Running head: ADULTS NURSING PROCESS PAPER
Nursing Process Paper
Megan Miglionico
Kent State University- Stark Campus
October 22, 2012
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Nursing Process Paper
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Client Profile
The client is a fifty-five year old female, admitted on September 8, 2012, from a
skilled nursing home. Her chief complaint was respiratory distress and shortness of
breath. Her oxygen saturation was 88 percent on six liters of oxygen via simple face
mask.
The client has a recent history of adenocarcinoma of the left lower lung, which has
metastasized to the bone, brain, liver, and adrenal glands. She was undergoing
chemotherapy/radiation treatment, which was postponed due to (D/T) a low red blood
cell (RBC) count. She also has a past medical history of gastroesophageal reflux disease
(GERD), tubal ligation, and heavy tobacco use. She quit smoking in 2008.
Cancer is a disease that has an effect at the molecular level. It may begin with a
mutation or damage to a genome, within the DNA of a cell. It changes the normal growth
and proliferation mechanisms of cells. This mutation or damage can be caused by
numerous factors; exposure to radiation, chemicals, viruses, or other physical agents.
These factors or agents are called carcinogens. A person can also be predisposed, or have
already acquired a mutation due to ethnicity, age, gender, and genetics (Black &
Hokanson Hawks, 2009).
The structure and function of the cells are changed after exposure to a carcinogen.
These cells no longer serve their original purpose, but continue to multiply. If left
unchecked, these cells can travel to other parts of the body, which is called metastasize,
or mets for short. The patient has adenocarcinoma. Her cancer began in glandular tissue
of her left lower lung, and spread to her bone, brain, liver, and adrenal glands (Black &
Hokanson Hawks, 2009).
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Lung cancer is the most common type of cancer worldwide. Eighty percent of lung
cancer cases are attributed to the use of tobacco products. Cancer is diagnosed by a
complete history, physical exam, and diagnostic testing. Laboratory tests include;
complete blood cell counts (CBC), which will show the presence of abnormal functioning
within the body, tumor marker tests (PSA), which will show markers within the blood
secreted due to tumor growth, and metabolic testing, which will be abnormal before signs
and symptoms of cancer are present (Black & Hokanson Hawks, 2009).
Imaging studies used to diagnose cancer include; basic x-rays, computerized
topography (CT), magnetic resonance imaging (MRI), positron emission topography
(PET), and ultrasound. Cancer can also be diagnosed by surgery. A needle biopsy or
incision biopsy can be performed to test a tissue specimen for the presence of cancer cells
(Black & Hokanson Hawks, 2009).
Signs and symptoms of cancer are relative to the location of growth. Large growth
of nonspecific cancer can cause; pressure on surrounding areas or organs, distortion of
surrounding tissues, interference of blood supply of surrounding tissues, interference of
organ function, disturbance of metabolic processes, and mobilization of the body’s
defense systems. Clinical manifestations include; weight loss, fatigue, weakness, pain,
and central nervous system alterations (Black & Hokanson Hawks, 2009).
Signs and symptoms specific to lung cancer include; cough with or without
hemoptysis, shortness of breath (SOB), wheezing, hoarseness, chest pain, bone pain,
headache, and significant weight loss. Treatment of cancer is a multi-dimensional
approach. Surgical procedures may be possible if the growth is a substantial size or has
not metastasized to the surrounding tissues (Black & Hokanson Hawks, 2009).
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Chemotherapy and radiation are utilized to stop the growth of the effected cells. A
variety of other treatments are also used in management for side effects and side effects
from chemotherapy/radiation treatment. Pertaining to lung cancer the patient may need;
oxygen therapy, respiratory therapy to increase gas exchange, medications, procedures to
relieve pressure from fluid accumulation; such as a thoracentecis, and numerous other
treatments (Black & Hokanson Hawks, 2009).
Gastroesophageal reflux disease (GERD) affects about fifty percent of the
population. It is a chronic condition caused by the back flow of gastric contents into the
esophagus, due to the relaxation of the gastroesophageal sphincter, between the stomach
and the esophagus. The cause of GERD is unclear and may be due to several factors;
delay in gastric emptying, obesity, drugs/prescription medications, lifestyle, tobacco use,
alcohol use, and a high fat diet (Black & Hokanson Hawks, 2009).
