CLIENT INFORMATION FORM
Student's Name Date of Care:
Client Initials Room Number Sex: Age :
Admission Date: Admitting Diagnosis: Rt. Lobe infiltrate, Breast & Bone Cancer
Secondary Diagnosis if any): Respiratory Distress
Surgery Type/Date (if any): Lumpectomy on Rt. Foot at 2002
Working Medical Diagnosis/Etiology (describe definition, pathophysiology, and sign/symptoms)
Metastatic Breast Cancer
Metastatic breast cancer is the term used to describe cancer that has spread from the original site in the breast to other organs or tissues in the body. Cancer cells can break away from the original cancer in the breast and the cancer cells that break away can spread to other parts of the body via blood vessels or lymphatic vessels. The original site where the cancer cells came from is called the primary cancer. When cancer cell travels from the breast around the body they can lodge themselves in various body organs or tissues. These cells can begin to form breast cancer in new place and this new cancer is called secondary or a metastasis.
Breast cancer most commonly spreads to one or more sites: bone, liver, brain and lungs. The sign or symptoms that may experience will depend on where the cancer is in the body and the extent of the cancer. If its spread to the:
Bone- pain is fairly constant, aching pain. It may increase with movement or activity.
Lungs/pleura- will experience shortness of breath, dry cough, fatigue, chest pain or feeling of heaviness in the chest.
Liver- it includes weight loss, lack of appetite, fatigue, and discomfort at the right side of the abdomen, nausea, jaundiced and swelling of the abdomen.
Brain- will experience headache, nausea and vomiting, weakness in arm or leg, unsteadiness in walking, change in vision, seizure and confusion or disorientation or personality changes.
Developmental Needs (actual tasks and behaviors exhibited according to Erickson)
Ego integrity vs. Despair
Despair- As of the moment, patient is experiencing despair related change in active lifestyle as being an active member in church and does volunteer at the hospital to being so unproductive at the hospital just sits there and don’t do anything and also significant change in health. The other factor that will contribute to the task is the death of her husband and brother. Lastly is the change in living arrangement especially she’s feeling weak and just had tracheostomy that needs meticulous care and will be needing help from home health community resources.
Marital Status S M W D Role in Family: Mother
Occupation: Unemployed, used to be a teacher Education: College Graduate
Family Members: none Cultural background: Caucasian, Native Oklahoman
Religious affiliation: Baptist Spiritual practices: prayer, reading bible, listens Christian song
Interests/hobbies : Read children books, volunteer at The Children’s Hospital
Lifestyle habits: Smoking yes no Amount: not applicable
Recreational drug use: Amount NONE Frequency: not applicable
Allergies (drugs, foods, other) : NKDA
Describe reaction: Not applicable
Medications taken at home:
Zoloft 200 mg Daily, Zyprexa 10 mg Daily, Advair 100/50 1 puff Daily, Theophylline 300 mg Daily, Ativan 0.5mg PRN HS, Lortab 5/500 1 tab Q4-6H PRN, Glipizide 5 mg Daily, Flonase 1 squirt PRN.
Taken for: anti-depressant, anti-psychotic, to control asthma, anti-anxiety, anti-pyretic, lowering blood sugar level
Pertinent Medical History: Asthma, depression, radiation&chemo, back pain and breast & bone cancer.
Nutritional analysis for client:
Ht 5’ 5” Wt 89.3 Kg Diet Ordered: Oxepa 50 ml/hr
Circle whether the client has any of the