1
Student’s Name: Morgan Whitmore Unit:DT8
Date: 4-5-2011
History/Physical and
Summary of Hospitalization
Init. RMcC
Age 72 years old Gender male
Rm. # 65-2 Ethnicity Caucasian Admit Date 4-1-2011
Admitting Diagnosis Chemotherapy for recurrent Primary CNS lymphoma.
Past Medical History (This should include information on any other medical problems the pt. may have such as heart disease, diabetes, HTN, etc. as identified in physician's
H&P, progress, consultations and medications.) Patient has a history of benign paroxysmal positional vertigo, bilateral sensorineural hearing loss, lymphoma of central nervous
system, removal of prostate, pulmonary embolism, and craniotomy tumor.
History of Current Illness/Injury (What precipitated this hospitalization): Patient had last round of chemotherapy 3/11-3-18. He is back for his continuation of chemotherapy
treatment to treat his recurring CNS lymphoma.
Vital Sign Trends for Previous 24 hours: T max. 36.3-36.5 P 6-71
R 14-18 BP 132/80-160/90 O2 Sat 95-97
Intake last 24/hrs 6,023.5 mL Output last 24/hrs 4,475 mL Wt today 70.7 Kg; Wt yesterdays 70.7 Admit wt 70.217 Kg,
Braden scale score 21; Fall risk score 35
Abnormal Physical Assessment findings: (Use Prep day data) Patient was very nauseated and vomited frequently.
Nursing Care:
Activity: as desired
Nutrition/Route: regular diet
DVT Prophylaxis: continuous alternating leg pressure devices
Type of IV / IV solution: NS 0.9% 20 mL/hour continuous
Pulmonary Care/Airway: pulse oximetry with vital signs
Code Status: Full Code
Tubes/Drains: None
Allergies: Dilantin/Phenytonin Sodium, Contrast Dye, Heparin Agents
Wound Care: None
Special Precautions: None
Misc: Vital signs every 4 hours, methotrexate lab values every 12 hours, weigh daily
Nursing Diagnoses:
1. Risk for imbalanced nutrition related to chemotherapy.
2. Risk for infection related to chemotherapy.
3. Risk for fluid overload related to chemotherapy.
2
Laboratory Results Explanations
Lab Test
Decreased
potassium
Decreased BUN
Decreased glucose
Increased glucose
Decreased calcium
Decreased protein
Increased AST
Increased ALT
Decreased WBC
Significance/Explanation As It Relates to Your Patient
He is on chemotherapy, he has had nausea and vomiting due to the chemotherapy
which decreases one’s potassium levels.
This is decreased because his protein is decreased related to his chemotherapy.
This indicates the patient’s malnutrition.
He has cancer therefore is on chemotherapy – which decreased the patient’s
appetite.
Stress, medications, and his illness caused her glucose to increase.
Patient has a decreased appetite related to chemotherapy.
Patient’s appetite and oral intake are decreased due to chemotherapy.
Patient is on chemotherapy.
Patient is on chemotherapy.
WBC’s decreased due to the patient being on chemotherapy.
Nursing Diagnoses
1. Risk for infection related to chemotherapy
2. Risk for malnutrition related to chemotherapy
3
Nursing
Implications:
Drug:
Generic Name
Trade Name
Sennosides
(Senokot)
Drug Class /
Mechanism of
Action
Laxative
Senna alters
water and
electrolyte
transport into
large intestine
causing
increased
peristalsis
Leucovorin
Folinic Acid
Antidotes for
methotrexate
Vitamins
Normal Dosage
Range
Frequency
12-50 mg/day;
once or twice
daily
200 mg followed
by 370 mg
fluorouracil
Docusate
(Colace)
Laxative/stool
softener
Adds water into
the stool and
electrolytes and
water into the
colon
Current
Prescribed
Dosage /
Time /
Route
Why is your patient
taking this
medication?
17.2 mg
tablet
Daily at
bedtime
oral
He may become
constipated from
decreased nutritional
intake and
chemotherapy.
Diarrhea
Cramping
Nausea
200 mg
every three
hours
Minimize
hematologic effects
of high doses of
methotrexate therapy
Thrombocytosis
IV increase
dose
according to
parameters.
Reduces form
of folic acid that
serves as a
cofactor in the
synthesis of
DNA and RNA.
50-400 mg/day in
1 -4 doses
three most
common side
effects
100 mg
Twice daily
Oral
Nursing Diagnoses
List one nursing
diadiagnosis for each
memedication
Drug effectiveness:
How will you know
if the drug is working
for the your patient?
Interactions with
other meds?
Risk for constipation
related to
chemotherapy.
He has a bowel
movement
Risk for imbalanced
nutrition.
Patient’s lab values
are within normal
ranges and patient
doesn’t develop
complications related
to methotrexate.