Diagnosis of GERD is made with a patient history, physical exam, the presence of
symptoms, and a twenty-four hour PH probe monitoring study. The probe monitoring
study entails the placement of a PH probe into the esophagus to monitor PH levels for
twenty-four hours. If the PH levels are low, on the acidic side, then the presence of
gastric contents in the esophagus is more than likely. An Esophagogastroduodenoscopy
(EGD) may be done to assess the complications from GERD in the esophagus (Black &
Hokanson Hawks, 2009).
Signs and symptoms of GERD include gradual or sudden onset of ; heart burn,
epigastric pain, retrosternal burning, dysphasia, acid regurgitation, water brash (the
release of salty secretions in the mouth), and hoarseness. The treatment of GERD can
include; alterations in lifestyle, such as smoking and alcohol cessation, diet modification,
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weight loss, and medication therapy. Medications that may be given include; histamine
receptor antagonists, such as Zantac or Pepcid, proton pump inhibitors, such as Prevacid
or Nexium, and calcium carbonate supplements, such as Maalox or Mylanta (Black &
Hokanson Hawks, 2009).
A tubal ligation is a surgical procedure for reproductive sterilization. The woman’s
fallopian tubes are severed or blocked, to prevent the fertilization of an egg by sperm.
This is a permanent form of birth control performed at the patient’s request (Black &
Hokanson Hawks, 2009).
The patient undergoes general anesthesia. Two small incisions are made, below the
navel to access each fallopian tube. Then the tube is either severed or tied, and the
incisions are closed (Black & Hokanson Hawks, 2009).
Concept Care Map
Refer to included poster board
Assessment Data
Upon assessment, the patient suffered from alopecia, related to (R/T) radiation
and chemotherapy. Pupils were equal, round, and reactive to light and accommodation
(PERRLA) at 2mm. The patient’s mucous membranes were dry. She took sips of water
throughout the assessment and said that the oxygen therapy “dries me (her) out”. Her skin
was warm, dry, and sallow in color.
The patient had a normal cranial nerve assessment; appropriate rise and fall of the
uvula, smile was equal, and she could successfully puff out her cheeks. She was Alert and
Oriented x 2 (A + O x 2), to person, place, but not time. It was 0830 when the assessment
took place, and the patient thought it was in the late afternoon. Her speech was clear.
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The patient had appropriate range of motion (ROM), but all four extremities
showed signs of severe weakness. She is currently on bed rest. She had a peripherally
inserted central catheter (PICC line) in her upper right extremity. The bandage was
changed on September 10, 2012, and was clean and dry. She showed signs of moderate,
bilateral (bilat.) edema on her hands, +2. Lung sounds were diminished bilaterally upon
auscultation. Slight rhonchi were heard with inhalation.
While the patient was resting, her respirations were shallow, even, and
tachypneic, but as the assessment went on, she used accessory muscles to help her breath.
She had pulling under the clavicles and showed severe signs of dyspnea upon exertion.
She had an occasional, non-productive cough.
The patient’s heart sounds were normal upon auscultation, but her rate was
tachycardic and the rhythm was bounding. The patient’s abdomen was soft, round, and
non-tender. She had bowel sounds present in all four quadrants. She had normal genitalia
and was incontinent.
The patient had a stage two decubitus ulcer on her mid-coccyx. The ulcer was red,
the skin was broken, and the surrounding area was pink. She complained of severe pain
D/T the ulcer, an 8 out of 10, and was given 2mg Morphine Sulfate intravenously (IV).
She was also repositioned for comfort.
The patient had moderate edema in her feet, rated at a +2. All pulses were present,
and were a +3. Her vital signs (VS) were as follows; temperature 97.6 degrees
Fahrenheit, heart rate 115, blood pressure 126/74, respirations 22, and oxygenating at 93
percent on a venturi mask at 55 percent.
Nursing Process Paper
Lab information and Diagnostic Test Results
Refer to Table 1-1 and Table 1-2
Medication Information
Refer to Table 2
Analysis (NANDA), Planning (NOC), Intervention (NIC), and
Documentation/Evaluation
Refer to Table 3
Evidence- Based Practice Nursing research Article
Refer to attached article after Table 3
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References
Ayello, E. A., & Sibbald, G. (2012, July). Nursing standard of practice protocol:
Pressure ulcer prevention and skin tear prevention [Fact sheet]. Retrieved October 3,
2012, from ConsultGeriRN.org website:
http://consultgerirn.org/topics/pressure_ulcers_and_skin_tears/want_to_know_more/
Black, J. M., & Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St. Louis, MO: Saunders Elsevier.
Conroy, R. M., Cowman, S., & Moore, Z. (2011). A randomized controlled clinical trial
of repositioning, using the 30° tilt, for the prevention of pressure ulcers. Journal of
Clinical Nursing, 20(17-18), 2633-2644.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans:
Guidelines for individualizing client care across the life span (8th ed.). Philadelphia,
PA: F.A. Davis Company.
Hopfer Deglin, J., & Hazard Vallerand, A. (2005). Davis's drug guide for nurses (10th
ed.). Philadelphia: F.A. Davis Company.
van Rijswijk, L. (2009). Wound wise: Pressure ulcer prevention updates. American
journal of nursing, 109(August), 56-56.
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Table 1-1, Lab Information and Diagnostic Test Results
Lab Test
Abnormal Result
Normal
Value/Range
What does the
abnormal result
suggest to the
nurse?
What is the
significance to
your patient’s
condition?
Red Blood Cell
Count (RBC)
3.36million/mm3
4.2-5.4million/mm3
RBCs can be
decreased by
anemia, fluid
overload, recent
hemorrhage,
leukemia,
malnutrition, and
certain
medications
including
chemotherapy.
RBCs carry
hemoglobin and
oxygen to the cells
of the body. The
patient was on
chemo/radiation
therapy, which was
discontinued d/t a
low RBC count.
Chemo/radiation
therapy may have
caused the
abnormal count.
The patient may
also suffer from
imbalanced
nutrition d/t the
side effects of
nausea, vomiting,
and anorexia from
chemo/radiation
therapy.
The patient’s RBC
count was low,
thus decreasing her
oxygen carrying
ability. She may
have impaired gas
exchange at the
molecular level.
Hemoglobin
9.3g/dL
12.0-16.0g/dL
Hemoglobin can
be decreased by
the above factors
cited for a
decreased RBC
count.
Hemoglobin is the
oxygen carrying
pigment for RBCs.
The above
statements for the
abnormal RBC
count, are also true
for the patient’s
abnormal
hemoglobin count.
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Hematocrit (Hct)
30.5%
38-47%
The above
statements for a
decreased RBC
count, also apply.
Hematocrit
measures the
percentage of
RBCs in a whole
blood sample. The
patient’s low
hematocrit level
was a low level of
RBCs in the
patient’s whole
blood count. It has
the same effect as
the abnormal RBC
and hemoglobin
levels. The patient
has lowered oxygen
carrying capacity
and may have
impaired gas
exchange at the
molecular level.
The above
statements for
abnormal RBC
count, also apply.
Platelet Count (Plt)
53/mm3
150-450/mm3
Platelet counts
can be decreased
by hemolytic
disorders, aplastic
anemia, viral
infections, and
chemo/radiation
therapy.
Platelets play the
main role in the
clotting of blood.
The patient was on
chemo/radiation
therapy treatment
for cancer. She may
have a decreased
clotting time d/t
treatment. The
patient should be
monitored for
bleeding.
Nursing Process Paper
Sodium (Na+)
146mEq/dL
11
135-145mEq/dL
Increased sodium
levels can be d/t
renal losses,
diuretics, profuse
diaphoresis,
decreased thirst,
excessive fluid
loss from skin and
lungs,
administration of
concentrated
sodium solutions,
and diabetes.
Sodium is an
essential
nutrient/electrolyte
responsible for
water balance
within the body. It
also assists with
electrical
connections within
nerves and
muscles. The
patient may be
losing water
through her lungs
d/t increased
respirations. She
may have
imbalanced
hydration and
should be
encouraged to take
in adequate fluids
p.o. The patient is
also currently on
Dexamethasome,
which increases
sodium.
Nursing Process Paper
Potassium (K+)
3.0mEq/dL
12
3.5-5.0mEq/dL
Decreased
potassium can be
caused by
inadequate
potassium intake,
G.I losses,
vomiting,
diarrhea,
diuretics, and
medications.
Potassium is an
essential
nutrient/electrolyte.
Its major
responsibility is to
conduct electrical
activity of nerves
and muscles,
specifically the
heart. The patient
may have low
potassium levels r/t
anorexia, nausea,
and vomiting from
chemo/radiation
therapy. She also is
on several
medications that
lower potassium
levels. This should
be monitored
closely. The patient
is on oral
potassium
supplements and
received an
additional dose of
potassium IV.
