Source: Tom Jean and Jane Rosenstein (Boston: Bedford/SST. Martin’s, 2007). Title page consists of a descriptive title in the center of the page and the writer’s name, the course, the instructor, and the date centered at the bottom of the page. Headings and subheadings, in PAP style, mark the sections of the report and help readers follow the organization. Historical and Physical Assessment Physical History E. B. Is a 16-year-old white male 179 CM tall weighing 86. 9 keg. He was admitted to the hospital on April 14, 2006, due to decreased platelets and a need for a PRICE transfusion.
He was diagnosed in October 2005 with T-cell acute lymphatic’s leukemia (ALL), after a 2-week period of decreased energy, decreased oral intake, easy bruising, and pathetic. The client had experienced a weight loss in the previous 6 months. At the time of diagnosis, his CB Iris begins by summarizing the client’s history using information from his chart and her interview. Showed a WEB count of 32, an H & H of 13/38, and a platelet count of 34,000. His initial chest X-ray showed an anterior medications mass. Cardiograms showed a structurally normal heart.
He began induction chemotherapy on October 12, 2005, achieving Benedictine, 6-enrapturing, distribution, intertribal metamorphose, and then high-dose metamorphose per protocol. During his hospital stay he required packed red cells and platelets on two different occasions. He was diagnosed with hypertension (TN) due to systolic blood pressure readings consistently ranging between sass and 1 ass Iris respects the client’s privacy by using only his initials in her paper. And was started on unfeminine. E. B. Has a history of mild ADD, migraines, and deep vein thrombosis (DTV).
He has tolerated the induction and consolidation phases of homoeopathy well and is now in the maintenance phase, in which he receives a daily dose of enrapturing, weekly doses of metamorphose, and intermittent doses of steroids. Psychosocial History There is a possibility of a depressive episode a year previously when he would not attend school. He got into serious trouble and Source: Tom Jean and Jane Rosenstein (Boston: Bedford/SST. Martin’s, 2007). 2 was sent to a shelter for 1 month. He currently lives with his mother, father, and 14- year-old sister.
Family History Paternal: prostate cancer and hypertension in grandfather Maternal: breast cancer and heart disease Current Assessment Client’s physical exam reveals him to be alert and oriented to person, place, and time. He communicates, though not readily. His speech and vision are intact. He has an equal grip bilaterally and can Iris describes her detailed assessment of the client, using appropriate medical terminology. Move all extremities, though he is generally weak. Capillary refill is less than 2 s. His peripheral pulses are strong and equal, and he is positive for posterior tibiae and dorsal piped bilaterally.
His lungs are clear to auscultation, his respiratory rate is 16, and his oxygen saturation is 99% on room air. He has positive bowel sounds in all quadrants, and his abdomen is soft, round, and entendre. He is on a regular diet, but his appetite has been poor. Client is voiding appropriately and his urine is clear and yellow. He appears pale and is unkempt. His skin is warm, dry, and intact. He has aliped as a result of chemotherapy. His mediator site has no redness or Assessment uses a neutral tone. Inflammation. He appears somber and is slow to comply with nursing instructions.
Medical Diagnosis #1 : Acute Lymphatic’s Leukemia Leukemia is a nepotistic disease that involves the blindfolding tissues of the bone arrow, spleen, and lymph nodes. In leukemia the ratio of red to white blood cells is reversed. There are approximately 2,500 cases of acute lymphatic’s leukemia (ALL) PAP allows extra space above headings when it improves readability. 3 per year in the United States, and it is the most common type of leukemia in children–it accounts for 75%-80% of childhood leukemia. The peak age of onset is 4 years, and it affects whites more often than blacks and males more often than females.
Risk factors include Down syndrome or genetic disorders; exposures to ionizing radiation and certain chemicals such as engine; human T-cell leukemia/lymphoma virus-I; and treatment for certain cancers. ALL causes an abnormal proliferation of lymphomas in the bone marrow, lymph nodes, and spleen. As the lymphomas proliferate, they suppress the other homeopathic elements in the marrow. The leukemia cells do not function as mature cells and so do not work as they should in the immune and inflammatory processes.
Because the growth of red blood cells and platelets is suppressed, the signs and symptoms of the disease are infections, Iris paraphrases the source and uses an PAP-style in-text citation. Leading, pallor, bone pain, weight loss, sore throat, fatigue, night sweats, and weakness. Treatment involves chemotherapy, bone marrow transplant, or stem cell transplant (Lemon & Burke, 2004). Medical Diagnosis #2: Hypertension Primary hypertension in adolescence is a condition in which the blood pressure is persistently elevated to the 95th to 99th Iris demonstrates her understanding of the medical condition. Recently for age, sex, and weight (Huckleberry, 2003). It must be elevated on three separate occasions for diagnosis to be made. Approximately 50 million people in the United States suffer from hypertension. It most often affects middle-aged and older adults and is more prevalent in black adults than in whites and Hispanics. In blacks the prevalence between males and females is equal, but 4 in whites and Hispanics more males than females are affected. Risk factors include family history, age, race, mineral intake, obesity, insulin resistance, excess alcohol consumption, smoking, and stress.
Hypertension results from sustained increases in blood volume and peripheral resistance. The increased blood volume causes an increase in cardiac output, which causes systemic arteries to vasoconstriction. This increased vascular resistance causes hypertension. Hypertension accelerates the rate of atherosclerosis, increasing the risk factor for heart disease and stroke. The workload of the heart is increased, causing ventricular hypertrophy, which increases risk for heart disease, dysphasia, and heart failure. Early hypertension usually exhibits no symptoms.
The elevations in blood pressure are temporary at first but then progress to being permanent. A headache in the back of the head when awakening may be the only symptom. Other symptoms include blurred vision, nausea and vomiting, and nocturne. Treatment involves medications such as ACE inhibitors, diuretics, beta adrenaline lockers, calcium channel blockers, and vacillators as well as changes in diet, such as decreased sodium intake. An increase in physical activity is essential to aid in weight loss and to reduce stress (Lemon & Burke, 2004).
Chart Review Active Orders: Vital signs quo Fall precautions BOB as tolerated Iris uses specialized medical 5 Geometry monitoring–continuous CB with manual differential daily in am Regular diet Weight–daily Strict intake and output monitoring Type and cross match PRESS–2 units Platelets–1 unit Discharge after CB results postulations shown to MD Rationale for Orders Iris shows how physiology, restricted treatments, and nursing practices are related. Vital signs are monitored every four hours per unit standard.
In addition, the client’s hypertension is an indication for close monitoring of blood pressure. He has generalized weakness, so fall precautions should be implemented. Though he is weak, ambulation is important, especially considering the client’s history of EDT. A regular diet is ordered–lam not sure why the client is not on a lissome diet, given his hypertension. Intake and output monitoring is standard on the unit. His homological status needs to be carefully monitored due to his anemia and hermaphroditic; therefore he has a CB with manual differential done each morning.
In addition, his homological status is checked postulations to see if the blood and platelets he receives increase his RUB and platelet counts. Transfused platelets survive in the body approximately 1-3 days, and the peak effect is achieved about 2 her postulations. Though platelets normally do not have to be cross- matched for blood group or type, children who receive multiple transfusions may become sensitizes to a platelet group other than their own.
Therefore, 6 platelets are cross-matched with the donor’s blood components. Blood and platelet transfusions may result in hemolytic, febrile, or allergic reactions, so the client is carefully monitored during the transfusion. Hospital protocol requires a set of baseline vital signs prior to transfusion vital signs. After the blood and platelets have been given, the physician is apprised of CB results to be sure that the client’s thermodynamic has resolved before he is discharged.