Joel Angelo C. Villarino July 19, 2011 BSN 4 - C Elective Course 2 Case Analysis No.

4 Situation: A 37-year-old female is scheduled to undergo breast biopsy for a lump she discovered in her left breast four days ago. Her history includes cigarette smoking for 17 years, use of oral contraceptives, one who is 4 years old and family history of coronary artery disease. She denies breast trauma, alcohol use or exposure to radiation. She is 20 pounds overweight for her height. 1. What risk factors, if any, does the woman have for breast cancer? -cigarette smoking for 17 years - smoking has been linked to many cancers -use of oral contraceptives - one of the greatest risk factors in developing breast cancer -parity above 30 years old - pregnant women above 30 are prone to developing breast cancer -overweight - women who are overweight or obese are more prone 2. What is the most significant screening that can be conducted for breast cancer? Why? Mammograms are probably the most important tool doctors have not only to screen for breast cancer, but also to diagnose, evaluate, and follow people whove had breast cancer. Safe and reasonably accurate, a mammogram is an x-ray photograph of the breast. The technique has been in use for about 40 years. The mammogram would take pictures of the breast tissues, thereby identifying unusualities. 3. What are the implications of early pregnancy on the development of breast cancer? Women who have their first full-term pregnancy at an early age have a decreased risk of developing breast cancer later in life. For example, in women who have a first full-term pregnancy before age 20, the risk of developing breast cancer is about half that of women whose first full-term pregnancy occurs after the age of 30. This risk reduction is limited to hormone receptor-positive breast cancer; age at first full-term pregnancy does not appear to affect the risk of hormone receptornegative breast cancer. 4. How are the concerns of client with breast cancer similar to those with cervical or uterine cancer? Gender - breast, uterine and cervical cancer are cancers of women, and this would entail similar concerns of patients suffering from this disease

Etiology - these cancers have unknown cause, but the most common etiology is the influence of female hormones on the development of this disease. Therefore, having the same etiologic factors, recurrence is also possible Secondary cancer - few women who develop breast cancer also develop another cancer later in life, such as uterine or cervical (Smeltzer, 2009). Fear among women with breast cancer to develop another form of carcinoma is inevitable Sexual activity - women with breast cancer has more or less the same concerns regarding sexual activity, especially after a surgery, to those women who develop uterine or cervical cancer Maternal role - the family role of being a mother to children and a wife to their husbands are also common concerns of women with this forms of cancer Case Analysis No. 5 Situation: A 50-year-old woman was admitted to the intensive care unit after her family finds her unconscious early this morning. Her husband and three teenage daughters accompany her. The admission assessment reveals no history of hypertension or other health problems, client complains of headache a day prior to admission. Vital signs: BP = 150/100 mmHg, respiratory rate = 16 cpm, PR = 56 bpm, T = 38.3 0C and GCS 5. Her admitting medical diagnosis is CVA, bleed. 1. Prioritize the following nursing interventions with 1 being the most important. Give rationale for each priority. __3__ __2__ __4__ __1__ Monitor temperature. Assess neurological status. Assess respiratory status. Elevate the clients head to a 45-degree position.

Rationale: 1. Elevating the clients HOB helps alleviate the increased ICP and would facilitate venous drainage. 2. Assessment of neurological status would follow. Assessment of this status is a standard procedure in dealing with patients with cerebovascular disorders, to monitor responses to interventions and the progress of the disease or improvement of the condition. 3. Monitoring temperature is done next. The patient is currently manifesting a temperature of 38. 3 0C, and changes in the temperature is a sign of increased ICP. 4. In the case of the patient, the respiratory rate is at normal value of 16 cpm. 2. The client begins to seize as her condition worsens. Cite three nursing interventions that are essential at this time. Three essential nursing interventions are raised prior to the worsening situation of the patients condition. These are: (1) maintain proper airway by suctioning secretions, hyperoxygenating the client before the suctioning starts and also discouraging the client to do coughing because it might increase intracranial pressure; (2) achieve patients adequate breathing pattern by proper positioning, head must be in a midline position or in a 0-60 degree angle position so as to prevent injury; and (3) do not attempt to try opening patients jaws that are clenched in a spasm or to insert anything in the mouth, it may just increase injury to the oral mucosa as well as skin integrity is altered.

3. What signs other than seizure, should alert the nurse that the client is developing increased intracranial pressure? Aside from seizure, the signs the nurse should alert for are the following: change in the level of consciousness, which is the earliest indicative of increased intracranial pressure; abnormal respiratory and vasomotor responses, slurring of speech, delayed response to verbal suggestions, increasing drowsiness, becomes stuporous, restlessness (without apparent cause), confusion and reacts only to loud or painful stimuli. Vital signs should be monitored closely as these are altered. 4. After determining the client had suffered extensive cerebral damage, the doctor wrote a DNR order per familys request. List three nursing diagnosis that is appropriate at this time. Decreased intracranial adaptive capacity related to extensive cerebral damage Anticipatory grieving related to impending loss secondary to DNR order Hopelessness related to patients condition and prognosis secondary to extensive brain damage Case Analysis No. 6 Situation: B. C., is an elderly male diagnosed with dementia five years ago. He lives with his wife, who is also an elderly person. His wife is concerned with his behaviour and deteriorating mental status, and is finding it increasingly difficult to care for him at home. He wanders out of the house, is disoriented to time and place, and is unable to dress or groom himself. Their attending physician encourages placement in a nursing home, but his wife resists. The physician instead arranges for a home health nurse to visit B. C. and his wife at home. 1. Identify the pertinent client and caregiver information requiring nursing intervention. Client information: -elderly client, diagnosed with dementia, with deteriorating mental status, wanders out of the house, disoriented to time and place, unable to groom himself or even dress himself Wife/Caregiver information: -also an elderly, wife expressed concerns regarding patients behaviour and mental status, wife is against the idea of sending the patient to a nursing home 2. What instructions regarding B. C.s safety should be given to his wife? -Camouflage exit doors with decorative wallpaper, curtains, painting door same color as adjoining walls. -Place locks high on exit doors so out of direct vision. Consider double locks with keys. -Provide door chimes or announcing system over exit doors; alerting caregiver when door opens. -Install window safety latches to limit how much windows can open. -Secure the yard with high fence and locked gate.

