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CRITICAL THINKING SUMMARY
Student: Jade Gamber
Client Dx: NEUTROPENIC FEVER UNKNOWN CASE
Age: 64
Allergies: IODINE, LACTOSE
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Febrile neutropenia secondary to chemotherapy, Stage III BSCLC h/o CHI, dementia, seizure disorder
PATHOPHYSIOLOGY of diagnosed disease: (From text)
“Fever associated with an abnormally low neutrophil level, usually caused by infection. This condition is treated with
empirical antibiotic therapy pending the results of cultures. Neutropenia has many causes, including chemotherapy, radiation
exposure, aplastic anemia, bone marrow infiltration from malignancy, and complications of bone marrow transplantation.
The risk of potentially life-threatening infection is substantial when the absolute neutrophil count is below 500/mm3.”
(Mayo Clinic, 2013).
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Patients with febrile neutropenia may have few localizing findings, i.e., a patient with pneumonia may not have a cough,
pleurisy, or radiographic evidence of pneumonia because many of the clinical symptoms of a lower respiratory infection are
produced by the infiltration of the infected organ by neutrophils.
(Mayo Clinic, 2013).
CLIENT’S SYMPTOMS of the diagnosed disease include:






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Tachycardiac with rates in 140s and febrile
Temp of 100.4*F
Neutropenic with an ANC (Absolute neutrophil count) of 100
No chills or changes in health
Chronic area of skin breakdown from radiation.
Chest pain with swallowing
Loose stools
NUTRITIONAL ASSESSMENT:
Height (actual or estimated): 170.18 cm
Weight (actual or estimated): 89.5 kg
Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5’. Female: 100lb + 5lb/inch > 5’): 54 kgs
BMI: 31
No weight loss or gain during hospital stay.
Does this client have characteristics of a well-nourished person? Yes _____ No X
Explain your answer.
Pt has poor appetite, side effect related to chemotherapy, radiation therapy, and forgetfulness
Pt complains of a poor appetite, reports he is not eating anything, also complaining of loose stools. Observed 2 cups of broth
at bedside, however pt. reports he does not feel like drinking and feels as if he is going to vomit.
A normal serum albumin is a measure of good nutrition (3.5-5.0), because serum albumin level is below desired limits (2.4) it
indicates that the pt is not getting enough protein and may become malnourished, potentially leading to complications.
Pt presented with weak muscle tone, thinned hair, and decreased skin tugor.
What is the client’s developmental stage?
Middle Adulthood (40 to 65 years)
Generativity vs. Stagnation
Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that
benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow
involvement in the world (McLeod, 2008).
Has he/she met the necessary accomplishments? Yes
Explain.
No X
Pt has a history of alcohol abuse and has dementia which was evident while caring for the patient. He seemed very
uncomfortable and eager to leave the hospital. I do not believe that the pt was aware of his condition and the severity.
How is this illness affecting the client’s ability to meet these necessary accomplishments?
Because of the pt’s pain, his history, as well as his condition, this causes him to rely on the nurses and aids to care for him as
well as accomplishing his personal accomplishment (e.g., going to the bathroom on his own, feeding)
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnoses that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Risk for infection r/t neutropenia, over 60 years of age
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
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
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Weakness
Low WBC (0.19)
Decreased activity tolerance
OBJECTIVE/PATIENT OUTCOME for this diagnosis:
1. Remain free from symptoms of infection
2. Maintain normal lab values
3. Demonstrate appropriate hygienic measures such as hand washing, oral care and perineal care
NURSING INTERVENTIONS that will assist the patient to resolve the above identified diagnosis:
1. Establish/maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, normal body temperature,
normal oxygenation (if the client experiences low oxygen saturation, deliver supplemental oxygen), normal BP, RR, HR.
Monitor for any trend occurring in these manifestations.
2.Determine if the client is nourished, watch for possible protein-calorie malnutrition. Consult with physician or dietitian as
needed if malnutrition is present to ensure good nutrition
#2 NURSING DIAGNOSIS (problem r/t)
Nausea r/t chemotherapy treatment
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Aversion to food; gagging sensation; increased salivation; increased swallowing; report of nausea; sour taste in mouth.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Pt will state relief of nausea.
