1. AZUSA PACIFIC UNIVERSITY
SCHOOL OF NURSING
GNRS 555: MEDICAL SURGICAL CARE OF THE ADULT
COMPREHENSIVE CARE PLAN #: 2
Student: Priscilla Martinez
Instructor: ProfessorBrenda Jerez-Aguilar
Date of Care: 11/18/15
Date of Submission: 11/25/15

2. Nursing Clinical Worksheet
Student Name: PriscillaMartinez Date: 11/18/15
Patient Initials:
AW
Age:
71
Sex:
F
Isolation and Type:
None
Code Status:
Full
Admit Date:
11/17/15
Allergies:
None
Diet:
Diabetic
Fall Risk:
Morse Scale: 45
Low Risk
Braden
Score:
17
Activity:
Bed rest
LOC:
Alert and oriented
X3
PrimaryMD: Marquez, F
Consulting MD: Mary Rinko Oefelein
AdmittingDiagnosis:Rightshoulderpain
SecondaryDiagnosis:
(Past Medical Hx and surgical Hx)
HTN(2006),DM withCKD stage 3 (2008),osteoarthritis (2009),recentRULmasswith lungcancerdx,carpeltunnel(2004),Severe
obesity(2011), Chronic anemia(2012),Gaitabnormality(2012),Hip jointpain(2012), Pseudophakos(2006),Colonoscopy(2008),
Cararactremoval(1995),Left leglipomaexcision(1992),Cataractextraction(1997),Oriffracture(1998),Totalkneereplacement(2014)
Patient’sHospitalCourse (referto progressnotes):
Patient presentedto ED on 11/17/15with complaintsofdizziness, swellingof chest,and paininR arm. Pt admitsthat she cannotmoveher
R arm without pain.Saw PCP on 11/05/15for complaintsofR arm shoulderpainand subsequentCT scanshowedmassandnodules on
RULof lung indicatinglungcancer.Transferred from KaiserRiversidefor in-patienttreatmentof radiation.Chestx-ray conductedyesterday
showedevidencethat R clavicleisfractureddueto cancermetastasizingandweakeningthebone.
Prioritized To Do List (refer to patient’s orders) :
SuperiorVena Cava CompressionSyndrome DM2withdiabetic CKD
– repeatCT scan,checkecho,avoidtoo muchIVF, – continueto monitorelectrolytesandcreatinine,continue
radiation/oncologyconsultationinthemorning to monitorbloodglucosebeforemealsandbeforebedtime
NauseaandVomiting Osteoarthritisof left knee
– supportive careIVF, antiemetics,checkMRIformalignancy – supportive care
EssentialHTN Leukocytosis
– conductoutpatientmedicalregimen – continueto monitor
Hyperlipidemia Anemia
– checklipidlevel,continueStatin – continueto monitorserialH/H, transfuse PRN, monitorvitals
Diagnostic tests and procedures
Tests (Date completed) Results
1) MRI brain with or without contrast
(11/17/15)
2) CTA Chest
(11/17/15)
3) Chest X-Ray
(11/15/15)
1) Mild cerebral volume loss. Noevidence of metastasis. Lesion is seen. Gray and white matter
differentiation is preserved. Nointracranial hemorrhage, mass-effect, or midline shift identified. No
suspicious T1 or T2 signal abnormalities in brain. Noareas of restricted diffusion. Nointra or extra-
axial collections. Unremarkable paranasal sinuses, marrow, or muscle structures.
2) Results not present
3) Fracture on R clavicle found. Bone weakened due to nearby lung cancer
Abnormal / Pertinent Lab Values
Test Range Valueat
Admission
Recentvalue
(Date)
Why thistestwas ordered and whatisthesignificanceof
thevalue?
CBC –WBC 4 – 11 x 1000/mcL 19.3 x 1000/mcL 13.1 x 1000/mcL Part of the CBC. Usedto determine the amount of WBC in the blood. Level
is high. May indicate infection.
