Amiodarone
Route/Dose/ Freq:
Pharmacologic
Classification & Action
antiarrhythmics
Nursing Implications
Brand/Generic Name:
Furosedmide
Route/Dose/ Freq:
PO 40 mg Tab
Pharmacologic
Classification & Action
diuretic
Inhibits the reabsorption of sodium and chloride from the loop of
Henle and distal renal tubule
Hypertension
Nursing Implications
Assess fluid status. Monitor daily weight, intake and output ratios,
amount and location of edema, lung sounds, skin turgor, and
mucous membranes. Notify health care professional if thirst, dry
mouth, lethargy, weakness, hypotension, or oliguria occurs.
Brand/Generic Name:
Magnesium Oxide
Route/Dose/ Freq:
Po 400 mg
Pharmacologic
Classification & Action
Treatment/prevention of hypomagnesemia.
diarrhea.
Nursing Implications
Brand/Generic Name:
Pantoprazole/Protonix
Route/Dose/ Freq:
PO 40 mg
Pharmacologic
Classification & Action
Nursing Implications
Brand/Generic Name:
Spiriva
Route/Dose/ Freq:
Inhale 18 mcg
Pharmacologic
Classification & Action
Bronchodilators
Acts as anticholinergic by selectively and reversibly inhibiting M3
receptors in smooth muscle of airways.
ANGIOEDEMA
Nursing Implications
Brand/Generic Name:
Warfarin
Route/Dose/ Freq:
PO 2.5 mg
Pharmacologic
Classification & Action
Anticoagulants
Interferes with hepatic synthesis of vitamin K-dependent clotting
factors (II, VII, IX, and X).
BLEEDING
Nursing Implications
aspirate).
Brand/Generic Name:
Albuterol
Times: PRN
Route/Dose/ Freq:
Pharmacologic
Classification & Action
Bronchodilators
Binds to beta2-adrenergic receptors in airway smooth muscle,
leading to activation of adenyl cyclase and increased levels of
cyclic-3$, 5$-adenosine monophosphate (cAMP).
Nursing Diagnoses
Nursing Implications
Brand/Generic Name:
Oxycondone
Times: Q4H
Route/Dose/ Freq:
PO 5-10 mg PRN
Pharmacologic
Classification & Action
opioid analgesics
Binds to opiate receptors in the CNS. Alters the perception of and
response to painful stimuli, while producing generalized CNS
depression.
Nursing Implications
6. Labs: give patient result and normal range; for abnormal results give possible reasons
for the abnormal results and how the abnormality might affect the patient.
Lab
HCT
Hgb
Na
K
Glucose
BUN
creatinin
e
WBC
Pt
result
38.2
12.6
144
3.5
110
28 (H)
Normal range
0.6
11.4 (H)
3.8 - 11.0 K / mm
cubed
39 - 54%
14 - 18 g/dL
135 - 148 mEq/L
3.5 - 5.5 mEq/L
70 - 110 mg/dL
6 - 23 mg/dL
If abnormal:
why
Affect on patient
Kidneys aren't
working as well
as they should
Stress, drug
reaction,
infection, post
surgery
ABG
pH
7.35
7.31 - 7.41
CO2
2
41 - 51 mm Hg
HCO3
28
22 - 29 mEq/L
Others
II. Assessment: Complete as much as possible of this section before caring for the patient
Health Perception Health Management
Upon discussion of the patients general health he expressed how he new how bad his
health is. He not only battles Lung cancer as a smoker but also has heart issues and
Hepatitis C. He knows what he needs to do to prolong his life at this point but doesnt
really see the point as it will probably only give me a few extra months because my
health is already so far gone. I sensed a bit of depression in that comment and tryied to
console him.
**After caring for the patient list nursing diagnoses related to health perception/health
management:
Risk for infection
Risk for injury
Risk for perioperative positioning injury
Ineffective health maintenance
Risk for trauma
Nutritional/Metabolic
1. Diet which has been ordered for the patient: Soft Meal Plan with protein supplement
2. IV fluids and rates: Patient was not on fluids due to potential stress on his heart.
NO
8. What is the plan for checking vital signs?
Every hour on the hour
Time
HR
RR
BP
O2
Temp
07:00:00 AM
80
20
145/91
98
36.5
08:00:00 AM
78
24
154/98
97
37.1
09:00:00 AM
97
22
128/87
95
36.6
10:00:00 AM
106
26
145/92
98
37.9
12:00:00 AM
109
24
150/89
98
37.2
01:00:00 PM
85
20
129/87
98
36.5
02:00:00 PM
91
20
135/89
97
36.8
03:00:00 PM
84
20
127/91
96
36.9
04:00:00 PM
79
20
135/98
98
36.7
Cognitive/Perceptual
The patient understood everything why he was in the hospital. He also was oriented to
time and place. He also knows exactly what he is doing to himself by continuing to smoke
despite his cancer and surgeries.
**After caring for the patient, list nursing diagnoses related to cognition/perception:
Deficient of knowledge
readiness for enhanced comfort
Self-perception/Role Relationships
The patient described himself as someone typically in a good mood despite his many
medical issues. He said he does like having to come to the hospital for things like his
cancer, surgery, and other ailments but he knows it is needed. He appeared to be in a
pretty good mood the whole time I was with him. He never complained and always was
willing to allow us to do what we needed to with him even thought that meant us waking
him up on a number of occasions.