Nursing Process Paper
Phosphorus (Phos)
1.2mEq/dL
13
2.4-4.1mEq/dL
Decreased
Phosphorus levels
maybe caused by
imbalanced
nutrition,
increased tissue
growth or tissue
repair, and
administration of
high levels of IV
glucose.
Phosphorus helps
metabolize protein,
glucose, and other
minerals within the
body. It is also used
by the kidneys in
filtering waste. The
patient had
imbalanced
nutrition d/t
anorexia, nausea,
and vomiting r/t
chemo/radiation
treatment. The
patient also may
have increased cell
growth d/t the
growth of the
cancer cells within
her body. She also
had a low serum
albumin level. This
may be possible d/t
the low
phosphorous level
within the body.
The decreased level
of phosphorus may
decrease the level
of protein being
metabolized. This
patient may need
nutritional
supplements.
Nursing Process Paper
Serum Albumin
1.8g/dL
14
3.5-5.0g/dL
Decreased
albumin levels
maybe caused by
malnutrition, over
hydration, trauma,
and protein loss.
Protein is necessary
for building and
repairing the
body’s tissues. It
also helps regulate
water balance and
produces essential
enzymes. The
patient had
imbalanced
nutrition, she also
had a slow healing
stage 2 decubitus
ulcer on her
coccyx. The
decreased level of
protein in her blood
and malnutrition,
may have
contributed to the
formation and the
slow healing of the
ulcer. The patient
also may be losing
water to increased
respiration. The
decreased level of
serum albumin
maybe responsible
for the loss of
water.
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Table 1-2, Lab Information and Diagnostic Test Results; Arterial Blood Gas Results
Lab Test
Abnormal Result
Normal Result
PH
7.37
7.35-7.45
PC02
69.3
35-45
P02
51
70-100
Bicarbonate (Bicarb)
39.4
22-28
The patient’s PH is within normal limits, but her other arterial blood gas values are all
abnormal. PC02 acts as an acid in the body. It is retained when significant respiratory
depression or inadequate oxygenation is present.
The patient has lung cancer with large masses and pulmonary edema, which has
impaired her gas exchange, thus raising her PC02 levels. This has also affected her P02
levels because she is not receiving enough oxygen in the blood.
Bicarbonate is excreted in the kidneys and acts as a base. When the PC02 levels are
elevated in the body, the kidneys excrete higher levels of bicarb to try and maintain
homeostasis. Since she has retained higher levels of PC02, her body has excreted higher
levels of bicarb.
The patient is in compensated respiratory acidosis. She is compensated because her
PH is within normal limits and bicarb is elevated, so the body is trying to return to
homeostasis. It is respiratory because she has high levels of PC02 and low levels of P02.
It is acidosis because PC02 is an acid.
*The above laboratory information in Tables 1-1 and Tables 1-2 was acquired from:
Black, J. M., & Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St. Louis, MO: Saunders Elsevier.
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Table 2, Medication Information
Medication Name
Classification
Morphine Sulfate4mg IV q4hrs PRN,
patient also received
15mg p.o. q3hrs PRN
Opiod analgesic.
Normal
therapeutic ranges
are IV; 4-10mg
q3-4hrs, p.o.; 1530mg q3-4hrs.
Albuterol
Sulfate/Ipratropium
Bromide2.5mg/0.5mg Inhaled
BID
Bronchodilator.
Normal
therapeutic range
for Albuterol
inhaled; 2.510mg q1-4hrs
PRN. Ipratropium
Bromide inh;
0.5mg
Why the patient
is receiving the
medication
The patient had
moderate pain
associated with her
adenocarcinoma of
the left lower lung
with mets to bone,
brain, liver, and
adrenal glands.
She also had a
stage 2 decubitus
ulcer that was
quite painful.
The patient has
lung cancer, and
pulmonary edema
AEB rhonchi
heard on
inhalation, PC02
retention due to
inadequate
O2/CO2 exchange
and a admitting
saturation level at
88% on 10 liters
per minute.
Bronchodilators
will dilate the
bronchioles to
facilitate oxygen
exchange, decrease
dyspnea, and
improved breath
sounds.
Nursing
Implications
Side Effects
Morphine is a CNS
depressant and
LOC, BP, P, and
RR must be
assessed before and
during treatment.
