Marymount University Patient Worksheet

Student Name: __Chanelle Husbands Date: _10/16/12___ Location: _WHC 3NE Patients Identifying Data: Pts. Initials or Room: J.R. Age: _57yo_ Sex: __F_ Code Status: _Full____ Language: English Admit Date: 10/11/12 Chief Complaint: Fever, chills, swelling, tenderness Ethnicity: African American Religion: _Christian__ Admission Diagnosis: Left Breast Cellulitis__________________________________ Secondary Diagnosis (if present): ____Ovarian Cancer Surgery and Date (if applicable): 10/11/12 Left Breast incision and drainage, implant removal Assessment Data Allergies:______Hay fever ___________________________________ Pertinent History: ______See Attached _____________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Present Illness: ___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Vital Signs: Time: 7:40amT: _99.9F P:_89_ R: _18__ B/P: 139/64 Pulse Ox:_94%_ Activity Level: _Self _ Diet: ___Regular____ Oxygen: __Room Air___ IV: _Right Forearm NS ___ Intake: _NPO___ Output: ____ BM: 10/12/12 Drains:___No Drains __________________________________________________ Blood Glucose: Time: _7am___ Value: __193__ Time: _11am___ Value: __137__ Pathophysiology: (Related to patients present condition and current findings) _SeeAttatched____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Patient Snapshot: 63 year old African-American female came to Washington Hospital Centers Hematology Department on 10/11/12 for a routine Anemia consult. During the consult, patient stated that for the last two days she had been experiencing fever, chills and increased swelling, warmth and tenderness to left breast. Resident admitted on same day with Left Breast Cellulitis. Resident has a past medical history of Breast Cancer, Vitrectomy, Diabetes Mellitus, HPLP, Coronary Artery Disease, and Anemia. CT scan done to show appearance of cellulitis. Current medications include Protonix, Insulin, Arimidex, Aspirin, Lovenox, Imdur, Lisinopril, Metoprolol, Oxycodone, Juaniva, Vancomycin, Neurontin, Crestor, and Levothyroxine. Present illness includes worsening of the left breast cellulitis showing breast to be red, swollen, indurations, and slight serous drainage from nipple. Anemia History: stable normocytic anemia since 8/20/11; slight anemia prior to cancer diagnosis; worsened with chemotherapy; required transfusion twice; has sickle cell trait. Oncology History: 7/14/11 palpated mass in left breast, diagnosed with Metastic Breast Cancer; 8/26/12 left breast mastectomy with reconstruction; 10/11/11 vitrectomy for vitreal bleeding; 3/5/12 Chemotherapy- 10 cycles taxol; 5/20/12 Cardiac MI; 6/1/12 Completed radiation therapy Surgical History: Left Breast Reconstruction with Implant 2012; Virectomy 2011; Right subclavian MediPort 2011 (Removed 2012); Mastectomy 2011; Cholecystomy 2010; Thyroidectomy 2010; Hysterectomy 2002 Pathophysiology: The patient was admitted to the hospital with Left Breast Cellulitis. Cellulitis is a generalized infection with either Staphylococcus or Streptococcus and involves the deeper connective tissue. With cellulitis the localized area of inflammation may enlarge rapidly if not treated. Common side effects include redness, warmth, edema, tenderness, and pain. On rare occasions, blisters are present. The patient did exhibit almost all of these symptoms; her lefts breast showed signs of redness, warmth, and edema and she experienced tenderness upon palpation. This onset of cellulitis was likely secondary to her recent Breast Reconstruction surgery done in September. Patients who undergo surgery for breast cancer, whether in the setting of breast conservation, mastectomy, or implants, are at risk of developing infection at the surgical site and in soft tissue. Surgical trauma predisposes patients to skin infection by breaching normal tissue barriers. (Ignatavicius & Workman, 2012)

Lab Data: Test Hct 35.0

Result

Explanation of Abnormal Results Normal

Nursing Care Implications

Hgb

11.4

Normal

RBC

3.74

Normal

RDW

18.7

High

Platelet WBC

166

Normal Low Purpose of Test To see if any anatomical changes may have caused the cellulitis Nursing Care Implications Monitor for pain

3.4 Diagnostic Tests: Test Result CT Scan of Left Breast Implant in place

Systems Evaluation
A. Neuro Pupils Glasgow Coma Scale Orientation B. Cardiovascular Skin Color/temp. Capillary Refill Radial Pulses and Brachial pulses L/R Pedal Pulses L/R Edema site Rhythm Alert and Oriented X 3 PERRLA

Assessment Findings

Color appropriate to ethnicity, temperature warm Brisk Present on Left and Right side, equal, +2 Present on Left and Right side, equal, +2 Left Breast Normal

Mucus membrane Skin turgor C. Respiratory Breath Sounds Oxygen Oxygen saturation D. Gastrointestinal Bowel Sounds Abdomen E. Nutrition

Pink, moist, intact Elastic, no tenting

Clear, Symmetric, no adventitious sounds Client on no oxygen at this time 94%

Present x 4 quadrants, Hypoactive Soft, round, non-tender in 4 quadrants, non-distended