**After caring for the patient, list nursing diagnoses related to self perception/role relationships :
Fear and anxiety
Hopelessness
Powerlessness
Risk of loneliness
Situational low self-esteem
Sexuality/Reproduction (5%)
I did not assess this area of the functional health patterns with this patient. I felt it
unnecessary.
**After caring for the patient, list nursing diagnoses related to sexuality/reproduction:
Sexual dysfunction
Coping/Stress Management/Values/Belief Patterns (5%)
He said he is not a very religious man but believes in a god none the less. He said it isn't
usually a means of stress relief for him to resort to religious practices. He said it is
actually somewhat of a stressor instead. He said his form of relief is his wood working
hobbies and unfortunately smoking.
He said he generally feels good about himself and his life. He did mention that he wished
he could go back and undo a few choices here and there (like him starting to smoke and
other drugs he used).
**After caring for the patient, list nursing diagnoses related to this functional health pattern:
Ineffective coping
Patient HOB 45 degrees, no pulsations, heaves or lifts, no thrills are palpitated, Patient showed
atrial fibrillation for a few hours until he performed his physical therapy which sent him into a
perfect sinus rhythm thereafter.
IV sites Right forearm Patent, non-painful, intact, saline lock
Monitoring lines Patient has no IV lines connected to IV.
Drains:
Foley Catheter pateint and intact with some discomfort,
Heimlich drain from chest surgery site patent and intact with some pain upon
movement.
Dressings gauze dressing around Heimlich drain and on surgical device insertion sites.
Dressings are changes by doctor. Show no sign of bleeding through the dressings.
Braden Score: 21
IV. Look at all of the nursing diagnoses from the above assessment. Prioritize the first 5 nursing
diagnoses according to which are most threatening to the life and integrity of the patient
and/or family. Include at least one psychosocial nursing diagnosis.
1. Impaired gas exchange
2. Ineffective airway clearance
3. Acute Pain
4. Deficient of knowledge
5. Fear and Anxiety
V. Care Plan: make a plan of care for one of the priority nursing diagnoses. Each clinical paper
must have a care plan for a nursing diagnosis which is different from previous papers.
Subjective &
Objective data
pertinent to
nursing diagnosis
Nursing
Diagnosis R/T
& AEB
Nursing
Interventions:
Documented
rationale for
your
interventions
Evaluation of
goals:
Subjective:
Patient receiving a
second Upper
Lobectomy and
still having lung
cancer.
Impaired gas
exchange R/T
Removal of lung
tissue AEB
Dysnea,
verbalized
difficulty
breathing in
fully, and
needing oxygen
to stay in the 90
and above range
whilst on a
Short Term:
Patient will
understand the
reason we ask
him to use the
incentive
spirometer by
the end of the
shift
- Note respiratory
rate, depth, and
ease of
respirations.
Observe for use of
accessory muscles,
pursed-lip
breathing, changes
in skin or mucous
membrane color,
pallor, cyanosis.
- Respirations may be
increased as a result of
pain or as an initial
compensatory
mechanism to
accommodate for loss
of lung tissue;
however, increased
work of breathing and
cyanosis may indicate
increasing oxygen
consumption and
energy expenditures
and/or reduced
respiratory reserve.
Short Term:
Patient states
understanding
for use of
incentive
spirometer and
used it multiple
times during
the day.
- Auscultate lungs
for air movement
(LeMone 2013)
Also patient
stating that it is
harder to get a full
breath anymore
Objective:
Short Term: Be
Short Term:
Unable to
assess at this
saturation
monitor.
free of severe
symptoms of
respiratory
distress. By the
end of the week
Long Term:
Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within patients
normal range in
three months
time.
and abnormal
breath sounds.
- Investigate
restlessness and
changes in level
of consciousness.
- Assess patient
response to
activity.
Encourage rest
periods and limit
activities to patient
tolerance.
- Note
development of
fever.
- Consolidation and
lack of air movement
on operative side are
normal in the
pneumonectomy
patient; however, the
lobectomy patient
should demonstrate
normal airflow in
remaining lobes.
(LeMone 2013)
- May indicate
increased hypoxia or
complications such as
mediastinal shift in
pneumonectomy
patient when
accompanied by
tachypnea,
tachycardia, and
tracheal deviation.
(LeMone 2013)
- Increased oxygen
consumption demand
and stress of surgery
can result in increased
dyspnea and changes
in vital signs with
activity; however,
early mobilization is
desired to help prevent
pulmonary
complications and to
obtain and maintain
respiratory and
circulatory efficiency.
Adequate rest
balanced with activity
can prevent respiratory
compromise. (LeMone
2013)
time.
Long Term:
Unable to
assess at this
time.
Citations
Complete Blood Count. (n.d.). Retrieved February 12, 2015, from
http://labtestsonline.org/understanding/analytes/cbc/tab/test/
LeMone, P. (2013). Medical-surgical nursing: critical thinking in patient care. (5th ed., Pearson
new international ed.). Upper Saddle River, N.J.: Pearson.
Lung Cancer. (n.d.). Retrieved February 12, 2015, from
http://thoracicsurgery.stanford.edu/patient_care/lung_cancer.html
Nursing Diagnosis and 11 Gordon's Functional Health Patterns. (2011, March 11). Retrieved
February 12, 2015, from https://irmanweb.wordpress.com/2011/03/11/nursing-diagnosisand-11-gordons-functional-health-patterns/
Taber's cyclopedic medical dictionary (Ed. 21 ed.). (2005). Philadelphia: F.A. Davis.
Wilkinson, J. M., & Treas, L. A. (2011). Fundamentals of nursing (2nd ed.). Philadelphia: F.A.
Davis Co..