Case studies - Nrsg of Adults

Angela Clayton, a 7-year-old girl, was diagnosed with sickle cell disease at birth. She was outside playing in the snow when she developed severe abdominal pain. Her parents immediately took her to the emergency room ...

Angela Clayton, a 7-year-old girl, was diagnosed with sickle cell disease at birth. She was outside playing in the snow when she developed severe abdominal pain. Her parents immediately took her to the emergency room suspecting a sickle cell crisis. Describe the nursing process for the patient with sickle cell crisis Assessment  Identify precipitating factors  Assess pain  Assess fatigue  Assess for swelling  Assess abdomen for pain and tenderness  Assess cardiopulmonary and neurologic systems  Assess for infection  Assess laboratory values: CBC with differential Nursing diagnosis  Acute pain  Risk for infection  Risk for powerlessness  Deficient knowledge Nursing intervention for the diseases  Manage pain with analgesics. Aspirin is effective for mild to moderate pain. NSAIDs can be used for moderate pain, but renal function must be monitored. If pain is not controlled with NSAIDs, opioids can be used in combination with NSAIDs or alone. Morphine is the drug of choice  Support and elevate joints that are swollen  Administer oxygen  Implement nonpharmacologic approaches to pain management, such as distraction and relaxation, physiotherapy, and physical therapy  Reinforce teaching of signs and symptoms of infection. Any fever should be reported to the physician. If taking a daily antibiotic, it is important to take it at the same time daily  Ensure that all immunizations, including the annual influenza, are current  Manage fatigue by assisting the patient with ADLs  Balance activity and rest  Promote adequate sleep  Maintain hydration and nutrition. Adequate hydration helps to reduce sickling. If unable to take oral fluids, IV fluids will be required  Provide emotional support to the patient and family  Educate patient and family on medication and medical management of disease  Refer the parents to a support group Evaluation  Control of pain and fatigue  Absence of infection  Increased knowledge  Absence of complication  Expresses improved sense of control Mary Saeger, a 56-year-old woman, is receiving outpatient chemotherapy for bladder cancer. A round of chemotherapy consists of gemcitabine on day 1 and day 8. Cisplantin is administered on day 2. A CBC with differential is ordered prior to the chemotherapy on day 1, day 8, and 1 week after the chemotherapy. The absolute neutrophil count (ANC) is 489/mm³ at 1 week after the chemotherapy. The patient’s temperature is 97.6°F. What is the significance of the absolute neutrophil count? Neutrophils prevent and limit bacterial infections. The absolute neutrophil count (ANC) of 489/mm³ suggests that the patient is at high risk for an infection. Based on the reason for the neutropenia, what medical management would you anticipate? Since the patient is afebrile and demonstrates no signs of infection, the physician will not admit the patient to the hospital. Admitting the patient to the hospital would increase the patient’s risk of acquiring infection. Since the chemotherapy is considered to be curative, the physician will not want to stop or reduce the dose of the treatment. The physician will order growth factors, such as granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF), to increase the neutrophil production. If the growth factor is not effective in stimulating neutrophil production, the chemotherapy will be stopped until the neutrophil level improves. What patient teaching will the nurse provide to the patient? The nurse would teach the patient the following:  Signs and symptoms of infection. The patient should be instructed to report any signs of infection, including fever to the physician.  Avoid crowds and contact with those who have infections  Maintain good handwashing and hygiene, including oral hygiene  Use hand sanitizer when handwashing is not possible  Maintain a high-calorie, high-protein diet with a fluid intake of 3,000 mL/day, unless contraindicated  Avoid activities that pose a risk for environmental infections such as gardening, and cleaning up after pets  Instruct that growth factors may cause muscle and bone discomfort, especially in the sternum.  Acetaminophen is effective in relieving the discomfort Case Study 2: Immune Deficiency Disorders The nurse educator for an oncology unit is preparing an in-service presentation for new nurses about the care of patients with immunodeficiencies. Patients with cancer who are receiving chemotherapy, as well as those with bone marrow transplants, are immunocompromised and require special attention to assess for signs of infection. The nurse educator focuses on special care needs of this patient population. What is the rationale for assessing the pulse and respiratory rates for 1 full minute in a patient with immunodeficiency? Immunodeficiency results in a compromised immune system and a high risk of infection, careful assessment of the patient’s immune status is essential. Pulse rate and respiratory rate should be counted for a full minute because even subtle changes can signal deterioration in the patient’s clinical status. Changes in respiratory status can indicate a pending infection. What special precautions about dietary restrictions and food preparation should be included in the teaching for a patient with immunodeficiency? Patients with immunodeficiencies should cook all foods thoroughly to prevent infection. Perishable foods always should be refrigerated to prevent contamination. A healthy and wellbalanced diet and adequate caloric intake help to decrease risks of infection. What nursing actions should be implemented to decrease the risk of infection in the patient with immunodeficiency?  