Risk of constipation
related to
chemotherapy.
He has a bowel
movement.
Many decrease
absorption of other
oral drugs because
of decrease transit
time
Allergic reactionsRash/wheezing/
Urticaria
Be careful with
barbiturates,
alcohol,
sulfamethoxazole,
fluorouracil.
He may be
constipated from
chemotherapy.
Throat irritation
Mild craps
Rashes
No drug to drug
interaction
4
Bisacodyl
Laxative
(Dulcolax)
Stimulates
peristalsis by
changing fluid
and electrolyte
transport to go
to the colon
Sodium Bicarbonate
5-15 mg in a
single dose
10 mg= 2
tablets
30 mg/day max
Daily at
1300
Anti-ulcer agent
Antiemetic
Zofran
Blocks effects of
serotonin and the
chemoreceptor
trigger zone in the
CNS.
Abdominal cramps
Nausea
Risk of constipation
related to
chemotherapy.
He has a bowel
movement
Cramping
Orally
Be cautious with
antacids, histamine
H-2 receptor
antagonists, gastric
acid-pump
inhibitors, may
decrease absorption
of oral drugs
because of increase
motility and
decreased transit
time.
2-5 mEq/kg
Acts as an
alkalinizing agent
by releasing
bicarbonate ions.
Following oral
administration
releases bicarbonate
which is capable of
neutralizing gastric
acid.
Ondansetron
In case he becomes
constipated.
0.15 mg/kg 15-30
minutes prior to
chemotherapy.
Repeat four and 8
hours later= 32
mg/day
150 mEq D5W
1,000 mL
200 mL/hour
IV
Continuous
To decrease his
risk of developing
a ulcer from
chemotherapy.
Also used to
alkaline urine due
to his
chemotherapy.
Metabolic alkalosis
Hypocalcemia
Hypokalemia
4 mg every 6
hours PRN
In case he has
nausea or vomits.
Headache
IV push over 2
minutes
Risk for excess
fluid volume.
Patient doesn’t
develop an ulcer.
Urine is within
normal lab ranges
for alkaline.
Risk for
constipation.
Patient doesn’t
develop nausea
and vomiting.
Salicylate or
barbiturates may
have decreased
effects, increases
blood levels of
quinidine,
mexiletine,
flecainide,
amphetamines.
Constipation
Diarrhea
May affect drugs
altering the activity
of the liver
enzymes.
5
Reglan
Antiemetic
Metoclopramide
Blocks dopamine
receptors in
chemoreceptor
trigger zone.
Stimulates motility
of the upper GI
tract and accelerates
gastric emptying.
NaCl 0.9%
Acetaminophen
Tylenol
Mineral and
electrolyte
replacements and
supplements
Sodium is a major
cation in
extracellular fluid
and helps maintain
water distribution
,fluid, acid base
balance, osmotic
pressure, and
electrolyte balance.
Chloride is a major
anion in extracellulr
fluid and used in
maintaining acid
base balance.
Antipyretic
Non-opioid
analgesics
Inhibits the
synthesis of
prostaglandins hat
my serve as
mediators of pain
and fever.
10-20 mg four
times daily
10 mg tablet
four times daily
IV Push every
six hours PRN
He is having
chemotherapy and
has nausea and
vomiting.
Drowsiness
Restlessness
Risk for
imbalanced
nutrition.
Patient doesn’t
develop nausea
and vomiting and
maintains an
healthy weight,
with electrolytes
in normal ranges.
Patient’s
electrolyte and
mineral lab
values are within
desired limits.
Neuroleptic
malignant
syndrome
Additive CNS
depression with
other CNS
depressants. May
increase absorption
and risk of toxicity
from cyclosporine.
1 Liter contains
150 mEq sodim/L
Rate and amount
determined by
condition being
treated
20 mL/hour
from 1,000 mL
bag
Continuous
IV
He is in the
hospital for
chemotherapy
having a
continuous IV
helps keep him
hydrate and his
electrolytes
balanced.
Congestive heart
failure
Pulmonary edema
Hypervolemia
Risk for deficient
fluid volume.
1 gram 3-4 times
daily
650 mg tablet
every 4 hours
PRN
Oral
In case he
experiences mild
pain.
Hepatic failure
Neutropenia
Rash
Risk for pain.
May increase risk
of bleeding with
warfarin.
Concurrent use of
sulfinpyrazone and
barbiturates may
increase liver
Risk for
excessive fluid
volume.
Patient doesn’t
develop pain or
pain is tolerable.
6
Aluminum and Magnesium
Hydroxide DBL
Str with Simethicone
Maalox Max Liquid
Hydrocodone/Acetaminophen
Vicodin
Lorazepam
Ativan
Anti-ulcer agent
Neutralizes gastric
acid following
dissolution in
gastric content.
