Comprehensive Care Plan-Comprehensive Care Plan.pptx

Comprehensive Care Plan-Comprehensive Care Plan

1. COMPREHENSIVE CARE: MEDIASTINAL TUMOR, SMALL CELL LUNG CARCINOMA AND SMALL BOWEL OBSTRUCTION SHAMEKA HACKMAN 6 TH APRIL, 2022

2. Presentation Objectives and Outline History of Present Illness Past Medical History Patient Medications Patient Allergies Timeline of Admission to Discharge Abnormal Labs Evidence-based Research Related To Patient’s Illness 2

3. History of Present Illness Initials : GM Age/Gender : 72/F Primary Diagnosis : Small Bowel Obstruction (SBO), mediastinal mass, pleural effusion and atrial fibrillation Secondary Diagnoses: Small cell lung CA (SCLC) – Multiple METs, Nicotine dependence with COPD, and hyponatremia Coexisting health problems/diagnoses: Syndrome Of Inappropriate Antidiuretic Hormone (ADH) Secretion (SIADH) 3

4. Past Medical History High blood pressure (hypertension ) Hypercholesterolemia Osteoporosis 4

5. Patient Medications Enoxaparin (40mg), sodium chloride (3mg), nicotine (21mg), lactobacillus acidophilus Enoxaparin 40mg 8 Nicotine 21mg 8on/20off Lactobacillus acidophilus 6/14/20 Sodium chloride 3gm 6/14/20 APAP 650mg prn 96 Maalox 30ml prm Melatonin 3mg Nicotine 2mg Q2H Zofran 4mg IV push 5 List Drug orders as written by MD:

6. Patient Allergies Patient had no Allergies 6

7. Abnormal Labs High WBC -14.0 Low RBC - 3.74 Low Hemoglobin - 11.4 Low potassium - 3.4 7

8. Timeline of Admission to Discharge Respiratory Assessment Lung sounds: crackles throughout diminished bases Character of respirations: SBO with nonproductive cough Chest tubes: pericardial window, thoracotomy, tube placement Cardiac Assessment Cardiac rhythm: A fib Heart sounds: A fib irregular Character of peripheral pulses: (+) strong Edema (location(s) & amount(s)): edema noted 8 Assessment

9. Timeline of Admission to Discharge GI Assessment Abdominal contour: WNL BM: Date last: 1/31/22 Color: brown Consistency: formed Toileting capabilities: bedside commode Output clinical day(s): 2 bowel measurements large 9 Assessment Continued

10. Timeline Continued Nursing Diagnosis Risk of impaired gas exchange due to hypoventilation. Risk of ineffective airway clearance due to pleural effusion Risk of fluid volume deficiency due to small bowel obstruction (SBO) Risk of acute pain due to the video-assisted thoracic surgery, disruption of intercostal nerves, or tissue trauma Risk of anxiety characterized by anger, withdrawal, or apprehension 10 Nursing Diagnosis

11. Timeline Continued To Address Impaired Gas Exchange (Vera, 2014) 11 Nursing Interventions Interventions Rationale GM’s respiratory rate was closely observed, noting subtleties such as ease of respiration, depth, pursed-lip breathing, use of accessory muscles, pallor, etc. The patient’s respiration may be increased in response to the loss of lung tissue and pain. Conversely, increased oxygen consumption has a positive relation with cyanosis and increased work of breathing. Levels of consciousness and restlessness were periodically investigated To identify possible signs of hypoxia and other complications. Rest periods were encouraged while assessing the patient’s response to activity To prevent pulmonary complications associated with such as increased dyspnea and alteration of vital activity. It was also done to maintain circulatory efficiency through a careful balance between rest and activity.

12. Timeline Continued To address Ineffective Airway Clearance (Vera, 2014) 12 Nursing Interventions Interventions Rationale The patient’s chest was auscultated to determine breath character and rule out secretions. To identify signs of airway obstruction such as noisy respiration and wheezing. The patient was assisted with deep breathing exercises through respiratory splinting and appropriate coughing techniques. To facilitate maximum lung expansion through coughing in an upright position. Oral fluid intake within cardiac tolerance was encouraged (about 2600ml daily) To enhance expectoration through sufficient hydration.  

13. Timeline Continued To Address Fluid Volume Deficit (Wayne, 2019) 13 Nursing Interventions Interventions Rationale GM was urged to drink the prescribed amount of fluid To facilitate oral fluid replacement. This was especially important bearing in mind the patient's age and the decreased sense of thirst. Fluid replacement was done through a creative choice of fluid such as flavored gelatin and oral rehydration solutions. The patient was assisted with eating and the family was encouraged to facilitate her feeding. To assist the patient meet prescribed fluid intake, despite weakness from dehydration The patient was provided oral fluids when tolerable and placed at her bedside with a straw for easy access.   To remind the patient of the importance of rehydration especially since they were likely to forget.

