Pt help!!!!!!

I searched the website of the NCI and only found this information:

• National Cancer Institute http://www.cancer.gov/
  • What You Need to Know About Cancer of the Larynx http://www.cancer.gov/cancertopics/wyntk/larynx

I've had cancer 3 times. My hospitalizations related to them were for surgery, radiation therapy, and a wound infection. Oncology is a specialty of internal medicine so this patient could be hospitalized for a complication related to the cancer or the treatment for the cancer. If this patient already has a trach and a PEG tube his cancer was diagnosed and treatment for it started some time ago. The trach and PEG tube were placed because either structures in the neck were resected and removed or the patient has refused treatment and these things were placed as palliative measures when the impinging tumor blocked the airway and food pipe.

nursing diagnosing is done by use of the nursing process adapted to care planning (which is simply problem solving):

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms, pathophysiology and treatments.

• epiglottis ca scca stage 4
  
• tracheostomy
  
• peg tube
  
• foley

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data -

• pain
  
• nausea/vomiting
  
• persistent cough
  
• trouble swallowing
  
• high wbc, mcv, mch, rdw, neutrophils, calcium
  
• low rbc, lymphs

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - is this man an alcoholic? the reason i ask is because of his anemia and b-12 deficiency which might indicate liver disease going on. of course, that could also be due to metastasis.

• impaired gas exchange r/t ventilation perfusion imbalance (this man has a new trach and is coughing--they put a trach in because he was not able to breathe)
  
• ineffective airway clearance r/t excessive mucous (new trachs cause an excessive amount of secretions to be generated and they need a lot of suctioning)
  
• pain
  
• adequate nutrition -
  
• impaired physical mobility
  
• self care deficit - will need mouth care because of the trach
  
• impaired verbal communication r/t presence of tracheostomy
  
• risk for imbalanced fluid volume (i think this man has anemia)
  
• confusion (from pain meds) - how about using risk for acute confusion r/t opioid use instead
  
• risk for infection r/t inadequate immune system (presence of foley, ivs, peg tube, trach)

I think that this is going to turn into a complex patient. Collect as much data as you can find. This is probably a real sick dude. My guess is that he is probably very malnourished and he probably has metastatic disease going on. He's probably not real happy about the trach.