Watch for the
combined effect
with other
sedatives. If RR
<10bpm, assess
level of sedation
and evaluate the
possibility of
administering
Narcan to reverse
the effects. P.O;
take with meals or
a snack to reduce
G.I. upset. IV; push
over 4-5mins to
prevent the chance
of decreased
respiratory
depression,
hypotension, and
circulatory
collapse.
Assess lung
sounds, pulse, and
blood pressure
before and during
administration. The
patient was given a
combined
treatment of
Albuterol Sulfate
and Ipratropium
Bromide
(Duonebs) in a
nebulizing
treatment. The
combined a 3ml tx,
which will last
approximately 10
mins. Set oxygen
flow rate at 6-10
liters per minute.
Confusion (the
patient was alert
and oriented to
person, place, but
not time. Might be
d/t medication side
effect or brain
cancer), sedation,
dizziness,
dysphoria,
euphoria, blurred
vision, respiratory
depression,
hypotension,
bradycardia,
constipation,
nausea and
vomiting, urinary
retention, flushing,
itching, sweating,
and
physical/psycholog
ical dependence.
Nervousness,
restlessness,
tremor, headache,
chest pains,
palpitations,
hypertension,
nausea, vomiting,
hypokalemia (the
patient’s last serum
potassium level
was 3.0, which
maybe caused by
imbalanced diet, or
from current
medications).
Nursing Process Paper
Dexamethasone4mg p.o. q12hrs
Corticosteroid
and anti
asthmatic.
Dexamethasone is
in the
corticosteroid
family. The
dosage depends
on what the drug
is being used for.
Tablets come in
0.25, 0.5, 0.75, 1,
1.5, 2, 4, and
6mg. The patient
is receiving a
large dose at 4mg
q12hrs.
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I’m not sure
specifically why
the patient is
receiving this
medication.
Corticosteroids can
be used to treat a
wide variety of
illnesses; asthma,
adrenal
insufficiency,
chronic illnesses,
cerebral edema,
and adjunct
therapy used to
treat nausea and
vomiting from
chemotherapy. The
patient may have
cerebral edema
due to brain
cancer. She also
has adrenal cancer
which maybe
causing adrenal
insufficiency. This
drug is also used
as an antiinflammatory for
illnesses such as
asthma. The
patient has lung
cancer which may
have caused
swelling, edema,
or inflammatory
processes within
the lung. This
medication could
be given to
suppress the
inflammation to
make respiration
easier. She was
also on
chemotherapy until
her RBC count had
dropped, so this
may have been
given to suppress
nausea and
vomiting
associated with
treatment.
Administer with
meals to avoid G.I
irritation. Do not
administer with
grape fruit juice.
Tablets maybe
crushed and mixed
with soft foods to
enable swallowing.
This drug is taken
to treat many
illnesses. Assess
involved systems
periodically before
and during
treatment. Assess
for signs of adrenal
insufficiency and
changes of LOC.
Monitor intake and
output, and daily
weights. Watch for
signs of peripheral
edema (patient has
+2 in hands and
feet), weight gain,
rales/crackles, and
dyspnea (which
patient has but
probably attributed
to lung CA). May
decrease serum
potassium and
calcium levels
(patient’s last
potassium was 3.0
and calcium was
7.9). May also
increase sodium
and glucose levels
(patient’s last Na+
was 146).
Depression,
euphoria,
headache,
psychoses,
cataracts, increased
intraocular
pressure,
hypertension
(patient has
prehypertension at
126/74, but has
been seen
fluctuating
between pre and
hypertension),
anorexia, nausea,
slow wound
healing (coupled
with her low serum
albumin could be
the cause of the
slow healing of her
decubitus ulcer),
fluid retention,
hypokalemia
(patient has both),
muscle wasting,
cushingoid
appearance, and
increased
susceptibility to
infection.
Nursing Process Paper
Heparin Sodium300-900units IV
q12hrs/PRN, and
5000units IV PRN
Anticoagulant
and
antithrombolytic.
Heparin has
different
therapeutic ranges
based on the
reason for
treatment. The
patient is
receiving a large
dose in regards to
the usual dosage
of IV; 10100units/ml.
