Student name: Heather Rush				Date of Care:  04/10/2012                             
History of Present Illness (HPI)
Patient Initials: RC  Pt Age: 58 Gender: F   Date of Admission: 04/6/2012

Review the last 24 hours of nursing notes and the admitting physician’s history and physical exam to answer the items below, summarize the notes you read in your own words. 

Tell the story of how your patient ended up in the hospital:   (1pt)
The patient ended up in the hospital due to sortness of breath and dyspnea on exertion 

Medical & Surgical history (list the year of the diagnosis/ surgery)  (1 pt)
-	Pneumonia March 2012
-	COPD
-	Thyroid Surgery; resection some 10 to 15 years ago
Social History   (1pt)
Occupation: Odd jobs with home maintenance 
Lives with? Lives with daughter 
List family members involved with your patient’s care: Husband, daughter and son
Habits (Tobacco/Alcohol/ Drugs): Smoker 1PPD for 40-45 years; Drink alcohol in past, marijuana recreational use

Nursing Care:   (1 pt)
Isolation: none
Code Status: Full
Pain: 6
Fall Risk: 1
Hygiene: Refused bed bath; Independent 
Activity:  Independent up to as tolerated
Diet: Regular, no limitations
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
IV #20 Heplock Left-hand 
Right Chest tube (Dry seal)- Low continuous 64mmHg Vacuum 

Pathophysiology:

Identify the primary disease(s) that will be explained in this paper.    (1pt)
Lung cancer

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).  
Lung cancer is associated with cigarette smoking and it is a preventable form of cancer. Lung cancer is far advanced before it is discovered making the prognosis generally poor. The survival rate over five years is 13 to 15%.  The genetic change mainly from cigarette smoking converts normal bronchial cells to cancer cells.  It is extremely variable it can be local or systemic, often the malignancy develops insidiously giving little to no warning of its presence.  The manifestations can be in three categories: 1. Adjacent structures 2. Effects of local spread and metastasis                      3. Nonmetastatic paraneoplastic involving endocrine, neurologic and connective tissue functions.  Lung cancer can also cause nonspecific symptoms because they are often related to smoking and chronic bronchitis which are often dismissed.  Many of the manifestations of lung cancer result from local irritation and obstruction of the airways and from invasion of the mediastinum and pleural space. The early symptoms usually are chronic cough, SOB, and wheezing because of airway irritation and obstruction. In addition, the mass or tumorous cells evolve due to rapid and uncontrollable replication of normal cells. The diagnosis of lung cancer is based on a careful history and physical examination and on other tests such as chest radiography, bronchoscopy, cytologic studies of sputum or bronchial washing, percutaneous needle biopsy of the lung tissue and scalene lymph node biopsy. CT scan and MRI studies and ultrasonography are used to locate lesions and evaluate extent of disease (Porth, 2011, pg. 556).

What laboratory tests and diagnostics are used to diagnose this pathology, identify below which ones your patient has done and relate the results to the pathology. (5pts)
Laboratory Testing
     Hematology Value	Normal	If not, why?  Please relate to the disease process
Date   4/10 				Normal Value	
WBC   19.6L				4.0 – 11.0 10^3 / mm3  Possibly due to secondary lung 									   cancer	
	RBC    3.65L				3.63 – 5.04 10^6 / µL anemia-like possibly related to 									lung biopsy and pneumothorax
	Hgb    11.4L				12 – 15.3 g/dL anemia-like possibly related to 									lung biopsy and pneumothorax
HCT    33.8L				34.7 – 45.1  anemia-like possibly related to 									lung biopsy and pneumothorax
PLT     238				150-450 X 109/L 
INR     1.0		   -		0.9-1.2        
     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Date       4/10				Normal Value
Na           139				135 – 145 mEq/L	
K             4.2	             		3.4 – 4.5 mEq/L 

Cl            107				98 – 109 mEq / 24 hr
	BUN        16				6 – 26 mg/dL
	Cr            0.8    			.5 – 1g / 24 hr  
	Glucose  160H          			70 – 99 mg/dL High glucose levels possibly due to 
								Inadequate amounts of insulin 
								Secretion from the pancreas  

Other:  None
Diagnostic Imaging: none
a.	In your own words why is this test done- relate it to the pathology.
b.	If abnormal, what changes in your nursing care need to be made?  

