307 Careplan Essay example

Submitted By DavidShagwellKap
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Pages: 6

LA SALLE UNIVERSITY
NURSING 307

MEDICAL-SURGICAL CORRELATIONAL DATA SHEET

Student Name: David Kaplan

Patient Initials:________D.H.__Age:____65____Room #__443_____

Developmental stage:____ Integrity vs. Despair ________________________________

Cultural Considerations: Patient noted that he is protestant but no special religious or food or preferences. English is the patient’s first language and there are no restrictions on medications.

Reason for Admission:__ Pleurodesis

Code Status___Full code__________________________

Patient is a 65-year-old male admitted with exacerbation of mesothelioma. He looks younger than the age indicated. He lives with his wife and has 2 children and 1 granddaughter. He worked full-time as an electrician which is where he contracted the disease. Patient is Caucasian and is part of the protestant religion. Patient has a past medical history of PL effusion, Mu prolapse, and Mitral valve prolapse.

Mesothelioma is a rare cancer that occurs in the thin layer of tissue that covers the majority of your internal organs (mesothelium). Signs and symptoms of mesothelioma vary depending on where the cancer occurs.

Pleural mesothelioma, which affects the tissue that surrounds the lungs, causes signs and symptoms that may include:

Chest pain under the rib cage
Painful coughing
Shortness of breath
Unusual lumps of tissue under the skin on your chest
Unexplained weight loss (Mayoclinic 2012)

Priority Nursing Diagnoses:___ Impaired gas exchange related to difficulty breathing, Pain during inspiration related to mesothelioma, dyspnea on exertion due to painful breathing.

Based on Textbook (Theory) Your Actual Assessment
Clinical manifestations of disease:
Chest pain
Painful coughing
Shortness of breath
Unexplained weight loss

Review of Systems/Symptoms observed:

Neuro: AAOx 3, PERRLA
CV: +PP, no edema, NSR on monitor.
Pulm: pulse ox 100%, unilateral ronchi.
GI: + Bowel sounds in all 4 quadrants, abdomen is soft, non-tender. Last bowel movement was in the morning. Patient is on a regular diet.
GU: Voiding clear, yellow urine
Skin: Warm, dry, intact
Ambulation: Ambulatory without assistance
Safety: Standard risk

Diagnostic tests for this patient:

Hgb/Hct
Glucose
BUN
Ca

Test results and their significance for the patient:
Hgb 13.1 – this shows if proper oxygenation is reaching the organs through the lungs.
Normal 13.8 - 17.2 g/dL in males
Hct 38% this shows if proper oxygenation is reaching the organs through the lungs.
Normal 41-50% in males
WBC 16 billion cells/L – this may be the first sign of infection
Normal 3.5-10.5 billion cells/L
BUN 23 - A BUN test can reveal whether your urea nitrogen levels are higher than normal, suggesting that your kidneys or liver may not be working properly.
Normal 7 to 20 mg/dL
Ca 7.7 - calcium can help keep bones strong through the treatment process. Weakening bones can be a side effect of a cancer patient’s lack of energy and mobility.
Normal 8.5 - 10.3 mg/dL

Test findings indicate improvement of Mesothelioma but is still room for improvement.

Treatment options for this disease:

Pleurodesis
Exploratory thoracotomy
Chemotherapy
Radiation

Collaborative Interventions for this pt:

Medications as ordered
Pulmonary rehabilitation
Oxygen therapy
Breathing tube
No light or sun exposure

Medications Prescribed:
Allergies Noted: _______________NKDA_______________ Reaction_________________________________ ______________________________ _________________________________
Medication
Classification
Mechanism of Action
Rationale for use by THIS patient
Nursing Considerations

Ampicillin-sulbactam IVPB 1.5 grams in sodium chloride .9% 100mL intravenous. Infuse over 30 min

Docusate Sodium capsule 100 mg oral 2 times a day

Morphine ER
Tablet extended release, 15 mg oral every 12 hours

Ranitidine 150 mg oral every 12 hours

Tamsulosin
0.4g oral every night before bed.

Vancomycin…