, pruritus, a palpable abdominal mass, recent onset of diabetes, and clay-colored stools if the pancreatic and biliary ducts are obstructed (Mosbys Dictionary, 2009, p. 1376). This type of cancer is the fourth leading cause of cancer death in men in the United States, and the fifth leading cause in women (Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever, 2010). Although seventy percent of pancreatic cancers develop in the head of the pancreas, pancreatic cancer can originate in any part of the pancreas. Because symptoms are usually nonspecific, many people do not seek medical attention until it is late in the progression of pancreatic cancer. Therefore, pancreatic cancer only has a 5% survival rate at five years regardless of the stage of disease at diagnosis or treatment (Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever, 2010, p. 1191). People who smoke more than 10-20 cigarettes a day, have diabetes mellitus, or have been exposed to polychlorinated biphenyl compounds are at increased risk of development of pancreatic cancer (Mosbys Dictionary, 2009, p. 1376). References Pancreatic cancer. (2009). In Mosbys Dictionary of Medicine, Nursing, and Health Professions (8th, p. 1376). St. Louis, MO: Mosby Elsevier. Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever. (2010). Brunner & Suddarths Textbook of MedicalSurgical Nursing (12th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins.
Vital Information Height: 411 Weight: 126 lbs Allergies: Talwin, Latex, Adhesive Time TPR BP SPO2 RR Pain 0800 99F (oral) 97/44 98% 18 0/10 1600 98.1F (oral) 103/58 96% 18 0/10
Laboratory Data
Client Value Sodium 137 Potassium 4.0 Chloride 100 Anion Gap 6 BUN 10 Creatinine 7.8 (high) GFR MDRD non-african 85 eGFR 103 Normal Value 135-145 3.5-5.3 98-106 12+/-4 6-20 0.7-1.3 100-130 60-90 Why was the lab ordered? Evaluates electrolyte balance and kidney function; to monitor for hypernatremia Increased potassium levels are seen with tissue injury and infection Determine acid-base imbalance Monitors acid-base balances Determines renal function Determines renal function; elevated level may be d/t diabetes Determine how the kidneys are filtering waste (creatinine) Monitor kidneys status and check for kidney damage
RBC 2.87 (low) Hemoglobin 9.1 (low) Hematocrit 26.8 (low) Platelet 17 MCV 93.4 MCH 31.7 MCHC 34.0 RDW 19.7 Neutrophils 44 Lymphocytes 27 Monocytes 4 Eosinophils 4 Basophils 0
4.20-5.80 M/uL 13.2-17.1 g/dL 35.0-45.0 140,000-450,000/mL 78-98 fL 31-37% 11.5-14.5% 50-81% 14-44% 2-6% 1-5% 0-1%
Part of CBC, looks at the number of red blood cells Screen for anemic conditions Screen for anemic conditions Monitors coagulation of the blood Measures the volume of red blood cells Measures the concentration of hemoglobin in a red blood cell Measures the variation in size of red blood cells Used to evaluate and manage immune, blood, and cancer disorders, including suspected neutropenia. Used to evaluate and manage disorders of the blood or the immune system Checks WBC for infection. Checks WBC for infection. Checks WBC for infection.
Medications Name 0.9% Sodium Chloride 1000 mL Dose 42 mL/hr Portacath right chest Action Replaces Na+ and Cl and maintains levels Major SE Labs to monitor Rehydration Electrolyte imbalances; monitor sodium and potassium levels Relief of muscle SE: dry mouth or spasm and pain in throat, blurred musculoskeletal pain vision, dizziness, drowsiness, loss of appetite, muscle weakness, GI upset. AE: pounding heartbeat, dysrhythmias, chest pain, numbness, sudden HA, fainting, confusion, lack of coordination, bleeding, hallucinations. LABS: Cancer medication SE: rash, diarrhea, to treat PTs fatique, anorexia, pancreatic cancer. dyspnea, cough, N/V, elevated ALT and AST. LABS: Client-specific purpose Client/Family Teaching Teach PT to watch for reactions r/t solution
cyclobenzaprine (Flexeril)
5 mg PO PRN
Potentiates norepinephrine and binds to serotonin receptors, reducing spasticity (centrally-acting muscle relaxant)
(https://online.epocrates.c om/noFrame/showPage.d o? method=drugs&Monogra phId=753)
Avoid alcohol, avoid hazardous activities, avoid cough meds and antihistamines
erlotinib (Tarceva)
100 mg PO q day
Inhibits intracellular tyrosine kinase domain of epidermal growth
Hazardous agent, use caution when handling. Avoid exposure to sunlight. Stop taking and call MD
factor receptor (EGFR), resulting in cell cycle arrest and angiogenesis inhibition
liver functioning, thyroid functioning, creatinine, electrolytes.
filgrastim (Neupogen)
300 mcg/mL SQ in 1 mL injection
stimulates WBC production granulocyte and to treat PTs macrophage neutropenia proliferation and differentiation, and activates some endcell functions
insulin glargine (Lantus)
10 units SQ
Stimulates peripheral glucose uptake, inhibits hepatic glucose production, inhibits lipolysis and proteolysis, regulating glucose metabolism.
(https://online.epocrates.c
To treat PTs DM type II.
SE: bone pain, fever, splenomegaly, nausea, flank pain, HA, thrombocytopenia, anemia, hypotension, leukocytosis LABS: WBC, CBC with diff, Platelets before chemo then 2X wk., neutropenia SE:hypoglycemia, myalgia, pruritus, rash, URI, weight gain, HA, hypokalemia. LABS: blood sugar
immediately if you develop new or worsening lung problems (wheezing, chest pain, dry cough w/ fever, feeling short of breath). Do not consume grapefruit products. Do not smoke. Call MD immediately if you experience sudden or severe pain in left upper stomach spreading up to your shoulder, rapid breathing or feeling SOB, signs of infection (fever, chills, sore throat, flu SX, etc.). Avoid people who are sick or have infections. Monitor blood sugar often. Know the signs of low blood sugar: HA, hunger, weakness, sweating, tremors, irritability or trouble concentrating. Wear a medical alert tag or bracelet/carry an ID
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card stating you are on insulin.
levofloxacin (Levaquin)
500 mg tablet q day
Bactericidal; inhibits DNA gyrase and topoisomerase IV

