Posted: September 13th, 2017

Clinical Assignment due within ONE week of the date of care.

COMPLETED Clinical Assignment due within ONE week of the date of care.

Patient Initials:

Reason for Hospitalization: (SOB) Shortness of breath, Bilateral Pleural effusion.
Surgical Procedures with dates:  TURP with lithotripsy of a bladder stone on 5/2011, Biopsy of the left upper lung lobe on 4/25/2014 the biopsy report came back a lung adenocarcinoma, bilateral cataract surgery four years ago.
Admitting Medical Diagnosis: Bilateral pleural effusion. Intermittent partial small bowel obstruction, metastatic non-small cell lung cancer, Hypertension, fatigue with activity

Current Medical Diagnosis:  Bilateral pleural effusion. Intermittent partial small bowel obstruction, metastatic non-small cell lung cancer, Hypertension,

Past Medical & Surgical History:  Hypertension, BPH, Hypothyroidism, Gerd, Lung cancer, either small cell lung cancer or adenocarcinoma.
Smoking History: Patient quit smoking 50 years ago

Allergies:  No food or drug allergies.

Psychosocial and Cultural Assessment

Marital Status:  0 married     0 single     0 divorced     0  partnered     0 widowed
Occupation (if retired, list previous): Patient retired business man, from Italy and love to speak Italian.
Mood/Affect:  calm  but stated  loss of interest in social activity/depressed since the wife died in January.
Ethnicity: Italian
Other relevant psychosocial and cultural data:  patient is from Italy and loves to speak Italian, and seems to have for -gotten some of his English knowledge. He has his son bedside his bed at the time of assessment. Also son participated in answering some of the questions. Patient quit smoking 50 years ago, of importance, the patient’s wife died in January and the patient has been depressed since then. However no anti/depressive medication on his profile. His son now lives with him and helps him, taking care of his medical issues including taking his medication regularly. Patient sister is also a doctor and will like to be informed with treatments and all those issues.
Advance Directives (Nursing Admission Assessments)

Do not resuscitate (DNR) order:  0 yes  0 no          Living will:  0 yes   0 no

Physical Assessment Data?RANGE OF FINDINGS (ESPECIALLY IF UNSTABLE)
ASSESSMENT PARAMETER    FINDINGS
Temp:
8:30am  98.6
12:00pm  98.8    (4/3/15)

HR
8:00am 81
12 : 00pm  86       (4/3/15)
RR:
8:00am  22
12:00pm 22                                               (4/3/15)
SpO2 (pulse oximetry):
8:am 97% on room air                                   (4/3/15)
12:0087% room air
BP:
8:00am 165/89 mmgh right arm standing  position
8:00am 159/85 mmgh left arm sitting
12:00am 132/80 mmgh left arm lying position.                    (4/3/15)
12:00pm 137/80mmgh right arm sitting position.
PAIN Assessment:
TYPE OF PAIN SCALE:    (note location, intensity etc.) Patient verbalized no pain on the scale 0/10. And stated  that he has a very good pain tolerant.  With son at the bedside confirmed that the patient hardly complain of pain.  Patient educated on verbalizing pain and to ask for pain pill when needed.

Height:  163
Weight: 169.4                                                                            BMI: 28.9
CHANGE from BASELINE?  How much? + or –
Hemodynamic Monitoring
(IF APPLICABLE)
Swan Ganz catheter:
location, waveform, dressing, readings:    n/a
Arterial line:
location, waveform, dressing, Allen’s sign:    n/a
Balloon pump:
location, dressings, settings, distal pulses    n/a
REVIEW OF SYSTEMS
Briefly describe assessment finding in the areas outlined below.
Include any additional abnormal findings that are not listed below.

Physical Assessment Data?RANGE OF FINDINGS (ESPECIALLY IF UNSTABLE)
Psychosocial:
Anxiety level:
Seems calm but stated he has be depressed since the wife died in January of 2015.
Visitors/support systems:
One of the son’s. He also lives with patient and helps him, taking care of his medical issues including his medications regularly.
Neurological:
Glasgow coma scale (explain any deficiencies)    total____15________

Pupils (size/ reaction/ consensual):     Rt:      3mm       PERL                   Lt: 3mm       PERL
Movement of extremities:
Patient was able to move all extremities with no pain verbalized..
BIS monitor reading:    n/a
Other:    Patient alert and oriented to self, time and place (A,O X 3). Cranial nerves 11-X11 appear grossly intact.

Skin and Mucous Membranes:
Color:
Pink
Temperature (route):
8:30am  98.6
12:00pm  98.8
and skin dry and warm to touch equal
Edema (specific location and grade):    Bilateral ankle + 2 edema.
Wounds/incisions/drains
(including location, dressing, drainage):    No wound present.
Other:
Cardiovascular:
ECG rhythm    EKG: result show normal sinus rhythm with ventricular extrasystoles    ??? what is this??  Extrasystoles are extra beats or contractions that disrupt the usual rhythm of the heart. It happens when there are electrical discharges from somewhere other than sino-atrial node..
Heart sounds:
Lung/ chest somewhat barrel formed. The patient has wheezes and a few crackles, basilar as well as overall somewhat
Pulses(specific location and grade)::    Bilateral ankle edema. no palpable bilateral dorsalis pulses, 2+ Redial pulses bilaterally
Pacemaker:         rate/mA/sensitivity: N/A
IV sites   (List location, type of line, dressing appearance, fluid/rate)

No iv line or iv medication. According to the son in ER patient was treated with 1000cc of normal saline iv. On assessment patient has no iv line or medication. Patient condition has improved from the time he was admitted to the ER to the time of admitted to my floor.  Patient is now on po medications and Ventolin inhaler 90mcg I puff inhaled every 6 hour PRN for SOB or wheezing.

