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NURS 550 Clinical Worksheet Remember NO Patient IDENTIFIABLE INFORMATION HERE Student Name: ____Monica Sias____________________ Client Initials: SL_____ Gender: F_ Age: 77____ Unit/Rm#: _______305 Date of Admission: ___03/22/2025_________ Healthcare Provider: Lauren Fleischer, MD Admitting Diagnosis: ___Radiation Esophagitis ___ Concurrent Diagnoses: ____Malignant neoplasma of unspecified lung, gastroparesis, COPD, throat pain, _ Surgery: _CABG x3 (2023)____________ Date: 04/01/2025_____________________ Allergies to Drugs or Foods: None known Advanced Directives / Code Status: _Full code________ Nursing Kardex/Chart/Orders: Therapeutic Modalities Vital Signs and Frequency Vitals at 11am: 154/80mmHg (@ 11:00am), O2 saturation 96%, temperature 98.7 F, vitals taken every 4 hours I & O/ Fluid Restrictions Liquids as tolerated, IV bolus for nutrition Diet IV nutrition Neutropenic precautions (gloves, mask, yellow jacket) Activity Level Pt can ambulate with assistance (walker), but is on fall precautions as she is connected to IV nutrition, wall oxygen, on opiates for pain, and IV fluids Dressing Changes N/A Resp. Therapy 4L of oxygen via a nasal cannula Self Care Ability Pt can care for herself Daily Weights 55.2kg (04/01/2025), SCD, TEDS, CPM N/A Daily Labs. Blood glucose = 111, Arterial blood gas: CO2 = 36 (abnormally high), Other Treatments: Braden = 19, Foley Catheter present Admitted Diagnosis: ____Radiation Esophagitis_________________________
Pathophysiology Radiation esophagitis is an adverse effect of radiation therapy. This patient has received 6 out of 8 necessary radiation treatments to treat her lung cancer. Radiation therapy causes the destruction of mucosal cells in the esophagus which can cause an inflammatory response, resulting in scarring and damage of the esophageal tissue (Nesheiwat & Mahajan, 2020). This inflammatory response is what causes pain, inflammation, and difficulty swallowing. This patient is also at higher risk for developing radiation esophagitis due to risk factors that increase her risk: white race, over 70 years old, female sex, low body mass index, GERD, and dysphagia. Nesheiwat, Z., & Mahajan, K. (2020). Radiation Esophagitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499920/ Therapeutic Regimen Changing diet to soft bland foods that don’t irritate the esophagus, hydration therapy, analgesics like oral lidocaine, and some studies suggest Amifostine may be beneficial in eliminating the free-radicals that can lead to esophagitis (Nesheiwat and Mahajan 2020). Nesheiwat, Z., & Mahajan, K. (2020). Radiation Esophagitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499920/ Current health problems and related functional changes Radiation Esophagitis Malignant neoplasm of the unspecified area of lung Acute esophageal pain due to radiation treatment Chronic pain due to lung cancer diagnosis COPD Abdominal Aortic Aneurysm Gastroparesis GERD Hospital inserted urinary catheter
Diagnostics Tests (LAB, RADIOLOGY, CARDIAC FUNCTION i.e. EKG, stress test) Diagnostic Test Normal Finding Result for patient Definition and description of test Significance of the test for your patient Throat x-ray No inflamma tion Esophagus inflammation Throat x-ray X-ray showed inflammation in the esophagus and scarring.
Medication List Medication + Route and Dose Pharmacologic Classification Action/Therapeutic effect Side effects Adverse reactions Contraindication s Nursing Considerations for Administration Recommended Dose Range Clonidine 0.1 mg Antiadrenergic agents Lowers blood pressure Lowered heart rate Kidney disease Monitor for dysrhythmias 0.1 mg - 0.3 mg Sucralfate 100 mg GI agent Treats duodenal ulcers Constipation, diarrhea Diabetes, dialysis, Monitor for bowel obstruction 1g Isosorbide mononitrate 10mg Nitrate; vasodilator Treats chest pain Headache Use with sildenafil Monitor for hypotension 10mg – 40 mg Ethanol topical (nostril) Disinfectant Reduces bacteria and viruses on skin Skin thinning Damaged skin Monitor for pressure ulcers
N/A
Heparin 5000u (1mL) Anticoagulant Blood thinner Thrombocyto penia Actively and uncontrollably bleeding Subcutaneous injection 1-100mL
Integument: Nutrition: Pain Assessment: Skin well and intact without any noticeable pressure ulcers or injuries. IV bolus for nutrition and fluids by mouth Verbalized 9/10 at 9am, 8/10 at 1PM Wound / Surgical Incision Assessment: Assessment Wound #1 Wound #2 Wound # Type of wound and Stage N/A N/A N/A Location N/A N/A N/A Length N/A N/A N/A Width N/A N/A N/A Depth N/A N/A N/A Drainage N/A N/A N/A Odor N/A N/A N/A Undermining / Tunneling N/A N/A N/A Wound bed tissue type N/A N/A N/A Tubes/Lines/Drains Assessment: N/A
Assessment Priority Nursing Diagnosis Goal/ Outcome (Short and Long Term) Nursing Interventions Rationale Evaluation of Goal Achievement Subjective Data: Patient stated that her throat pain is a 9/ Objective Data: Patient grimacing in pain and clenching jaw and hands. Esophageal pain related to radiation treatment for lung cancer as evidenced by patient stating that her pain is a 9/10 and patient grimacing in pain. Short-term goal: Patient will verbalize pain is a 7/10 by the end of shift. Long-term goal: Patient will discuss pain management to reduce breakthrough pain, with oncologist and attending physician before discharge home. Short-term:
**1. Nurse to create plan with patient to develop a schedule for pain medications
- Nurse will work with patient for comfortable position techniques to manage pain
- Nurse will work with pt to encourage drinking and eating small amounts Long-term:
- Nurse will arrange for oncologist to have a phone call with the attending physician to discuss discontinuing radiation
- Nurse will assist the attending physician in arranging or a hospice meeting
- Patient will work with her family to discuss comfort** Pt must be able to manage her pain at home after discharge. Pt must do a risk/benefits analysis of the radiation therapy with her oncologist. Pt must be able to ingest nutrition and not have pain or difficulty swallowing. Short Term Goal: Goal not met, Pt reports pain 8/10 at 1400 Long Term Goal: Goal not met; pending evaluation