(https://online.epocrates.c om/noFrame/showPage.d o? method=drugs&Monogra phId=861&ActiveSection Id=7)
Used as prophylactic SE: N/V, HA, approach to bacterial diarrhea, insomnia, infection prevention. constipation, dizziness, dyspepsia, CDIFF, superinfection, phototoxicity. LABS: Creatinine at baseline, glucose if diabetes.
Avoid taking antacids, vitamins/mineral supplements, sucralfate (Carafate) w/in 2 hours before or after you take levofloxacin. Black Box Warning: tendinitis/tendon rupture in patients. Contact MD immediately if you experience muscle weakness or trouble breathing, joint problem.
Name losartan (Cozaar)
Dose 100 mg tablet q day
Action Selectively antagonizes angiotensin II AT1 receptors

(https://online.epocrates.c om/noFrame/showPage.d o? method=drugs&Monogra phId=551&ActiveSection
Client-specific purpose HTN
Major SE Labs to monitor SE: hypotension, dizziness, fatigue, musculoskeletal pain, dyspepsia, diarrhea, chest pain, cough, BUN and creatinine elevated, ALT,
Client/Family Teaching Hold if systolic is <130. Avoid alcohol, do not take potassium supplements or salt substitutes. Monitor blood pressure often. Call MD immediately if you have muscle pain,
Id=7)
zolpidem (Ambien) PRN
10 mg tablet PRN
Interacts w/ GABAbenzodiazepine receptor complexes

To induce sleep
ondansetron (Zofran) PRN
4 mg/2 mL q 6 hours PRN *inject over at least 30 seconds, preferably over 25 minutes
Selectively antagonizes serotonin 5-HT3 receptors

