Nursing Care Plan A Client with Cancer James Casey, age 72, is of Northern European heritage. He has moved in with him to provide care and sup been receiving medical care for the chronic obstructive pulmonary port during his final months. The daughter has the ac- disease, chronic bronchitis, status postmyocardial infarction, and accepts, saying she is glad to be able to spend this time with her fa- type I diabetes mellitus for over 15 years. He reports that he lost her; she has been informed of the physical and emotional stress of his wife from lung cancer 5 years ago and still" misses her terribly." this will entail. He describes his bad habits as smoking two packs of cigarettes a day for 52 years (104 packs/year), one to two six-packs of beer an ASSESSMENT week, one " bourbon and water" a night, and "a lot of sugar-free Glynis Jackson, RN, the hospice nurse assigned as case manager junk food, like french fries." He assures the nurse that he quit for James Casey, completes a health history and physical exami- smoking 2 years ago, when he could no longer walk a block with- nation during her first two visits in his home, 1 day apart. She out considerable shortness of breath, and just quit drinking alco- gathers this information over 2 days to conserve his strength hol a few weeks ago at his physician’s insistence. About a year and allow more time for James and his daughter to talk about ago, he had a basal-cell carcinoma removed from his right ear. Six their concerns. months ago, cancerous tumors were discovered in his bladder, During the physical assessment, Glynis notes that James is pale and he underwent two 6-week chemotherapy courses of bladder with pink mucous membranes, thin with a wasted appearance instillations of BCG. His latest report indicates that the tumors and a strained, worried facial expression. He complains of severe have grown back and no further chemotherapy would be useful. back pain no longer adequately relieved by Percodan and Vicodin The urologist had considered surgery but believed that James’s alternating every 2 to 4 hours. His blood pressure is 90/50, right other medical problems would compromise his chances of sur- arm in the reclining position with no significant orthostatic vival. James decides to let the disease run its course and to be change; his apical pulse is 102, regular and strong; respiratory rate managed at home through hospice care. Because he lives alone 24 and unlabored; breath sounds are clear but diminshed in the in a modest home, he asks his daughter, Mary, and her family to bases; oral temperature is 96.8.F. (continued) Nursing Care Plan A Client with Cancer (continued) A tunnelled Groshong catheter as a VAD PLANNING AND IMPLEMENTATION is present in the right anterior chest. There is no . Ask about favorite foods, and ask Mary to offer a small portion drainage, redness, or swelling at the site. The catheter was placed of one of these foods each day. last week when the client was being evaluated at the anesthesiol- Encourage drinking up to four cans of liquid nutritional supple- ogist’s office for pain management, but no medication is running ment with fiber a day, sipping them throughout the day. via the VAD. Mary reports that his urinary output is adequate. Talk with the physician about prescribing a medication to help Approximately 200 mL of yellow, cloudy, nonmalodorous urine is stimulate the appetite. present in the urinal at the bedside from his last voiding. Plan to have a home health aide come to the home, give him a James states that he spends most of his time either in bed or shower or bed bath daily, and assist his daughter with some of sitting up in a chair in his room. He reports that he has no energy the household chores. any more and is unable to walk to the bathroom unassisted, dress Talk with Mary about having her adult son and daughter relieve himself, or take care of his own personal hygiene. Glynis rates her of the housework and stay with James so that she can get James’s functional level at ECOG level 4: capable of only limited out of the house occasionally. Offer to talk with them if she is self-care, confined to bed or chair 50% or more of waking hours uncomfortable doing so. (Karnofsky 10 to 20). He tells the nurse that his daughter "is work- Request a volunteer to spend up to 4 hours a day, twice a week ing day and night to help me and is looking awfully tired." with James so that Mary can attend to outside activities and Many reports that James is eating very poorly: He usually eats a chores. small bowl of oatmeal with milk for breakfast and vegetable soup Talk with the anesthesiologist, and work out a pain control pro- and crackers for lunch, but he tells her that he is too tired for dinner gram, using the VAD and a CADD-PCA infusion pump with a and wants only fruit juice. James tells the nurse that he has no ap- continuous morphine infusion. petite and eats just to please Mary. He does drink at least three to four Call the infusion therapist to set up the equipment and supplies glasses of water a day plus juice. His fingerstick blood sugars remain (including the medication) for the morphine infusion. within normal range. Teach how to use the pump and about the side effects of the His current weight is 120 pounds at 67 inches tall, down from morphine infusion, including those that require a call to the 180 pounds a year ago. He has lost about 30 pounds over the last nurse for assistance. Teach which untoward effects should be 2 months. reported. Available laboratory values from his visit with the doctor show Request a physical therapy consultation to evaluate current the following: level of functioning and determine how to maintain current Total protein: 4.1 g/dL (normal range: 6.0 to 8.0 g/dL) level. Albumin: 2.2 g/dL (normal range:3.5 to 5.0 g/dL) Instruct Mary to allow ample rest periods for James between Hemoglobin: 10.2 g/dL (normal range: 13.5 to 18.0 g/dL) activities. Hematocrit: 30.5% (normal range: 40.0% to 54.0%) Order a hospital bed with electronic controls to be delivered to BUN: 30 mg/dL (normal range: 5 to 25 mg/dL slightly higher in the house. older people Order a special foam pad for bed and chair and a bedside com- Creatinine: 2.2 mg/dL (normal range: 0.5 to 1.5 mg/dL) mode from the medical supply house. Instruct Mary and the home health aide to inspect skin daily, DIAGNOSIS give good skin care with emollient lotion after bathing, and Imbalanced nutrition: Less than body requirements related to report any beginning lesions immediately to the nurse. anorexia and fatigue Risk for caregiver role strain related to severity of her father’s ill- EVALUATION ness and lack of help from other family members James Casey did increase his oral intake a little, sometimes eating Chronic pain related to progression of disease process the special treats his daughter prepared and drinking one or two . Impaired physical mobility related to pain, fatigue, and begin- cans of liquid nutritional supplement a day. However, his weight ning neuromuscular impairment did not increase; it stayed at about 120 pounds until his death Risk for impaired skin integrity related to impaired physical mo- 2 weeks later. His daughter was very grateful for the extra help bility and malnourished state from the home health aide and the volunteer, though she could not bring herself to ask her son and daughter for help and did not EXPECTED OUTCOMES want the nurse to do so. She did become more rested and re- . Increase oral intake and show improvement in serum protein ported that "Dad and I had some wonderful 3:00 A.M. talks when values. he couldn’t sleep." Daughter will be able to maintain supportive caretaking activi- James was started on 20 mg of morphine per hour with bo- ties as long as James needs them. luses of 10 mg 4 times a day, for breakthrough pain.

