Contributing factors involved in this

hospitalization: former smoker 1

pack/day for 20yrs, Alcohol: seldom
drinks beer

Secondary medical diagnosis #1:

ESRD
Medications for this condition
- Not taking any medications
directly related to treating this
problem

Pertinent Physical Examination findings:

Patient has periods of confusion, where he
would wake up from sleep calling for help
and would need to be reassured that he
was okay. He also had a lot of secretions
despite the medications he was on to
reduce the secretions, the secretions were
part of the reason why he would wake up
out of his sleep. Also, he would have
periods of apnea where he would stop
breathing for about 30 seconds and
suddenly take a deep breath.

Not directly related to

primary diagnosis

Priority Nursing Diagnosis (3 parts)

Risk for ineffective breathing pattern/risk for impaired
gas exchange related to retained secretions as evidenced
by periods of apnea (Doenges, 2010)
Measurable outcome w/ timeframe: Patient will
have reduced secretions and be able to sleep
peacefully by 2:00 pm on 2/19/15.

Nursing interventions you used with rationales:

1. Auscultate breath sounds, noting areas of
decreased or absent ventilation and presence of
adventitious breath sounds. Suggests developing
pulmonary complications or infections, such as
atelectasis or pneumonia (Doenges, 2010).
2. Note rate and depth of respiration, use of
accessory muscles, increased work of breathing,
and presence of dyspnea. Tachypnea, cyanosis,
restlessness, and increased work of breathing
reflect respiratory distress and need for increased
surveillance or medical intervention" (Doenges,
2010).
3. Investigate reports of chest pain. Pleuritic chest
pain may reflect nonspecific pneumonitis or pleural
effusions associated with malignancies (Doenges,
2010)
Evaluation: Goal met. Patient was able to sleep
peacefully and I could hear that the secretions
were diminishing in his mouth and lungs.

Secondary medical diagnosis #2: Pulmonary

Edema

Pulmonary complications are also potentially serious

adverse events that may develop in patients with MM.
Dyspnea may manifest as a symptom of multiple
underlying etiologies associated with various MM
therapies, or it may arise as a complication of MM,
including as a result of severe anemia, infection, and heart
failure" (Wang, Cheng, 2013).

(G.L.H., 62, M)

Multiple
Myeloma

Pathograph of this condition:

"Multiple Myeloma is characterized by neoplastic
proliferation of plasma cells involving more than
10% of the bone marrow. Increasing evidence
suggests that the bone marrow microenvironment of
tumor cells plays a pivotal role in the pathogenesis
of myelomas" (Dhaval, 2014). "The precise etiology
of MM has not yet been established. Roles have
been suggested for a variety of factors, including
genetic causes, environmental or occupational
causes, MGUS, radiation, chronic inflammation, and
infection" (Dhaval, 2014).

Anticipated patient teaching

required:
Patient needed consistent
reminders to push PCA button
when in pain

Medications for this

condition (name, route, dose,
action)
Not taking any medications
directly related to treating this
problem

Medications for this condition (name, route, dose, action)

- fentanyl 25mcg/hr 1 patch
(MOA) Opiate receptors are coupled with G-protein receptors and
function as both positive and negative regulators of synaptic
transmission via G-proteins that activate effector proteins.
-morphine PCA 150mg 130ml I.V.
(MOA) The precise mechanism of the analgesic action of morphine
is unknown. However, specific CNS opiate receptors have been
identified and likely play a role in the expression of analgesic
effects. Morphine first acts on the mu-opioid receptors.
- Atropine 1% drops, 3drops sublingual
(MOA) Atropine inhibits the muscarinic actions of acetylcholine on
structures innervated by postganglionic cholinergic nerves, and on
smooth muscles, which respond to endogenous acetylcholine but
are not so innervated.

Psychosocial / Spiritual issues and discharge

needs: Patient will continue to receive comfort
care from hospice until he passes away in the
hospital. Patient has a strong family presence and
a great support system during this time of need.

Recent laboratory/diagnostic tests results

with significance (i.e. why are they
high/low?)
RBC 3.04 (low), HGB 9.2 (low), HCT 28.9
(low) **these labs are abnormal because of
the patient's worsening condition and
1
medical diagnosis