Palliative NP Consult:

Patient Information: - Mrs. