Case Study, Dehydration Related To Multiple Medical Issues In A Medical Surgical Clinical Setting Nursing 262 Acute Care

6695 words - 27 pages

This is a medical case study, it is very indepth with care plan, teaching plan, medication list and medication information, laboratory values and explainations, physical assessment, and medical history. This is not an english paper.Case Study, Pt DPPatient was a healthy hospital administrative aide, began to lose weight one year ago, a doctor at his place of work noticed the weight lose and inquired as to other symptoms, i.e. night sweats, fever of unknown origin, loss of appetite, and change in bowel habits. He was referred to Internal Medicine and was later diagnosed with prostate cancer and colon cancer with mets. Removal of Prostate in 2005 was successful and chemotherapy for colon cancer was started. Later that year surgery was done to resect the bowel for comfort and palliative care. Cancer to the right upper quadrant of the kidney was found during a bone scan, and a Right Nephrectomy was done. During this surgery there was an injury to the pancreas and the patient developed a Paralytic Ileus related to the aggressive abdominal surgery to correct that injury (21% of patients have had this injury during left or right radical nephrectomy) (Varkarakis, 2004) later during the hospital course the patient developed a pleural effusion from immobility and shallow breathing related to pain. The patient later received a shunt from the pancreas for drainage as an Anastomosis and JP drain for additional drainage to the outside of the body related to the actual surgery. The patient was started on pancreatic enzymes to assist with digestion and insulin utilization, A Dophoff feeding tube was placed with use of fluoroscopy and a continuous feeding of Vionexx was started at 75cc/hr and continued for home health care to monitor on discharge to home. Patient was discharged home with home health care. At the time of this admission patient presents with history of right side nephrectomy resulting in pancreatic injury, prostate cancer, Ileus, Pleural Effusion, and Metastatic Colon cancer, patient has a JP drain from left lower quadrant of an abdominal transverse incision for repair of pancreatic injury i.e. shunting for drainage; current symptoms include diarrhea, nausea, vomiting, fever, low blood pressure and extreme fatigue and weakness. On physical assessment in the emergency room the patients Dophoff feeding tube is found to be displaced, pt is made NPO and feeding tube is removed. Attempts were made to reinsert Dophoff and were unsuccessful. Patient is admitted to Surgical Floor for further testing and assessment of condition with diagnosis of dehydration.In initial assessment of this patient he is found to be alert an oriented to person, place, and time. Speech is appropriate and cranial nerve function is grossly intact. Patient is weak but has full range of motion with +4 strength to all extremities, gait is steady and patient has no complaint of vision deficit, hearing deficit or vertigo. Breathing pattern is deep and even with respiratory rate 18,...

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