My patient is a forty-one-year-old female who was diagnosed with cholangiocarcinoma of the biliary tract. Her secondary diagnosis includes a jujuneostoomy, infection of her incision and wound care. Prior to admission she had a cholecystectomy which required her to be admitted to the hospital to receive skilled nursing care because she cannot care for herself. She has a large abdominal incision that requires packing. Additionally, she requires tube feeding and lots of IV antibiotics. She will be in the hospital until she dies or is cleared to go into hospice.
One of many concepts that my patient can be related to is cellular regulation because of her diagnosis of terminal cancer. Since, the cancer is terminal there are many other concepts …show more content…
The three nursing interventions for this diagnosis are to provide nonpharmacological comfort such as a massage, administer analgesics as indicated for discomfort, and determine location, frequency, duration, and intensity of pain using a zero to ten rating scale. Secondly, she is at risk for deficient fluid volume related to excessive losses through abdominal routs evidence by JP tube and output of dark urine. Her nursing interventions for this include monitor intake and output, assess vital signs, capillary refill, skin turgor, peripheral pulses, and mucous membranes, and administer IV fluids as prescribed and encourage fluid intake. Her third nursing diagnosis is she is at risk for infection related to inadequate secondary defense’s evidence by low lymphocyte counts (Wittmann, 2013). Three nursing interventions for this diagnosis include monitor her temperature, monitor lab values like the ANC, and require good hand washing techniques for personnel and visitors. Goals for her are to report maximum pain relief or control with minimal interference with ADLs. This goal was met because before she would administer her pain medication we would try and find a way to support her back when sitting in the chair. She will maintain adequate hydration with stable vital signs and appropriate output. This goal was met by stable vital signs, but her urine output still was dark amber in color later in the morning. I would add to this goal of drinking at least half of a cup of a beverage preferably water every hour to help with her hydration status (Mayo Clinic, 2015). She will identify actions to prevent or reduce risk of infection. She met this goal (Wittmann, 2013). Finally, her overall goal is that she will express feelings appropriately. She did express her feelings and let the nurses know what she specifically wanted, but this goal could be improved by giving her additional
One of many concepts that my patient can be related to is cellular regulation because of her diagnosis of terminal cancer. Since, the cancer is terminal there are many other concepts …show more content…
The three nursing interventions for this diagnosis are to provide nonpharmacological comfort such as a massage, administer analgesics as indicated for discomfort, and determine location, frequency, duration, and intensity of pain using a zero to ten rating scale. Secondly, she is at risk for deficient fluid volume related to excessive losses through abdominal routs evidence by JP tube and output of dark urine. Her nursing interventions for this include monitor intake and output, assess vital signs, capillary refill, skin turgor, peripheral pulses, and mucous membranes, and administer IV fluids as prescribed and encourage fluid intake. Her third nursing diagnosis is she is at risk for infection related to inadequate secondary defense’s evidence by low lymphocyte counts (Wittmann, 2013). Three nursing interventions for this diagnosis include monitor her temperature, monitor lab values like the ANC, and require good hand washing techniques for personnel and visitors. Goals for her are to report maximum pain relief or control with minimal interference with ADLs. This goal was met because before she would administer her pain medication we would try and find a way to support her back when sitting in the chair. She will maintain adequate hydration with stable vital signs and appropriate output. This goal was met by stable vital signs, but her urine output still was dark amber in color later in the morning. I would add to this goal of drinking at least half of a cup of a beverage preferably water every hour to help with her hydration status (Mayo Clinic, 2015). She will identify actions to prevent or reduce risk of infection. She met this goal (Wittmann, 2013). Finally, her overall goal is that she will express feelings appropriately. She did express her feelings and let the nurses know what she specifically wanted, but this goal could be improved by giving her additional