Inactivates pepsin if
pH is raised to
greater or equal to
4.
Opioid analgesic
Binds to opiate
receptors in the
CNS. Alters
perception of
painful stimuli
while producing
generalized CNS
depression.
Sedative/hypnotic
Anti-anxiety
Benzodiazepines
Depresses the CNS
by potentiating
GABA.
Magnesium Sulfate
Mineral and
electrolyte
replacement
Essential for many
enzyme activities.
5-30 mL
2.5-10 mg every
3-6 hours PRN
15 mL every 6
hours PRN
Oral
5 mg/500 mg=
1-2 tablets every
6 hours PRN
Oral
In case he
experiences
indigestion, help
prevent him from
developing an
ulcer related to his
nausea and
vomiting from the
chemotherapy.
For moderate to
severe pain.
damage, concurrent
use of NSAIDS
increase the risk of
adverse renal
effects.
Constipation
Diarrhea
Hypomagnesaemia
Absorption of
tetracyclines,
itraconazole, iron
salts may be
decreased.
Hypotension
Constipation
Sedation
Risk for
imbalanced
nutrition related
to chemotherapy.
Patient doesn’t
develop an ulcer
and his
electrolyte labs
remain stable.
Risk for pain
related to
lymphoma.
Patient’s pain
levels are
controlled or no
pain is
experienced.
Risk for injury
related to
Ativan’s side
effects.
Patient doesn’t
develop nausea
and vomiting,
nausea and
vomiting are
reduced, patient
doesn’t injury
self.
Risk for injury.
Patient doesn’t
injury himself.
Patient’s lab
values increase.
Be careful with
MAO inhibitors,
antihistamines, and
sedative/hypnotics.
2 mg 30 minutes
prior to
chemotherapy
Repeated every 4
hours PRN
0.5-1 mg every
4 hours PRN IV
1 gram every 6
hours for 4 doses
or 250 mg/kg
over 4 hours
2 grams PRN
IV
For breakthrough
nausea and
vomiting
For
hypomagnesaemia
Dizziness
Drowsiness
Apnea
Levodopa may
have decreased
efficacy, valproate
can increase serum
concentrations,
additive with other
CNS depressants.
Drowsiness
Diarrhea
Arrhythmias
May potentiate
calcium channel
blockers and
neuromuscular
blocking agents.
7
Potassium Chloride
Mineral and
electrolyte
replacement
10-20 mEq/dose
max 40 mEq/dose
10 mEq IV
PRN
For hypokalemia
Maintains acid base
balance and
electrophysiological
balance of the cell.
Activates many
enzyme reactions,
helps with muscle
contraction, tissue
synthesis, and
carbohydrate
metabolism.
Prochlorperazine
Compazine
Zolpidem
Ambien
Antiemetic
Alters the effects of
dopamine in the
CNS. Possess
significant
anticholinergic and
alpha adrenergic
blocking activity.
Depresses
chemoreceptor
trigger zone in the
CNS.
Sedative/hypnotic
Produces CNS
depression by
binding to GABA
receptors.
5-10 mg- can repeat
once
Arrhythmias
Confusion
Paralysis
Imbalanced
nutrition.
Used with
potassium sparing
diuretics or ace
inhibitors or
angiotensin 11 may
lead to
hyperkalemia.
5-10 mg every 6
hours PRN IV push
For nausea and
vomiting
Constipation
Dry mouth
Blurred vision
Risk for deficient
fluid volume.
Patient doesn’t
develop worsening
of nausea and
vomiting. Patient
states he is not
nauseated or
vomited.
Risk for ineffective
sleep patterns.
Patient is able to
sleep through the
night. Patient isn’t
tired during the
day.
Additive
hypotension with
antihypertensive,
nitrates, or alcohol.
Antacids may
decrease
absorption.
10 mg at bedtime
5 mg tablet daily at
bedtime
Oral
For insomnia
Daytime
drowsiness
Dizziness
Anaphylactic
reactions
Increased CNS
depression with use
of additional
sedatives, alcohol,
opioids, tricyclic’s.
Patient doesn’t
develop
hyperkalemia.
Lab values
increase into
normal ranges.
8
Critical Assessment
Cardiovascular: Assess BP, heart tones, capillary refill, pulses
Respiratory: Assess breath sounds, oxygen saturation, encourage ambulation, deep breathing, and coughing
Immune- trend WBC labs, assess for signs of infection/SIRS/Sepsis- VS frequently and trend them
Skeletal- assess movement and strength
Integument- Assess for pressure ulcers, dry, warm, intact, assess IV site
Neurological- assess pain level, LOC, assess for dizziness
Digestive- assess nausea, vomiting, electrolyte labs and trend them, assess abdomen- look, listen, and palpate, assess last bowel movement.