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Used
prophylactically
and to treat various
thromboembolytic
disorders. It is also
used in low doses
to prevent clots in
intravenous
catheters. The
patient is on a
relatively low dose
q12hrs and a low
PRN dose in
regards to other IV
therapies, but a
large dose in
comparison to the
usual 10100units/ml for
line flushing. She
also has a PICC
line, which may
require a larger
dose when
flushing the line. I
think she is
receiving this
medication
prophylactically to
prevent clots in her
PICC line.
Have another
healthcare
professional verify
the dose before
administration.
Flush with normal
saline before and
after injection.
Maybe given
undiluted over 1
minute.
Venipuntcure and
injection sites
require pressure to
prevent bleeding
and hemorrhage.
Assess patient for
signs of
hemorrhage and
notify physician if
they are found.
Monitor patient for
hypersensitivity
reactions; chills,
fever, uticaria.
Activated PTT and
hematocrit (last
serum hct count
was 30.5) should
be monitored
throughout therapy.
Monitor platelet
count every 23days. May cause
thrombocytopenia
(last platelet count
was 53).
Drug-induced
hepatitis, alopecia
(which patient has,
but is probably
attributed to
chemo/radiation
therapy), bleeding,
anemia,
thrombocytopenia
(anemia is
characterized by a
low RBC count,
her last RBC count
was 3.36, but is
probably attributed
to chemo/radiation
therapy and not
Heparin
administration.
Patient’s last
platelet count was
53, which maybe
due to Heparin),
osteoporosis, fever,
and
hypersensitivity.
Nursing Process Paper
Potassium Chloride40mEq/250ml of
0.9% NaCl IV x1
dose, patient also
received K-dur20mEq p.o. daily
Mineral and
electrolyte
replacement.
Normal range for
IV; serum
potassium
>2.5mEq/L, do
not exceed
10mEq/hour up to
a combined
40mEq. Patient
was receiving
40mEq/250 ml at
a rate of
67.5ml/hr. She
was receiving
10.8mEq/hr,
which is a higher
than normal dose,
but can still be
tolerated by the
body. P.O.
normal therapy
depends on the
severity and
usage; ranges
from 20100mEq/day.
19
Patient’ last serum
potassium level
was 3.0, which is
quite low. She has
an imbalanced diet
due to anorexia
from
chemo/radiation
therapy. She is
also is on several
medications which
deplete potassium;
Albuterol and
Dexamethasone.
Infuse slowly at a
rate of
approximately 10
mEq/hr, check
hospital policy for
maximum infusion
rates. Use an
infusion pump.
Maybe mixed with
NS, LR, D5W, and
any combination of
the above. Rapid
infusion/bolus
errors can result in
fatality. Assess
patient’s potassium
values before
administration.
Assess IV site for
extravasations;
severe pain and
tissue necrosis may
occur. P.O.; give
with or after meals
to decrease G.I.
irritation.
Confusion (patient
was alert and
oriented to person,
place, but not time.
Might be d/t
medication side
effect or brain
cancer),
restlessness,
weakness (patient
has severe
weakness, which is
probably attributed
to impaired oxygen
exchange and not a
side effect of
potassium
administration),
arrhythmias, EKG
changes,
abdominal pain,
diarrhea, nausea,
vomiting, G.I.
ulceration,
irritation at the IV
site, paralysis, and
parathesia.
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Levetiracetam500mg p.o. BID
Anticonvulsant.
Normal
therapeutic range;
up to
3,000mg/day
20
Patient does not
have a seizure
disorder in her past
medical history,
but she has brain
cancer. Brain
cancer/tumor can
cause pressure
changes within the
cranium, or a
disturbance in the
conduction of
electrical activity.
She may be taking
this medication
because she has
had seizure
activity since she
was diagnosed
with brain cancer,
or be taking it
prophylactically to
prevent seizures
d/t brain cancer.
Maybe
administered
without regard to
meals. Administer
tablets whole. If
discontinued, must
be discontinued
gradually to
minimize the
potential for
seizures. Assess
location, duration,
and severity of
seizures. Assess
patient for CNS
adverse side effects
throughout therapy;
coordination, and
behavioral
abnormalities. May
cause decreased
RBC (which
patient has, but
most likely
attributed to
chemo/radiation
therapy), WBC,
and abnormal liver
function tests.
Dizziness, fatigue,
weakness (patient
has both, but most
likely attributed to
impaired oxygen
exchange),
behavioral
abnormalities, and
coordination
difficulties.
Nursing Process Paper
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Pantoprazole- 40mg
p.o. daily a.c.
