Concept Map #2 by audrey jamieson

Medical Diagnosis & Patient & Gender

16jamiesonaud — 2019-04-16 01:50:28 UTC

Left Melanoma Choroid
Gender: Female
Age: 74
Post Op Day: 1
Diet: General Diet
Allergies: Penicillin (hives), Insole (anxiety), Propronolol (GI intolerance)
Code: Full Code
Surgery: Patient underwent plaque brachytherapy on 4/8/19 to treat their left melanoma choroid. The patient had a 22mm plaque placed with 21 seeds of Iodine-125 radiation beads placed surgically placed over the left eye. The patient also had a ultrasoncic localization of plaque and a hangback procedure of the left lateral rectus. There was no blood loss.

Assessment Findings

16jamiesonaud — 2019-04-16 01:58:25 UTC

Shift Assessment
General Survey (appearance): Clean, dry and warm. Pleasant mood, anxious about assessments.
Eyes, ears, nose, mouth and throat X no drainage, right eye adequate response to light, right Pupil is round, equal, react to light, 3mm. Unable to assess left eye due to eye shield.
Neurological (orientation, level of consciousness (LOC), neuro checks, cranial nerves, Glasgow Coma Scale (GCS), Confusion Assessment Method (CAM)) - eye opening spontaneous (4), Verbal response oriented (5), and motor response obeys command (6). LOC- alert, stated full name, date of birth, what month it is (April), and where they were (hospital, mayo clinic). The total score was 15. CAM- alert, followed directions, attentive and asking relevant questions about health condition. Negative CAM. RASS score= 0. Patient had signs of anxiety when performing admission question answering. She was concerned multiple times if this was routine questioning or if something was wrong with them.
Respiratory (lung sounds, breathing pattern) WNL clear lung sounds and normal breathing pattern symmetrical lung expansion.
Cardiovascular (heart sounds, edema, capillary refill pulses) Capillary refill under 3 seconds, no edema present in patients extremities. Heart sounds strong and WDL, unable to hear murmur.
Gastrointestinal (bowel sounds, abdominal characteristics, nausea/vomiting) Bowel sounds were present and no signs of nausea or vomiting. No pain or tenderness in abdomen. Patient had 3 unmeasured voids. No BM on shift last BM 4/7. Patient stated they have been passing gas.
Integumentary (Braden scale, turgor, skin integrity, incisions) Braden scale: Braden scale score of 21. skin integrity= incision left eye. IV site right hand.. Clean, dry, Skin turgor= bounces back within 2 seconds. No signs of skin breakdown or pressure ulcers.
Other: color, warmth, movement, sensation (CWMS of extremities), dressings, etc. Warm, color adequate for ethnicity, pain score 1/10 on numeric scale due to surgical pain. Movement: Sensation full sensation of left and right upper extremity, full sensation of left and right lower extremity. No numbness or tingling. Dorsal and plantarflex- strong able to move lower extremities and upper extremities. walks independently. Walked 2 times during shift 1200ft. Able to wiggle left and right fingers and toes. Iv assessment: Right: clean, dry , intact, capped, transparent dressing. Eye shield- clean, dry, intact. Fall risk - 0.

