Question

Create a care plan concept map. Note – you will only need to create one Nursing Diagnosis for this activity.Case Scenario:

Situation: A.M. is an 85-year-old female with advanced breast cancer with extensive metastasis to the bones, brain and liver. Patient was transported by ambulance and directly admitted to inpatient Hospice Unit for symptom management; arrived 4 hours ago. Seen by MD who wrote orders for patient. Arrived on Room Air, but due to dyspnea symptoms the patient was placed on 2L of Oxygen via nasal cannula. IV has been started. Patient received a dose of Morphine 5 mg IV push 2 hours ago because the patient was moaning loudly and RN was concerned patient might be in pain. Oral care was given to patient 30 minutes ago; RN taught daughter how to perform oral care for patient. Patient is now resting quietly; spouse and daughter are at bedside.

Background: Patient is receiving care in a Medical/Surgical unit hospice bed as the family does not feel they are able to adequately manage her care at home. She was diagnosed with breast cancer 18 months ago and underwent a lumpectomy of the right breast, followed by chemotherapy and radiation treatments. Two months ago the patient started experiencing pain in her hips, back and shoulders, a feeling of losing her balance at times, and right upper quadrant abdominal pain. The medical work up revealed extensive metastasis to bones, brain and the liver. The medical team determined further treatment to be futile. Patient admitted to home hospice care. Six days ago the patient was admitted to the Oncology Unit where she presented with significant dyspnea and malignant ascites. A palliative abdominal paracentesis was performed with 3000 mL of fluid removed. The patient was discharged home the following day. Over the past 5 days the patients’ abdomen has again become distended and tight. The ascites is causing the patient to be dyspneic and more uncomfortable.

(Medical History): Diagnosed with cancer 5 years ago – treatment included Bilateral Salpingo-oophorectomy and total abdominal hysterectomy and chemotherapy. BRCA1 Positive. Diagnosed with breast cancer 18 months ago – Lumpectomy of Right Breast, chemotherapy and radiation treatment. Two months ago she was diagnosed with metastatic disease to bones, brain and her liver. No Known Drug Allergies (NKDA). No history of Tobacco, Alcohol or illicit drug use. (Medications): Morphine 2-4 mg liquid PRN Q4 hr for pain. (Code Status): Do Not Rescuscitate (DNR). Spouse is named as surrogate health-care decision-maker.(Social History): Patient is married and has 2 adult children who live out of state. Spouse and daughter are at bedside. Son is married and cares for his two small children. Son has visited patient three times since her symptoms began two months ago. Assessment: VS – T 36.4 C/97.5 F, HR 104, BP 90/46, RR 26, SpO2 92% on 2LPM via nasal cannula. Cardio – Sinus rhythm, S1 & S2 audible, no murmurs. Respiratory – Crackles in all lung fields, mild dyspnea noted secondary to ascites. GI – Bowel sounds hypoactive, abdomen firm/distended. GU – dark/concentrated urine, incontinence. Lower Extremities – Decreased movement/strength in all four extremities. Neuro – Pupils, equal/round, minimally reactive to light. Responds to name only and painful stimuli. IV – 20 gauge in Right forearm, running 0.9% NaCl at 30 mL/hr. Morphine infusing at 1 mg/hr.(Fall Risk): Not at a risk for falls(Pain): Some grimacing, slight moaning, clenched mouth and restlessness notedRecommendation: Evaluate patient status, treatment plan, compliance, stress level and copingProvider Orders: Admit to hospice bed on Medical/Surgical unitMedical Diagnosis – Advanced breast cancer with extensive metastases to bones, brain and liverDNREnd-of-life comfort measureNPOVS Q4hrComplete bedrestO2 at 2 LPM via nasal cannula; titrate PRN for dyspnea0.9% NaCl 30 mL/hrMorphine Sulfate per continuous IV infusion 1 mg/hrMorphine sulfate 5 mg IV Q2 hr PRN for breakthrough pain, call MD if pain not relievedLorazepam 1 mg IV Q4hr PRN for AnxietyHaloperidol 1 mg IM Q1hr PRN for AgitationGlycopyrrolate 0.2 mg IV Q4 hr PRN for excessive secretionsApply barrier cream to skin after each bowel and bladder incontinence

Answer 1

The concept map for a patient with breast cancer based on nursing diagnosis is as following