2.18.2009

Client: #327

Diagnosis: right lung mass

DATA :

Assessment: Client did not demonstrate orientation or alertness but responded to direct questioning about pain by raising hand. Client in semi-fowlers position, eyes unfocused with left eyelid dropping, head arched back into pillow, mouth open, chest heaving, vesicular breath sounds, bloody sputum, crackles and wheels identified, neck veins extended, capillary refill +3, yellow concentrated urine output 25 ml, no bowel sounds noted, skin flushed, very warm, very dry with flaking, turgor loose, severe cachexia with visible skeleton and large darkened patches on both arms. Patent catheter line and morphine IV drip running. Client is DNR.

VS 93/59 151pulse 44resp 83 96axillary

Medications: Atrovent 0.02% NEB 0.5, Decadron 4mg/ml, Levaquin 500mg/100ml, Protonix 40mg, Proventil 2.5mg, Reglan 10mg, Ativan 0.5, Compazine 10mg, Morphine carpuject 1-2mg, Morphine 100mg, Zofran 8mg

PLAN : The client is a 55-year old white male with a right lung mass in end-stage cancer, MI in 2005, history of multiple illnesses. Daughter at beside. Comfort measures to be provided.

            Nursing Diagnosis: none

IMPLEMENTATION :

0720 IV Morphine drip dosage increased to maximum allowable per physician’s order

0830 Daughter left room to tell nurse that her dad the client had passed away. Declared dead by attending physician at 0840. Post mortem care provided, including removing all lines and cleaning body, arranged client for family viewing.