-Ensure items to leave or travel are out of sight, i.e. keys, coats, shoes. -Enroll in Medic Alert and Safe Return program with the Alzheimers Association. -Place name labels in garments to assist with identification. -Notify neighbors of the individuals potential to wander. -Provide local police, neighbors, and relatives of recent photo, with pertinent information, i.e. medical. -Ensure that the person with a history of wandering has adequate supervision. -Have medication profile evaluated -Assess the individuals reality. -Provide a safe environment for the individual to move about; remove clutter, ensure adequate lighting. -Provide structured program of exercise and movement as part of daily routine. -Provide reassurance to redirect the individual to a different activity.

Case Analysis No. 7 Situation: A 60-year-old male is admitted into the emergency room with complaints of shortness of breath, wheezing, and fatigue exacerbated by activity. Assessment revealed a thin, frail man with barrel chest who leans forward to breathe. Breath sounds are decreased bilaterally and the client is tachypneic with RR of 36 cpm. His past medical history indicates a 40-year history of smoking, one and a half pack of cigarettes per day. The client is admitted to the ICU with a medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). His physician placed the client on bed rest with bathroom privileges and orders a chest x-ray and STAT ABG. The clients admission blood gas analysis reveals: pH 7.25; PaO2: 52 mmHg; HCO3: 20 mEq/L and O2 saturation 84%. 1. What do the ABG findings suggest and why are these findings indicative of COPD? The ABG of the patient shows a pH of 7.25, which is acidotic, and HCO3 of 20mEq/L, which is also acidotic, indicating of acidosis. The bicarbonates are involved, which would indicate that the patient, based on his ABG results, has metabolic acidosis. Arterial blood gas (ABG) analysis plays a role in the emergent assessment of a patient with an acute COPD exacerbation. It helps to assess baseline oxygenation and gas exchange and also to determine impending respiratory failure in the patient with chronically severe COPD, and can indicate the need for intervention with bilevel positive airway pressure (BiPAP) or consideration of intubation. The most common finding on ABG analysis is a respiratory acidosis and a metabolic alkalosis, together with some degree of hypoxia. While there are limited outcome data to

support its routine use, an ABG analysis may also be beneficial in the setting of an unclear diagnosis, a patient refractory to therapy, a patient with prior ABG values available for comparison, or in the postintubation patient. 2. After evaluating the ABG results, the attending physician ordered O2 @ 2 L/min per nasal cannula. What is the rationale for limiting the amount of oxygen administered to the client? Because hypoxemia stimulates respiration in the patient with severe COPD, increasing the oxygen flow to a high rate may greatly raise the patients blood oxygen level. At the same time, this will suppress the respiratory drive, causing increased retention of carbon dioxide and CO2 narcosis. The nurse should closely monitor the patients respiratory response to oxygen administration via physical assessment, pulse oximetry, and/or arterial blood gases. 3. As the nurse caring for the client, what criteria will you use to evaluate the effectiveness of the clients oxygen therapy? The criteria to be used in evaluating the effectiveness of the clients oxygen therapy are the O2 saturation as monitored by the pulse oximeter, absence of cyanosis especially on the extremities, and the PaO2 levels of the patient. 4. The next morning, the clients vital signs are: T=38.6 0C, apical rate of 96 bpm; respirations 30 cpm; BP= 150/90 mmHg. The client has persistent, productive cough that is mucopurulent and copious. What is the clients priority diagnosis at this time? Clients priority diagnosis at this time is Ineffective Airway Clearance related to obstruction of airway secondary to increased mucous production as evidenced by increased RR. 5. In relation to the priority nursing problem in number 4, prioritize the following nursing intervention with number 1 as the most important intervention and give your rationale. __5__ Initiate infusion of intravenous antibiotics as prescribed. __2__ Check O2 saturation. __1__ Auscultate breath sounds. __3__ Administer Paracetamol for fever as prescribed. __4__ Collect and send sputum specimen to the lad for culture. Rationale: 1. Assessment of breath sounds is priority in relation to ineffective airway clearance. Proper assessment leads to proper collection of data and ruling in and out of actual and potential problems. 2. Oxygen saturation assessment would follow next to determine the impact of constricted airway to the amount of oxygen being inspired by the client. 3. With a spiking temperature of 38.60 C, administration of paracetamol to alleviate the increased temperature. Hyperthermia also causes increased respirations, and treating the hyperthermia would also reduce the increased respiratory rate. 4. Collection of sputum specimen for culture follows the initial priority interventions.

5. The result of the culture and sensitivity of the sputum specimen would determine what antibiotic is the culture sensitive to. Thus the doctor prescribes this antibiotic for administration.