CBC –RBC 4.2 – 5.4 mil/mcL 3.88 mil/mcL 3.6 mil/mcL Part of the CBC. Usedto determine if body cells are getting enough
blood/oxygen. Level is low. May indicate anemia
CBC –HGB 12 – 16 g/dL 9.5 g/dL 8.8 g/dL Part of the CBC. Usedto determine if there is enough tissue oxygenation.
Level is low. May indicate anemia.
CBC –HCT 37% – 47% 30.5% 28.3% Part of the CBC. Usedto determine the percentage of blood that are
RBCs. Level is low. May indicate low O2 supply.
CBC –MCV 81 – 99 fL 78.6 fL 78.6 fL Part of the CBC. Usedto determine the average volume of RBCs in the
blood. Level is low. May indicate smaller than normal or anemia.
CBC –MCH 27 – 35 g/dL 24.5 g/dL 24.5 g/dL Part of the CBC. Usedto determine the average mass of HGB per RBC.
Level is low. May indicate RBCs smaller than normal or anemia
CBC –MCHC 11.5 – 37 g/dL 31.2 g/dL 31.1 g/dL Part of the CBC. Usedto measure the concentration of HGB in a given
volume of packed RBCs. Levels are low. May indicate anemia.

3. Blood RDW 11.5% – 14.5% 14.7% 15.0% Used to measure the range of variation of RBC volume. Level is high. May
indicate anemia.
Platelets 130 – 400 x 1000/mcL 467 x 1000/mcL 426 x 1000/mcL Used to determine the amount of platelets in the blood. Level is high. May
indicate thrombocytosis.
Glucose, fasting 70 – 99 mg/dL n/a 275 mg/dL Used to determine the amount of glucose in the blood. Level is high. May
indicate hyperglycemia d/t pt being diabetic
Electrolyte – Cl 101 – 111 mEq/L 96 mEq/L 97 mEq/L Part of the electrolyte panel. Used to determine concentration of chlorine in
blood. Level is low. May indicate dehydration
Protein – Albumin 3.3 – 4.8 g/dL 3.4 g/dL 2.4 g/dL Part of the protein serum. Used to determine the amount of albumin in
blood plasma. Level is low. May indicate underproduction of globulins r/t
liver or kidney problems
WBC – Neutrophils 1.8 – 3.6 x 1000/mcL 17.3 x 1000/mcL 12.1 x 1000/mcL Part of the WBC count. Used to determine the amount of neutrophils in the
blood. Level is high. May indicate inflammation and/or infection.
WBC - lymphocytes 1 – 3.6 x 1000/mcL 0.7 x 1000/mcL 0.4 x 1000/mcL Part of the WBC count. Used to determine amount of lymphocytes in the
blood. Level is low. May indicate lower immune system
WBC - Monocytes 0.1 – 1 x 1000/mcL 1.2 x 1000/mcL 0.6 x 1000/mcL Part of the WBC count. Used to determine the amount of monocytes in the
blood. Level was high at admission. May indicate inflammation or infection
Doc Flowsheet Data
Vital Signs 0800 1200 1600 Blood Glucose (POC) IV fluids
B/P 146/74 166/67 171/78 Time Value Type Rate ( ml / hr)
Pulse 69 77 73 0630 241 mg/dL NS 0.9% IV Premix 50 mL/hr
RR 14 16 18 1000 235 mg/dL
Oxygen Sat % 96 96 94 1600 300 mg/dL
Pain Level 2 0 5
Temp 96.2 96.8 96.3
Intake/Output
Intake ( ml per shift) Output (ml per shift)
Oral Enteral IV TOTAL Urine Output BM Emesis Drains TOTAL
450 0 500 950 1050 0 0 0 1050
If any,pleasestatewhythereisa significant differencein theI/O : total input-total output= 100 mls
No significancedifferenceintheI/O
Complete Head-To-Toe Assessment
General
Survey
Physical
Appearance:
Pt appears well groomed and clean. Dress is appropriate to situation
Mood: Pt’s mood and affect are appropriate to situation
Signs of Acute
Distress:
Pt showed sign of distress and worry d/t news that her cancer had caused her clavicle to
become fractured but was determined to get better
Neurologic
Orientation Pt is alert and orientated to person, place, and time
Speech Speech is clear and understandable
Pupil (L) Pupil is 3mm, equal, round, reactive to light
Pupil (R) Pupil is 3mm, equal, round, reactive to light
GCS score GCS = 15; eye open spontaneously (4), normal conversation (5), obey command (6)
Abnormal
Muscles
Location None
Strength Muscles able to resist push and pull
Pain
Assessment
Provocation/
palliation
Movement and lifting of R arm
Quality Sharp at times
Region/
Radiation
Radiates to upper arm
Severity 7/10 to 10/10
Time Continuous
Pulmonary
Oxygenation  Room Air ☐Device: n/a Flow rate: n/a FiO2:n/a O2Sat: 96%
Respiration Quality: symmetrical expansion, bilateral chest rise and fall, unlabored _
Rate: 16 BPM
Rhythm: Regular _
R. Lung Clear lobes all around, unlabored breathing, no grunting or nasal flaring present
L. Lung Clear lobes all around, unlabored breathing, no grunting or nasal flaring present
Cardio- Capillary Refill < 3 seconds all extremities

4. vascular SkinColor/
Temp
Pink, warm, dry
Apical Pulse Location in fifth intercostal space left midclavicular line. Regular rate and rhythm.