Pt will explain methods they can use to decrease nausea and vomiting.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Document each episode of nausea and/or vomiting separately as well as effectiveness of interventions. Consider an
assessment tool for consistency of evaluation.
2. Administer appropriate antiemetics, according to emetic cause, by most effective route, considering the side effects
of the medication.
3. Provide oral care after patient vomits.
COMPLICATIONS:
If this client’s condition were to worsen, what would be the most likely reason and why?
If this client’s condition were to worsen it would be because his chemotherapy is taking a toll on his body and his nausea and
vomiting never were controlled. His condition could also worsen because he can’t be put into remission and his cancer
worsens.
How would you know this is happening?
His labs values are not within normal limits. He may also lose weight and have a lot of fatigue, lose muscle strength, and
become weak.
What will you do if this happens?
If this were to happen, keeping him hydrated would be important to his care. He would also need antiemetics and maybe even
a PT and OT consult. If his worsening was due to cancer spreading, he may want to reevaluate his original plan of care with
his doctor and family members.
(Ladwig & Ackley, 2011)
PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS
MEDS/IVs/TX/
DIET
(Include dose,
route,
frequency)
Calcium
Gluconate, 500
mg, PO, bid
REASON
PRESCRIBED
(Drug
Classification,
What is it
treating?)
mineral and
electrolyte
replacements/
supplements
Treating: calcium
deficiency
NURSING IMPLICATIONS FROM TEXT
(Checking for adverse reactions, preparation &
administration concerns)
CLIENT DATA FROM YOUR ASSESSMENT
(What data is important to know before & after giving)
High Alert: Errors with IV calcium gluconate and
chloride have occurred secondary to confusion over
which salt is ordered. Clarify incomplete orders.
Confusion has occurred with milligram doses of calcium
chloride and calcium gluconate, which are not equal.
Chloride and gluconate forms are routinely available on
most hospital crash carts; physician should specify form
of calcium desired. Doses should be expressed in mEq.
Calcium Supplement/Replacement: Observe patient closely for
symptoms of hypocalcemia (paresthesia, muscle twitching,
laryngospasm, colic, cardiac arrhythmias, Chvostek's or
Trousseau's sign). Notify physician or other health care
professional if these occur. Protect symptomatic patients by
elevating and padding siderails and keeping bed in low position.
Monitor BP, pulse, and ECG frequently throughout parenteral
therapy. May cause vasodilation with resulting hypotension,
bradycardia, arrhythmias, and cardiac arrest. Transient increases in
BP may occur during IV administration, especially in geriatric
patients or in patients with hypertension. Assess IV site for
patency. Extravasation may cause cellulitis, necrosis, and
sloughing. Monitor patient on digitalis glycosides for signs of
toxicity.
PO: Administer with a full glass of water, with or
following meals.
Lab Test Considerations: Monitor serum calcium or ionized
calcium, chloride, sodium, potassium, magnesium, albumin, and
parathyroid hormone (PTH) concentrations before and periodically
during therapy for treatment of hypocalcemia. May cause
decreased serum phosphate concentrations with excessive and
prolonged use. When used to treat hyperphosphatemia in renal
failure patients, monitor phosphate levels.
Toxicity Overdose: Assess patient for nausea, vomiting, anorexia,
thirst, severe constipation, paralytic ileus, and bradycardia. Contact
physician or other health care professional immediately if these
signs of hypercalcemia occur.
Depakote, 500
mg, PO, tid
anticonvulsant
Treating: seizure
disorder
Do not confuse Depakote ER and regular dose
forms. Depakote ER produces lower blood levels than
Depakote dosing forms. If switching
from Depakote to Depakote ER, increase dose by 820%.
Single daily doses are usually administered at bedtime
because of sedation.
PO: Administer with or immediately after meals to
minimize GI irritation. Extended-release and delayedrelease tablets and capsules should be swallowed whole,
do not open, break, or chew; will cause mouth or throat
irritation and destroy extended release mechanism. Do
not administer tablets with milk or carbonated beverages
(may cause premature dissolution). Delayed-release
divalproex sodium may cause less GI irritation than
valproic acid capsules.
Shake liquid preparations well before pouring. Use
calibrated measuring device to ensure accurate dose.
