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C. R 12/12/78 years ago - Coggle Diagram
C. R 12/12/78 years ago
Allergies: Penicillin.
Full Code.
Principal problem.
Advanced lung cancer with metastasis.
Has been on chemo and radiation for the past 2 years. Cancer has metastasized to brain and bones.
Chief complaint.
Pain/Restless.
Orders
Meds
Atropine
For excessive oral secretions. 2 drops q8h PRN.
Lactated Ringer's
1000 mL. Rate: 125 mL/hour.
Lactulose
For constipation. 30 mL 3X daily.
Lorazepam
2 mg q4h PRN. IVP.
Oral. 4 mg q4h PRN.
Morphine Sulfate
4 mg qh PRN. IVP. If pain is not adequately controlled.
Morphine Sulfate (Immediate Release).
40 mg q2h PRN, oral.
Sodium Chloride flush
2 mL, IVP.
Active orders
Consult social services
Diet - Regular/Soft
Encourage turn, cough and deep breathing.
q1h.
Oral Care
q2h
Oxygen - Nasal cannula
For patient comfort and to keep sats above 90%. May titrate 1 to 4 liters.
Continuous.
Suction Oral
PRN, Comfort
Past Medical History
Benign prostatic hypertrophy: 15 years ago.
Hypertension: 20 years ago. Was taking meds but recently stopped.
Lung cancer: 2 years ago. Receiving chemo and radiation for past 2 years.
Past Surgical History
Right lobectomy. 2 years ago. Right upper and middle lobe removed due to cancerous infiltrates.
Hernia-inguinal. 20 years ago.
Groin hernia.
Lives with S/O. Does have adult children that live nearby and offer some assistance.
Family has requested home care to visit but have not been receptive to entering hospice.