Heart Sounds S1/S2 noted, no murmurs or gallop
Peripheral
Pulses
R/L radial pulses 2+
R/L pedal pulses 2+
Gastro-
intestinal
Oral Mucosa Intact, moist, pink
Tongue Pink, moist, midline
Abdomen Normoactive all four quadrants, unremarkable sounds
Nutrition Diabetic diet
Tube Feeding Current Rate: Goal Rate: __________
Residuals: ________ml Type: ☐ N/A ☐ NGT ☐ PEG ☐ J-tube
Bowel Sounds Normoactive all four quadrants, unremarkable sounds
Bowel
Movement
Last BM date: 11/14/15; unremarkable amount and consistency
Genito-
urinary
Urination Unremarkable, no burning or frequency
Urine Color Yellow
Urine
Character
Clear, no sediments
Urine (ml) 1050 mL
Urinary
Catheter
Insertion date: ______________
Skin
(wounds)
SkinColor Very light brown, as expected for ethnicity
SkinIntegrity Skin warm,dry, and intact. No lesions, ulcers, or incisions
Wound/
Ostomy
None
Insertion Site(s) R forearm
IV Assessment IV dressing dry and intact, no signs of redness or infiltration
IV Fluids NS 0.9% IV Premix (50 mL/hr)
Musculo-
skeletal
Describe
abnormalities:
Fractured clavicle causing pain and decreasing mobility of R arm
Psychosocial Assessment
Psychosocial
History
Marital status Divorced 40 years ago
Education level Associates Degree
Social resources Family (3 sons and 3 daughters in law), friends
Spiritual resources Strong faith (nondenominational Christian)
Occupation Retired (worked for the San Bernardino County housing department)
Employment Retired 8 years ago but highly involved at her apartment home community
Smoking Former smoker: ½ pack a day for 5 years. Quit in 1986
Alcohol Denies
Recreational Drugs Denies
Spiritual Assessment
Spiritual Integrity 1) Look: (Signs of Meaning, Relationships, Hope and Joy) Spiritual Distress
Presence of….. Provide checkmark in either box for each criteria Absence of….
Family, friends, visitors, wedding ring, photographs 
 Cards, letters, phone calls, flowers, pets
 Attention to personal care and appearance
Work, projects, hobbies, music, books, tapes 
 Newspapers, magazines, television, radio
Special dress, prayer cap, head scarf, cross 
Articles of faith, pictures, statues, rosary, star 
Books of faith, Bible, Koran, Torah prayers 
 Smiles, motivation, coping skills, healthy lifestyle

5. Uses the observations listed above to begin your Spiritual Assessment
No flowers, gifts, or photographs found in room
Pt stated that she enjoys working at her community center at her apartment home and organizing events
Pt is very proud of the work she did before she retired and expressed strength and desire to fight her cancer
Pt stated she was nondenominational Christian and that she has strong faith
While her current mood was distressed and worried, she expressed resilience and determination to fighter her cancer
With your client as your guide, and after a sense of trust and connectedness have been established, continue with the
assessment. Phrase your questions and indirect statement in ways that convey your genuineness, style, and comfort.