Syrup may be mixed with food or other liquids to
improve taste. Sprinkle capsules may be swallowed
whole or opened and entire capsule contents sprinkled
on a teaspoonful of soft, cool food (applesauce,
pudding). Do not chew mixture. Administer
immediately; do not store for future use. To convert
from valproic acid to divalproex sodium, initiate
divalproex sodium at same total daily dose and dosing
schedule as valproic acid. Once patient is stabilized on
Seizures: Assess location, duration, and characteristics of seizure
activity. Institute seizure precautions.
Lab Test Considerations:
Monitor CBC, platelet count, and bleeding time prior to and
periodically during therapy. May cause leukopenia and
thrombocytopenia. Monitor hepatic function (LDH, AST, ALT,
and bilirubin) and serum ammonia concentrations prior to and
periodically during therapy. May cause hepatotoxicity; monitor
closely, especially during initial 6 mo of therapy; fatalities have
occurred. Therapy should be discontinued if hyperammonemia
occurs. May interfere with accuracy of thyroid function tests. May
cause false-positive results in urine ketone tests.
Toxicity Overdose: Therapeutic serum levels range from 50–100
mcg/mL (50–125 mcg/mL for mania). Doses are gradually ↑ until
a pre-dose serum concentration of at least 50 mcg/mL is reached.
However, a good correlation among daily dose, serum level, and
therapeutic effects has not been established. Monitor patients
receiving near the maximum recommended 60 mg/kg/day for
toxicity.
divalproex sodium, attempt administration 2–3 times
daily.
Folic Acid, 1
mg, PO, daily
antianemics
vitamins
Treating: help the
body produce and
maintain new cells,
helps prevent
changes to DNA
that lead to cancer.
LamoTRIgine,
75 mg, PO,
daily
Anticonvulsant
Treating: seizure
disorder
Do not confuse folic acid with folinic acid (leucovorin
calcium). Because of infrequency of solitary vitamin
deficiencies, combinations are commonly administered
(see combination drugs). May be given subcut, deep IM,
or IV when PO route is not feasible.
PO: Antacids should be given at least 2 hr after folic
acid; folic acid should be given 2 hr before or 4–6 hr
after cholestyramine.
Do not confuse lamotrigine (Lamictal) with lamivudine
(Epivir) or levothyroxine. When converting from
immediate-release to XR form, initial dose of XR should
match the total daily dose of immediate-release
lamotrigine; monitor closely and adjust and needed.
PO: May be administered without regard to meals.
Swallow XR tablets whole; do not break, crush, or
chew. Lamotrigine should be discontinued gradually
over at least 2 wk, unless safety concerns require a more
rapid withdrawal. Abrupt discontinuation may cause
increase in seizure frequency.
Orally Disintegrating Tablets: Place on the tongue and
move around the mouth. Tablet will rapidly disintegrate,
can be swallowed with or without water, and can be
taken with or without food.
Lidocaine
patch, 1 patch,
TOP, qhs
anesthetics
(topical/local)
Treating: pain r/t
radiation burn
High Alert: Lidocaine is readily absorbed through
mucous membranes. Inadvertent overdosage of
lidocaine jelly and spray has resulted in patient harm or
death from neurologic and/or cardiac toxicity. Do not
exceed recommended doses.
Transdermal: When used concomitantly with other
products containing local anesthetic agents, consider
amount absorbed from all formulations.
Multi-vitamin,
1 tab, PO, daily
vitamins
Treating: vitamin
deficiency
Vitamins are usually given orally but may be given
parenterally to patients in whom oral administration is
not feasible. Combinations with >1 mg folic acid require
a prescription.
PO: Forms are not standardized. Chewable tablets
should be crushed or chewed before swallowing. Liquid
preparations may be dropped directly into the mouth or
mixed with juice or cereal.
silver
anti-infectives
Generally applied after cleansing and debriding of burn
Assess patient for signs of megaloblastic anemia (fatigue,
weakness, dyspnea) before and periodically throughout therapy.
Lab Test Considerations: Monitor plasma folic acid levels,
hemoglobin, hematocrit, and reticulocyte count before and
periodically during therapy. May cause ↓ serum concentrations of
other B complex vitamins when given in high continuous doses.
Monitor closely for notable changes in behavior that could indicate
the emergence or worsening of suicidal thoughts or behavior or
depression. Assess patient for skin rash frequently during therapy.