Endocrine- trend blood glucose levels
Urinary- assess input and output
Reproductive - N/A
Assessment of Knowledge Deficit: Patient’s
knowledge deficit related to importance of nutrition as
evidenced by patient’s decreased appetite from
chemotherapy.
Outcomes/Evaluation Parameter: Patient verbalizes
importance of nutrition for healing and decreasing
risks for complications. Patient’s intake of nutrition
increases and is adequate for discharge. Patient drinks
adequate fluids. Patient identifies foods he can
tolerate. Patient understands importance of food
pyramid and how it applies to him.
Planning and intervention with rationale: Weigh
the patient daily and trend results. Encourage food and
fluids. Teach patient about nutrition, food pyramid,
and risks related to his personal nutrition.
Diagnosis: Chemotherapy for reoccurring CNS Lymphoma
Secondary Dx: History of pulmonary embolism, positional
vertigo, bilateral sensoineural hearing loss, removal of prostate,
and craniotomy tumor.
Critical Assessments: See Above
List of all actual and potential physiological and psychosocial nursing diagnosis: Risk for infection, imbalanced
nutrition, imbalanced electrolytes, risk for deficient fluid volume knowledge deficit regarding discharge needs, Risk for
impaired gas exchange, risk for sexual dysfunction, risk for ineffective coping, risk for caregiver role strain, , impaired
urinary elimination.
:
Nursing Diagnosis with assessment parameters Risk for infection related to
Chemotherapy.
Outcomes/Evaluation Parameter: Patient doesn’t develop an infection. Patient can
verbalize sign and symptoms of infection. Vital signs are stable. Patient verbalizes
how he will protect himself from unnecessary germs in the environment. Patient’s
skin remains intact.
Planning and intervention with rationale: Teach patient signs and symptoms of
infection. Teach patient how to protect himself in the environment from germs.
Monitor vital signs for SIRS/sepsis, trend lab reports- WBCs.
Nursing Diagnosis with assessment parameters Imbalanced electrolytes related to
chemotherapy as evidenced by patient’s decreased potassium and calcium.
Outcomes/Evaluation Parameter: Patient doesn’t develop cardiac complications
related to decreased potassium levels. Patient’s lab values increase into normal
ranges. Patient no longer needs supplements. Patient is able to eat meals without
vomiting. Patient verbalizes signs and symptoms of myocardial infarction.
Planning and intervention with rationale: Provide electrolyte supplements
according to MD’s orders. Trend electrolyte labs, provide nausea medication before
meals so that electrolytes increase through his diet. Patient’s heart remain stablesmonitor VS and regular EKG assessments. Teach patient signs and symptoms of
myocardial infarction.
Assessment of Discharge Planning needs:
Patient’s vital signs, hemodynamics, and labs
9
are stable. Patient doesn’t develop
complications from chemotherapy. Patient
no longer vomiting or it decreases.
Electrolytes are increased and supplements
are no longer needed. Patient completes
chemotherapy.
Outcomes/Evaluation Parameter: Patient
verbalizes understanding on medications and
side effects. Patient’s vital signs and labs are
stable.
Planning and intervention with rationale:
Trend patient lab values and assess for
imbalance electrolytes and infection.
Administer medications according to MD’s
orders. Teach patient about medications and
side effects about discharge medications.
Nursing Diagnosis with assessment parameters Imbalanced nutrition
related to chemotherapy as evidenced by patient’s decrease appetite, emesis,
and skipping meals.
Outcomes/Evaluation Parameter: Patient is able to tolerate meals without
vomiting. Patient eats 75% of meals. Patient’s fluid intake is adequate.
Patient no longer needs nausea medication or only takes oral nausea
medication. Lab values are stable.
Planning and intervention with rationale: Encourage eating and drinking
fluids throughout the shift. Assess frequently for nausea and vomiting,
administer nausea medication according to MD’s orders. Trend patient’s lab
values. Call for dietitian consult-advocate for Ensure or another type of
calories.
Nursing Diagnosis with assessment parameters Risk for deficient fluid volume
related to chemotherapy.
Outcomes/Evaluation Parameter: Patient doesn’t develop dehydration.
Patient’s body and oral fluids are adequate. Patient doesn’t display any physical
signs of deficit fluid volume. Patient’s urine is 30 mL/hour. Patient’s vomiting
decreased or is no longer a concern. Patient’s blood pressure remains stable
Patient’s urine pH is within normal range.
Planning and intervention with rationale: Encourage patient to drink fluids.
Patient’ Administer IV solutions according to MD’s orders. Assess skin,
mucous membranes, and LOC. Assess urine output hourly and document
amounts. Assess urine pH due to chemotherapy. Measure emesis and document
amounts. Assess and record blood pressures.
10