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Digital Care Plan
3
DIGITAL CARE PLAN
PHENIX MCCURDY
NOTICING
AGE: 84
ADMITTING DX: LUNG CANCER METASTASIS- Refers to the spread of cancer cells from the lungs to other parts of the body. When cancer cells break away from the primary tumor in the lungs, they can travel through the bloodstream or lymphatic system to establish new tumors in distant organs or tissues.
CLINICAL MANIFESTATIONS: REDUCED APPETITE, N/V X1 WEEK, SOB, CHRONIC COUGH, CP
PAST HISTORY: LUNG & BREAST CANCER. WHICH THE LUNG CANCER HAS RETURNED AND IS THE REASON FOR THE HOSPITTAL STAY. ALSO A HX OF SMOKING FOR 20 YEARS
PHYSICAL ASSESSMENT DATA
LINES: SALINE LOC (FOREARM 20G)
TUBES/DRAINS: N/A
OXYGEN: 2L O2
WOUNDS & DRESSINGS: N/A
Gait: unsteady- due to reduced bone density
Capillary Refill: <3 seconds
Respiratory: Increased respiratory rate, use of accessory muscles, decreased breath sounds.
Cardiovascular: Tachycardia.
Integumentary: Pallor, signs of cachexia.
Oxygen: On nasal cannula at 2 L/min to alleviate hypoxia.
REASONING FOR S&S
Due to the cancer affecting lung tissue and metastasizing to bones, leading to decreased lung function and bone pain.
Complications to Assess For:
Respiratory failure
Infection due to compromised immunity
Severe pain due to bone metastasis
PSYCHOSOCIAL ASSESSMENT & MEDICATION
Limited support from family; they live out of state.
Patient is anxious and depressed due to diagnosis and prognosis.
Morphine Sulfate:
Purpose: Alleviates severe pain associated with cancer and metastasis.
Monitoring: Watch for signs of respiratory depression, constipation, and potential opioid addiction. Ensure dosage adjustment as needed.
Patient Teaching: Educate on the risk of dependency and the importance of taking medication as prescribed.
Cefepime (Maxipime):
Purpose: Broad-spectrum antibiotic to prevent or treat infections due to a compromised immune system.
Monitoring: Look out for allergic reactions, kidney function, and effectiveness against infection.
Patient Teaching: Take the full course of antibiotics, even if feeling better.
Sertraline (Zoloft):
Purpose: An SSRI to help alleviate symptoms of depression and anxiety.
Monitoring: Monitor for changes in mood, suicidal thoughts, and other side effects.
Patient Teaching: Inform about the potential for withdrawal symptoms and the necessity to taper the dose under supervision.
Albuterol Inhaler:
Purpose: Bronchodilator to help ease breathing difficulties.
Monitoring: Monitor for increased heart rate, palpitations, and jitteriness.
Patient Teaching: Educate on the proper technique to use the inhaler and to avoid overdosage.
Zoledronic Acid (Zometa):
Purpose: Helps strengthen bones and reduce pain from bone metastasis.
Monitoring: Monitor for hypocalcemia, renal function, and osteonecrosis of the jaw.
Patient Teaching: Educate on the importance of good oral hygiene and regular dental check-ups to prevent jaw issues.
DIAGNOSTIC TESTS
K
WBC
10.7
3.7
CT Scan: To assess the extent of metastasis and the impact on bone and other organs.
Other Disciplines Involved:
Oncology, palliative care, physical therapy, nutrition
Do They Have All the Support/Help:
Yes, but could benefit from more psychological support for depression and anxiety.
Mobility and Safety Risks:
Fall risk due to weakness; at risk for skin breakdown (12)
15. Safety Precautions:
Implement fall prevention strategies; regular turning and positioning to prevent pressure ulcers.
CREATINE
GLUCOSE
BUN
Na
1.28
109
20
150
Responding & Reflecting:
A. Prioritized Plan of Care:
Manage Pain: Severe due to bone metastasis.
Respiratory Support: Due to decreased lung function.
Emotional Support: Anxiety and depression.
Nursing Interventions
Administer pain relief, provide oxygen therapy, psychological support.
Evaluate the Response:
Pain decreased from 8 to 4; breathing easier with oxygen; patient is still anxious.
Other Interventions:
Could consider stronger pain relief; respiratory physiotherapy; counseling for anxiety.
Reflection:
The pain management was partially effective; anxiety remains a challenge; would explore additional psychological support options.
OVERVIEW
What went well: Pain management was effective to a certain extent, and the patient's respiratory status was stable with oxygen support.
What did not go as planned: The patient's anxiety and depression levels remain elevated, and nutritional intake is less than optimal.
What would you do differently: Integrate more holistic and psychological care approaches earlier in the care plan, involve family more effectively, and consider alternative pain management strategies.