Other:
Gastrointestinal:
Abdomen (inspection):
Abdomen the patient’s upper area, especially in the epigastric corner, seems hardened and slightly tender to touch. But denied pain.
Bowel sounds:
Present in all four quadrants.
Diet:
Apetite:    Regular diet, and moderate, 50 % of breakfast and lunch each. With no N/V observed.
Tube feeding (rate and type):                                          n/a                                                Residuals:
Ostomy (site and appearance):    n/a
Stools:    Patient stated that he had problem sometimes moving his bowel, sometimes every two days.  Patient stated he last move formed bowel two days ago. However did not see any laxative on his medication profile.
Other:    n/a
Genitourinary:
Urine (color, odor, character):
Clear yellow no odor urine
Catheter:
n/a
Conduit:    n/a
Dialysis access:
n/a
INTAKE/OUTPUT
(24 hour total)    INTAKE: 360cc            PO:             IV:  0cc                   OUTPUT: urinal 300cc
Respiratory:
Artificial airway:    n/a
ET tube (size):
(cm/mark-taped at teeth/gumline):   n/a
Ventilator settings:
n/a
O2 saturation %:
97% on room air
Supplemental O2:
2L N/C PRN, not in use at the time of assessment.
Rate/depth/pattern/effort:
Labored breathing, RR 22-22
Breath sounds:
Breathing labored, wheezing and a few crackles, basilar as well as overall somewhat decreased appearing respiration
Sputum:
Moist clear white
Chest tubes (location, drainage, amount of suction):
N/A
Other:    Hx of present illness. Patient is an 85 years old man who was diagnosed with lung cancer, likely an adenocarcinoma on year ago. He developed shortness of breath increasingly over the last 4 weeks and he had a CT April 4/1/2015 which shown fluids on his lungs as well as a gastrointestinal blockage, according to the son in ER patient was treated with 1000cc of normal saline iv. X-Ray of the chest showed moderate left pleural effusion and small right effusion as well as compression atelectasis.

Diagnostic Tests
Include relevant normal and abnormal findings; provide complete ABGs with interpretation

Test
Norms
Baseline
Current value/date
Why
Abnormal?
Test
Norms    Admission
Value/date        Current
value/date
Why
Abnormal?
White blood cells
4.00 -11.00        4.53    Within normal limit    K

Blood Sugar
70-100        93    Within normal limit    Mg    1.5-2.4mEq/l        2.2mEql    Within normal limit
Hemoglobin
13.3-17.5        11.1    Low due to  metastatic no small cell lung cancer    Na
137-145
143    Within normal limit
Hematocrit
41.0-53.0        36.0    Low due to  metastatic no small cell lung cancer    Cl            8.34
Platelets

130-400        248    Low due to  metastatic no small cell lung cancer    Ph
PT/INR                    Ca
APTT
BUN
9.0-20mg/dl        16mg/dl     Within normal limit
CK-MB
Creatinine    0.6-1.3        0.84    Within normal limit
Myoglobin
Albumin    3.4-5.4g/dl        2.3g/dl    Low due to  metastatic no small cell lung cancer
Troponin
Protein
OTHER:

Other: TSH     0.35-4.94        0.20    Low due to  Hypothyroidism
Chest x-ray:  Abdominal x-ray showed moderate left and a small right pleural effusion as well as compression atelectasis.

12 lead EKG: result show normal sinus rhythm with ventricular extra systoles.    Other abnormal:
ABGs: (pH, PCO2, HCO3, PO2, BE)

Interpretation:
Echo:

CT:    Other abnormal:
Other:    Other abnormal:

Medication    Medication    Medication

Synthroid 175mcg po daily  for Hypothyroidism    Tylenol 650mg po every six hours for pain or headache.

Lisiopril 10mg po every day for hypertension    Ventolin inhaler 90mcg I puff inhaled every hour PRN for SOB or wheezing.

Tarceva 100mg po Q daily for lung cancer. Take I hour befor breakfast.    Tramsulosin 0.4mg po daily for BPH.

Multvitamin tablet po daily supplement.    Prevacid po prn every 8 hours.for gerd

Vitamin D3 1000 unit’s po daily for supplement.

Hydrocodone/acetaminophen 5/325mg tablets 1 tablet every six hours PRN for pain.

PART II: Key Problems and Associated Nursing Diagnoses
Directions: Based on the completed, corresponding patient data profile, do the following:
1)    select 4 key problems
2)    select 4 associated nursing diagnoses
3)    prioritize the selections

PRIORITIZE
(label 1-4)    KEY PROBLEM    NURSING DIAGNOSIS

1    Shortness of breath, Pleural effusions.      Impaired Gas exchange

2
2+ pitting edema    Fluid volume

3
Decreased nutritional intake    Nutrition, less than body requirement

4

Depression    Ineffective coping