In any clinical setting, which health care team member is responsible for developing an individualized plan of care that includes nursing diagnoses, interventions, and outcomes including the patient's self-management care plan?

Neurologic Case Study

Patient Profile:

• Age: 68 years.
• Gender: Male.
• Medical History: Hypertension, Type 2 Diabetes Mellitus.
• Medications: Lisinopril, Metformin.
• Allergies: None.

Chief Complaint: The patient presents to the emergency department (ED) with a sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

What is a potential complication of the patient's condition?

Patient Profile:

• Name: Sarah Johnson
• Age: 54
• Diagnosis: Metastatic breast cancer, Stage IV, diagnosed six months ago with metastasis to the liver and bone

Treatment Plan:

• Surgery: Lumpectomy with axillary lymph node dissection
• Chemotherapy: Adriamycin and Cyclophosphamide (AC) regimen
• Radiation Therapy: Targeted treatment to the chest wall post-surgery

Clinical Presentation:

Subjective Data:

• Reports of nausea and vomiting, especially after chemotherapy sessions
• Expresses feelings of sadness and fear regarding her prognosis and the impact on her family
• States she has lost 10 pounds in the last month due to decreased appetite and nausea
• Describes pain in the surgical area and generalized body pain that worsens at night
• Mentions experiencing a red, itchy rash on her chest from radiation therapy

Objective Data:

• Vital signs: HR 78 bpm, BP 120/80 mmHg, Temp 98.6°F
• Weight: 135 lbs (down from 145 lbs)
• Physical examination reveals tenderness in the left breast and axilla, and a rash in the radiation field
• Labs: Mild anemia (Hgb 10.5 g/dL), elevated liver enzymes

Nursing Diagnoses:

1. Nausea related to chemotherapy as evidenced by patient report and vomiting episodes
2. Imbalanced Nutrition: Less than Body Requirements related to nausea and weight loss as evidenced by a 10-pound weight loss and decreased appetite
3. Acute Pain related to surgical procedure and cancer

Which educational point should the nurse emphasize regarding skin care during radiation therapy? Select all that apply.

Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Patient Profile:

• Name: Mr. John Smith
• Age: 68 years
• Medical History: Osteoarthritis of the hip, Type 2 diabetes, hypertension, and atrial fibrillation
• Current Medications: Lisinopril, Metformin, Warfarin
• Surgical Procedure: Total hip replacement (THR) due to severe pain and limited mobility.

Preoperative Care:

• The nurse conducts a comprehensive assessment, including a physical examination, vital signs, and a review of Mr. Smith's medical history.
• Preoperative labs are ordered with the following abnormal values noted:
  • Complete Blood Count (CBC):
    1. Hemoglobin: 12.0 g/dL (normal range: 13.5-17.5 g/dL)
    2. Hematocrit: 36% (normal range: 38.8-50%)
  • Basic Metabolic Panel (BMP):
    1. Serum Creatinine: 3 mg/dL (normal range: 0.6-1.2 mg/dL)
    2. Blood Urea Nitrogen (BUN): 24 mg/dL (normal range: 7-20 mg/dL)

• • Coagulation Studies:
    1. INR: 5 (normal range: 0.8-1.1)

Intraoperative Care:

• The scrub nurse assists in positioning Mr. Smith on the operating table.

Who is responsible for documenting the patient's vital signs during the intra-operative period?