Jeanine Avalos Banner Gateway 4-12-24

NA

Improve airway patency

Improve tolerance to activity

noooooodooned
 1500

Hx breast ca stage 4 with Mets radiation treatment 4-9-24 chemo

treatment 4-6-24. Hx of ulcerative colitis Penicillin
ooo
Oxycodone
NA

Gcs 15
Clear speech NA 9.4 Na
Follows commands and moves all extremities Na
NA 1.5
Na
64 Na
Na Na NA Na Na
NA
WNL 19
NA
22

Na Iv #18 g R AC
500 ml 1000 ml
NA NA

Vancomycin 1600 IVPB

Na
96%ooo
2 l NC

#18 R AC
0.9 ns 1000 ml

Vancomycin 750 mg ivpb

NA 250 ml ns

Continent Of B&B Urine yellow, no pain or WNL

burning reported NA
NA
Pneumonia NA
99.9 NA
NA
R upper chest used only for chemo
Yes

Na

Na NA Na Na Na Na Na
Na
Na
Na Na
Vancomycin 750 mg IVPB Q 6 hrs Vancomycin 750 mg IVPB Q 6 hrs
The pt’s WBC is severely low because she is on chemotherapy that puts her at a very high risk for further infections and her more risk for not
overcoming this infection.

I practiced active listening with her when she talks about her young son because I can’t imagine having a child and going through
cancer and being in and out of the hospital. Patient stated that she has lost a lot of her sons life because of her circumstances.

PRN

PRN

PRN
 4-11 4-12

2.5–7.0 2 2.5

Na. Na
CXR Multifocal pneumonia To determine pneumonia

CBC ↓ wbc from chemo Pts risk for reoccurring infection

Sputum culture Pending results To determine if the abx she’s on is helping infection

85N
JAN
ASEYE

range
ISN

Infection
Patient will display improvement in infection evidenced by
vital signs and lab values within normal limits
Patient will display a patent airway with breath
sounds clearing absence of dyspnea, cyanosis as
evidenced by keeping a patient and airway and
effectively clearing secretions .
Perfusion
acute pain and The patient will report a reduction in pain when
breathing
discomfort
1. Monitor for worsening signs of infection or sepsis.
(Dropping blood pressure, hypothermia or hyperthermia, elevated heart rate, and tachypnea are signs of sepsis Goal met the pt does not present with a fever or worsening infection.
that require immediate attention.)
2. Administer antibiotics.
3.Encourage fluid intake and nutrition.
1: assess respirations, no quality rate rhythm depth use of
accessory muscles Goal met patient was using the incentive spirometer
Patient was breathing adequately maintaining a oxygen level
2: observe the color of skin, mucous membranes, and nailbeds,
noting the presence of peripheral cyanosis or central cyanosis above 95
3: assess mental status restlessness changes in LOC confusion Patient’s refill was less than three
1: assess pain characteristics ex: stabbing access reports of pain with
breathing or coughing
Goal met by the end of the day the patient have reported no pain .
2: provide comfort measures such as position changes massage encourage
the use of relaxation and or breathing techniques
3: Instruct and assist the patient in chess learning techniques during
coughing episodes
1800
Skin intact no wounds
No pain at this time
 It went great the patient will be discharged in the AM!

The pt wants to get better and has hope for her son and has a lot of motivation.

Stable

Wash hands, wear a mask in public and take neutropenic precautions due to ↓ wbc.

The nurse I had was amazing. I had her at the last clinical and she was so hands on and helped learning so much more enjoyable

I wish we were in a more critical unit. I enjoy this unit, however I have no icu experience and wish I was able to say I knew more
about critical patients

I will work on time management .