Labs

16jamiesonaud — 2019-04-16 02:17:45 UTC

3/6
All Labs are WDL and were ordered due to the patients diagnosis of Left Melanoma Choroid. The liver panel was ordered to ensure there was no metastases to the liver or kidneys.
Alkaline Phosphate- 84 (35-104 U/L) - Part of a routine liver panel. Findings WDL signifies that the patient does not have symptoms of bile, bone, or liver cancer. Elevated levels could signify liver disease or a bone disorder.
ALT- 12( 7-45 U/L) Part of a routine liver panel that screens for liver damage or to diagnose liver disease. Results show that the patients levels are WDL and does not have liver damage. High levels could indicate liver disease, acute hepatitis. Results show that cancer has not metastasized to the liver.
AST- 17 ( 8-43 U/L) Used to detect liver damage and disease. Results show that patients levels are WDL and does not have liver disease or damage. High levels indicate acute hepatitis. could be increased due to certain cancers in the liver. Results show that cancer has not metastasized to the liver.
Bilirubin Direct <.02 ( 0.0-o.3 mg/dL.) Used to monitor liver disorders, hemolytic anemia, bile duct blockage, liver related- metabolic problem. Increased levels higher than total bilirubin could indicated decreased elimination of bilirubin by the liver cells by drug reactions, viral hepatitis, tumors, and gallstones present in bile ducts. Results show that cancer has not metastasized to the liver.
Bilirubin total 0.04 (<=1.2 mg/dL)
increased total could be due to hemolytic anemia, cirrhosis. Low levels are not concerning and are not monitored.
GGT 14 ( 5-36 U/L)- Used to evaluate possible liver disease, and bone disease. GGT is elevated in the blood in most diseases that cause damage to the liver or bile ducts.Used to determine high levels of ALP.
Creatinine - 0.80 (0.59-1.04 mg/dL) Measures the amount of creatinine in the blood that is used for skeletal muscle contraction. It helps diagnose impaired renal function. Results show patient has WDL creatinine level which could indicate no impaired kidney function present.

eGFR-nonblack 73 ( >=60 mL/min/BSA) Used to assess kidney function. eGFR plays a role in growth of cancer cells. The lab is being monitored due to high levels could cause loss of vision and pt. stated their vision in their left eye is compromised and will eventually loose all sight.
eGFR-Black 85 ( >=60 mL/min/BSA) Used to assess kidney function. Used to also diagnose eye damage due to chronic kidney disease being a factor for eye diseases. The results show that the patients levels are WDL and there is no sign of kidney disease to rule out kidneys as a contributing factor for vision loss in the left eye.

Medications

16jamiesonaud — 2019-04-16 02:17:51 UTC

Senokot-S (Senna)
1) Stimulant laxatives PO BID 4/9 last given 0855 oral . Due 2100 1 tablet.
2) Laxative reaction Active components of Senna alter water and electrolyte transport in the large intestine .
3) Nursing Considerations: Do not give if patient has diarrhea Monitor I/O. Laxatives should only be used for a short-term therapy.
4) Patient Teaching Can cause urine to change colors such as pink, red, yellow, or brown. Take with a full glass of water and on an empty stomach.
4) Side Effects: Urine color Diarrhea, nausea, cramping, pink/red colored urine .
Tylenol (acetaminophen)- 650 mg oral every 6 hours last given 1230, 1800.
1) To control patients surgical pain. Works by inhibition of prostaglandin synthesis and hypothalamic heat-regulator center.
2) Nursing Considerations: Pain assessment before and after , check temp, Check hepatic enzyme tests, monitor liver function.
3) Side effects: upset stomach, red, rash, itching, nausea
4) Patient Teaching: Tell provider if you have any symptoms listed above. Tylenol is only for short-term use and long term use can cause hepatic damage
Tylenol #3 ( acetaminophen-codine)
1) PO 1 tablet every 6 hours Last given 4/9 0447
2) Opioid agonist works by blocking pain impulse generation and alters the perception and pain to response.
3)Side effects- hypotension, drowsiness, confusion, anorexia, leukopenia, angioedema, constipation.
4) nursing considerations: assess pain before and after.
5) Teaching: Take a full glass of water or food/milk. Do not use with other drugs containing Acetaminophen.
Narcan (Novalox)
1) Opioid Antagonist IV as needed .02 mg last given: N/A
2) To reverse respiratory depression by beating out the opioids at the receptor site and blocks them.
3) Nursing Considerations: Make sure to dilute Narcan for administration. Monitor respiratory rate, rhythm, depth, pulse, and BP 3-4 hours after given. doses should be titrated carefully to avoid interference with control of postoperative pain.
4) Patient Teaching :notify nurse if experiencing side effects including, increased difficulty with breathing or increased sedation, itching, rash, nausea, and/or increased pain.
5) Side effects- can experience pain from the reversal of opioid, headache, hypotension, hypertension, tachycardia, sweating, nausea, vomiting, pulmonary edema
Metamucil (Psyllium w/ aspartame) - PO 1 packet TID last given 4/9 0856 Due 1400 and 2100.
1)Antidiarrheal. Works by absorbing water in the intestine to form a viscous liquid which promotes peristalsis and reduces transit time
2) Side effects: abdominal cramps, constipation, diarrhea, esophageal obstruction, bronchospasm.
3) Nursing Considerations: assess I/O, assess patients bowel movements.
4) Patient Teaching: Take with 8 ounces of fluids.
Zofran (Ondasetron ODT) - disintegrating tablet 4mg every 6 hours for nausea/vomiting Last given N/A.
1) anti-nausea- works by blocking serotonin receptors, reduce the effect of increased serotonin due to chemotherapy.
2) Side effects: headache, diarrhea, dizziness, fatigue, malaise
3) Nursing Considerations: assess for nausea, vomiting, abdominal distention, and bowel sounds prior to administration. may increase serum bilirubin.
4)Patient Teaching- take as directed, notify nurse if irregular heartbeat, involuntary movement of eyes, face, or limbs occur.