This medica- Minimal pain for the rest of his life. tion relieved his pain quite well; after 2 days he was alert enough Able to continue his current activity level. most of the time to carry on a normal conversation and still walk Maintain intact skin. to the bathroom with help up until 2 days before he died. The hospital bed simplified James’s care and made it much 3. One of the specified interventions was to easier for him to rest comfortably and change position. His skin consult the physician regarding medication remained intact and in good condition. to increase James’s appetite. What medications might fulfill that Mary reported that James died peacefully in his sleep, about function? What side effects might they have that would con- 2 weeks after care was started. She said spending the last weeks of traindicate these medications for him? his life together was a healing experience for both of them. 4. If James had developed signs and symptoms of sepsis, what manifestations would you expect to see? As the nurse making Critical Thinking in the Nursing Process the home visits, what would be your nursing actions, and in 1. What other tests could be done to evaluate James Casey’s what order of priority? nutritional status? See Evaluating Your Response in Appendix C. 2. James had severe back pain. What were the possible patho- physiologic reasons for his pain?

 

Assess the culture of the organization for potential challenges in incorporating the nursing practice intervention. Use this assessment when creating the strategic plan. Discuss with your preceptor the culture of your organization and what are the potential problems.  my plan

Patients’ limited English proficiency (Population), what is the effect of the implementation of interpreting/translating services or tools increase communication between the two parties  (Intervention) in the absence of bilingual staff (Comparison) on a patient’s understanding and treatment compliance (Outcome)?  This at a walk-in clinic

What strategic plan defines how the nursing practice intervention will be implemented in the capstone project change proposal?

