Running head: CTS

CRITICAL THINKING SUMMARY

Student: _Kelli Koop_____________________________ Client Dx: __Abdominal Pain_______________________________ Age: __42___ Allergies: ___No known Allergies (NKA)______ The MEDICAL DIAGNOSIS that brought the client to the hospital is:

Metastatic Colon Cancer with Acute Pancreatitis

PATHOPHYSIOLOGY of diagnosed disease: (From text)

Colon Cancer: Most colon cancers are sporadic or associated with a family history of colon cancer. They are caused by multiple gene interactions, including gene deletion, mutations of oncogenes, tumor-suppressor genes, and repair genes. Adenocarcinomas of the colon usually arise from adenomatous polyps. Once the malignant cells of an adenoma traverse the muscularis mucosae, the tumor becomes invasive and highly malignant. These tumors have a long pre-invasive phase, and when they invade, they tend to grow slowly. It usually starts in the glands of the mucosal lining. Pancreatitis: is usually a mild disease and resolves spontaneously. It develops because of obstruction to the outflow of pancreatic digestive enzymes caused by bile and pancreatic duct obstruction (gallstones). The obstructed ducts result in accumulation of pancreatic secretions and pathologic activation of enzymes within the pancreas. The activated intracellular enzymes cause auto digestion of pancreatic cells and tissues, resulting in inflammation and acute pancreatitis. (Huether & McCance, 2012)
SYMPTOMS typically seen with this diagnosis include (as identified in your text):

Colon Cancer: Symptoms depend on location, size, and shape. Right side incudes pain, palpable mass in the lower right quadrant, anemia, fatigue, and dark red colored blood mixed with the stool. Left side includes abdominal distension, pain, vomiting, constipation, cramps, and bright red blood on surface of the stool. Pancreatitis: Constant pain (mild to severe) caused from edema of pancreas ducts, chemical irritation or inflammation, and irritation or obstruction of the biliary tract. Nausea, vomiting, jaundice, fever, leukocytosis, abdominal distention, (Huether & McCance, 2012)
CLIENTS SYMPTOMS of the diagnosed disease include:

The patient did not have any of the typical symptoms of the diagnosis because he was recovering from surgery that treated his cancer and pancreatitis. However, he was experiencing abdominal pain and fatigue due to the surgery. When asked about his previous symptoms before the surgery, the client stated he had bloody stool, serve abdominal pain, and nausea (no vomiting). (Huether & McCance, 2012)

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NUTRITIONAL ASSESSMENT: Height (actual or estimated): _182.88 cm (72 inches)_ Weight (actual or estimated): _83 kg (183 lb)__

Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5): _______80 kg (177 lb)__________ Does this client have characteristics of a well-nourished person? Yes _____ No __X___ Explain your answer.

The patient has no current labs relating to his health nutrition. Based on his healthcare practices, he does not have characteristics of a well-nourished individual: he is an alcoholic and current smoker, which has caused him to develop dangerous health conditions including pancreatitis. His pancreatitis almost prevented him from receiving his needed splenectomy and subtotal pancreatectomy. However, the patient has a current BMI of 25, which is very close to normal limits of 18.5 to 24.9. He is on a general diet and eats an adequate amount of food and fluids while staying in the hospital. When asked the patients weight before being admitted, the patient was not sure and state the acquired weight was similar. His physical appearance looks healthy, not to thin or large, although slightly fatigued.
PSYCHOSOCIAL STAGE OF DEVELOPMENT What is the clients developmental stage?

Stage 7: Middle Adulthood (age 40-65)

Has he/she met the necessary accomplishments? Yes _____ No __X___ Explain.

The patient exhibits behaviors that are only concerns with his own well being rather than the care of others. He continues to consume alcohol and smoke even with his current poor health conditions. During his care, I did not witness any interest in the care, teaching, or guidance of the younger generations.
How is this illness affecting the clients ability to meet these necessary accomplishments?

Due to his current health conditions, he has been in an out of the hospital for several years and hospitalized for the past month. He is unable to work and has to go on disability. He had two drains and an ileostomy placed recently, making activities of daily live (ADL) harder. He must adapt to his new lifestyle conditions physically and emotionally. These challenges and lifestyle behaviors could have prevented him from having his own family or becoming involved with other social groups. He has created a gap between him and the next generations. (Taylor, Lillis, LeMone, & Lynn, 2011)

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NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS Indicate below the 2 priority nursing diagnoses that are most relevant for your client. #1 NURSING DIAGNOSIS (problem r/t)

Risk-prone health behavior r/t lack of motivation to change behaviors and addiction
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:

Failure to achieve optimal sense of control; minimizes health status change; Relating factors: smoking; impaired ability to modify lifestyle behavior in a manner that improves health status.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:

Patient will alter behavior and limit or eliminate alcohol consumption as evidence by improved physical and mental health status within the next 6 months.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis: 1. Manipulate the environment to decrease stress 2. Maintain consistency and continuity in daily schedule 3. Assess and identify clients definitions and barriers to health and wellness.

(Ladwig & Ackley, 2011)

#2 NURSING DIAGNOSIS (problem r/t)

Risk for infection r/t invasive procedure and incision.

DEFINING CHARACTERISTICS (S/S) that support this diagnosis:

Inadequate primary defense: broken skin; increased environmental exposure to pathogens; insufficient knowledge to avoid exposure to pathogens.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:

Remain free from symptoms of infection as evidence by WBC within normal limits, no redness, swelling or discharge at incision, and temperature within normal limits during his recovery.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis: 1. Encourage adequate fluid and nutrition intake 2. Assess, observe, or report signs of infection 3. Educate and ensure good hand washing for all visitors and follow sterile technique during wound care.