ECG / Telemetry: none
CT (Cat Scan): none
MRI: none
Ultra Sound: none
Other: Lung Biopsy: Results did not come back

Medications
List all medications your patient has used in the last 24 hours including: 
1.	Medication name (generic) with prescribed dose & frequency, 
2.	The usual dose & frequency, 
3.	Classification & mechanism of action, 
4.	Why this medication is being used for this patient, 
5.	What nursing precautions considerations do you need to know to SAFELY administer / monitor this medications and lastly 
6.	Evaluate the medications effectiveness for this patient (patient response).  (10 pts)

Name (generic) 
prescribed dose 
& frequency, 
usual dose & frequency	Classification/
Mechanism 
of action	Why use this 
medication 
for this 
patient?	Nursing precautions/ 
safety considerations
To administer this medication	Evaluation
Patient response	
Proventil 2.5 mg/ 0.5mL vial
Albuterol Sulfate 2.5mg 0.5% solution RT Q4H NEB
Usual dose: 2-4 mg PO tid-qid	Beta- adrenergic agonists selectively stimulates beta-2 adrenergic receptors, relaxing airway smooth muscle
	Used to relax smooth muscle and expand bronchi for asthma  	caution if ischemic heart dz
caution if HTN;
caution if arrhythmias;
caution if hypokalemia;
caution if diabetes mellitus
	Signs of smoother breathing patterns with less tension	
Zithromax 500mg in Sodium Chloride 0.9% 250 mL
Azithromycin in 500mg in sodium chloride 0.9% 250mL
Usual dose: 500 mg IV q24h x2 or more days	Macrolid
bacteriostatic; binds to P site of 50S ribosomal subunit, interfering w/ protein synthesis	Used to treat infection caused by certain bacteria	azithromycin-assoc. cholestatic jaundice hx ;azithromycin-assoc. hepatic impairment hx ;caution if hepatic impairment; caution if renal impairment	No diagnostic results to determine decrease in bacterial infection	
Lovenox
Enoxaparin 40mg/ 0.4 mL SVR 40mg SC daily @14
Usual dose: 40 mg SC qd x6-11 days	Binds to antithrombin III and accelerates activity, inhibiting thrombin and Factor Xa (low-molecular weight heparin)	Anticoagulant used to prevent blood clots in certain illnesses or certain types of surgery	Hypersens. to pork products ;
Hypersens. to benzyl alcohol (mutidose vial form) ;active major bleeding ;thrombocytopenia hx, enoxaparin-assoc. 
; caution in elderly pts ;caution in pregnant pts w/ mechanical heart valve	No diagnostic results to determine if antibiotics were useful	
Solu-Medro
Methyprednisolone Sodium Succinate 125mg IV Q8hrs
Usual dose: 10-250 mg IV/IM q4h	Exact mechanism of anti-inflammatory action unknown; inhibits multiple inflammatory cytokines; produces multiple glucocorticoid and mineralocorticoid effects	Corticosteroid, used to reduce inflammation	Intrathecal (IT) administration; neonates or premature infants (benzyl alcohol-containing INJ forms) 
;thrombocytopenic purpura (IM use) 
; systemic fungal infxn 
;active or recent varicella infxn	No signs of inflammation	
Rocephin 1 GM in Sodium Chloride 0.45% 50mL Ceftriaxone sod 1GM in 0.45% Sodium Chloride 50 mL 200mL/hr IV Q24HR; usual dose:  1-2 g IM/IV q24h	Antibiotic/ bactericidal; inhibits cell wall mucopeptide synthesis	Cephalosporin antibiotic used to treat bacterial infections	Caution if concurrent nephrotoxic agents; hepatic and renal impairment; vitamin K deficiency; GI disorder 	No observation of dizziness , nausea or jaundice symptoms	
Atrovent INH solution
Ipratropium bromide NEB Q4H 0.02% Neb sol 2.5 ml vial RT QID
Usual dose: 0.5 mg NEB q6-8h	Antagonizes acetylcholine receptors, producing bronchodilation
	Prevents symptoms of emphysema of chronic bronchitis	caution if glaucoma, angle-closure; caution if prostatic hypertrophy; caution if bladder neck obstruction
	Patient experienced coughing in spurts 	
Oxycodone PO 15mg Q4-6HRS PRN
Usual dose: tart 5-15 mg PO q4-6h prn in opioid-naive pts;	Opioid, binds to various opioid receptors, producing analgesia and sedation (opioid agonist	Used to decrease pain levels	Hypersens. to drug/class/compon. ;respiratory depression, severe 
;asthma, acute or severe; hypercarbia 
;paralytic ileus; labor and delivery	Patient described pain level decreasing from a 6 to a 2	

(Comerford, 2012)

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)  (5 pts)     All subjective 
& objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %:
97%
Room Air 	BP:
 133/87
Right arm
Auto machine	Pulse:
Rate: 109 auto mach.
Rhythm: regular
	Respirations:
Rate: 19
Rhythm: regular	Temp:
96.9
Route: 
Tympanic	Pain:
Rating:     6   /10    Characteristics:  
Right side pain due chest tube which causes pain during suction of vacuum         	Ht: 175.26 cm ______
Wt: 67.217 kg___	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	-Muscle strength weakness bilaterally in uppers limbs, lower limbs 5/5
-A/O x 3 Aware, Alert and Oriented; could hear, see, talk  (knows name, date, place),orientation appropriate cooperative, anxiety mild
-No focal or gross neurological deficits

MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score__1__________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment  
            Needs support to stand and walk 	-No limitation of ROM
-Strength weakness bilaterally in upper limbs contributing to pneumothorax on right side
-Independent  without assistance or devices
-No pedal edema
-No acute phlebitis
-No cyanosis or clubbing 
 	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _3sec______
Neck Vein Distention:   Y   N      Edema  Y    N
Location of: ___________	-Heart sounds regular 
-All Peripheral pulses 2+, no murmurs, gallops or rubs
-All peripheral pulses no bruits	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	-Respiration with mild difficulty
-Lungs scattered rhochi; wheezing and diminished sounds in Right lower lung field 
-Some occasional expiratory wheezing in the right and left upper lung field, No wet crackles
 -Chest moves equally bilaterally upon inspiration and expiration. 
 -Also in place a pneumothorax tube upper right quadrant of thoracic
	
GASTROINTESTINAL:
Diet at home :  Regular        Current Diet:  Regular 
Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________	-Active bowel sounds in all quadrants
-No rebound or guarding, no obvious heptosplenomegaly, no inguinal adenopathy except near upper right quadrant due to pneumothorax
-BSx4 soft, flat, non-tender, non-distended, no organ omegaly
- LBM 04/7 
-Pain=6
-No masses, No distention	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _23__-No risk for ulcers__
Drains present:  Y         N       Type__Pneumothorax tube_____________	-R hand and R arm tattoo 
-Pink, warm and dry; turgor 
-IVsite L hand #20; no redness, intact
- No bruises
-No skin ulceration or petechiae 	
EENT: 
Ears:   Not HOH                              Eyes: Glasses bilaterally
Nose:  patent                           Teeth: own teeth  
                                                            	-Not HOH bilaterally
-Clear vision bilaterally/ wears glasses
-Own teeth except top 2nd tooth loose  
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type: ________	-Yellow/clear urine sediment, no pain, quantity 1810mL

PSYCHOSOCIAL/CULTURAL:
Educational level-- high school
Developmental level ; Appropriate for age
Coping methods; information seeking/ with guidance       
Health Beliefs: no affiliation
Occupation (previous if retired): Lawn care 
Religion & what it means to pt no affiliation
Personal/Family Data    (Think about home environment, family structure, and available family support)	

Lives with daughter  and her 4 children and someone who is like a son to him also is contributing 
(total of 5 children  29 grandchildren) 	
USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

Other: Priority Nursing Diagnosis: (Use NANDA format) (2pts)

Risk for airway obstruction related to inflammation and masses in upper right and left lobes in lungs evidence by SOB and secondary to lung cancer.

What does the patient/client need to accomplish?
GOALS/OUTCOMES
(2pts)
Measurable patient centered goals are identified, realistic and contain a time element.
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions
(2pts)
Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format
(2pts)
Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 
(2pts)
Includes all the following: 
1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 
3. Modifications to the plan of care.	

The goal is to teach and explain to the patient the importance of quitting smoking. Therefore, the goal would be for the patient to decrease the amount of cigarettes smoked per day (PPD). Goal:
1 cigarette Q3H over a 24hr period for 1 week then cut it down in half to 4cig per day @ 1 cig Q6HR/ 24hr for 1 week, the final week 2 cig total per day (24hr period) @ 1cig BID. No cig smoking the next following week and going forward (goal is continue to not smoke FOREVER).  

Monitor for signs of respiratory insufficiency
Such as increased respiratory rate, labored respirations, restlessness, agitation, confusion, increased pulse and BP, decreased SaO2 and increased PaCO2

	
Respiratory insufficiency can result from airway obstruction, ventilator problems, atelectasis, bronchospasm, or pneumothorax.
 (Moyet, 2009, p.721).

	
1. Corporative
2. Goals were not met
3. Modifications 
Continue to work on goals until completed if having a difficult request for a nicotine prescription from the physician

Reference List for all references used in this document.     Use APA format.          (1 pts)	

References

Comerford, K. C. (Ed.). (2012). Nursing 2012 drug handbook (32nd ed.). Philadelphia,   PA: 

Lippincott Williams & Wilkins.

Moyet, L. (2009). Mechanical ventilation. In J. Rodenberger, & M. Clark (Eds.), Nursing care plans & documentation: Nursing diagnoses and collaborative problems (5th ed.). Philadelphia, PA: Wolter Kluwer | Lippincott Williams & Wilkins.
Porth, C. M. (2011). Inflammation, the inflammatory response, and fever. In H. Surrena, & S. Loht (Eds.), Essentials of pathophysiology (3rd ed.). Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins.