Ncp of Client With Cancer Servix With Multiple Bone Metastasis (1)

8/20/2019 Ncp of Client With Cancer Servix With Multiple Bone Metastasis (1)

1/17

NURSING CARE PLAN IN PATIENT WITH MULTIPLE BONE AND PULMONARY

METASTASIS SRINAGARIND HOSPITAL KHON KAEN

279 731 Advanced Nursing Practice in Selected Areas of Interest 1 (Adult 1)

Presented to:

Assoc Prof. Dr. ar!"orn #$ong%ra&ai

'eida ael *a!dani +,+-,-1292

Master of Nursin S!ien!e Prora"

#a!u$t% of Nursin& K'on Kaen Uni(ersit%

#irst Se"ester& A!a)e"i! Year *+,-

1


2/17

CLIENT ASSESMENT WITH MULTIPLE BONE METASTASIS IN ACCIDENT AND

EMERGENCY WARD *& SRINAGARIND HOSPITAL KHON KAEN

A. /A#/ /IS#0*

Assess!ent at 2 August 2-11. 4lient Profile

'rs. N. is a 27 ears old5 S$e lives 6it$ $er $usand and 2 doug$ters in Nong 8$ai. #$e

first doug$ter is 2 ears old and t$e second doug$ter is !ont$. #$e 'a&or reason for

see%ing $ealt$ care in Srinagarind /os"ital is severe "ain in $er lo6 ac% (rig$t $i")

es"eciall in t$e rig$t side. S$e arrived at Srinagarind /os"ital at 21 August 2-15 6it$

t$e !a&or reason severe "ain in $er $i" and lo6 ac% one. S$e feel severe "ain at least +

!ont$ ago. At "resent $er lood "ressure: 127735 Pulse rate 1-+ "er!inute5 res"irator

rate: 2- "er!inute and te!"erature: 3.39 -4. aorator record: / : 7 5 /ae!atocrit:

2. (nor!al: )5 *4: ,-5-- (Nor!al: )5 Platelet: ,,. --- (nor!al: )5 Neutrofil: 92

(nor!al: )5 asofil 3 (Nor!al: )5 'onocte: 3 (nor!al: )5 ;4: 3 (nor!al: )

2. #reat!ent'edication

efore s$e 6ents to Srinagarind $os"ital5 s$e ca!es to t$e !an doctor 6$ic$ is closer

fro! $er $ouse. ut t$e result after t$e !edication 6as sa!e5 t$e "ain 6as not relieve et

and still severe.

3. Past illnesses/os"itali


3/17

and t$e %ind of t$e disease. If s$e got sic% s$e 6ent to t$e doctor or $ealt$ care services.

Pain is ver severe and s$e e"ect t$at s$e 6ill get sic% for a long ti!e after $os"italiI don=t $ave "role! 6it$ o6el "attern5 efore sic% and

$os"itali


4/17

/earing: s$e $as not "role! in $er ears. S$e does not 6ear an $earing aids. Does

not as% for Cuestion to e re"eated at nor!al $ealing level. S!ell: states s$e $as no decrease in s!ell. No allergies5 noseleeds5 or disc$arge

#ouc$: #$e "ain area feel co!fort and feel etter if so!e one touc$ and give t$e soft

!assase in t$e ac% area and $er rig$t leg. Pain: ad!it "ain in $er lo6er $i" and lo6er etre!it5 and t$e rig$t side !ore severe

t$an t$e left side. >I feel ver "ain if I !ove ! od. I can not 6al%5 I &ust le do6n

in t$e ed. I need so!e one to $el" !e if I 6ant to sit5 I can not do it ! self?.

13. 4ognitive Pattern S"eec$ clear 6it$out stutter. ;ord c$oice a""ro"riate to education and culture. S$e

can s"ea%s nglis$ 6ell and fluentl. ollo6s veral cues a!ines ideas clearl and concisel. *ecalls "ast events 6it$out difficult5 oriented

to ti!e5 "lace5 and "erson5 and co!!unicative.

