Care Map Vulva Cancer Andrea Evans PDF

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Relevant Medications: Oxycodone immediate release 4mg IV injection q 6 hrs, acetaminophen 650mg q 6 hrs PRN, Ondansetron 4mg IV injection q 6 hrs PRN, Lidocaine ointment topical 2 X daily PRN. NOTE: Just completed 5 cycles of chemotherapeutic drug Cisplatin on 11/2 before admission.

Scheduled Treatments: External beam radiation therapy 11/9, 11/10, 11/11, 11/12 @ 1200. Labs: MBP WDL. CBC (didn’t write down) but I remember it did not flag concern.

Past medical history: Stage IVB SCC of Vulva, Essential Hypertension, Hypothyroidism, AKI, Hospital acquired MRSA, Aortic dissection thoracic, Atrial Fibrillation, Asthma

Interventions for Impaired Skin Integrity: - Used pillow for client’s position from R-L-back q 2 hrs. - Applied Lidocaine to burns and Z Guard Paste to gluteal. - Received orders from Gynecologic Oncology that a wound management care team would evaluate pressure ulcer today or tomorrow. - Client refused care to her skin tear. - Lotion was applied peripherally to moisten skin for sake of elasticity. - Performed catheter care to prevent infection of peritoneal area. - Did gluteal and peri care with each incontinent episode. - Told HCP about loose stools that could promote skin breakdown and a test was ordered.

73 yr-old female admitted for general weakness. Client states her issues with weakness began following radiation for her vulva cancer. Vital Signs: * R- 18 * BP- 97/58 (WDL for client) * HR- 75 (WDL) * Pain- 0 at 0730am at rest. 8 at 0830 with PT activity. 0 at 0900 with rest. 4 at 1040 with activity. 2 at 1320 after radiation. 0 at 1345 after treatment.

Physical Assessment: Resp- (unlabored/ pattern regular/ diminished). Client about once an hour coughs up a scant amount of phlegm due to preexisting sinus issues. Cogn- WDL except pain between 0 at rest. 2 after radiation, 4 w/ transfer and 8 with walking. AAO X4 Musc- Gait unsteady, weakness in L leg and L upper arm. R shoulder pain. Pedal and hand strong bilaterally. Neuro- numbness and tingling in both legs. Edema +2 L lower leg and + 1 elsewhere. Braden Scale Score- 16. Pressure ulcer sz quarter L gluteal. Skin tear sz dime R lower leg. I/ O balanced but incontinent passive brown liquid stools- no blood. Indwelling catheter w/ amber urine. ROM limited. Assist X1. Radial and pedal pulses 2+ bilaterally, Cap refill < 3 sec. Skin has good turgor, but is thin, dry and cirrhotic.

Interventions for Acute Pain: -

Analgesic given at time of pain. -Opioid analgesic given before radiation. Nurse discussed premeditative medications before PT to eliminate pain. -0.9% saline cool soaked gauze over burns for pain relief....