Explain how neurons communicate using action potentials and neurotransmitters. the answer must compare and contrast the similarities and differences between these two means of communication

BACKGROUND

SUBJECT: Under resting conditions, the concentration of sodium ions — shown here in red — is about 10 times higher outside the neuron compared to the concentration inside. At the same time, levels of potassium ions — shown here in blue — are about 15 times higher inside the neuron compared to the extracellular environment. This ion gradient is maintained by the continuous operation of the sodium-potassium ATPase pump, which moves three sodium ions from the inside of the neuron to the outside environment, and at the same time, shifts two potassium ions from outside the neuron to the inside of the cell. Therefore, at each cycle of the sodium-potassium ATPase pump, the cell loses one positively charged ion from the intracellular environment. The action of the sodium-potassium ATPase pump is needed, because there is a constant flow of potassium ions down their concentration gradient from the inside of the neuron to the outside through leaky potassium channels that are situated in the membrane of the neuron. These two processes — diffusion of potassium out of the cell and exchange of intracellular sodium for extracellular potassium by the sodium-potassium ATPase pump — are continuously taking place in the neuron. This ultimately results in more positive charge outside the neuron compared to the inside of the neuron. The difference in charge across the membrane of the neuron is referred to as polarisation. If you subtract the value of all the positive charges inside the neuron — in this case, 30millivolts — from the value of the positive charges outside of the cell — in this case, 100millivolts — there is a difference of minus 70millivolts inside the neuron compared to the outside of the cell. This is called the resting membrane potential of the neuron.

 

 

 

Neurons communicate with each other via action potentials. Action potentials start in the axon hillock at the base of the cell body and then travel down the axon towards the dendrites of the neuron. To understand how an action potential is initiated, we need to look at the plasma membrane of the neuron.At rest, the neuron maintains a constant membrane potential of approximately minus 70 millivolts. Embedded in the membrane of the neuron are ion channels that are sensitive to the voltage of the cell. These channels open only when the voltage in the cell reaches a certain value. They are called voltage-gated ion channels.Voltage-gated sodium channels have both an activation gate and an inactivation gate. At rest, the activation gate is closed and the inactivation gate is open. Voltage-gated potassium channels have only one gate, which opens to allow the flow of potassium ions through the channel and closes to stop the flow of potassium ions.When the membrane potential is minus 70 millivolts, voltage-gated sodium channels are closed and the concentration of sodium outside the cell is higher than inside the cell. When the neuron receives an excitatory signal or stimulus, small amounts of sodium will move down their concentration gradient into the neuron, and the resting potential will start to become less negative.Once the membrane potential reaches a critical threshold of minus 55 millivolts, voltage-gated activation gates in the sodium channel open quickly, allowing sodium to flood into the neuron. As a result of the large influx of positively charged sodium, the neuron loses its negative charge and undergoes depolarisation.When the inside of the neuron becomes highly positive, the pore of the voltage-gated sodium channel is plugged by the inactivation gate, and the flow of sodium into the neuron stops.Eventually, the intracellular environment of the neuron becomes sufficiently positive that voltage-gated potassium channels begin to open slowly. Opening of these channels allows potassium to flow down its concentration gradient, out of the cell. This movement of potassium causes the inside of the neuron to quickly regain its negative charge in a process called repolarisation.In response to the increasingly negative charge inside the neuron, the voltage-gated potassium channels close. Because this process is slow, some potassium ions continue to move outside the cell while the channel is closing. This extra efflux of potassium causes the membrane potential to become more negative than the resting potential of minus 70 millivolts. This process is called hyperpolarisation.During the period of hyperpolarisation, the neuron will not be able to fire another action potential. This is termed the refractory period. Eventually, the action of the sodium potassium ATPase pump will restore the resting membrane potential to minus 70 millivolts, and the neuron will be ready to fire another action potential.The process of depolarisation and repolarisation is referred to as an action potential. A single action potential takes only milliseconds– that is one-thousandth of a second– to complete, enabling the neuron to quickly fire in response to the hundreds of signals it receives every second.

 

 

Movement of Na⁺ ions into the neuron causes the neuron to undergo depolarisation. (b) Movement of K⁺ ions out of the neuron causes repolarisation.

The action potential is initiated at the base of the cell body in the axon hillock. As you saw in Section 1.4, the signal will then be transmitted down the axon. However, the myelin covering does not allow for the exchange of ions across the cell membrane. How then does the action potential propagate to the end of the axon? Small gaps in the myelin, called nodes of Ranvier, allow ion movement across the axon membrane at these sites. This effectively permits the action potential to ‘jump’ from one node to another, thereby allowing the signal to be transmitted very quickly. This type of transmission is called saltatory conduction (Figure 2.1). Information is coded by the frequency of the firing of action potentials (i.e. the number of spikes over a given period of time), rather than the size of the action potential, which is always the same.