Diagnostics

16jamiesonaud — 2019-04-16 02:18:06 UTC

3/7 Tests done for diagnosis of Left Melanoma Choroid.
OCT- results showed left macula loss of foveal depression, choroidal elevation reaches the subfovcal region, diffuse retinal thickening with sub retinal fluid, disregulation of retinal layers overlying lesion.
Fundus Photos+ Auto Fluoresence- left eye shows an area of hypofluorsen in temporal macula. Choroidal mass associated with orange pigment, homogeneous in color, dome shaped 15x14mm by 5.5 mm round. Results confirm diagnoses.
CT Chest with IV contrast- Results showed a 2mm nodule in left upper lobe. moderate esophageal hiatal hernia. No evidence of metastasis.
CT abdomen pelvis with IV contrast- Results showed lymph nodes have no evidence of adenopathy. No findings to suggest metastaes in abdomen pelvis.
B-Scan ultrasound & US/UBM left eye- Results showed that there was a left eye lesion 5.5-5.6x 16.7 x13.9mm overlying subretinal fluid. low internal reflectivity. Retina detached. no ciliary body movement.

Monitoring

16jamiesonaud — 2019-04-16 02:18:18 UTC

Vitals Q4- Vital signs (1330) temp 36.6 oral, pulse 65, resp 20, BP 141/63, spO2 96%. Vital signs 1730: Temp 36.7 oral, Pulse 90, Resp 21, BP 152/54, spO2 95%, pain 1.
Vital signs 2000: temp 36.7 oral, pulse 78, resp 18, BP 152/59, SpO2 93, pain 0.

No blood loss or complications.

Monitoring quality of pain and irritation in the eye.

Monitoring for regular bowel movements and intake. Also monitoring patients nutritional intake due to only eating 25% of her meal. May have to consult dietary to increase appetite and intake.

Ordered to ambulate 6 times during a day. Patient has ambulated 2 times today.

Collaborating services.
Patient worked with RST ophthalmology
Is a radiation oncology patient.
Requested services with social worker to discuss more information on advance directives.
Patient worked with the respiratory team during surgery.

Nursing Diagnosis #1

16jamiesonaud — 2019-04-16 02:18:53 UTC

Powerlessness r/t complex treatment of plaque brachytherapy secondary to left melanoma choroid, m/b frustration on inability to perform previous activities, radiation postop restrictions, verbalizing anxiety, saddness, and inability to control cancer.