(https://online.epocrates.c om/noFrame/showPage.d o? method=drugs&Monogra phId=1441&ActiveSectio nId=7)
Antiemetic for N/V
morphine (MS Contin)
30 mg q 12 hours
Binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
For moderate to severe pain.
AST elevated. LABS: BUN/Creatinine at baseline then periodically. Electrolytes, BP. SE: HA, drowsiness, dizziness, lethargy, drugged feeling, diarrhea, suicidal ideation, hallucinations. LABS: no routine tests recommended. SE: HA, constipation, fatigue, diarrhea, hypoxia, fever, urinary retention, agitation, pruritus. LABS: ECG if electrolyte abnormalities, CHF, or bradyarrhythmias SE: respiratory depression, apnea, hypotension, constipation, N/V, diaphoresis, HA, abdominal pain,
weakness, fever, N/V, and dark colored urine.
Avoid alcohol. Avoid driving wait at least 4 hours before you drive. Ambien may be habit forming take exactly as prescribed by MD. Do not crush swallow pill whole. Use caution when driving may impair thinking or reactions. Take with a full glass of water.
May be habit forming use as prescribed by MD. Avoid alcohol death can occur by combining with alcohol. Do not stop abruptly
miconazole 2% cream (topical)
2Xday
Inhibits 14-alpha Small pressure sore demethylase, on bottom. reducing fungal cell membrane ergosterol synthesis and increasing cellular permeability
(https://online.epocrates.c om/noFrame/showPage.d o? method=drugs&Monogra phId=3420&ActiveSectio nId=7)
xerostomia, flushing. LABS: Creatinine at baseline, s/sx of respiratory depression SE: irritation, burning/stinging, pruritus, maceration, contact dermatitis, erythema. LABS: no routine tests recommended.
after taking long-term. Do not use if taking a MAOi. Monitor respirations may cause respiratory depression. Avoid getting medication in your eyes, nose, mouth. Use this medication for the full time prescribed by MD. Do not cover with occlusive bandages or dressings.
oxybutynin (Diptropan)
5 mg tablet q day before lunch
Antagonizes acetylcholine at muscarinic receptors; relaxes bladder smooth muscle, inhibits involuntary detrusor muscle contractions (anticholinergic)
For patients overactive bladder
SE: xerostomia, dizziness, constipation, nausea, HA, blurred vision, diarrhea, urinary hesitancy/retention , UTI, dry eyes, palpitations, confusion, HTN. LABS: no routine tests recommended.
Use caution when driving, this medication may impair thinking/reactions. Stop using and contact MD immediately if you have hot/dry skin, extreme thirst, severe stomach pain or constipation, pain/burning when urinating, or if you stop urinating.
A general assessment will be done in each area. Generally an interview is collected first then the physical examination is completed. Star(*) the area of prime importance for a focused assessment r/t client health problems, medical diagnosis or collaborative problems, nursing needs such as actual nursing diagnoses, risk diagnosis, health promotion or education needs, and technical skill related needs.
Functional Patterns *
Subjective Objective Interview Head to Toe Health Percep/ Manage General Survey Mental Status Eyes, ears, nose, throat
ASSESSMENT
Data
Subjective & Objective findings
DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes
IMPLEMENATION Interventions
Teaching & Discharge Planning
EVALUATION Outcome criteria met, not met, need to be reevaluated at the end of clinical
NutritionMetabolic
Skin Mucous membran e Color Wounds, intake, wt. Ht.
72 y.o. female with stage 4 pancreatic cancer presented to ED on 4/20/2013 complaining of fatigue. Admitting DX: altered mental status, pancytopenia. 4/25/2013: A&OX4. Labs indicate neutropenia and thrombocytopenia. Eyes: PERRLA. Ears: no drainage, lesions. Nose: symmetry, no drainage/congestion noted upon observation. Throat: no abnormalities, no masses noted. Skin warm/dry/pale in color. S PT has small decubitus ulcer on right bottom. Weight: 126 lbs Height: 411 PT self-feeds, and consumes approximately 80% of meals. PT drinks water and diet soda. Intake 4/24-4/25: PO: 1380 IV: 1049.3 Total: 2429.3
Subjective Objective Interview Head to Toe
ASSESSMENT
Data
Output: not measured
ActivityExercise
Heart Lungs Extremitie s mobility
Pulse 2+ Cap refill <3 Lungs clear AEB auscultation, regular breathing pattern, respirations: 18 PT ambulates independently, and toilets herself without assistance.
Nursing DX: Activity Intolerance/Fatigue related to progressive disease state AEB inability to maintain usual routines. Desired Outcome: PT will not experience activity intolerance by end of shift on 4/25/2013 AEB: 1. No reports of fatigue/weakness 2. Ability to perform ADLs within physical limitations/restrictions without a significant
Assess for S/SX of activity intolerance: 1. Statements of fatigue/weakness 2. Abnormal HR in response to activity 3. Significant change in BP Implement measures to prevent activity intolerance 1. Minimize environmental activity/noise
Desired outcome met by end of shift on 4/25/2013
Subjective Objective Interview Head to Toe
ASSESSMENT
Data
change in vital statistics
2. Organize nursing care to allow for periods of uninterrupted rest 3. Assist PT with ADLs as needed 4. Keep supplies/personal articles within easy reach
Subjective Objective Interview Head to Toe Eliminatio n Bowel sounds Bowel/ Bladder
ASSESSMENT
Data
Abdomen soft, flat, non-tender. BS normal X4 per auscultation. PTs medical HX includes chronic constipation LBM: 4/22/2013 PT ambulates independently, toileting without assistance.
Nursing DX: Constipation related to irregular bowel habit Desired Outcome: PT will have a BM by end of shift on 4/25/2013
Encourage fluids if not contraindicated. Provide dietary fiber Encourage PT to ambulate frequently Obtain order for PRN laxative if previous bowel elimination interventions are not achieved
Goal not met by end of shift on 4/25/2013
Subjective Objective Interview Head to Toe SleepRest Uninterrupte d
ASSESSMENT
Data
PT awake throughout shift on 4/25/2013
Cognitive Perceptua l
Pain Scale LOC
PT denies pain throughout shift on 4/25/2013
Subjective Objective Interview Head to Toe SelfPercept & SelfConcept Body language Voice Calm, anxious, irritable, restless
ASSESSMENT
Data
PT anxious when talking with MD regarding Hospice.
RoleRelationship
Family interactio n Attachme nt
PT crying with family following Hospice discussion with physician. Family support observed. PT gradually became calm throughout shift on 4/25/2013.
Subjective Objective Interview Head to Toe SexualityReproductive Pregnancy or OB, gender organ surgery, Lesions, growths, drainage, bleeding;
ASSESSMENT
Data
N/A
Subjective Objective Interview Head to Toe CopingStress Overt signsCrying, wringing of hands, clenched fists
ASSESSMENT
Data
PT crying when talking with MD about beginning Hospice care.
Nursing DX: Anticipatory Grieving related to perceived impending death Long Term Goal: PT will plan for the future one day at a time. Desired Outcome (Short term goal): 1. PT will express feelings of sorrow and anger by end of shift on 4/25/2013. 2. PT will seek help in dealing with problems associated with impending death by end of shift on 4/25/2013.
Respond to PTs call lights quickly, and spend time in room with PT. Assess PT for evidence of suffering including crying, pain, and coping inability. Actively listen to PT and familys expressions of grief. Use therapeutic communication and open-ended questions with PT and family.
Desired outcome (short term goal) met by end of shift on 4/25/2013
Subjective Objective Interview Head to Toe ValueBelief CultureAlteration
ASSESSMENT
Data
PT crying when talking with physician and nursed about impending Hospice care. PT consolable when family is called.
Development Erikson
Growth chart Weight/Ht. Chart G&D all ages
PT is currently in the Ego Integrity vs. Despair Erikson stage.
Safety Physio-
Morse medium fall risk (24-44) PT appears agitated at 1600 d/t not being released from hospital.
Environmental