Describe the main structures of the brain stem, the midbrain, and the forebrain, including the basal ganglia, the limbic system, and the cerebral cortex. What functions and behaviors are these regions known to control?

Mr. Joshua is a 55-year-old male with a long history of delusional thinking of a grandiose nature. He was brought to the ED on an emergency petition because he was found by the police to be argumentative with the salesman of a car dealership over the topic of buying a new car.

This client proclaimed angrily that he had a special relationship with a movie star that he claimed sent him there to purchase a new BMW 2021, SUV. When the dealer called for a financial background check, the client’s credit score was below 200. It was determined upon investigation that this client is homeless and unemployed. He has been sleeping in a nylon tent sitting on the sidewalk over a subway train vent that provides warm steam.

This client was noted as unkept with his hair and body. He also had a foul odor coming from his clothing which was dirty and that he wore in 4 layers. This client became extremely angry with the salesman that told him that he did not meet the criteria through the credit bureau to be able to purchase a car.  Joshua also could not provide an address for the salesman except for the corner of Light and Holliday Street. He was noted invading the personal space of the sales manager that asked that he him leave his car dealership.   This client was hyperverbal with rapid pressured speech. He was constantly in motion noted swinging his arms and hands in the air as he spoke.

The policeman said that this client seemed to require medication to slow himself down and decrease his threatening behavior towards others. He was allowed to use the phone at the dealership to call the famous movie star he claimed to know personally to verify to sales that he would help Joshua pay for the BMW.  This client is angry in affect and laughs loudly at times. Joshua is labile in mood with elation at times. He has purchased a color television from a local store but cannot pick it up because he has no place to plug it up and watch it.   This client has an angry affect at times and mood swings. Has been unemployed for 1 year.

Page 2 Case Situation- Joshua

Has been sleeping on the sidewalk over a ventilator vent from the subway in a tent downtown. He is disheveled, wearing layers of clothing for the past 2 years. He eats his meals at a soup kitchen. He has family but claims that he cannot stay with them because they say that he is to hyper, loud, not sleeping and has unpredictable periods of anger. This client reports that the children of his family are frightened to be around him. Joshua reports not taking his drugs or seeking treatment for 3-4 months due to his complaints of the side-effects of the drugs prescribed.     He complains of the drugs cause him to have sexual problems and weight gain. This client has been living on the sidewalk or under a bridge. This client is pacing rapidly around the store . He was asked not to keep going into the store asking people for money and becoming angry when they did not give any to him. Joshua was seen in the Ed due to his aggressiveness, hyperactivity, and paranoid grandiose ideations  and was involuntarily  admitted to the inpatient behavioral health unit. Upon admission to the floor this client proceeded to hit the technician and was administered Haldol 10 mg. IM. The client agreed to stay in his room for an hour to let the medication help to decrease his agitation and anxiety.   After an hour, this client was at the nurses’ station complaining of thickness of his tongue, some drooling, and his eyes were going up in his head. The client was unable to make the eyes to stay own. All that could be seen was the whites of his eyes .   He was certified by the ED doctors after medical clearance. Joshua was given the diagnosis of Bipolar Disorder, Mania

Instructions:

1.     Identify what the client is experiencing.

2.     Define what was going on with his eyes and his tongue.

3.     What causes reactions like that?

4.     Use the SBAR format to provide a report to the Nurse Practitioner on duty.

Page 3 Case Situation-Joshua

5.    What medication might be ordered for this client?

6.    Would this client need to receive medication in po. or IM. form?

7.    What might this client’s psychiatric diagnosis be?

8.    Might this client be described as neurotic or psychotic, explain!

9.    Provide a Nursing Diagnosis?

10. What kind side effects is this client experiencing.   Name and define the classification of the drugs that

would be given (refer to Chapter 4 of Townsend and Morgan 10^th. Edition.

Please fill in the Axis according to the DSM 5

Axis I_________________________________

Axis II ________________________________

Axis III ________________________________

Axis IV ________________________________

Axis V ________________________________

>>>Use a SBAR form to document what you would report to the oncoming RN about this client’s experience the shift.