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Student Name: Chrisna Khoun

Patient Initials: L.J.M

Patho:
Gastric cancer is a multifactorial disease. Helicobacter
pylori infection is an essential risk factor in 65–80% of
gastric cancers, but in only 2% of such infections. Early
cancers may be associated with indigestion or a burning
sensation (heartburn). However, less than 1 in every 50
people referred for endoscopy due to indigestion has
cancer. Gastric cancers that have enlarged and invaded
normal tissue can cause weakness, fatigue, bloating of
the stomach after meals, abdominal pain in the upper
abdomen, nausea and occasional vomiting, diarrhea or
constipation. It is diagnosed using gastroscopic exam
and abdominal CT scans. It treated by surgery,
chemotherapy, or radiation. The prognosis of stomach
cancer is generally poor, due to the fact the tumour has
often metastasised by the time of discovery and the fact
that most people with the condition are elderly (median
age is between 70 and 75 years) at presentation.

Nursing diagnosis:
1. Pain management r/t postop
2. Risk for infection r/t abd
incision
3. Risk for falls r/t need assist
when ambulate
4. Ineffective coping r/t

Interventions:
1) Pain medication will be administered as ordered.
2) Pt will be taught proper wound care and signs of
infection to report.
3) Pt will be educated on use of call-light and have
within reach
4) Pt will be taught effective coping techniques such as
daily journal or talking about feelings concerning pain
or anxiety of going home.

Current Diagnosis:

Room:

8010

Assessment:
See page 2.

Gastrectomy r/t
Gastric cancer

Date: 10/26/2014
Abnormal Labs:
RBC 3.78 L
HGB 11.0 L
HCT 33.7
Leukocytes 47.1 H
Monocytes 15.5 H
Body is most likely still under stress due to
post-surgery and pt’s anxiety about going home.

Medications
C.C.: admitted on 10/15/14 for abd pain r/t gastric mass
History: Pt is a 66 yo female who admitted on 10/15/14 for
abd pain r/t gastric mass which worsened with eating. She is
65 inches and 109 lbs. Pt had subtotal gastrectomy on
10/21/14. Pt is former smoker and had 3 cycles of
chemotherapy.
PMH: HTN, CHF, MI(7/14), L breast cancer with L mastectomy,
cervical laminectomy, NKDA, African American, Full code

Goals:
1) Pt will reach a pain goal of 5 on 10 point scale by 1400
today.
2) Pt will verbalize proper wound care
3) Pt will verbalize understanding to call for assistance
before attempting to relieve BM/void on own
4) Pt will verbalize effective coping technique to use when
anxious about going home.
Outcomes:
1) Pt states pain is 8/10.
2) Pt does not want abdomen touched.
3) Pt has ROM of extremities but has frail build
4) Pt states frustration of unsatisfactory pain management
and wanting about going home b/c does not like nights at
hospital.

Crestor (Rosuvastin calcium) tab 20 mg HS
for cholesterol
Dilaudid IVP 1mg q4h prn for
moderate/severe pain
Coreg (carvedilol) tab 12.5mg bid PO for
HTN
Norco 10/325 mg tab 1 tab q4h prn for
moderate pain
Ativan tab 0.5mg q8h PO prn for anxiety
LR IV 1000ml q14h18min 70ml/hr fluid
replacement
Protonix for GERD prevention
Zofran IVP 4mg q6h prn for nausea

Evaluation: Goal not met,
Extend goal until abd wound
heals completely
1)

Administered pain med Norco when
pain 8/10 and re-evaluated at 7/10.
2) Pt repeated back teaching on proper
wound care when asked to.
3) Pt verbalized understanding of call-light
and used for assistance in going to
bathroom and help in moving IV pole.
4) Pt verbalized frustrations when asked
about pain level and about staying the
night. Pt seems less angry after discussion.

Student Name: Chrisna Khoun

Patient Initials: L.J.M

Room:

8010

Date: 10/26/2014

Head to toe physical assessment
Head: AOx3 positive, cooperative with exam, appropriate expression and speech,attention span normal, PERRLA, negative head
wounds, no visual/hearing aid present. No JVD present, positive neck ROM.
Cardiac:
Radical pulse: 72 bpm; Apical pulse: 74 bpm, regular rate and rhythm; s1 and s2 noted. Peripheral pulses palpable in all extremities.
Negative clubbing. Cap refill <3.
Pulmonary:
Respirations are even, unlabored. Breath sounds heard bilaterally, clear to auscultation of lungs (anterior and posterior). Trachea
midline.
Abdomen:
Post- gastrectomy diet, soft regular food; able to feed self, but states feels nauseated when tried to eat lunch, ate 5% of meal (3 bites);
abdomen soft & slightly tender with bowel sounds active in all 4 quadrants and last BM: today, small, solid stool.
GU:
Last void: today, states urinate frequently; 500 ml, yellow, clear, no sediments, independent use of bathroom.
Extremities:
Pt has positive ROM of all extremities, hand grips equal, push/pull positive for upper extremities, Homan’s sign negative bilaterally.
Positive push/pull of lower extremities. Feet cool, dry, intact.
Skin:
Pt skin is dry and cool, consistent in color. No skin breakdown present. Skin turgor <3, Braden scale: 15
Pain:
T: 97.9°F, oral; P: 74 bpm, R: 20 per min, BP: 160/80, Pain: 8 (1-10), verbal, back, continuous, aching; O2 sat: 96%, RA
IV’s if any:
Peripheral IV R lower arm 20G, inserted 10/24/14
L side restriction due to L mastectomy