Pt stated that all her sons are grown with children and that they visit her periodically
Pt stated she lives alone with her dog Jessie whom she loves and values very much.
Pt stated her dog brings her a lot of joy in her life as well as spending time with her family
Pt expressed having her sons grow to be good people and helping to relocate homeless illegal immigrants and veterans as
some of her biggest accomplishments and senses of pride in her life
Pt stated her next goal in life is to beat her lung cancer
Pt stated her personality and self-reliance are what gives her strength
Pt stated that she turns to her sons in tough times
Pt did not verbalize desire to pray
Spiritual Integrity
Listen: (Actively listen for signs of meaning, relationships, hope, and
joy)
Spiritual Distress
Pt verbalizes... **Provide checkmark in each box that is applicable Pt verbalizes…
 Sense of purpose and meaning My life has no meaning
 Source of pride & accomplishment Guilt, if only….I should have
 Source of joy & happiness Sense of sadness and despair
 Future Goals and desires Lack of motivation
 Hope and Courage Hopelessness “What is the use?”
 Interest in world & concern for others Lack of concern for others
 Personal Strengths Powerlessness I am useless.
 Connection to others Loneliness and isolation
 Connection to a higher source Helplessness, anxiety, fear
 Religious affiliation “This is not fair. Why me?”
Request for special diets, clergy “Why am I being punished?”
Appreciation for nature Apathy
Ability to adapt to changes Inflexibility
2. Nursing Diagnosis: Analyze the data, and if appropriate, select one of the following nursing diagnoses.
Potential for Enhanced Spiritual Well-Being
 Spiritual Distress
Hopelessness
Other_______________________________________________________
3. Plan: Develop a short-term goal and a long term goal for your client.
ST Goal: The Client will verbalize what she will do at her apartment community center once she goes back home
LT Goal: The Client will take active steps to fight her cancer, such as changing diet, doing exercise, and medication treatments
4. Interventions: Identify the specific nursing interventions you will use with your client.
 Be present.
 Establish a therapeutic relationship conveying respect, warmth, empathy and genuineness
 Active listening.
Assist client to identify strengths, supports, and interconnections.
 Instill hope.
Use of touch, if client is comfortable with closeness.
Provide an environment conductive to reflection, prayer, and spiritual growth.
Provide an environment conductive to client’s beliefs (food, ceremonies.)
Provide religious articles as requested.
 Support client in search for meaning and purpose in life, illness, and death
 Support client in search for a relationship with a higher power.
Pray with the client.

6. Pray for the client.
Promote private time with people who are significant in client’s life.
 Be available and approachable to assist client with meeting spiritual needs, and making spiritual choices.
Collaborate with chaplain or spiritual leader.
Other:______________________________________________
Other:______________________________________________
5. Evaluation: Evaluate the client’s progress towards the goals.
(Note: Each person’s spirituality is highly variable, individual, and ever changing!)
ST Goal: Goal not met by the end of the shift due to having done spiritual care late in the shift
LT Goal: Goal not met due to not enough time having passed for the client to take active steps to fight her cancer
Scheduled Medications and PRN Medication Given
(Also include all saline flushes and IVFs)
Generic Name : Amlodipine Trade Name : Norvasc
Classification : Antianginal,anti-HTN, Ca+2 channel
blocker,dihydropyridine
Dose: 10 mg Route: PO Frequency/ Rate: Qday
Pt. Specific Indications: To control blood pressure
Mechanism of Action: Inhibits transmembraneinflux of extracellular calciumions acrossmembranes of myocardial cellsand vascular
smooth muscle cells withoutchangingserum calciumconcentrations.This inhibits cardiacand vascularsmooth musclecontraction,
thereby dilatingmain coronary and systemic arteries.Italso increases myocardial oxygen delivery in patients with vasospastic angina
Contraindications: Hypersensitivity to Ca+2 channel blockers or antianginal agents
Side Effects: Edema, pulmonary edema, headache, fatigue, palpitations, dizziness,nausea,flushing,abdominal pain,somnolence,
drowsiness,puritus, skin rash,musclecramps,muscleweakness
Patient Family Education: Use with caution in pts with hypertrophic cardiomyopathy becauseitmay worsen symptoms. Make sure to
titrate slowly if the pt has hepatic impairment. Symptomatic hypotension with or without syncope is possibleto make sureto tell the pt
to call thenurseif they want to get out of bed.
