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The importance of accurate patient history
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Health History Patient’s name: B.C Age: 38 Gender: Female Ethnicity: African American Weight: 137 Height: 5 ft. 5 in Surgical History: Three C-sections. Cholecystectomy. Past medical history: History of chronic cervical infections, menorrhagia, long term oral contraceptive use. Current medical history: Unexplained weight loss and dizziness. Social history: She is married with 3 children in all. She does not drink but she used to smoke 1 pack of cigarettes a day. She stopped smoking 3 years ago. Chief complaint: Bleeding of the Vagina, chronic fatigue and severe pelvic pain. History of present illness on admission: Mrs. B.C. is a 38-year-old, African America female that has a past medical history of chronic cervical infections and menorrhagia. Upon admission she complained of dull pain …show more content…
Abnormal ranges are used to detect many different disorders. Collaborative Management In the early stage of cervical cancer treatments consist of surgery or radiation with a combination of chemo. Since the pt. already have three children she has decided to undergo a simple hysterectomy. A simple hysterectomy involves surgical removal of the uterus, including the cervix and a small amount of the surrounding normal tissue (Cancer Research). Approximately 95% of people diagnosed with stage I cervical cancer survive without the cancer recurring after surgery. The other 5% of patients will experience recurrence of the cancer (Texas oncology). The management of care and treatment for Mrs. B.C. may require the involvement of a gynecologic oncologist to treat the cancer and manage it. A social worker to provide counseling and help the pt. determine the right health care services. And a pharmacist to help manage the required medications. Nursing Management Physiological Nursing Diagnosis: Acute pain related to surgical procedure as evidence by, pt. stating pain level is 7 out of 10, and pt. grimacing with
Winfield, H., Katsikitis, M., Hart, L. and Rounsefell, B. (1989). Postoperative pain experiences: Relevant patient and staff attitudes. [online] 34(5): pp.543-552. Available at: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8V-45WYV7R-7G&_user=10&_coverDate=12%2F31%2F1990&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=35e6b5e8c8f803b487b35d4ae3b06cef&searchtype=a[ [accessed 8/5/2013]
What? The patient is 65-year-old man Mr. John Douglas who is suffering from dysphagia and have been admitted to the surgical ward for insertion of a percutaneous endoscopic gastrostomy (PEG). Apart from that, he is a Type 1 diabetes patient and has weakness in his right leg and arm because of right-sided hemiplegia. He is thin in appearance and has stage 1 pressure sore on his right heel.
...tive pain management and Improvement in patients outcomes and satisfaction [Magazine]. Critical Care Nurse, 35(3), 37,35,42. Retrieved from
Pain Management Nursing, 10(2), 76-84.
What is the human papillomavirus (HPV)? According to the US government’s National Cancer Institute, human papillomaviruses (HPVs) are a collection of more than one hundred viruses, many types having the ability to grow tumors or polyps that are malignant and others benign. Certain of the viruses are capable of forming genital warts. The HPVs that cause the common warts on hands and feet are different from those that cause growth in the throat or genital area (Human Papillomavirus). Professors Joe Cummins and Dr. Mae-Wan Ho inform us that some types are associated with cancer, and are called “high risk” HPVs. Of the more than one hundred types of HPVs, over thirty can be passed on through sexual contact. Most HPV infections occur without any symptoms and go away without treatment over the course of a few years. However, HPV infection sometimes persists for many years, with or without causing detectable cell abnormalities. Infection from “High risk” types of HPV is the main cause of cervical cancer. Pap smears have also led to earlier detection of these infections. Nearly all women who are sexually active will have HPV inf...
on Pain Care will evaluate the adequacy of pain assessment, treatment, and management; identify and
Patient stated discomfort and pain level is 7 out of 10 on the numeric pain scale
...amount of pain) is a great teaching tool for the patient who is able to self-report (Nevius & D’Arcy, 2008). This will put the patient and nurse on the same level of understanding regarding the patient’s pain. The patient should also be aware of the added information included with the pain scale: quality, duration, and location of the pain. During patient teaching, it should be noted that obtaining a zero out of ten on the pain scale is not always attainable after a painful procedure. A realistic pain management goal can be set by the patient for his pain level each day.