S$e don=t $ave a "role! in $er cognition.1. *olerelations$i" Pattern

'arried for 3 ears. ives 6it$ $usand and $er 2 little doug$ters5 t$e first one 2 ears

old5 and t$e second one is !ont$. /er $usand ver loves $er5 and ta%e care of $er and

t$eir doug$ters. ;$en s$e is $os"italiI a! ver stress5 I do not %no6 6$at 6ill I do no6 and after t$is5 I 6ill

get sic% and severe "ain for a long ti!e. I can not doing ant$ing. If I a! u" to 3+ ears

old is o%a if I get sic% li%e t$is5 ut I a! 27 ears old5 I a! a ounger !ot$er5 I $ave t6o

aies5 I $ave a $usand? and s$e cried 6$en s$e told to t$e nurse.

. EN*A P/ISI4A ASSS'N#

Eeneral "$sical surve

4


5/17

• /eig$t: 1+ c! 5 ;eig$t: +- %g Ideal od 6eig$t: 2- (nor!al)5 s$e loss $er 6eig$ ,

%g !ont$s.

• od #e!"erature: 3.39 -45 "ulse 1-+ "er!inute5 res"irator rate 2- !nt lood

"ressure: 12773 !!/g5 client attentive and coo"erative. ing do6n5 on su"ine5

so!eti!e se!i fo6ler if s$e got tired and t$e rig$t leg "ro" 6it$ "illo6. So!eti!e

$er face s$o6n li%e $olding "ain5 gra!icing5 and $old t$e "ain area. eel severe "ain

in $er rig$t $i" and lo6 ac% one5 scale of t$e "ain is 9.

17. Asses!ent of S%in5 /air and Nails

• S%in: dar% ro6n color5 consistent t$roug$out t$e od. #e!"erature 6ar! on $ands5

ar!5 leg5 and t$e ac%. S%in s!oot$5 no de$dration sign5 so!eti!e itc$ing ecause

s6eating5 and t$e s%in 6et. No ede!a

• /air: S$e $as a long lac% $air5 and t$ic%. S$e used $air color5 and t$e color is reddis$.

No recent $air loss or c$ange in teture.• Nails: fingernails s$ort5 t$ic% and clear. No cluing or eaus lines. Nor!al 4a"illar

refill (F3 second)

1. Asses!ent of /ead and Nec%

• /ead s!!etricall rounded5 nec% 6it$ full *0'5 and nontender. No scars5 !asses or

"ulsation. #rac$ea !idline. 4arotid "ulse 2 G ilaterall 6it$out ruits5 can rise

eero65 and s!ile (4N BII intact)19. Asses!ent of e and ear

• Nor!al ee: eCual si


6/17

• No visile "ulsation5 $eaves5 lifts5 or virations.

• S15 S2 sounds5 $eard no s"litting sounds5 !ur!urs5 gallo"s5 or rus.

23. Asses!ent of P$ari"$eral Bascular sste!

• Ar!s: eCual in si


7/17

• 4aseas one at rig$t acetaular G "elvis

• No anor!al soft tissue lesion (after io"s)

29. Neurologcal Asses!ent

• Neurological status: oriented to ti!e5 "lace5 "erson5 and events.

• acial e"ression correlates 6it$ state of $ealt$ and to"ic eing discussed (a""ears

so!e6$at sad5 $a""5 anious)

• S"eec$ clear and co$erent

• Huestions an6ered a""ro"riatel

• ongter! and s$ortter! !e!or intact

• 4oo"erative t$roug$out intervie65 vocaular correlates to educational level.

• As%ed a""ro"riet Cuestion relevant to illness and ans6ered all Cuestion "osed.