Generic Name : Aspirin Trade Name : N/a
Classification : Antiplatelet agents, NSAID, Salicylate Dose: 81 mg Route: PO Frequency/ Rate: Qday
Pt. Specific Indications: To prevent DVT and acute coronary syndromes
Mechanism of Action: Inhibits synthesisof prostaglandin by cyclooxygenase.Inhibitsplateletaggregation.Has antipyretic and analgesic
activity
Contraindications: Hypersensitivity to aspirin or NSAIDS, allergy to tartrazinedye, bleeding disorders
Side Effects: Angioedema, bronchospasm,CNS alteration,GI pain/ulceration/bleeding,hepatotoxicity,hearingloss,nausea,premature
hemolysis,pulmonary edema, rash,renal damage, tinnitus,uticaria,vomiting
Patient Family Education: Discontinueif tinnitus develops, should be taken with food or 8-12oz of water to avoid any adverseGI effects.
Generic Name : Atenolol Trade Name : Tenormin
Classification : Antianginal,anti-HTN, beta
blocker
Dose: 100 mg Route: PO Frequency/ Rate: Qday
Pt. Specific Indications: to treat HTN
Mechanism of Action: Blocks responseto beta adrenergic stimulation.Cardioselectivefor beta1 receptors atlow doses, with littleor no
effect on beta2 receptors
Contraindications: Pulmonary edema, cardiogenic shock, sinus bradycardia,2˚ or 3˚ heart block without a pacemaker, uncompensated
congestive heart failure,sinusenodedysfunction
Side Effects: Bradycardia,chestpain,cardiac failure,cold extremities,Reynaud’s syndrome, hypotension, tiredness,nausea,diarrhea,
lethargy, lightheadedness
Patient Family Education: Use with caution in anesthesia or surgery because can causemyocardial depression.This may also mask effects
of hyperthyroidism.Avoid abruptwithdrawal becauseit can exacerbate angina and lead to MI. This medication may also increaserisk for
developing DM and causeor exacerbate CNS depression (usewith caution with pts that have psychiatric illness)
Generic Name : Atorvastatin Trade Name : Lipitor
Classification : Antilipemic,Statins,HMG- Dose: 40 mg Route: PO Frequency/ Rate: QDay

7. CoA reductase inhibitors
Pt. Specific Indications: To lower cholesterol and keep arteries open
Mechanism of Action: Hypersensitivity to atorvastatin,liver disease,pregnancy,breastfeeding
Contraindications: HMG-CoA reductaseinhibitor.Inhibitsratelimitingstep in cholesterol biosynthesisby competitively inhibitingHMG-
CoA reductase
Side Effects: Diarrhea,nasoparyngitis,arthralgia,insomnia,UTI,nausea,dyspepsia,musclespasms,musculoskeletal pain,myalgia,limb
pain,pharynogolaryngeal pain
Patient Family Education: There is a risk for myopathy in elderly patients. Use with caution In pts with hepatic impairment or who’ve had
a recent stroke. May causeincreased blood sugar so make sureto monitor the pts glucoselevels
Generic Name : Fenofibrate Trade Name : Triglide
Classification : Fibric acid agent Dose: 160 mg Route: PO Frequency/ Rate: QDay
Pt. Specific Indications: Used to decrease cholesterol and triglyceridelevels
Mechanism of Action: Increases VLDL catabolism,fatty acid oxidation,and elimination of triglyceriderich particles by enhancingsynthesis
of lipoprotein lipase,which in turn results in 30-60%decrease in total plasma triglycerides.
