Brief Description of Client Name: Julia Morales Gender : Fem
Brief Description of Client Name: Julia Morales Gender : Female Age… Brief Description of Client Name: Julia Morales Gender: Female Age: 65 Race: CaucasianWeight: 123 lbs. /55.7 kg Height: 64 in / 163 cm Religion: Unitarian Major support: Partner – Lucy Grey Allergies: No Known Allergies Immunizations: Influenza and H1N1 Up-to-date Primary Care Provider/Team: Dr. Ann Davis Past Medical History: Aggressive breast cancer, treated with radiation and chemotherapy. History of present illness: Julia was seen in her oncologist’s office yesterday. Dr. Davis and his NP met with Julia and her partner, Lucy, to discuss her treatment plans. Julia has decided to stop chemotherapy treatments. The nurse practitioner recommended a home health agency referral to assess and support Julia and her family in their home. Social History: Retired from work in local nursery/garden center. Lives with partner Lucy. Son Neil, age 42, lives 20 miles away. Private insurance. Primary Medical Diagnosis: Breast cancer, Stage 4. Surgeries/Procedures and Dates: Hysterectomy at age 44. Complete the following data for Breast cancer:Signs and symptoms Complications and Risk factors Treatment options What are the areas of potential metastasis for a patient with breast cancer? Complete the following related to medications:MedicationDrug ClassHow is this med given? If given IV, over what period of time?Mechanism of Action (how does it work in the body)Side EffectsWhy would this medication be ordered for this patient?Patient education needed (in Layman’s terms)Enoxaparin Docusate Sodium Morphine Zofran What orders for lab work and/or diagnostic testing should the nurse anticipate for this patient? What is the difference between benign and metastatic cancer? What are some community resources available for people with metastatic/terminal cancer? Potential Problems: Identify 3 potential problems that the patient is at risk for. What objective or subjective data might your assessment reveal to support each problem? How would you manage each of these problems (interventions)? Potential ProblemsSubjective or objective dataInterventions1. 2. 3. Health Science Science Nursing NSG 170
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