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Situation

Karen is an 87-year old female with advanced breast cancer with extensive metastasis. She was brought to the hospital via ambulance and was treated for dehydration and uncontrollable pain. She was on a medical/oncology unit for 3 days and then transferred to inpatient hospice. Karen’s provider has written orders for admission. She is currently complaining of pain and shortness of breath. She is currently on 2 LPM via nasal cannula. Her IV was placed and she was just given morphine 2.5mg IV about 2 hours ago. Karen was turned, repositioned and oral care was provided about 30 minutes ago.

Assessment

Vital Signs: HR: 98, BP 95/65, RR 28, SpO2 92% on 2 LPM per nasal cannula, T 37â—¦C

General Appearance: Frail, very thin and pale with mild dyspnea. Appears comfortable overall.

Integumentary: Skin breakdown in peri area and coccyx.

Cardiovascular: Sinus rhythm is S1 and S2 audible. No murmurs. 

Respiratory: Crackles in both lung fields. Mild dyspnea noted secondary to ascites.

GI: Bowel sounds hypoactive, abdomen firm and distended with positive fluid wave.

GU: Voiding dark concentrated urine. Incontinent, some skin breakdown noted.

Extremities: Decreased movement and strength in all extremities.

Neurological: Pupils equal, round, and minimally reactive to light. Responds to her name only.

IVs: 20-gauge peripheral catheter intact in right arm with D5 ½ NS infusing at 30mL/hour and morphine infusing at 1mg/hr.

Fall Risk: High-risk

Pain: No grimacing, moaning, clenched mouth, restlessness, sighing or crying noted at this time.

Orders

Initial Healthcare Provider Orders

Admit to inpatient hospice bed
Diagnosis: Advanced breast cancer with extensive metastases to bones, brain and liver
Do Not Resuscitate
Nothing by mouth
Vital signs every 4 hours
Complete bedrest
Oxygen at 2 LPM via nasal cannula; titrate as needed for dyspnea
Dextrose 5% in 1⁄2 NS at 30 mL/hour
Morphine sulfate per continuous IV infusion at 1 mg/hour
Morphine sulfate 5 mg IV every 2 hours prn for breakthrough pain, call healthcare provider if pain not relieved
Lorazepam 1 mg IV every 4 hours prn for anxiety
Haloperidol 5 mg IM two times every day
Glycopyrrolate 0.2 mg IV every 4 hours
End-of-life comfort measures
Apply barrier cream to skin after each bowel and bladder incontinence

As the primary RN, what do you see with knowing all the information that Karen’s primary nursing problem approach would be (name at least 3)? List four nursing interventions, can be nursing and dependent interventions ?

SCIENCE
HEALTH SCIENCE
NURSING
NURISNG 250

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