Contraindications: Hypersensitivity to fenofibrate, severe renal impairment, activeliver disease,gallbladder disease,nursingmothers
Side Effects: Name
Patient Family Education: Can causecholelithiasisso makesureto look for the signs of it and encourage diet with lowlevels of fat to
prevent it. Monitor blood counts periodically becausethe medication can causethrombocytopenia and agranulocytosis.Monitor renal
function in pts at risk of renal impairmentbecause it can increaseserumcreatininelevels.
Generic Name : Heparin Trade Name : N/A
Classification : Cardiovascular and
hematologic anticoagulant
Dose: 5000 units Route: Sub Q Frequency/ Rate: Q12H
Pt. Specific Indications: Prevent DVT
Mechanism of Action: Inactivates factor Xa and inhibits conversion of prothrombin to thrombin; inhibits activation of factor VIII.At high
doses,it also inactivates factors IX,X,XI,and XII and thrombin and inhibits conversion of fibrinogen to fibrin
Contraindications: hypersensitivity to heparin,pork products,corn, or sulfites;thrombocytopenia, uncontrolled activebleeding,
hemorrhage, coagulation problems
Side Effects: Hemorrhage, thrombocytopenia, HIT/HITT, bleeding, prolonged clottingtime, uticaria,fever, rigots,osteoporosis
Patient Family Education: Since this medication helps thin your blood,try not to get any cuts,lesions,bruises,etc.because they will take
longer to heal. If it does occur,make sureto apply pressurefor a prolonged period of time to ensure proper clottingwill occur
Generic Name : Ondansetron Trade Name : Zofran
Classification : Antiemetic, selective 5-HT3
antagonist
Dose: 8 mg Route: IV Frequency/ Rate: Q6H
Pt. Specific Indications: Used to treat nausea and vomiting
Mechanism of Action: Medication binds to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI tract. Has no effect
on dopamine receptors and therefore does not causeextrapyramidal symptoms.
Contraindications: Hypersensitivity to ondansetron, coadministration with apomorphine(combination reported to causeprofound
hypotension and loss of consciousness,reducedosewith severe hepatic impairment, do not use instead of NG suction
Adverse Effects: Headache, malaise/fatigue,constipation,hypoxia,drowsiness,diarrhea,dizziness,fever, anxiety, urinary retention,
puritus,paresthesia,cold sensation,elevated liver function test results
Patient Family Education: Inform the pt that this medication will begiven accordingto a schedule, not PRN. Inform the pt that he will be
monitored usingECG monitoring sincehe has electrolyte abnormalities.Sincethe route of this medication is IV, educate the pt on proper
positioningto keep IV linepatent.
Source:(Medscape,2015)
Present History and Relevant Past History:
(Provide a synopsis of patient’s history leading to hospitalization)

8. On 11/05/15, pt wasdiagnosedwithlungcancerinherRUL and startedradiationtreatmentforit. Patientpresentedto
ED 11/17/15 withcomplaintsof dizziness,swellingof chestandpaininthe R arm.11/18/15, after a CXR wasconducted
on the affectedarea,itwasshownthat herclavicle wasfractureddue to cancerouscellsbreakingdownherbone andthis
was whatwas causingherpainand decreasedROM.Pt wasdx withosteoporosisin2009 whichmeansthather bonesare
alreadyfragile andare more susceptibletobeinginfiltratedwiththe damagingcancerouscells. The ptalsohas DM2 and
anemia,which impairsherhealingability.Thiscanmake iteasierforherlungcancer to damage her lungtissue since her
bodywill notbe able to heal itself inatimelymanner.
Pathophysiology of Admitting Diagnosis:
(Describe pathophysiology as you would explain it to the patient.)
What youwere recentlydiagnosedwithwaslungcancer. Asyouknow,there are differenttypesof cancerandtheyall
affectthe bodyindifferentways.The waythatlungcancer affectsyourbodyisthat there are certaincellsinthe toppart
of yourrightlungthat are growingandmultiplyingtooquickly. Thesecellseventuallyformamass,or a tumor, whichcan
cause you to have chestpain. Lungcancer can alsocause you to have othersymptoms,like shortnessof breath,cough,
bone pain,andweightlos. If the cancer isnot controlledthroughtreatment,likechemotherapy,thenthe cancerouscells
will have enoughtime totravel tootherareasof yourbody,especiallyyourlymphnoes,liver,bones,adrenalglands
(whichare on topof your kidneys),andbrain. Whenthe cancerspreadsto otherareas,thisiscalledmetastasis.Thishas
unfortunatelyalreadystartedtohappensince the cancerouscellswereable togetinthe bone inyour clavicle andcause
it to become weakandthenfracture.