Appetite good, regular diet F. Genitourinary Bladder/Catheter

Non-distended, no masses, no catheter

G. Skin Intact Redness Wounds H. Musculoskeletal Range of Motion Gait/Posture I. Pain and Comfort Pain Score Location Intensity J. Psycho/Social Pt. adjustment to hospitalization Family/significant other Support/interaction K. Incision and/or Dressing Incision Dressing L. Knowledge

Skin intact, warm, good color; redness and swelling to Left breast; Scars on Left chest from mastectomy and breast reconstruction

Good ROM Steady gait; good posture

No Pain; some tenderness to left breast

Client adjusting well to hospitalization Self

Incision on Left breast from recent breast reconstruction; healing well No Dressing

Resident aware of diagnosis and diagnostic results M. Discharge Planning/Self Care Discharge date not yet set; planning will be implemented closer to discharge

N. IV Site/Access Right forearm, peripheral line O. Fall Risk Assessment Client not at risk for falls P. Activity/Functional Assessment Resident can participate in activities Q. Hygiene Practices good hygiene, no body odor or signs of poor hygiene

MEDICATION

DOSE/ROUTE

MEDICATIONS INDICATION SIDE FFECTS prevents blood clots

Abnormal heart rhythm, heart failure, Cutaneous vasculitis, easy bruising, discoloration of skin, skin necrosis, blisters, rash, Nausea, diarrhea, Anemia, major bleeding, reduced platelets, anaphylactic/ anaphylactoid reactions, itching, and hives, Pain, tenderness, irritation and redness, bleeding, Blood in urine, Difficulty in sleeping, lung swelling and inflammation, Increase in level of liver enzymes Nausea, vomiting, constipation, lightheadedness, dizziness, or drowsiness, mental/mood changes (such as agitation, confusion, hallucinations), severe stomach/abdominal pain, difficulty urinating, fainting, seizure, slow/shallow breathing, unusual drowsiness Low blood sugar with other medications, Headache, Inflammation of nasopharynx, Diarrhea, nausea, inflammation of pancreas, Upper respiratory tract infection.
Fatigue, increased weight, back pain, swelling in the extremities, weakness, infection, headache, accidental injury and abdominal pain, Dilatation of blood vessels, Indigestion, dry mouth or throat, constipation, increased appetite, diarrhea, nausea, vomiting and flatulence, Decrease in white blood cells, Muscle pain and fracture, Drowsiness, dizziness, incoordination, night blindness, tremor, nervousness, memory loss, depression, abnormal thinking and

Enoxaparin(Lovenox) 40mg/Subcut Q12h

NURSING CONSIDERATIONS Do not administer by IM injection Periodic blood counts, platelet count and stool occult blood test recommended. Do not use it in newborns or infants, because it contains benzyl alcohol. Monitor liver function carefully

Oxycodone (Oxycontin ER)

20mg PO Q12h

narcotic pain reliever, prescribed for moderate to severe pain.

Extended Release tablet; do not crush or chew

Januvia

50mg PO Q12h

Neurontin

300mg PO 3 times a day

used to control high blood sugar in people with type 2 diabetes anticonvulsant , prescribed for postherpetic neuralgia, and epilepsy

It may lead to low blood sugar, monitor blood sugar regularly.

*It may affect blood sugar level; monitor sugar level regularly. * Patient may develop with increased risk of suicidal thoughts; watch them carefully. * Monitor liver function, kidney function, and complete blood

twitching, Runny nose and cough, Abrasion, itching and rash, Swelling in the extremities, weight gain and increased blood sugar, Impotence, Blurred vision, eye inflammation, double vision and ear infection.

cell counts regularly while taking this medication.

Protonix Enteric Coated

40mg PO daily

gastro esophageal reflux disease (GERD)

Arimidex

1mg PO daily

may slow the growth of certain types of breast tumors that need estrogen to grow in the body Controlling diabetes Controlling diabetes prescribed for high blood pressure

Diarrhea; headache; nausea; stomach pain; vomiting, Severe allergic reactions; bone pain; chest pain; fast or irregular heartbeat; fever, chills, or sore throat; red, swollen, blistered, or peeling skin; liver problems; unusual bruising or bleeding; vision changes. Anxiety; back, bone, breast, joint, muscle, or pelvic pain; constipation; cough; diarrhea; dizziness; flu-like symptoms (eg, muscle aches, tiredness); hair loss; headache; hot flashes; loss of appetite; mild stomach pain; nausea; sore throat; stomach upset; sweating; trouble sleeping; vaginal dryness; vomiting; weakness; weight gain.