Discontinue lamotrigine at first sign of rash; may be lifethreatening. Stevens-Johnson syndrome or toxic epidermal
necrolysis may develop. Rash usually occurs during the initial 2–8
wk of therapy and is more frequent in patients taking multiple
antiepileptic agents, especially valproic acid, and much more
frequent in patients <16 yr. Monitor for hypersensitivity reactions
(fever, lymphadenopathy with or without rash) If cause cannot be
determined, discontinue lamotrigine immediately.
Seizures: Assess location, duration, and characteristics of seizure
activity.
Lab Test Considerations: Lamotrigine plasma concentrations
may be monitored periodically during therapy, especially in
patients concurrently taking other anticonvulsants. Therapeutic
plasma concentration range has not been established, proposed
therapeutic range: 1–5 mcg/mL.
Anesthetic: Assess degree of numbness of affected part.
Transdermal: Monitor for pain intensity in affected area
periodically during therapy.
Lab Test Considerations: Serum electrolyte levels should be
monitored periodically during prolonged therapy.
Toxicity Overdose: Serum lidocaine levels should be monitored
periodically during prolonged or high-dose IV therapy.
Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/mL.
Signs and symptoms of toxicity include confusion, excitation,
blurred or double vision, nausea, vomiting, ringing in ears,
tremors, twitching, seizures, difficulty breathing, severe dizziness
or fainting, and unusually slow heart rate. If symptoms of overdose
occur, stop infusion and monitor patient closely.
Assess patient for signs of nutritional deficiency before and
throughout therapy. Patients at risk include geriatric patients and
those who are debilitated, burned, or unable to take oral nutrition
and those with malabsorption syndromes or chronic alcoholism.
Toxicity Overdose: Toxicity rarely occurs with multivitamin
preparations because of the small amounts per unit of fat-soluble
vitamins. For symptoms, see individual vitamin entries. If
overdose occurs, treatment includes induction of emesis or gastric
lavage, calcium gluconate IV if hypocalcemic, and maintenance of
high urine output.
Assess burned tissue for infection (purulent discharge, excessive
sulfADIAZINE
, 1 application,
TOP, tid
Ondansetron, 4
mg, PO, q8h
(topical)
wound. Premedicate with analgesic.
Treating:
prevention of
infection on burnt
skin
Topical: Cream is white; discard if it becomes dark. Use
sterile technique to apply. Cover entire wound at depth
of 1.5 mm. Reapply to sites where cream rubs off as a
result of patient movement; burn should be coated at all
times. Burn may be dressed or kept open, depending on
order of physician or other health care professional.
antiemetics
First dose is administered prior to emetogenic event.
Treating: nausea
and vomiting
PO: For orally disintegrating tablets, do not attempt to
push through foil backing; with dry hands, peel back
backing and remove tablet. Immediately place tablet on
tongue; tablet will dissolve in seconds, then swallow
with saliva. Administration of liquid is not necessary.
moisture, odor, and culture results) and sepsis (WBC, fever, or
shock) prior to and throughout course of therapy. Monitor for
hypersensitivity reaction (rash, itching, or burning) at and
surrounding sites of application.
Lab Test Considerations: Monitor renal function studies and
CBC periodically when applied to large area, because systemic
absorption may cause nephritis and reversible leukopenia.
Decrease in neutrophil count is greatest 4 days after initiation of
therapy; levels usually normalize after 2–3 days.
Assess patient for nausea, vomiting, abdominal distention, and
bowel sounds prior to and following administration. Assess patient
for extrapyramidal effects (involuntary movements, facial
grimacing, rigidity, shuffling walk, trembling of hands)
periodically during therapy. Monitor ECG in patients with
hypokalemia or hypomagnesemia, HF, bradyarrhythmias, or
patients taking concomitant medications that prolong the QT
interval.
Lab Test Considerations: May cause transient ↑ in serum
bilirubin, AST, and ALT levels.
Potassium
phosphate, 2
tabs, PO, bid
mineral and
electrolyte
replacements/suppl
ements
Treating:Treatment
and prevention of
hypophosphatemia
or hypokalemia.
(Davis’s Drug Guide. 2013)
High Alert: Too rapid or bolus IV administration of
potassium has resulted in fatalities. See IV
administration guidelines below.