Antiulcer, gastric
pump inhibitor.
Normal
therapeutic range;
p.o. 40mg/day.
Medication is used
for the treatment of
gastroesophageal
reflux disease,
which the patient
has. It decreases
day and nighttime
heartburn
associated with
GERD.
May be
administered with
or without meals,
in the patient’s case
it is administered
daily before
breakfast. Do not
break, crush, or
chew tablets.
Antacids may be
used concurrently.
Assess patient
routinely for
adverse side
effects; epigastric
or abdominal pain,
and for frank and
occult blood in
stool, emesis, and
gastric aspirate.
May cause
abnormal liver
function tests
including; elevated
AST, ALT,
alkaline phosphate,
and bilirubin.
Headache,
abdominal pain,
diarrhea,
eructation,
flatulence, and
hyperglycemia.
Gabapentin- 200mg
p.o. q8hrs
Analgesic
adjuncts and
anticonvulsants.
Normal
therapeutic range;
p.o. 900-1800mg
in divided doses
BID. Patient is
receiving a lower
dose at 800mg
daily.
Gabapentin can be
used to treat
chronic pain and
seizures. The
patient may be
taking the
medication for
either of those
treatments.
Gabapentin is
usually associated
with nerve pain.
The patient maybe
using it for
treatment
regarding her pain
associated with
cancer. She may
also be using the
medication as an
anticonvulsant.
She is taking
Levetiracetam,
which may be d/t
seizure activity
attributed to brain
cancer.
May be
administered
without regard to
meals. Do not take
within two hours of
an antacid. This
may decrease the
absorption of the
medication. Do not
discontinue
medication
abruptly; this may
cause increase in
seizure activity.
Assess location,
quality, and
duration or seizure
activity/pain before
and during
treatment. May
cause leukopenia.
Confusion (patient
was alert and
oriented to person,
place, but not time.
Might be d/t
medication side
effect or brain
cancer),
depression,
drowsiness,
anxiety, dizziness,
fatigue, weakness
(patient has both,
but most likely
attributed to
impaired oxygen
exchange),
abnormal vision,
hypertension,
anorexia,
flatulence, ataxia,
altered reflexes,
facial edema.
Nursing Process Paper
Baclofen- 10 mg p.o.
q8hrs
Antispasticity
agents, muscle
relaxant. Normal
therapeutic range;
5mg/BID, up to
80mg/day in
divided doses.
22
Baclofen is used to
treat muscle
spasticity d/t spinal
cord injury or
lesion. The patient
has widespread
cancer with mets
to the brain. She
may possibly have
lesions on her
spinal cord, and
may have related
muscle spasms.
She may also be
receiving this
medication
prophylactically
d/t the above
condition.
Administer with
food or milk to
minimize G.I.
irritation. Assess
muscle spasticity
before and during
treatment. Monitor
for adverse side
effects; drowsiness,
dizziness, or ataxia.
These symptoms
maybe reduced by
lowering the
dosage. May cause
elevation in serum
glucose, alkaline
phosphate, AST,
and ALT.
Dizziness,
drowsiness,
fatigue, weakness
(patient has both,
but most likely
attributed to
impaired oxygen
exchange),
confusion (patient
was alert and
oriented to person,
place, but not time.
Might be d/t
medication side
effect or brain
cancer),
depression,
insomnia, nausea,
constipation,
pruritis,
hyperglycemia,
weight gain, ataxia,
sweating.
*The above medication information in Table 2 was acquired from:
Hopfer Deglin, J., & Hazard Vallerand, A. (2005). Davis's drug guide for nurses (10th
ed.). Philadelphia: F.A. Davis Company.
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23
Table 3- Analysis, Planning, Implementation, Documentation/Evaluation
Nursing Diagnosis #1:
Impaired gas exchange R/T adenocarcinoma of the left lower lung AEB; admitting oxygen
saturation at 88 percent on 10 liters of oxygen via simple face mask, admitting diagnosis of
respiratory distress, admitting complaint of SOB, bilateral diminished breath sounds upon
auscultation, slight rhochi heard on inspiration upon auscultation, tachypneic respirations (22
breaths per minute), accessory muscle usage during respiration, dyspnea upon exertion,
occasional non-productive cough, current oxygen saturation 93 percent on a venturi mask at 55
percent, the need for O2 therapy, the need for medications Albuterol Sulfate/Ipratropium
Bromide and Dexamethasone, skin sallow in color, fatigue, weakness, and change in mentation
( patient A+Ox2).
