Chief Medical Diagnosis Tongue Cancer

1. Impaired Mobility *Fall risk *multiple tubes *Chemotherapy -Cisplatin 75mg/ml -5 FU 750mg/ml -Taxotere 75mg/ml -Ehtyol 740mg/ml Ineffective Coping *Ativan prn *chronic pain *difficulty speaking Chronic Pain *6/10 on pain scale for mouth and PEG site *Methadone 5mg po q 8 hrs Chief Medical Diagnosis Tongue Cancer Primary Assessment: pain, nutrition, communication/swallowing, infection Impaired Verbal Communication *tumor on tongue *missing most teeth Risk for Impaired Skin Integrity *PEG site/drainage *PICC line *Braden score 16/23 Altered Nutrition *ht 5’7” wt 104 lbs. *PEG (Jevity tube feed 60/hr) *Zofran 8mg po *Albumin serum 3.0 L *globulin 4.1 H *RBC’s 4.24 L *tube feeding (Fibersource) *A/G ratio .7 L *I & O *Folate 1mg po daily *MVI 1 tab po *Thiamine 100mg po x 3 days *MgSo4 2g (in cisplatin) *MCV 101.2 H *Nexium 40 mg po daily *Zantac 50 mg in 100 ml *Phenergan 25mg in 250ml *lost 60-65 lbs. Risk for Injury *chemotherapy (side effects/adverse reactions) -Cisplatin 75mg/ml -5 FU 750mg/ml -Taxotere 75mg/ml -Ehtyol 740mg/ml Impaired Swallowing *tumor consumes tongue *medications given through PEG Infection *WBC 13.5 H *Cipro 500mg PO bid x 11days *bands % 14 H *neutrophils 9.6 H *Lymph % 10 L *Chemo may cause (adverse reactions) -Cisplatin 75mg/ml -5 FU 750mg/ml -Taxotere 75mg/ml -Ehtyol 740mg/ml *Decadron (pre-chemo) 8mg bid Impaired Urinary Elimination *BUN/CREAT 25 H *output 700 *I & O *Mannitol 25g