• 4N III intact and integrated

4. S@PP0*#D ASSS'N#1. '*I of #$oracic S"ine5 at -9 June 2-1

inding:

SP # la!inecto!#$e studt reveals nor!al t$oracolu!ar curve. Nor!al !arro6 signal intensit of

re!aining t$oracic verteral od is seen. #$e verteral dises5 verteral end"lates are

6it$in nor!al li!its. No evidence of s"inal cord intensit c$ange5 s"inal cord

co!"ression or verve root co!"ression is detected. No intradural collectionascess is

noted.#$e re!aining verteral dises and verteral ed"late are unre!ar%ale.

#$e conus !edullaris is at 1 level 6it$ nor!al a""erarance. A ., 1.1 c!

ri!en$ancing lesion at surgical sucutaneous ac% tissue is noted.I!"ression: no evidence of intradural or e"idural ascesscollection.

No evidence of s"inal cord intensit c$ange5 co!"ression or nerve root co!"ression.

A ., 1.1 c! ri! en$ancing lesion at surgical su cutaneous ac% tissue5 "sor o"erative

c$angesero!a.

2. '*I of u!osacral S"ine5 at/istor: lo6 ac% "ain.

inding:

#$e stud reveals decrease nor!al lu!ar lordotic curve. 'ini!al !arginal

osteo"$tes at 13 are seen. No colla"se verteral od or on destruction is

detected. #$ere is decrase nor!al $ig$ S1 on #2; of 12 discK so!e degree of

de$drating disc. 'ild narro6ing 12 interverteal disc s"ace is found. No verteral

suluation is oserved.

ulging 12 disc causes narro6ing s"inal canal 6it$out nerve root co!"ression.'ild ulging 23 disc causes !ild narro6ing s"inal canal 6it$out nerve root

co!"ression.

7


8/17

S!all Sc$!orl=s nodes at u""er 25 3 verteral odies.

No facet &oint or liga!entu! flavu! $"ertro"$.

#o" of conus !edullaris ter!inates at 1 level.Bisile !ass at cervi (. .3 c!) 6it$ inter!ediate S1 on #1; and $ig$ S1 on #2;.

I!"ression:

•ulging 125 23 disc cause !ild lu!ar stenosis 6it$out nerve rootco!"ression.

• Sc$!orl=s nodes at 25 3.

• A ..3 c! !ass at cerviK 4a cervi cannot e eluded"lease correlated

6it$tissue "at$olog.

3. aorator su!!ar

*outine /e!atolog

No

.

#est 2--2-1 212-1 27-2-1 22-1 3--2-1

1. / ,.+ .1 ., .9 .72. /ct 27.1 2+.2 27.1 2.2 2.

3. ;c 2.92- +7.--- 72.9- ,.2-- ,-.--

. Plt. ,9.--- ++7% ,73% ,22% ,,%

+. P'N 2. 91. , 9.2

,. !"$o +.+ ., 27 3

7. 'ono 2.1 + 3.+ 11 2

. os -.2 - -.1 , -

9. aso -.1 - -.1 , -

1-. Aniso 2G 1G 2G fe6

11. Poi%ilo e6 e6

12. Polc$ro e6 1G

13. #arget e6 e6 fe6

1. 'icrocte 2G 1G 2G

1+. 'acrocte

1,. /"oc$ro!ia 1G 2G fe6

17. *etic count 2.

1. P# 1.9

19. P## 2,.

2-. 0t$er (N*) 1.

No. #est Nor!al 2--2-1

1. @N +. L 19.1 !gd ,.9

2. 4r -.+ 1.+ !gd -.7

3. Na 13- 17 !C 13

. 8 3. .7 !C 3.,

+. /403 2-., 2.2 !C 22.+

,. 4l 9,1-7 !C 9

7. 4a .1-.2 !gd .

