Care plan assistance requested

[NewNurse91D]

Hello all!

I am doing my care plan for my Med-Surg clinical rotation and I've picked a pt.

It's kind of a unique pt. and I guess I'm just looking for a little bit of guidance or reassurance that I'm in the right direction before I get really in depth with my care plan.

My pt. is a 61yo M.

He was admin. with "altered mental status and agitation"

He has a h/x: HTN, high cholesterol, DM (type 2), DVT/PE. He also has malignant neoplasm of brain (he has a brain tumor). It was also given to me in report that he had h/x "Heart Disease" but I'm not too sure what that means.

He was d/x with the brain tumor in August & declined any treatment/surgery at that time and soon it matasisized to his whole body & the tumor is now inoperable. He has been in the hospital for a few days, and from talking with the nurse and his wife, since the worsening of the cancer-his personality and mental status has changed dramatically. He has been confused, agitated, disorientated, etc for a while now. These s/s recently worsened, which was why his wife admitted him to the hospital.

He is able to walk (with assistance, but doesn't use any assistive devices).

His labs, VS, glucose readings are all over the place (r/t his tumor according to the nurse).

My assessment:

VS: 96.4 (Orally)- 87bpm- resp. 20-96% pulse ox (on RA). His apical pulse was 120bpm.

I took his finger stick myself and it was 303. But according to the nurse, that has been his pattern.

He was oriented to himself only (unable to recognize family/facility personnel/etc),

has severe aphasia, no difficultly swallowing. He was extremely restless, agitated. His pupils were very slow to react to pen light (they BARLEY constricted at all and is was very sluggish) & he has very little peripheral vision & his gaze appeared very unfocused.

Both hands had involuntary tremors. When I did the hand grips-he was able to take the cue and grabbed both of my hands, but when I asked him to squeeze my hands, he swung them outward instead of squeezing them.

He has edema in his RLE, non-pitting.

Radial & pedal pulses all present bilaterally. No heart sound abnormalities. Lung sounds-clear in all lobes; no SOB or c/o cough. No c/o chest pain.

He c/o 0 out of 10 pain. Bowel sounds active x4 quads. No c/o tenderness. Abdomen is non-distended and non-tender. No issues with constipation/diarrhea. Last BM yesterday. No c/o burning, urgency, etc with urinating. He has rare periods of incontinence and uses the bathroom.

He has periods of crying and 'picks' at his skin & IV site. His skin is in good condition, no h/x bedsores. He does have a few scars/cuts on both calfs-r/t recent falls (according to wife).

Labs:

3+ glucose in urine,2+ protein in urine.

Gran. & Eos. were low. Creatinine was high.

I have all of his other labs but because this post has turned into a novel, I wont include them all because all of his other labs appear to be WNL.

My thought process:

Possible d/x:

1: "Impaired environmental interpretation syndrome"

2: "Ineffective health maintenance"

I'm currently working on my r/t and AEB for them BUT I just wanted to throw my assessment out there to see if anybody see's something I don't or maybe has a question that could help me see something that I might not be seeing.

Because my pt. doesn't want any treatment for his cancer and is in end-stage, my focus is mainly on what is going on 'now' with him and what I can do to make what I can better for him (which is why I'm looking at the d/x I listed above).

Thank you to anyone who responds & hope to hear back soon !

Sorry for the novel -_- lol