There are four stages to diagnosing ovarian cancer, determined by how far the cancer has spread in the body. Each stage is characterized by an A, B, or C letter, depending on the degree in which the symptoms present themselves. The differences in each stage are as follows; stage 1 is when the cancer is either found in one ovary or both, stage 2 the tumor is found in one or both ovaries and extends to other pelvic structures, stage 3 the cancer has spread beyond the pelvis to the lining of the abdomen or to the lymph nodes and finally in stage 4 the cancer has spread to other organs in the body including the liver or lungs (Ovarian Cancer National Alliance). Cancer is “staged” by taking a sample of the infected tissue surgically and sending it to a lab for examination. Staging is crucial in order for medical professionals to determine which course of treatment would be the most effective for the given patient. If misdiagnosed, an entire area affected by this disease could potentially be missed and left untreated.
History of Present Illness: KK is 49-year-old Caucasian female two weeks S/P TLH present to the office with c/o lower pelvic
This procedure may be carried out for several reasons. Among the major reasons for getting a hysterectomy, some notable ones are, uterine cancer, thickening of uterus (Adenomyosis), and endometriosis or the external development of the tissue lining the uterus. Lastly, pelvic pain and chronic vaginal bleeding may also lead to the decision to get a hysterectomy. Before going for a hysterectomy all possible treatment options are exhausted, the only exception being in the case of cancer, whereas surgery is the only viable option available. Knowing the reason for surgery is important as it dictates the types of hysterectomy that needs to be pursued. Depending upon the reason, surgery may involve complete (total hysterectomy), or partial removal of the uterus and the cervix. Or in a rare case it may involve removal of only the upper part of the uterus, more technically referred to as a subtotal hysterectomy. In severe cases like in cancer the surgeon might go for a radical hysterectomy, a procedure which not only involves complete uterus removal, but also the removal of the cervix and tissue surrounding the uterus. [3] According to leading statisticians, one in every nine women in the United States undergoes the procedure during their
In a pain assessment, the pain is always subjective, in a verbal patient; pain is what the patient says that it is. Nurses must be able to recognize non verbal signs of pain such as elevated pulse, elevated blood pressure, grimacing, rocking, guarding, all of which are signs of pain (Jensen, 2011). A patient’s ethnicity may have a major influence on their meaning of pain and how it is evaluated and responded to behaviorally as well as emotionally (Campbell, & Edwards 2012). A patient may not feel that their pain is acceptable and they do not want to show that they are in pain. For some people, showing pain indicates that they are weak. Other patients will hide their pain as they do not want to be seen as a bother or be seen as a difficult patient.
He is admitted to the ward with the chief complain of pain at right lower quadrant of the abdomen for 8 hours prior to his admission.
Many, C.S. & Co., Inc. (2003). The 'Secondary' of the 'Secondary'. Diagnosis, treatment, and nursing care of acute leukemia. Seminars in Oncology Nursing, 19(2), 98-108. Retrieved from http://www.nursingconsult.com/nursing/journals/0749-2081/full-text/PDF/s0749208103000068.pdf?issn=0749-2081&full_text=pdf&pdfName=s0749208103000068.pdf&spid=13652985&article_id=487088.
The Phase I trial will be discussed here as it pertains to the topic at hand. The typical treatment for cervical cancer if surgery is not a viable option – like if the cancer has spread, then called locally advanced cervical cancer – is chemotherapy and radiation treatment at the same time. This phase I clinical trial is simply looking to add ipilimumab to this regimen, but once the chemo/radiation has been completed (LACC article). Chemo and radiation destroy tumor cells, which causes tumor-associated antigens to be released. Once released, these antigens are exogenous (outside the cell) and will be presented to helper T cells to initiate an immune response.