8


9/17

. P0 2.+ L ., !gd 3.-

9. 4$ol 127 L 2,2 !gd 172

1-. #ot Prot ,.+ L . gd 7.1

11. Al 3. L +. gd 3.

12. Elo 2., L 3. gd .-

13. D - L -.+ !gd -.1

1. # -.2+ L 1.+ !gd -.31+. A# L 3, @ 7

1,. AS# 12 L 32 @ 11

17. Al% "$os 2 L 121 @ 123

1. 48 2+ L 2-- @ 17

19. 'g 1., L 2., !gd 1.9

@*INASIS

#S# 21 23 3- Nor!al

S" gr 1.--7 1.--7 1.--9

P/ ,.+ 7.- 7

Alu!in Elucose

8etone

lood 2G

ile

@roile

*4 +- L 1--

;4 + L 1- - 1

"i.sC - 1

. 4INI4A /S#0* (date of re"ort: 29 August 2-1):Patient "resent 6it$ anor!al uterine leeding.5 PB found eo"$tic !ass at 1 o=cloc%

6it$ contact leeding 6it$ $istor of c$ronic $i" "ain5 investigastion found osteoltic

lesion at rig$t acetaulu!.

4INI4A DIAEN0SIS: servical !ass 6it$ vaginal leeding and osteoltic lesion at

rig$t acetaulu!

PA#/00E DIAEN0SIS:

4ervi5 io"s: SCua!ous cell carcino!a5 large cell5 non%eratini


10/17

Section reveal s$eets of !alignanc cells s$o6ing !ar%ed "leo!or"$ic nuclei5 "ro!inent

nucleoli5 scant to !oderate a!ount eosino"$ilic cto"las! 6it$ identifiale intercellular

ridge5 nu!erous !itoses are noted

4linical Su!!ar De"arte!en 0rt$o"aedi (Attend: + Se"t 2-1)4ase cancer servi 6it$ one !etastases $ave fever since ad!it 21 August 2-15 od

te!"erature: 35 39 -4.

D. 'DI4A#I0N

No

.

#"e of Drugs Dose Note

1st 6ee%

1. 'or"$in 2 !g

2. 'or"$in 3 !g (v) ever $our

3. Pre o.eration for /io.s%0

NP0 A'N +M DN2

4efatoi!

4c

*eticoal

'or"$in 2 !g (v)"arenteral for #P

1--- !l

1 gr

(21)

. Nurontin 3-- !g

+. Paraceta!ol

DATA ANALY1E 0

No. 'edical *ecord:

Age: 27 ears old

No

.

0redered Selected data Prole! tiolog

1. SD:

client states >feel severe "ain in rig$t $i"

and lo6er5 ac% one5 t$e scale of "ain 6as

4$ronic "ain Disease "rocess: !ulti"le

one !etastase

10


11/17

95 and Cuantit of "ain is ver often?

0D:

• Pulse rate: 122!inute5 #e!"erature: 39-45 lood Pressure: 132- !!/g.

• acial !as% of "ain

• /eat in area of "ain• '*I of lu!osacral:

Decrease nor!al lu!arlordotic cureve.

'ini!al !arginal osteo"$tes at 12

4o!""resiion: ulging 12 disc causes

narro6ing s"inal canal 6it$out nerve root

co!"ression5 'ild ulging 23 dis causes

!ild narro6ing s"inal canal 6it$out nerve

root co!"ression5 s!all sc$!orl=s nodes

at 2 3

A 553 c! !ass at cerviK 4a cervi

cannot e eluded

• Euarded "osition

2. SD:

4lient states >so!eti!e I una""etite if severe

"ain arises?5 >loss od 6eig$t , %g

!ont$?OD:

• Alu!in : 3. gd (nor!al: 3. L +. gd)

• Patient le do6n and loo% 6ea%

• 'I: 2- (nor!al)

*is% for InadeCuate

Nutrition: less t$en

od reCuire!ents

Nausea and vo!iting5

disease "rocess and

treat!ent

3. SD: client states:

>last nig$t I sle"t onl 2 $ours5 I tried to slee"again ut could not. If I feel "ain5 I could not

slee"?OD0

• Dar% circle under ees and loo% concave in

around ee

• oo%ed "ale

• Pulse rate: 122 "er!inute

Slee" "attern5

Disturance

Severe Pain

. S:

4lient states >I can not 6al%5 I can not sit

! self5 ?