14. Timeline Continued To Address Acute Pain (Vera, 2014) 14 Nursing Interventions Interventions Rationale The patient’s pain characteristics such as aching, burning, stabbing were identified by intensity rating on a scale of 1-10. To evaluate pain symptoms due to small cell lung cancer and small bowel obstruction. The rating scale was used to evaluate the effectiveness of analgesics and enable GM to assess her pain levels, hence allowing her to control her pain. Psychological and pathophysiological sources of pain were identified To enhance the patient’s coping mechanism and reduce fear, grief, anxiety, or distress post-SCLC and small bowel obstruction diagnosis. The irritation of the pleura and multiple muscle incisions using chest tubes was likely to cause pain and discomfort. An assessment of GM’s verbal and nonverbal pain cues was made. To identify clues indicating pain levels and effectiveness of interventions based on discrepancies between verbal and nonverbal cues.

15. Timeline Continued To Address Fear and Anxiety (Vera, 2014) 15 Nursing Interventions Interventions Rationale The patient’s understanding of the diagnosis was evaluated. To understand the information the patient has assimilated and its influence on her lifestyle and self-image. It was necessary to form the framework for personalized care and advise the patient on the medical rationale for chosen interventions. A safe space for open inquiry was provided for the patient to ask questions and receive honest answers. To develop rapport and trust that reduces the potential for misconceptions or miscommunication. The patient’s fears, concerns, anxiety, etc. were acknowledged and she was encouraged to communicate her feelings openly. To provide the requisite support to cope with the realities of small cell lung cancer, small bowel obstruction, and their treatment. It was done to provide the patient with sufficient time to identify and confront her feelings.

16. Evidence-based Research Related To Patient’s Illness Pheochromocytomas, lymphomas, and thymomas are examples of masses in the anterior mediastinum that are more likely to be malignant (Babuci, 2021). Symptoms of mediastinal masses included dyspnea, with the majority of cases located in the anterior mediastinum. Other symptoms include voice hoarseness, dysphagia, and bronchogenic carcinoma SCLC is associated with numerous paraneoplastic disorders, especially endocrine paraneoplastic syndrome. This explains GM’s euvolemic hyponatremia, reduced plasma osmolarity due to disruptions in the secretion of antidiuretic hormone According to the WHO, SCLC can be categorized into two types – pure SCLC and combined SCLC (Rekhtman, 2010). Combined SCLCs are less common and are characterized by large or squamous cell carcinoma. 16 Mediastinal Tumor and Small Cell Lung Carcinoma

17. Evidence-based Research Related To Patient’s Illness GM’s pleural effusion was not by itself a disease but is an indication of underlying systemic disorders in the lungs or pleura. GM’s nicotine dependence with chronic obstructive pulmonary disease (COPD) due to a history of smoking pointed to a malignant pleural effusion diagnosis. Chest pain is likely a result of pleural inflammation of the parietal pleura due to friction in the movement of pleural surfaces ( Karkhanis & Joshi, 2012). Management of malignant pleural effusion (MPE ) is important due to its association with a terminal illness and the need for quality of life therapy Research attributes the dramatic reduction of MPE-associated morbidity to the introduction of video thoracoscopy (Murthy & Rice, 2013). 17 Pleural Effusion

18. Evidence-based Research Related To Patient’s Illness GM had small bowel obstruction (SBO) a mediastinal mass and pleural effusion The potential etiologies for SBO may be intrinsic, extrinsic, or intraluminal . E xtrinsic sources of SBO include compressions of the small bowel due to cancer, umbilical and inguinal hernias. Incidences of SBO occur in both males and females (Di Mizio , 2014). The potential risk factors include: Prior abdominal surgery Inguinal or abdominal wall hernias Chronic intestinal inflammatory disease Complete or partial blockages result in emesis leading to electrolyte abnormalities and fluid deficits 18 Small Bowel Obstruction

19. References Babuci , S. (2021). Clinical- Evolutive and morphopathological particularities in primary teratocarcinoma of anterior mediastinum in adolescents clinical case presentation and literature review. Journal of Medical Science and Clinical Research , 09 (04). https://doi.org/10.18535/jmscr/v9i4.20 Karkhanis , V., & Joshi, J. (2012). Pleural effusion: Diagnosis, treatment, and management. Open Access Emergency Medicine , 4 , 31–52. https://doi.org/10.2147/oaem.s29942 Murthy, S. C., & Rice, T. W. (2013). Surgical management of malignant pleural effusions. Thoracic Surgery Clinics , 23 (1), 43–49. https://doi.org/10.1016/j.thorsurg.2012.10.001 Di Mizio , R. (2014). Small-bowel obstruction. Springer. Vera, M. (2014, February 27). 5 lung cancer nursing care plans . Nurseslabs . https://nurseslabs.com/5-lung-cancer-nursing-care-plans/ Wayne, G. (2019, March 20). Deficient fluid volume – nursing diagnosis & care plan . Nurseslabs . https://nurseslabs.com/deficient-fluid-volume/ 19