(Ladwig & Ackley, 2011)

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COMPLICATIONS: If this clients condition were to worsen, what would be the most likely reason and why?

Patient health condition could worsen because of hemorrhaging, infection, or reoccurrence of cancer.
How would you know this is happening? If infected, the patients incision would become inflamed, red, swollen, and have discharge. His temperature and WBC count would increase. If hemorrhaging, the Hgb, Hct, and RBC counts would decrease, the patient would state a feeling of fatigue, or there could be blood in his stool or urine. If reoccurrence of cancer, a palpable mass would form, patient would state moderate to severe abdominal pain, cramping, nausea and vomiting, or abdominal distention. What will you do if this happens? First, sit the patient up and apply oxygen as needed making sure the patient is breathing easily. Assess vital signs checking if they are stable. Next, notify the physician of the patients current health status and if needed, prepare him for emergency surgery t o stop any internal bleeding. If infected, wound cultures would be obtained and medication prescribed; make sure the patients line was patent and administer antibiotics as soon as possible. If the cancer returned, pain management will be needed until the patient can be treated with another surgery or chemotherapy.

(Huether & McCance, 2012)

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PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS MEDS/IVs/TX/DIET (Include dose, route, frequency) REASON PRESCRIBED (Drug Classification, What is it treating?) Beta-blocker Hypertension NURSING IMPLICATIONS FROM TEXT (Checking for adverse reactions, preparation & administration concerns) Onset = within 1 hour Peak = 1-2 hours Duration = 12 hours Check BP before administration Onset = 30-60 minutes Peak = 1-3 hours Duration = 8-12 hours Check BP and apical pulse before administration Assess for signs of bleeding: bruising, tarry stool, hematuria, bleeding gums, etc. Assess and monitor for allergic reaction, bowl function, and skin integrity. Administer 30 minutes before meals and at bedtime. Use gloves when applying patch. Switch application sights daily. Administer on an empty stomach or with food/milk to minimize gastric irritation. May be crushed Assess pain 1 hour after administration. May cause drowsiness Do not break or crush. Can be taken with or without food. Do not take with NSAIDs or Aspirin. Take with a full glass of water. Take 1-3 hours after meals and at bedtime. Do not take with milk.

Carvedilol 25 mg, PO, twice daily.

CLIENT DATA FROM YOUR ASSESSMENT (What data is important to know before & after giving) Monitor intake and output, weight, and check for signs of fluid overload. Monitor intake and output, weight, and check for signs of edema. Monitor Platelet count every 2-3 days. Antidote: Protamine May cause an increase serum of AST, ALT, LDH, bilirubin, and Alkaline phosphate. Monitor for neuroleptic syndrome. Assess patients current smoking history.

Clonidine 0.2 mg, PO, every 8 hours.

Adrenergic Hypertension

Heparin 5,000 units, Subq, every 8 hours. Levofloxacin 750 mg, PO, every 24 hours. Metoclopramide 5 mg, PO, Three times daily Nicotine 1 patch, TOP, Daily

Antithrombic Prevention of Thrombus formation Anti-infective Bacterial Infection

Antiemetic Nausea and vomiting Smoking Deterrent Lessen sequelae of nicotine withdraw Anti-infective Colitis Infection/inflammation of the colon Opioid Agonist Decrease pain

Metronidazole 500 mg, PO, every 8 hours

May cause StevenJohnson Syndrome. May cause patients urine to become darkened. May cause respiratory depression. Assess vitals before and during. Antidote=naloxone. Monitor bowl function throughout therapy.

Oxycodone 20 mg, PO, every 8 hours

Pantoprazole 40 mg, PO, Twice daily

Sodium Bicarbonate 650 mg, PO, twice daily

Proton pump inhibitor Decreases acid accumulation in the stomach Alkalinizing agent Neutralizes gastric acid.

Used in cardiac arrest or urgent situations

(Deglin & Vallerand, 2010)

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Analysis of Diagnostic Tests

DIRECTIONS: 1. List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications) and provide the patient values for each test. Explain why they are pertinent for this patient. List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased or decreased in relation to your patient's medical condition. Diagnostic/Lab Test WBC 6.34 Patient Values Analysis of Values Lab value within normal limits. No sign of infection. Lab value is low due to blood loss from the patients two drains. Drains were placed to remove excess fluid and blood after splenectomy and subtotal pancreatectomy.

2.

HGB

10.3 - L

HCT

31.7 - L

RBC

3.39 - L

Platelet

203

Lab value within normal limits. No risk for blood clots or bleeding. Lab value is trending low because there is a low platelet count and low platelet volume due to the patients blood loss from the drains. Lab value is trending high because there is an increase number of immature RBCs during the regenerative process due to the excessive blood loss from the two drains.

MPV

11.4 - H

RDW

16.2 - H

(Deglin & Vallerand, 2010)

CTS References Deglin, J. H., & Vallerand, A. H. (2010). Daviss Drug Guide for Nurses (12th ed.) [Mobile application software]. Retrieved from http://www.skyscape.com/estore/productdetail.aspx?productid=219 Huether, S., & McCance , K. (2012). Understanding pathophysiology (fifth ed.). St. Louis, Missouri: Mosby Inc. Ladwig , G., & Ackley , B. (2011). Mosbys guide to nursing diagnosis. (Third ed.). Maryland Heights : Mosby, Inc. Taylor , C., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care. (Seventh ed.). Philadelphia: Lippincott Williams & Wilkins.