0:

•

Patient inailit to re"osition self in ed

• Patient can not to !ove fro! su"ine

to "rone

• Patient can not to !ove fro! su"ine

to sitting.

ed 'oilit

i!"aired

I!"aired "$sical !oilit

+. S:

4lient states >I can not !oving ! left leg5

P$sical !oilit

I!"aired

Severe "ain5 i!fla!antor

&oin disease (one !etastase

11


12/17

and ! lo6er etre!it5 and ver "ain if I

!oving ?

0:

• acial !as% of "ain

• Data fro! gnecologi de"earte!ent:

cancer

• *adiolog test:

fro! cancer cervi)

,. S:4lient states: I got leeding after $aving se

6it$ ! $usand

0:

• Post coital leeding

• Baginal leeding

• 4ancer servi

Seual dsfunction Pain5 Baginal leeding5 "ost

coital leeding5

7. S:

4ient states: I can not !ove t$e od !

self

0:

• #$e "atient lie do6n

•

Activit Intolerance 4$ronic disease: !ulti"le

one !etastases (rig$t

acetaular5 *ig$t "roi!al

fe!ur5 inferior "uicra!us)5 "ain

. S:

0D:

• od #e!"eraure 35 -4

• #ac$cardia: Pulse: 122 "er!inute

• ;ar! to touc$

• S"ecific ac$es and "ains

/"ert$er!ia Infection Process

9. S:

4lients states >I don=t %no6 6$at 6ill I do

after I get sic% li%e t$is?

0:

• 4lient ie in t$e ed

• 4lient 4r 6$en s$e told to t$e nurse

servical !ass 6it$ vaginal leeding

and osteoltic lesion at rig$t

acetaulu!

/o"elesness Prolonged "ain5 disco!fort

and 6ea%nessK i!"aired

functional ailities

(6al%ing)5 "rolonged

treat!ents

1-. S: s$e states > I $ave 2 doug$ters5 t$e first one

is 2 ears old and t$e secend one is !ont$5 I

love t$e! ver !uc$5 I a! 6orr if I can not

to e a good !ot$er5 and I can not ta%e care of

t$e! co!"letel?

0:

• S$e cr 6$en s$e told to t$e t$e nurse

Parenting5

i!"aired ris%

4$ronic illness5

11. S:

4lient states >I a! to oung to get disease li%e

t$is5 I a! 27 ears old and I $ave a $usand

and 2 little rot$er 5 I 6orr if I can not to e

Self estee!

distured

oss of od unction5

disfigure!ent

12


13/17

a good 6ife and good !ot$er ?

0:

• 4lient 4r

• #$e face loo% sad

• 4an not !ove $er rig$t leg ecause

ver "ain

12. S:

4lient states >I can not 6al%5 I can not sit

! self5 I can not to 6earing ! c$lotes and

! older sister $el" !e to do evert$ing for

!e0:

• /er sister $el"s $er if s$e needs

so!et$ing

Self care deficit:

at$ing5 Dressing5

instru!ental5

toileting

4$ronic "ain5 v$ronic

illness (cancer servi 6it$

!ulti"le one !etastases)

13. S:

4lient states >so!eti!e I feel itc$ing5 ecause

I s6eating and feel to $ot?

0:• #ouc$ 6ar!

• od te!"erature 35 o4

• #$e clot$es is 6et

S%in Integrit5

i!"aired (ris% for

i!"aired)

ong ed rest and

/"ert$er!ia

Nursin Dianosis a..ro.riate 2it' t'e .riorit%

,3 4$ronic "ain related to Disease "rocess: !ulti"le one !etastase2. /"ert$er!ia related to Infection Process and disease "rosess

3. Slee" "attern distured related to Severe Pain

-3 *is% for InadeCuate Nutrition: less t$en od reCuire!ents related to nausea and

vo!iting5 disease "rocess and treat!ent

43 P$sical !oilit I!"aired Severe "ain related to infla!antor &oin disease (one

!etastases fro! cancer cervi)