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Clinical Worksheet

Inhibits intracellular tyrosine kinase domain of epidermal growth

liver functioning, thyroid functioning, creatinine, electrolytes.

300 mcg/mL SQ in 1 mL injection

insulin glargine (Lantus)

To treat PTs DM type II.

om/noFrame/showPage.d o? method=drugs&Monogra phId=2397&ActiveSectio nId=7)

card stating you are on insulin.

500 mg tablet q day

Bactericidal; inhibits DNA gyrase and topoisomerase IV

Name losartan (Cozaar)

Dose 100 mg tablet q day

Action Selectively antagonizes angiotensin II AT1 receptors

Client-specific purpose HTN

zolpidem (Ambien) PRN

Interacts w/ GABAbenzodiazepine receptor complexes

ondansetron (Zofran) PRN

Selectively antagonizes serotonin 5-HT3 receptors

Antiemetic for N/V

morphine (MS Contin)

For moderate to severe pain.

weakness, fever, N/V, and dark colored urine.

(https://online.epocrates.c om/noFrame/showPage.d o? method=drugs&Monogra phId=992&ActiveSection Id=7)

miconazole 2% cream (topical)

5 mg tablet q day before lunch

For patients overactive bladder

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

Skin Mucous membran e Color Wounds, intake, wt. Ht.

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

Output: not measured

Heart Lungs Extremitie s mobility

Desired outcome met by end of shift on 4/25/2013

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

change in vital statistics

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

Goal not met by end of shift on 4/25/2013

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

PT awake throughout shift on 4/25/2013

Pain Scale LOC

PT denies pain throughout shift on 4/25/2013

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

PT anxious when talking with MD regarding Hospice.

Family interactio n Attachme nt

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

PT crying when talking with MD about beginning Hospice care.

Desired outcome (short term goal) met by end of shift on 4/25/2013

DIAGNOSIS AND PLANNING Nursing Diagnoses (PES) and Outcomes

Growth chart Weight/Ht. Chart G&D all ages

PT is currently in the Ego Integrity vs. Despair Erikson stage.

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