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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: 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: 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