A 69-year-old male client with a history of colorectal cancer arrives at the ED and reports that he has abdominal pain of 5/10 on a 0 to 10 pain intensity scale. The client reports a history of benign premature ventricular contractions (PVCs) and is taking metoprolol 50 mg twice daily for control. He tells the nurse that he recently completed his chemotherapy treatments and since then has had extreme fatigue, loss of appetite, sores in his mouth, and diarrhea. He is wondering if his symptoms are due to the effects of chemotherapy. He reports no allergies.
Nursing assessment findings include:
• Vital signs: temperature = 99.2°F (37.3°C), apical heart rate = 90 beats/min and irregular with an occasional skipped beat, respirations = 24 breaths/min, blood pressure (BP) = 168/90 mm Hg, oxygen saturation = 93% (on RA), abdominal pain level = 5/10 on a 0 to 10 pain intensity scale
• Reports loss of appetite, vomiting, constipation with diarrhea containing blood streaks, abdominal distention and tenderness; mass in mid-abdomen palpated, bowel sounds are high-pitched tinkling sounds; last bowel movement was during the night; weight is 145 lb (65.8 kg); reports a loss of 10 lb (4.5 kg) in the last month
• Breath sounds are clear bilaterally and client denies dyspnea or chest pain
• Skin is intact, dry, with poor turgor; sore white patches on mucous membranes in the mouth
• Reports urine output has decreased over the past week; denies burning or difficulty
• Moves all extremities and is able to ambulate independently; reports general fatigue and weakness
• Alert and oriented, coherent and responds appropriately; denies forgetfulness or memory loss; reports numbness and tingling in the ankles and feet bilaterally.
1. Name the client findings that require immediate follow-up by the nurse.
2. Which assessment finding is associated with each of the client's health problems?
Laboratory and diagnostic tests results include:
• White blood cell count = 4,500 mm3 (4.5 × 109/L)
• Hemoglobin = 11 g/dL (110 mmol/L)
• Hematocrit = 37% (0.37)
• Blood urea nitrogen = 25 mg/dL (9 mmol/L)
• Creatinine = 2.0 mg/dL (176 μmol/L)
• Sodium = 149 mg/dL (149 mmol/L)
• Potassium = 3.2 mg/dL (3.2 mmol/L)
• X-ray: A blockage in the large intestine is suspected; gas and liquid bowel contents above the area of the blockage appear to be present. Follow-up with CT scan is recommended.
• CT scan: A partial obstruction is seen in the large intestine. Gas and liquid bowel contents are seen both above and below the area of the blockage.
• ECG: normal sinus rhythm with occasional PVCs
3. Based on the client findings, the nurse begins to plan the client's care. What does the nurse recognize as the priority problems for the client?
4 What are the nursing interventions (action) for the client's care at this time?
5. The nurse is prioritizing actions. The nurse would first ___________1____________, and then would ______________2________________ followed by ______________3________________.