53 Activit Intolerance related to c$ronic disease: !ulti"le one !etastases (rig$t

acetaular5 *ig$t "roi!al fe!ur5 inferior "uic ra!us)5 c$ronic "ain

63 Self care deficit: at$ing5 Dressing5 instru!ental5 toileting related to c$ronic "ain5

c$ronic illness (cancer servi 6it$ !ulti"le one !etastases)

73 Seual dsfunction related to "ain5 vaginal leeding5 "ost coital leeding 5

83 Parenting5 i!"aired related to c$ronic illness

,+3 /o"elesness related to "rolonged "ain5 disco!fort and 6ea%nessK i!"aired functional

ailities (6al%ing)5 "rolonged treat!ents.

,,3 S%in Integrit5 i!"aired (ris% for i!"aired) related to long edrest and $"ert$er!ia

12. Self estee! related to oss od unction disfigure!ent

13


14/17

NURSING CARE PLAN

No3 Nursin Dianosis NOC NIC

1. Severe c$ronic "ain

related to disease

"rocess: !ulti"le

one !etastases

Goa$s:

#$e "erson 6ill relate i!"rove!ent

of "ain and increased dail activities

as evidenced (s"ecif).

Indicators:

o *elate t$at ot$ers validate t$at t$eir

"ain eists.o Practice selected noninvasive "ain

relief !easures.o 4o!!unicate i!"rove!ent in "ain

verall5 "ain assess!ent scale5

1. Assess for actors t$at Decrease Pain

#olerance:

• Diselief fro! ot$ers @ncertaint of

"rognosis

• ear (e.g.5 of addiction or loss of

control)

2. *educe or li!inate actors t$at

Increase Pain.

• stalis$ a su""ortive acce"ting

relations$i": a) Ac%no6ledge t$e "ain.5

) isten attentivel to client=s

14


15/17

or e$avior (s"ecif).

o 'aintain usual fa!il role and

relations$i"s t$roug$out "ain

e"erience5 as evidenced

(s"ecif).

discussion of "ain5 c) 4onve t$at ou

are assessing "ain ecause ou 6ant to

understand it etter (not deter!ine if it

reall eists.

• Assess t$e fa!il for an

!isconce"tions aout "ain or its

treat!ent: a) "lain t$e conce"t of

"ain as an individual e"erience. )

Discuss factors related to increased "ain

and o"tions to !anage. c) ncourage

fa!il !e!ers to s$are t$eir concerns

"rivatel (

3. Deter!ine 6it$ 4lient and a!il t$e

ffects of 4$ronic Pain on t$e Person=s

ife

• Discuss 6it$ client and fa!il t$e

t$era"eutic uses of distraction5 along

6it$ ot$er !et$ods of "ain relief.• !"$asi


16/17

Analgesics.

• @se oral route 6$en feasile5

intravenous or rectal routes if needed

6it$ "er!ission.

• Avoid inter!uscular routes due to erratic

asor"tion and unnecessar "ain.

• Assess vital signs5 es"eciall res"irator

rate5 efore ad!inistration.

• 4onsult 6it$ "$ar!acist for "ossile

adverse interactions 6it$ ot$er

!edications (e.g.5 !uscle relaants5

• tranCuili


17/17

in$iit slee".

o Identif tec$niCues to induce

slee".

valuate if t$ere is a "$siologic

condition or !edication t$at is

interfering 6it$ slee". *efer to related

factors under Pat$o"$siologic and

#reat!ent*elated. *efer to t$e

"ri!ar care "rovider for

!anage!ent.

valuate if a "sc$ological state is

interfering 6it$ slee". *efer to

Situation*elated actors. *efer to

'ental /ealt$ Professions.

Deter!ine if t$e lifestle or life events

are interfering 6it$ slee". *efer to

ot$er nursing diagnoses if

a""ro"riate: Grieving, Stress Overload,

Ineffective Coping 5 or Risk-Prone

Health Behavior .

17

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Ncp of Client With Cancer Servix With Multiple Bone Metastasis (1)

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