NURS 252: Case Study

NURS 252: Case Study

1. 62 year old female, PMHx:Stage 1 left breast cancer since 2009 currently undergoing radiation, Stage 2 skin breakdown at radiation site and highly anxious. Vital signs: 39.8, PR: 113, RR: 24, BP:160/78 O2:92% on R/A

   • 62 year old female, Scurrently undergoing radiation, Stage 2 skin breakdown at radiation site and hi
   • At rist for Impaired Gas Exchange related to Hypoxemia
     • Altered ventilation and perfusion ratio related to increased metabolic demands secondary to febrile state
       • Treatment/ Prevention:
         • Position patient with proper body alignment to facilitate optimal breathing.
           • Provide Reassurance to subside anxiety by staying with the patient.
             • Provide education on pursed lip breathing to help facilitate optimal breathing perfusion.
               • Utilize the pulse oximetry to monitor O2 saturation and pulse rate continuously and signs of cyanosis
                 • Administer a low flow of 2L of oxygen to maintain a O2 saturation of 95%
                   • Assess for changes in orientation and behavior.
                     • Monitor and evaluate SIRS (Systemic Infection Response Syndrome) criteria as per physicians orders
     • Increased cardiac output related to hypoxemia
       • Treatment/Prevention
         • assess blood pressure, pulse rate, characteristics including skin colour and temperature
           • Assess heart sounds noting any gallops or murmurs
             • Monitor continuous ECG as appropriate
               • Assess vital signs and mental status every 1-2 hours
                 • Assess fluid balance by taking a daily weight
                   • Administer antihypertensive medications as per doctors orders
     • Anxiety related to ineffective breathing pattern
       • Treatment/Prevention
         • Provide a calm, soothing environment to ease anxiety in order to ease rapid breathing
           • Utilize therapeutic touch to promote trust in the health care relationship
             • Administer pain medication to facilitate willingness to participate in deep breathing exercises
               • Identify, limit and discontinue the use of any stimulants such as caffeine, nicotine, theophylline, terbutaline, sulcate, amphetamines and recreational drugs
                 • Encourage and incorporate family participation as positive reinforcement/ support
                   • Instruct to deep breath and utilize incentive spirometer to optimize breathing
                     • Instruct to breath slowly and deeply to prevent hyperventilation
   • Impaired tissue integrity related stage 2 skin breakdown
     • Impaired homeostasis related to hyperthermia secondary to being immunosuppressed by radiation
       • Treatment/ Prevention
         • Monitor granulocyte count, WBC and susceptibility to infection
           • Encourage adequate fluid intake and a high protein diet to aid in primary defences against microorganisms
             • Implement a careful sterile technique where there is a loss of skin integrity.
               • Refer client and family to social services and community resources to obtain support in maintaining a lifestyle that increases immune function
                 • Administer an Antipyretic as needed per Doctors orders
     • Acute pain related to impaired skin integrity
       • Treatment/Prevention
         • Respond immediately to complaint pain to foster development of trust
           • Eliminate additional stressors or sources of discomfort
             • Provide periods of rest to facilitate comfort, sleep, and relaxation
               • Provide pain relief pharmacological methods and non-pharmacologicaly,
                 • Evaluate the effectiveness of pain relief methods by observing effectiveness and signs and symptoms and unexpected effects
                   • Notify physician if interventions are unsuccessful and if current complaint of pain is a significant change from past pain episodes
     • At risk for infection related to impaired tissue integrity secondary to suppressed inflammatory response
       • Treatment/ Prevention
         • Prevent invasion of microorganisms by practicing hand hygiene before and after contact of wounds, and maintaining sterility during dressing changes
           • Encourage patient to avoid rubbing, and scratching the affected area.
             • Wear loose fitting clothing to avoid shearing and friction, and a bra without underwire.
               • Hydrogel and hydrocolloid gel dressings have been used to decrease wound discomfort and wound healing time in radiation ulcers.
                 • Referral to Dermatologist for further assessment of skin breakdown.
                   • Inspection of skin and wound bed size, location,redness, heat, and wound bed drainage
                     • Observe and report signs of redness, warmth discharge and fever