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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 *+,-
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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
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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
$os"itali
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/earing: s$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
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• /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
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• 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"$eral Bascular sste!
• Ar!s: eCual in si
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• 4aseas one at rig$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$out nerve root
co!"ression.
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S!all Sc$!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
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. 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$t acetaulu!
PA#/00E DIAEN0SIS:
4ervi5 io"s: SCua!ous cell carcino!a5 large cell5 non%eratini
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Section reveal s$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$ronic "ain Disease "rocess: !ulti"le
one !etastase
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95 and Cuantit of "ain is ver often?
0D:
• Pulse rate: 122!inute5 #e!"erature: 39-45 lood Pressure: 132- !!/g.
• acial !as% of "ain
• /eat in area of "ain• '*I of lu!osacral:
Decrease nor!al lu!arlordotic cureve.
'ini!al !arginal osteo"$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
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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
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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
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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
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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.• !"$asi
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Analgesics.
• @se oral route 6$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$er
!edications (e.g.5 !uscle relaants5
• tranCuili
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in$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