PO: Powder packets should be dissolved in 75 mL of
water. Allow mixture to stand for 2–5 min to ensure that
it is fully dissolved. Medication should be administered
with meals to minimize gastric irritation and risk of
diarrhea. Do not administer simultaneously with
antacids containing aluminum, magnesium, or calcium.
Assess patient for signs and symptoms of hypokalemia (weakness,
fatigue, arrhythmias, presence of U waves on ECG, polyuria,
polydipsia) and hypophosphatemia (anorexia, weakness, decreased
reflexes, bone pain, confusion, blood dyscrasias) throughout
therapy. Monitor pulse, BP, and ECG prior to and periodically
throughout IV therapy. Monitor intake and output ratios and daily
weight. Report significant discrepancies.
Lab Test Considerations: Monitor serum phosphate, potassium,
and calcium levels prior to and periodically throughout therapy.
Increased phosphate may cause hypocalcemia. Monitor renal
function prior to and periodically throughout course of therapy.
Toxicity Overdose: Symptoms of toxicity are those of
hyperkalemia (fatigue, muscle weakness, paresthesia, confusion,
dyspnea, peaked T waves, depressed ST segments, prolonged QT
segments, widened QRS complexes, loss of P waves, and cardiac
arrhythmias) and hyperphosphatemia or hypocalcemia
(paresthesia, muscle twitching, laryngospasm, colic, cardiac
arrhythmias, or Chvostek's or Trousseau's sign). Treatment
includes discontinuation of infusion, calcium replacement, and
lowering serum potassium (dextrose and insulin, sodium
bicarbonate, or albuterol to facilitate passage of potassium into
cells, sodium polystyrene sulfonate as an exchange resin, and/or
dialysis in patients with impaired renal function).
Analysis of Diagnostic Tests
DIRECTIONS:
1.
List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications) and
provide the patient values for each test. Explain why they are pertinent for this patient.
2.
List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased or
decreased in relation to your patient's medical condition.
Diagnostic/Lab Test
Patient Values
0.19* CL
WBC
6.4 L
Calcium
0.5 L
Magnesium
1.1 L
Phosphorus
8.9 L
Hgb
25.4 L
Hct
Platelet
40.0 L
6.0 L
Urea Nitrogen
Low levels associated with anemia, bleeding,
destruction of RBC’s, Leukemia,
malnutrition, over hydration, nutritional
deficiencies (iron, folate, b12, b6).
Decreased platelets may be caused by a drug
side effect, immune system problem, or
leukemia. Nurses should watch for bleeding
b/c they don’t have much of a clotting
system.
Low levels indicate liver disease or damage,
malnutrition.
3.2 L
Low levels caused by kidney failure, diarrhea
and vomitting, excessive sweating, excessive
use of laxatives, and diuretics.
2.4 L
Low levels- kidneys diseases, liver diseases
(hepatitis, cirrhosis, ascites)
5.8 L
Indicates pt is not getting adequate protein
and may become malnourished, potentially
leading to further complications.
K+
Albumin
Total Protein
Analysis of Values
Low levels mean a decrease in disease
fighting cells caused by disrupted,
diminished or cancer of the bone marrow.
Also caused by immune disorders or even
some drugs (chemo).
Low levels caused by vit. D deficiency,
chronic renal failure, magnesium deficiency,
alcoholism, leukemia, diuretics and estrogen
replacement therapy.
Low levels caused by diuretics, antibiotics,
and antineoplastics, poorly controlled
diabetes, magnesium deficiency.
Low levels: hyercalcemia, overuse of
diuretics, malnutrition, alcoholism, severe
burns, hypothyroidism
Low levels could indicate blood loss or iron
deficiency.
References
Neutropenia. (2013). Mayo Clinic. Retrieved from http://www.mayoclinic.com/health/neutropenia
McLeod, S. A. (2008). Erik Erikson | Psychosocial Stages - Simply Psychology. Retrieved
from http://www.simplypsychology.org/Erik-Erikson.html
Ladwig, G., & Ackley, B. (2011). Mosby's guide to nursing diagnosis (3rd ed.). Maryland Heights, Mo.:
Mosby/Elsevier.
Nursing Central. (2013). Davis’s Drug Guide. Retrieved from http.//nursing.unboundmedicine.com