Source: (Cady & Jackowski,2014) & (Tan & Maghfoor, 2015)
Patient’s Plan of Care:
(Briefly describe patient’scurrentplanof care duringhospitalization,discussrelevantprocedures,therapies,tests,etc.)
To helpwiththe pts superiorvenacava compressionsyndrome,highamountsof IVFare tobe avoidedandan
echocardiogramwasscheduled.Zofranhasbeenprescribedtohelpwithanynauseathe patientmayhave.The patient
has HTN so hermedicationof amlodipineandatenolol isbeingcontinued.Tocontrol herhyperlipidemia,the patientwas
prescribedstatinmedication.The patientisonbedrestsoheparinhasbeenprescribedtopreventDVT andnurse has
beenmade aware to be cautiousof potential deliriumandfall risk.Patent wasalsogivenaslingtoholdup herrightarm
to helprelieve stressonherfracturedclavicle.Nocastisgoingto be made for furtherhealingof the fracturedclavicle.
List 4 Nursing Diagnosis In Order Of Highest Priority:
(Based on your patient’s specific needs, identify four nursing diagnosis and rank them in order of importance,
be sure to include at least one psychosocial diagnosis)

9. 1) Acute Pain R/T immobility of right arm AEB pain when lifting right arm, guarding and protection of right
arm 2˚ to fractured clavicle
2) Impaired Physical Mobility R/T limb immobilization AEB inability to move purposefully within the
physical environment with the right arm, reluctance to move the right arm, decreased ROM 2˚ to
fractured clavicle
3) Fear/Anxiety R/T change in health status AEB verbal expression of fear, shock at new diagnosis, concern
for future health 2˚ to diagnosis of lung cancer metastasis
4) Self-Care Deficit R/T musculoskeletal impairment AEB decreased strength in R arm, pain in R arm,
intolerance of activity on R arm 2˚ to fractured clavicle and lung cancer
Daily Care Plan
Assessment: (briefly discuss relevant assessment findings, labs, diagnostic tests, etc)
Objective: inability to lift or move right arm well, guarding and protection of right arm
Subjective: pain when lifting right arm, apprehension to move arm
Nursing Diagnosis:
Acute Pain
Goal: (specific to your patient’s needs)
• Report pain is relieved or controlled; pain reduced from 5/10 to 2/10
• Participate in desired/needed activities
Intervention Rationales
1) Note possible causes of pain
2) Evaluate effectiveness of pain control
3) Provide comfort measures
4) Assist with self-care activities
1) Knowing what causes pain will help the patient and nurse
prevent those aggravating factors in the future
2) To ensure that medication is working as expected or if
another pain management method is needed
3) Promotes relaxation and helps relieve discomfort
4) Prevents possible further injury and allows pt to continue to
do activities they need to do
Evaluation:
Patient is able to participate in activities of daily living and reports pain has decreased from 5/10 to 2/10
Source: (Ackley & Ladwig, 2014)
References

10. Ackley,B.J.,& Ladwig,G. B. (2014). Nursing diagnosishandbook (10thEditioned.).MarylandHeights,Missouri:Elsevier.
Cady,J., & Jackowski,J.A.(2014). Medical-surgicalnursing:Assessmentand managementof clinical problems. St.Louis,
Missouri:Elsevier.
Medscape.(2015, January1). MedscapeReference.RetrievedNovember16,2015, from Drugsand Diseases:
http://reference.medscape.com/
Tan, W. W., & Maghfoor,I. (2015). Smallcell lung cancer: Pathophysiology.RetrievedNovember24,2015, fromDrugs and
Diseases:http://emedicine.medscape.com/article/280104-overview#a3