Assignment

Patient initials: G. N

Date of Care: 03/22/2022

Background:

· Age: 63

· Sex: Male

· Ethnicity: White European

· Allergy: no known allergies.

Past medical History: Type 2 diabetes mellitus, dyslipidemia, hypertension, and colon cancer.

Pertinent social history, including living situation, for discharge planning or case management purposes: Mr. G. N is a 63-year-old White European male admitted for rectal cancer. Mr. G.N is a retired mechanic who lives with his wife. The patient was a smoker but quit 15 years ago. The patient’s grandfather died of colorectal cancer when he was a little child.

Discharge planning needs for the patient include home health nurse to provide ostomy care for the first few weeks and teach the patient about diet changes that include fiber and fluids and follow-up visit to the surgeon in 2 weeks.

Other: G.N does not speak English very well, speak Lithuanian; needs interpreter.

Reason for visit or hospitalization:

Rectal bleeding

S: G.N admitted to the surgical unit because of rectal bleeding. He states he is scared because his father died of rectal cancer several years ago and he is concerned about his own health status. Patient states that he notices changes in his bowel movements, as well as abdominal cramps, and general weakness. He denies having fever, chills, shortness of breath, chest pain. The patient also stated that he has not been taking his hypertension medications lately and has been losing weight.

O:

Physical Exam

The patient was alert and oriented ×4. No change in LOC noted per baseline, pupils equal, round, and reactive to light. Patient denies dizziness, headaches, tremors, numbness, or paralysis. Clear lungs and chest upon auscultation, no sputum, no cough and shortness of breath noted

· Abdominal tenderness

· Watery stool

· Abdominal mass feels during Digital Exam performed by the doctor.

· Ascites

Vital signs include:

· BP: 150/88

· Heart rate: 86

· Temperature: 97.4 oral

· O2 saturation: 100%

· O2 Modality: on Room Air

· Respiration: 14

Current Medication:

· Nifedipine for controlling hypertension

· Metformin for type 2 diabetes on hold because of surgery

· Sodium chloride 0.9% 100 ml/hr for hydration, specially because the patient is getting surgery and he will be NPO.

· Atorvastatin 80 mg tab PO daily for high cholesterol

· Potassium chloride 10meq tab controlled released for the low potassium seen during lab work

· Carvedilol 12.5 mg tab twice a day is used to treat high blood pressure

· Glucagon injection 1mg PRN, if blood sugar is between 50 and 69 mg/dl and patient is NPO cannot swallow safely

· IV morphine 2mg/1ml every 2 hours or PRN (MODERATE PAIN 4-6)

· Naloxone HCL 0.4mg vial in case of morphine toxicity

· PIPERACILLIN/TAZOBACTAM 3.375mg IV every 6 hours to prevent infection

· Ondansetron IV 2mg/1ml for nausea

Current orders:

· Colonoscopy which is done because of the family history of the patient and the different signs and symptoms that he has.

· Rigid proctoscopy: the healthcare provider uses a thin rigid lighted tube that is inserted through the anus to assess the involvement of sphincter.

· Abdominal CT scan: an ultra sound to look for tumor in the liver or elsewhere in the abdomen.

· NPO order, to prepare the patient for surgery

· Surgery scheduled: surgery is the first line of treatment to remove the tumor. It can be performed through colostomy or ileostomy depending on the areas of resections. it can be either reversible or irreversible.

· NGT tube placement after surgery

Lab work:

· Potassium Level 4 (normal range 3.5-5.0), normal

· Chloride level 109 (normal range 96-106) slightly elevated, could indicate high blood pressure

· CBC blood count to measure the different types of cells in the blood. People with colorectal cancer most commonly have anemia, because they bleed a lot and therefore their body cannot produce blood faster that their body is making; hence the CBC is ordered

· RBC: 3.7 (normal range: 4.7-6.7). The RBC is low, it indicates anemia

· WBC: 4.4 (normal range: 4.0-11.0). WBC is normal

· HTC: 34.3 (normal range: 36.0-44.0), a low hematocrit indicates anemia

· Hgb: 10.5 (normal range 12.1-15.1) a low indicates anemia

· Blood sugar: 170 mg/dl (70-100 normal range)

· Liver enzymes: to check the liver function, because cancer can spread to the liver.

· Tumor markers or Carcinoembryonic antigen (CEA): which is a substance of colorectal cancer cells that can be found in the blood.

· Creatinine: 0.7 (normal 0.6-1.2) normal creatinine

· Bun: 14 (normal 6-20mg/dl) normal BUN level. BUN and creatinine important we need to know how the kidney function in order to the anesthesia to be flushed later after surgery is completed

Additional information

· Schedule for a colorectal resection surgery and a permanent colostomy placement

· Patient will follow up with chemotherapy after surgery

· Spouse states not being able to change the ostomy bag, was not able to demonstrate appropriate techniques; need more teaching

· Show video the patient’s spouse about colostomy care in Lithuanian

Post operatives care

· Encourage the use of incentive spirometry every hour

· Perform deep breathing exercise

· Provide early ambulation to prevent DVT

· Use a small pillow, hug it against the abdomen to help incision if patient need to cough

· Inspect incision sites, auscultate bowel sounds

· Keep the dressing sites clean and dry

· No lifting more than 20 pounds

· Patient will be discharged when he will have few bowel movements and be able to pass gas

A: Medical diagnosis: Rectal colon cancer

The medical diagnosis has been evidenced by the patient's family history and the result of the different diagnostic test and the signs and symptoms. In some patients, cancer goes away completely and in some it may re-occur, requiring long-term management (Mármol et al., 2017). The patient is scheduled to surgery.