Signs & Symptoms

16jamiesonaud — 2019-04-16 02:28:35 UTC

S: flashing lights, string in eyes, loosing color in the left eye t leaves would look brown and dead through left eye where as right eye the leaves would be green, difficulty seeing in left eye. Pain score of 1 of the numeric scale 0-10, scotoma, ignored signs and thought it was just glaucoma and a normal part of aging.
O: unable to assess eye. annual eye exam identified a tumor in left eye. 16 pressure in both eyes. progressive vision loss 8/2019, Photosensitive, choroidal mass associated with orange pigment, homogeneous in color, dome shaped 15x14mm by 5.5 mm round. acoustic hollowness, thickness 7.2 mmVital signs (1330) temp 36.6 oral, pulse 65, resp 20, BP 141/63, spO2 96%. Vital signs 1730: Temp 36.7 oral, Pulse 90, Resp 21, BP 152/54, spO2 95%
Vital signs 2000: temp 36.7 oral, pulse 78, resp 18, BP 152/59, SpO2 93,
PMH: Nuclear sclerosis in both eyes, Post op nausea and vomiting, PUD both eyes, skin melanoma and basal cell carcinoma, nevus choroid left eye since 1994.

PC 1

16jamiesonaud — 2019-04-16 04:48:07 UTC

Infection
this is related to the pt having plaque brachytherapy on 4/8/19 to treat their left melanoma choroid and ultrasonic localization of plaque and a hang back procedure of the left lateral rectus.

The patient is undergoing radiation which can leave the patient at risk for infection due to their immune system being compromised.

Trying to prevent through assess for infections: redness, warmth, discharge, and increased body temperature.
Assessing eye shield, wound, and looking for drainage.
Washing hands thoroughly before and after contact with patient.

PC 2

16jamiesonaud — 2019-04-16 04:55:13 UTC

Vision Loss

This is related to the Pt having nevus choroid in the left eye since 1994 and vision loss can be a complication overtime. The patient also underwent plaque brachytherapy to treat their left melanoma choroid.

Trying to prevent vision loss through keeping the effective eye covered at all times, encouraging patient to wear protective eye wear outside. Assessing vision after therapy is complete, assessing eye shield placement and condition.

SBAR

16jamiesonaud — 2019-04-16 04:58:12 UTC

S- Pt. is an 72 y/o female post op 1 day ago and underwent plaque brachytherapy to treat their left melanoma choroid on 4/7/2019 and is scheduled for radiation to end 4/12/2019. Pt's lives alone in a retirement complex in Minnesota.

B- Patient was diagnosed with Left Melanoma Choroid and underwent surgery 4/7/19. The patient has a family history of skin melanoma in her sister and mother. The patient also has a history of skin melanoma and basal cell carcinoma on her cheeks and forehead. She was a smoker for 15 years quit 40 years ago and smoked 1-1.5 packs a day. The patient was diagnosed with choroidal nevus in 1994 and is thought to be the main contributing factor to her diagnosis. Patient had signs and symptoms of melanoma choroid and ignored the symptoms due to thinking they were a normal part of aging or just glaucoma. The patient went in for an annual eye exam and was refereed to a specialist due to the findings of a mass in the left eye. The patient consult with the surgeon on 3/6 on the surgery with the goal to treat the cancer through plaque brachytherapy. The patient was informed of the procedure and the risk of vision loss, stroke, blindness, ptosis, dry eye, infection, and double vision.The patient agreed on radiation therapy 4/7-4/12 and 3 months of weight and activity restrictions. Patients height is 154 cm, weight 67.4kg, and a BMI of 28. The pt is alert, oriented and on a general diet. The patient does have a history of post operative nausea and vomiting and is prescribed ondasetron ODT if needed. Patients last bowel movement was 2/7. The patients labs had no indication of abnormal values and underwent a CT of the chest and abdomen that show no evidence of metastases. Patient is allergic Penicillin (hives), Ilnsole (anxiety), and Propronolol (GI intolerance).