Do not crush or chew Monitor liver function regularly

*Do the lab test for menopause if status is doubtful. *Bone mass density (bone mineral density) test should be conducted at the start of the therapy and at regular intervals thereafter

NovoLog

2-8units SQ before meals 15 units SQ nightly 25mg PO daily

Low blood sugar

Lantus

Low blood sugar

Tiredness, dizziness, depression, confusion, short-term memory loss, headache, drowsiness, abnormal dreams and sleeplessness. Heart - Shortness of breath, slow heart rate, palpitations, heart failure, swelling in the extremities, fainting, chest pain, and low blood pressure. Respiratory - Wheezing and difficulty in breathing. Gastrointestinal - Diarrhea, nausea, dry mouth, gastric pain, constipation, flatulence, digestive tract disorders, and heartburn. Hypersensitive Reactions - Itching or rash. Miscellaneous - Musculoskeletal pain, blurred vision, decreased libido, and ringing in the ear. Swelling, redness, pain, soreness Dizziness, trouble sleeping, nausea, vomiting, diarrhea, headache, muscle cramps/spasms, easy bruising/bleeding, chest pain, confusion, new signs of infection, severe abdominal/stomach pain, slow/fast/irregular heartbeat, seizures, extreme tiredness, dark/cloudy urine, change in the amount of urine, yellowing eyes/skin. Swelling, redness, pain, soreness Dizziness, trouble sleeping, nausea, vomiting, diarrhea, headache, muscle cramps/spasms, easy bruising/bleeding, chest pain, confusion, new signs of infection, severe abdominal/stomach pain, slow/fast/irregular heartbeat, seizures, extreme tiredness

Metoprolol (ToprolXL)

Sliding Scale Coverage based on FSBS Monitor blood glucose Do not mix with other insulins Monitor blood glucose Extended Release tablet; do not crush or chew

Piperacillin-tazo + Sodium Chloride 0.9%

3.375gm/IVPB Q6h over 30min

to treat a wide variety of bacterial infections treats only bacterial infections of the intestines

Check patients allergies

Vancomycin in Sodium Chloride 0.9%

1.25gm/IVPB Q12h over 90min

Older adults may be more sensitive to this drug's effects, especially the kidney effects. Check patients allergies

(Hodgson and Kizior 2010)

Nursing Diagnoses: 1. Nsg. Dx: ____Risk for Infection _____________________________________________________ 2. Nsg. Dx: __Disturbed Body Image____________________________________ ______________________________________________________ 3. Nsg. Dx: ____Risk for Unstable Glucose Level ______________________________________________________ Time Plan (Scheduled activities, meds, treatments, nursing care, etc.) 0700 Vital Signs 0800 No BreakfastMaintain NPO status 0900 AM care done 1000 Medications

Physical Assessment Finger Stick 1100 Finger Stick Vital Signs 1200 No Lunch- Maintain NPO status

Linens Changed

1300

1400 Patient leaves to go to OR holding room to receive 2 units of blood before surgery

Notes: P- Left Breast Cellulitis, NPO, Preparing for Surgery, Diabetes Mellitus G- Pain management, maintain NPO status, maintain stable vital signs, and monitor
glucose I- Kept food and drinks away, check patients pain status twice this shift, took vital signs and checked blood glucose twice this shift, physical assessment, made bed E- Patient A&0x3. Vital signs stable. Blood Glucose 137 at 11am. No food or drinks given, NPO status maintained. Patient has no report of pain this shift. Patient left for the OR holding room at 2pm.

Care Plan: 1. Developed from one of the prioritized diagnoses. 2. Identify one short-term and one long-term outcome. 3. Identify one intervention for each outcome. 4. Complete evaluation of outcomes. Assessment Vital signs: T-99.9F P-89 R-18 B/P-139/64 Pulse Ox-94% Left breast swollen, red, serous discharge from nipple Patient to have implant removed in surgery today Patient appears uneasy, anxious, and nervous Patient verbalizes: I dont really want to have the implant removed, I hope everything is fine and they can put it back in Nursing Diagnosis Disturbed Body Image related to Left Breast Augmentation as evidenced by patient verbalization and appearance Expected Outcomes STG: Patient has knowledge and understanding of upcoming surgery LTG: Maintain a positive body image, regardless of the outcome of surgery Evaluate Outcomes STG: Goal Met. Patient reports understanding of surgery and outcomes LTG: Goal in progress. Patient education given but patient will need to demonstrate after surgery outcomes Interventions Evaluate level of clients knowledge of and anxiety related to situation. Observe emotional changes. Provide accurate information concerning surgery and outcome Discuss concerns about fear of mutilation, prognosis, rejection when client facing surgery or potentially poor outcome of procedure Provide patient teaching with information given at clients level of acceptance and in small pieces Rationale To determine what patient teaching is needed (Milgrom and Higgins 2009) To provide knowledge concerning surgery (Doenges 2011) To address realities and provide emotional support (Doenges 2011) To allow easier assimilation (Doenges 2011) Evaluation Patient exhibits decreased anxiety before surgery Patient expresses feelings concerning body image after the surgery Patient verbalizes I understand the possible outcomes of the surgery and I feel confident that I will be able to deal with any outcome

References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2011).Nurses pocket guide, diagnoses, prioritized interventions, and rationales. (12 ed.). F A Davis Co. Hodgson, B. B., & Kizior, R. J. (2010). Saunders nursing drug handbook 2011. W B Saunders Co. Ignatavicius, D., & Workman, D. (2012). Medical surgical nursing. (7 ed.). St. Louis Missouri: Elsevier. Milgrom, S., & Higgins, S. A. (2009). Management of cellulitis associated with treatment of breast cancer. The journal of supportive oncology, 7(5)

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