Closely monitor for subtle changes in vital signs that indicate infection  Monitor white blood cell count with differential, culture, and sensitivity results  Teach the patient to avoid use of alcohol and tobacco  Use strict aseptic technique when performing invasive procedures Josh Parsons, a 36-year-old patient diagnosed with leukemia, is immunocompromised. The patient’s absolute neutrophil count is 750. The patient has a moderate risk for infection. The nurse provides patient and family education on ways to decrease the risk for infection. What should the nurse include in the teaching session with the patient and family?  Instruct the patient on the proper way to perform handwashing, and have the patient demonstrate. Instruct the patient to wash hands before eating, after going to the bathroom, and before and after carrying out a health care-related procedure  Instruct the patient to use lotion or cream to keep skin supple, moist, and intact. Instruct the patient not to use lotion or cream between the toes  Instruct the patient to keep nails trimmed and free of rough edges  Instruct the patient to avoid crowds and anyone with known sickness  Instruct the family to screen visitors to make sure that visitors are free of possible infection  Instruct the patient and family on signs and symptoms of an infection to report promptly to the health care provider. Report fever of 100°F or higher; chills; cough; shortness of breath; white patches in the mouth; sore throat; swollen glands; burning upon urination or foul-smelling urine; persistent diarrhea; any sores or lesions that have redness, swelling, and drainage; and extreme fatigue. Instruct the patient to monitor the temperature daily because fever may be the only presenting symptom  Instruct the patient to avoid fresh flowers, fruits, and vegetables  Instruct the patient and family to cook food properly to kill bacteria and to refrigerate leftovers immediately. Date the leftovers and dispose of them properly. (Provide a handout on proper handling of food, such as the “USDA Food Safety for People with Cancer” available at the Web site included in the references)  Instruct the family to keep the bathroom and kitchen clean and disinfected on a daily basis to decrease bacteria. Instruct the patient and family to clean and disinfect all eating utensils and dishes properly  Instruct the patient to avoid pet feces, especially the litter box  Instruct the patient to avoid activities that could result in cuts or scratches on the skin, such as using a razor blade or gardening without gloves  Instruct the patient to avoid persons who have received a live vaccine within the past 3 weeks  Instruct the patient on proper oral hygiene to avoid bleeding gums that could lead to an infection. Instruct the patient to use a soft toothbrush and avoid alcohol mouthwash. Use a warm saline solution as a rinsing agent Reference US Department of Agriculture (2012). Food safety for people with cancer. Available at: http://www.fda.gov/Food/FoodborneIllnessContaminants/PeopleAtRisk/ucm312565.htm (Lin ks to an external site.)Links to an external site. The nurse is planning to provide education on HIV infection transmission and prevention strategies at a local senior center. What should the nurse include in the session considering the needs of the older population?  Share the statistics from the Centers for Disease Control (CDC) that approximately one quarter of people living with HIV are over the age of 50  Instruct the group on what HIV is and the basic ways it is transmitted. Provide a largeprint brochure on the topic  Instruct on ways HIV is transmitted in the older adult population: o Through unprotected sex because older adults view condoms as unnecessary birth control. The transmission of HIV is through body fluids, including vaginal secretions and semen or blood o Blood transfusions or organ transplants prior to 1985 o Through the use of IV drugs and sharing needles. The needles may have been contaminated with HIV o In older gay adult males who lost their lifelong female partner and are establishing a relationship with a new younger male partner. The male may have HIV and expose others to the virus  Instruct the group on the normal aging process of the immune system, which makes the older adult more susceptible to HIV, cancer, and other infections  Provide preventive education to decrease the spread of HIV: o Instruct the group that latex condoms are the only safe and effective barrier for decreasing exposure to HIV during sexual intercourse. Instruct on the proper way to use condoms, and provide a large-print brochure o Instruct the group that the female condom is also an acceptable measure to decrease exposure to HIV, and provide a brochure on its proper usage o Explain to the group that with oral contact with the vagina or rectum, the dental dam should be used as a barrier o Explain to the group that with oral contact with the penis, a condom should be used as a barrier o Explain to the group that currently no chemical products decrease HIV transmission o Instruct the group to avoid sexual practices that lead to cutting or tearing the lining of the vagina, rectum, or penis o Instruct the group of places to receive confidential HIV testing. Have information for the group on locations where a person may go for confidential testing o Instruct the group on needle exchange programs available in the area. Have information for the group on the locations of the programs Sallie Jefferies, 28-year-old patient, is at the obstetric clinic for a pregnancy visit. The physician informs the patient that her HIV screen test is positive. The patient has no evidence of AIDS. The