Nursing diagnoses include:

1) Acute pain related to abdominal incision as evidence by expressive behavior of moaning and patient reporting pain at 7 on the scale of 0 to 10

Treatment goal:

· Patient will use pharmacological and non-pharmacological pain relief strategies effectively

· Patient will describe a satisfactory pain control at a level less than 3 on the scale of 0 to 10 within 1hr

2) Fear related to threat of death as evidenced by patient verbalizing the death of his grandfather

Treatment goal:

· The patient will appear relaxed and will report anxiety is reduced to a manageable level

· Patient will display less fear

3) Disturbed body image related to colostomy bag as evidenced by refusal to look at and touch his abdomen

Treatment goal:

· wear clothing to enhance physical and emotional self-esteem

· Provide privacy when discussing concern about ostomy

P:

Nursing diagnoses include:

1) Acute pain related to abdominal incision as evidence by expressive behavior of moaning and patient reporting pain at 7 on the scale of 0 to 10

Rationale: patients who are in pain are unable to participating in care, it has a detrimental impact on vital signs and can affect the quality of treatment of the patient.

Implementation:

Assess the patient’s pain level by using the acronym PQRST and accurately document it every 2 hours.

Rationale: PQRST monitors degree, character, precipitator, duration, location and onset of pain for initial check.

Administering medications as prescribed and as needed

Rationale: Patients who are in pain have trouble participating in plan of care. We do what necessary to proactively treat the patient’s pain, and notify the provider of changes.

Educate the patient about adverse effects and the effectiveness of pain medication

Rationale: It is important to educate the patient about the side effects and the effectiveness, it will help determine if the medication is working and help the patient to identify undesired sides effects that require intervention.

Provide non-pharmacological techniques such as repositioning, cold/heat, and distractors techniques. Also use an abdominal binder which alleviate the abdominal pain and help organ stay in place.

Rationale: comfortable position, deep breathing exercise can relieve the patient’s pain

2) Fear related to threat of death as evidenced by patient verbalizing the death of his grandfather

Implementation:

Review patient’s and SO’s previous experience with cancer. Determine what the doctor has told patient and what conclusion patient has reached.

Rationale: Clarifies patient’s perceptions; assists in identification of fear(s) and misconceptions based on diagnosis and experience with cancer.

Encourage patient to share thoughts and feelings.

Rationale: Provides opportunity to examine realistic fears and misconceptions about diagnosis.

Assist patient in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears.

Rationale: Coping skills are often stressed after diagnosis and during different phases of treatment. Support and counseling are often necessary to enable individual to recognize and deal with fear and to realize that control and coping strategies are available.

Note ineffective coping (poor social interactions, helplessness, giving up everyday functions and usual sources of gratification).

Rationale: Identifies individual problems and provides support for patient in using effective coping skills.

3) Disturbed body image related to colostomy bag as evidenced by refusal to look at and touch his abdomen

Assess impact of body image disturbance in relation to patient’s developmental stage

Rationale: Young adults may be particularly affected by changes in the structure of their bodies

Encourage verbalization of positive or negative feelings about actual or perceived change

Rationale: it is important to encourage the patient to separate feelings about change in body from feeling about self-worth

Refer patient and caregivers to support groups comprised of individuals with similar alterations

Rationale: Lay persons in similar situations offer a different type of support, which is perceived helpful

Assist patient in incorporating actual changes into social life and occupational activities

Rationale: opportunities for positive feedback and success in social situations may hasten adaption.

Case management or discharge planning needs

Discharge planning needs for the patient include:

· home health agency for in his community for further following care regarding ostomy

· follow-up visit with the surgeon in 2 weeks

· Refer to rehabilitation cancer center for chemotherapy treatment

· Provide ostomy bag supplies for few days

· Provide a list of local medical supply for ostomy supplies

Patient education needs

· Patient needs to be educated on self-care including diet changes, adherence to medication.

· Teach colostomy care

· Instruct the patient to know the signs of the stoma problems like stoma turning black or purple, or stoma with a pus like discharge, ask him to immediately call his doctor.

· Avoid heavy lifting

· Call the provider if fever more than 101 F occurs, increased pain at incisions, worsened abdominal pain or vomiting or increasing abdominal distension (bloating).

· Any other concerns or questions regarding your surgery or recovery.

Psychosocial, spiritual, and/or family support needs

The patient is a dad of 3 children and grandfather of 2 grandchildren. He has a close relationship with his kids and his grandchildren. He is a family oriented. He lives with his wife. He has never had any mental illnesses and no history of substance abuse. He quit smoking 15 years ago. He has a strong family support. The patient is a Christian and asked the nurse to call the chaplain. The chaplain was praying with him in his room and participates in his church community.