A-Patient is a full code and Vitals are Q4. the most recent vitals were taken at 2000 with an oral temp of 36.7, pulse of 78, respiration of 18, Blood pressure 152/59, SpO2 93, and a pain score of 0 out of 10. Patient complains of a pain 1 out of 10 and was administered Tylenol for pain at 1700. The patients blood pressure has been borderline at 1700 152/59 as well. She does not complain of loss of appetite or discomfort eating but only ate 25% of her meal. The patient saved multiple deserts and is snacking on them periodically. The patient has an radiation eye shield on the left eye. The shield was clean, dry, and intact. Due to the radiation pregnant women and children are advised to not go into the room and visitors must stand 3 feet from the patient due to the radiation properties of her treatment. The patients skin temperature is normal and no complaints of numbness or tingling. Perrla on the left eye is unable to be assessed due to the eye shield and is advised to not be removed. Radial and pedial pulse are a strong pulse two and there is capillary refill under three seconds. Patient has one IV that is capped on the right hand. The pt is up ad lib and is independent while ambulating in their room. The patient is under supervision when walking in the hallway and has ambulated twice in the hallway for 1200 feet each time. The patient was anxious during the shift during the completion of admission questions and also verbalized sadness due to her inability to complete previous tasks at home due to the radiation post op restrictions. Pt. has not had a bowel movement today and last bowel movement was 4/7/2019. There were active bowel sounds present and patient stated they were passing gas.

R- The patient has been tired on shift and would like to rest. We scheduled meals and vitals with the patient to ensure energy conservation was a priority. We ambulated in the hallway twice for 1200ft. The patient stated they were down due to being cooped up in their room. I would like to see the patient go on more short frequent walks to boost mood and to get them out of their room. The patient at 25% of their meal and I suggest to encourage the patient to eat a nutritional snack or more frequent smaller meals to ensure their nutritional intake is adequate. Pt. had no complains of pain but continue to monitor. The patients blood pressure was border line at 1700 with 152/54 and 2000 with 152/59. I would suggest to monitor blood pressure Q15min to assess if it continues to rise. Provider is planning on patient discharging on 4/12 after the plaque brachytherapy is surgically removed.

Patient Teaching #1

16jamiesonaud — 2019-04-16 04:58:42 UTC

Teach the patient how they can take an active role in their care at home.

Teach patient stress reduction strategies and how to confront their own negative thoughts about their condition.

Nursing Interventions #1

16jamiesonaud — 2019-04-16 04:59:26 UTC

The nurse will engage the patient through listening and questioning to validate patients concerns.

The nurse will establish a therapeutic relationship with the patient through spending one on one time to provide encouraging support and empathy.
The nurse will encourage the patient to make decisions regarding her treatment schedules and future treatment regimes

The nurse will help the patient identify 4 factors in the patients life the patient can change to increase the feelings of having control in her life.

Patient Goals #1

16jamiesonaud — 2019-04-16 04:59:33 UTC

Patient will state feelings of powerlessness and other feelings such as sadness, anger, and hopelessness.

The patient will verbalize hope for the future and sense of participation in planning care.

The patient will identify factors that are uncontrollable.

Nursing Diagnosis #2

16jamiesonaud — 2019-04-16 05:01:48 UTC

Fatigue r/t negative life event secondary ultrasonic localization of plaque, hang back procedure of the left lateral rectus, and plaque brachytherapy m/b cancer treatment, plaque brachytherapy, tiredness, guilt about maintaining responsibilities, impaired ability to maintain usual physical activity, 25% meal consumption.

Patient Goals #2

16jamiesonaud — 2019-04-16 05:02:01 UTC

The patient will explain an energy conservation plan to offset their fatigue.

The patient will identify potential factors that aggravate and relieve fatigue.

Patient Teaching #2

16jamiesonaud — 2019-04-16 05:02:25 UTC

Teach patient strategies for energy conservation such as sitting instead of standing in the shower and storing items at waist level.

Teach patient the importance of following a healthy lifestyle with adequate sleep, nutrition, and fluid.

Nursing Interventions #2

16jamiesonaud — 2019-04-16 05:02:47 UTC

The nurse will assess the severity of fatigue on a scale of 0-10 with activities and ADL's.

The nurse will assess the adequacy of the patient sleeping patterns and daily nutritional intake. The nurse will encourage the patient to get adequate rest and have a routine walk/sleep schedule.