nursing 3-13 PATIENT WITH MASTECTOMY AND IV FLUID OVERLOAD 0700 Handoff Report:

ID: 139594 • Letter: N

Question

nursing

3-13 PATIENT WITH MASTECTOMY AND IV FLUID OVERLOAD 0700 Handoff Report: S Mrs. S, 58 years old, is 1 day postop right radical mastectomy. Her dressing is clean and dry. She has a Hemov 3/10, pulse ox 95%. She is using the PCA and also has lactated Ringer's at 125 mL/hr. I started a ne liter at 0600. Her right arm is elevated on a pillow; there is some swelling and she is complaining of some numbness ac that drained 50 mL. Her vital signs at 0600 are T 99.6°F, P 88, R 24, BP 150/90, pain level The following information is obtained from Mirs. S's electronic medical record: Patient:ES. Age:[S8] Sex:ID#[322491 Room:1601 Drug allergies: [NOA ] Food allergies: NONE T Time: [0700 Dx: Carcinoma Rt Breast Patient: [3] Age:Sex: E ] ID# 322491 Room:[BOT ] Drug allergies: INKDA Food allergies: NONE Time: [0700 ] Patient Plan of Care VS: q4h Diet: Clear liquid Up in chair IV: Lactated Ringer's 125 mUhr Dx: [CarcinomaRt Breast - LFA # 18 g angiocath Hemovac Hgb & Hct this AM History and Physical The patient is a 58-year-old female, widow She lives alone. Does not smoke, drinks socially Has hypertension 154/96 Meds: Atenolol 50 mg po bid Both parents deceased: mother died of breast cancer father died of heart disease Medication Record Routine Atenolol 50 mg po bid (0900-1700) PRN PCA: HYDROmorphone 10 mg/10 mL (0.1 mg/mL) 0.2 mg q 10 min, max dose 1.2 mg /hr Scheduled Time Patient has two married daughters and one son. She found a hard lump in the right breast 3 weeks ago A biopsy was done, results: Stage II CEA 5 ng/mL. Dx: Invasive ductal carcinoma right breast Plan: Right radical mastectomy Chemotherapy to follow Collaborative Learning Activity: With a partner, use the clinical situation and the electronic medical record to: 1. identify the pertinent 2. Identify the pertinent 3. Review the data in patient information made known to you in patient information madecolumns 1 and 2 and known to you from the identify information that the handoff report.electronic medical record.needs follow-up.

Explanation / Answer

COLLABORATIVE LEARNING ACTIVITY

Patient Name: Mrs.S

Age: 58yrs

Post op day: 1st POD

Surgical diagnosis:RT.Radical Mastectomy

POD: 1st POD

Vital signs

Temp:99.6 degree F

Pulse:88 beats/min

Respiration: 24 breaths/min

B.P- 150/90 mm of Hg

Pulse oxy 95%

Intravenous Fluid: 125ml/hr (started at 0600 hrs)

Her right arm is elevated on a pillow with complaints of Pain and Numbness.

Hemovac drain: 125ml/hr

Vital signs: Q4hrly0700 hrs

HTN: 154/96 mmof Hg

Medication: Tab 50mg/bd/PO

Plan: Right radical mastectomy

Chemotherapy to follow

PRN: PCA:Hydromorphine 10mg/10ml(0.1mg/dl)

0.2mg q 1omin

max dose 1.2mg/hr

Routine (Shedule time) 0900/hr

Tab.Atenolol 5mg/bd(0900-1700)

Vital signs q4hrly

Temperature 99.6F(increased)

B.P 154/96(has increased)

Up in chair position(change of position)

I.V fluid 125ml/hr(started at 0600 hrs.Will be over by 0900hrs)

Temperature 99.6 degree F

TAB.Atenolol 5mg bd due at 0900 hrs

Pain in the right arm and numbness.Assessment to be done

Pain scale 3/10

PCA: Hydromorphone 10mg/10ml(0.1mg/ml)

0.2 mg q 10 mins, max dose 1.2mg/hr

Hemovac drain(drain to be monitored and can be removed if no drainage is present)

chemotherapy follow up

PLAN OF CARE NEXT HOUR

Care at 0800hrs

As B.P is increasing inform to phsician.

Deep breathing and coughing exercises to be Taught to the patient

As patient has crackles initiate deep breathing exercises, nebulisation and steam inhalalation to be given to the patient.

1.Identify the Pertinent Patient Information made known to you in handoff Report 2.Identify the Pertinent Patient Information made known to you from the electronic medical record 3.Review the data in columns 1 and 2 and identify information that needs follow up