Planning:
Short Term Goal: The patient will maintain an oxygen saturation greater than 92 percent
during a 24 hour time period.
Long Term Goal: The patient will verbalize an accurate understanding of all medication
administration before discharge.
Interventions:
1. Administer supplemental oxygen via high humidity face mask to maximize available oxygen.
2. Assess patient’s respirations; rate, rhythm, use of accessory muscles, and skin color to assess
for oxygenation status.
3. Assess patient’s response to activity. Encourage rest periods and limit activity to patient
Nursing Process Paper
24
tolerance to increase oxygen supply and decrease oxygen demand.
4. Educate patient on proper usage, dosage, and purpose of medications to ensure they are being
used effectively and maximizing therapeutic effects.
Documentation/Evaluation:
Patient was being administered high humidity oxygen at 55 percent through a venturi mask. Her
oxygen saturation was 93 percent, which met the short term goal of keeps stats above 92 percent.
The patient’s respirations were assessed and found to be even, shallow, tachypneic (22 breaths
per minute), use of accessory muscles present, and skin sallow colored. Patient responded poorly
to activity and showed signs of dsypnea upon exertion. She also showed signs of fatigue and
weakness. The patient had a good understanding of her medication; use, dosage, and purpose.
Will continue education throughout admittance and before discharge.
Nursing Diagnosis #2:
Risk for impaired skin/tissue integrity R/T compound factors; imbalanced nutrition, immobility,
immunosuppressant medication therapy, decreased perfusion d/t decreased oxygen carrying
capacity, and altered level of consciousness AEB patient exhibited signs of anorexia and
suppressed appetite, her serum albumin level was decreased at 1.8g/dL, her phosphorus level was
decreased at 1.2g/dL. Patient is on bed rest, is incontinent, and already has a stage 2 decubitus
ulcer on her coccyx. Patient has moderate, +2 edema in hands and feet. Patient exhibits signs of
weakness, fatigue, and can not properly position herself. The patient was being treated for cancer
via chemo/radiation therapy, and is on Dexamethasone, which slows wound healing. The patient
also has decreased levels of RBC’s, hemoglobin, and hematocrit, which decrease oxygen
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25
carrying capacity, thus decreasing oxygenation to tissues and which in turn, increases wound
healing time. Patient A + O x 2, and was unaware of the time of day.
Planning:
Short Term Goal: The patient will exhibit no further signs of skin impairment within a 24 hr
time period.
Long Term Goal: The patient will verbalize an understanding of proper skin care before
discharge.
Interventions:
1. Perform a standardized skin integrity risk assessment (Braden scale) upon admittance, and at
regular intervals (every 24-48 hrs in a long term facility) to assess the need for assistive devices,
and prevention implementation procedures (Ayello & Sibbald , 2012).
2. Reposition the patient at least every 3 hours using the 30 degree tilt method to minimize
pressure placed over boney prominences and flat surfaces (Conroy, Cowan, & Moore, 2011).
3. Use pressure reducing devices; wedges, pillows, pressure reducing boots, and a pressure
reducing mattress in the prevention of pressure ulcers (van Rijswijk, 2009).
4. Provide nutritional supplements for patients at risk for imbalanced nutrition. A high protein
supplement is recommended for the patient d/t her decreased serum albumin levels (Ayello &
Sibbald, 2012).
5. Educate the patient on importance of skin care; keep skin clean and dry, wash with warm (not
hot) water, and apply emollient to dry skin (Ayello & Sibbald, 2012).
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26
Documentation/Evaluation:
The patient has a Braden score of 13 which is a moderate risk for pressure ulcers. She was
repositioned every two hours, and pillows and pressure reducing boots were used. The patient
was ordered a nutritional supplement d/t her low albumin and phosphate levels, but the patient
denies the supplements. She was encouraged to take in adequate nutrition, and had only one
small snack consisting of chocolate ice cream during the shift. No further pressure ulcers were
noted during the 5 hr shift. Educated the patient on the importance of skin care, but she denied
her daily bath stating that she was “just too tired”. Further education is required.
* The above information in Table 3 (excluding interventions with citations) was acquired
from: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans:
Guidelines for individualizing client care across the life span (8th ed.). Philadelphia,
PA: F.A. Davis Company.