Chronic Cancer Case Study
Intro
Well researched client history:
Diagnoses defined:
Congestive Heart Failure (CHF) –
Orthopnea –
Acute Coronay Syndrome –
Diabetes –
Hypertension –
Acute anxiety –
Chronic depression –
Past and present health status:
Present: Chronically ill (see diagnoses above)
Past: COPD, peripheral vascular disease (no surgery due to medical condition), acute coronary syndrome (Jul ’08), previous rt carotid endarterectomy, CVA, hypertension for many years, and type II diabetes for more than 15yrs.
Family, support systems, community, occupation:
Lives with female friend who helps her with her poor balance and walking. Good family support; observed daughter, son in law and granddaughter sit with her in hospital
How client assess …show more content…
the health care system:
Summary of medical treatments, procedures, diagnostic tests
Medical treatments: O2 4L; Bipap prn; narcotics (morphine fast acting via IV, and long acting 24hr PO); insulin sliding scale; all meds
Procedures:
Diagnostic tests: MUGA scan;
How have these results affected your client’s health status?
Client is not doing well. Night of the 28th she was tachycardia. 29th day she was extremely fatigued and slept most of the day due to morphine and Gravol. Blood glucose levels fluctuated from critically low to critically high. Before Gravol was administered she responded to verbal cues; after Gravol, she was difficult to wake.
Describe the client’s feelings and /or concerns about the medical condition
Describe the effect of the condition on the client’s quality of life: effects ADLs as client is in pain possibly due to lungs (edematous), ACS; she has been confused since acute coronary syndrome in Jul 2008 and therefore needs constant monitoring as far as ADLs and medication. She has chronic complaints of shortness of breath and severe fatigue
Describe how the condition affects family life
Describe what is similar and what is different about the client’s history and the description in the literature
Similar:
Different:
Discuss the nursing management of the client including:
Your assessment of the client: responds to verbal and physical cues but slowly as she sleeps most of the time. When answering questions at times she answers logically and at other times she doesn’t. Family noted that she will start talking about events that are not related to the present such as checking the stew etc. Skin warm to the touch and pink, but was diaphoretic; resting heart rate about 80 beats per minute due to meds (tachy throughout the night of the 28-29th). Blood pressure 154/89 avg. Abdomen obese and soft. Respirations at 22 breaths per minute on 4L O2.
Client’s strengths and weaknesses:
Client’s needs:
Nursing interventions implemented with the client:
Evidence of research/literature to support choice of nursing interventions:
Evidence of a complete analysis of the nursing care, including the client’s response
Well researched client history:
Diagnoses defined:
Congestive Heart Failure (CHF) –
Orthopnea –
Acute Coronay Syndrome –
Diabetes –
Hypertension –
Acute anxiety –
Chronic depression –
Past and present health status:
Present: Chronically ill (see diagnoses above)
Past: COPD, peripheral vascular disease (no surgery due to medical condition), acute coronary syndrome (Jul ’08), previous rt carotid endarterectomy, CVA, hypertension for many years, and type II diabetes for more than 15yrs.
Family, support systems, community, occupation:
Lives with female friend who helps her with her poor balance and walking. Good family support; observed daughter, son in law and granddaughter sit with her in hospital
How client assess …show more content…
the health care system:
Summary of medical treatments, procedures, diagnostic tests
Medical treatments: O2 4L; Bipap prn; narcotics (morphine fast acting via IV, and long acting 24hr PO); insulin sliding scale; all meds
Procedures:
Diagnostic tests: MUGA scan;
How have these results affected your client’s health status?
Client is not doing well. Night of the 28th she was tachycardia. 29th day she was extremely fatigued and slept most of the day due to morphine and Gravol. Blood glucose levels fluctuated from critically low to critically high. Before Gravol was administered she responded to verbal cues; after Gravol, she was difficult to wake.
Describe the client’s feelings and /or concerns about the medical condition
Describe the effect of the condition on the client’s quality of life: effects ADLs as client is in pain possibly due to lungs (edematous), ACS; she has been confused since acute coronary syndrome in Jul 2008 and therefore needs constant monitoring as far as ADLs and medication. She has chronic complaints of shortness of breath and severe fatigue
Describe how the condition affects family life
Describe what is similar and what is different about the client’s history and the description in the literature
Similar:
Different:
Discuss the nursing management of the client including:
Your assessment of the client: responds to verbal and physical cues but slowly as she sleeps most of the time. When answering questions at times she answers logically and at other times she doesn’t. Family noted that she will start talking about events that are not related to the present such as checking the stew etc. Skin warm to the touch and pink, but was diaphoretic; resting heart rate about 80 beats per minute due to meds (tachy throughout the night of the 28-29th). Blood pressure 154/89 avg. Abdomen obese and soft. Respirations at 22 breaths per minute on 4L O2.
Client’s strengths and weaknesses:
Client’s needs:
Nursing interventions implemented with the client:
Evidence of research/literature to support choice of nursing interventions:
Evidence of a complete analysis of the nursing care, including the client’s response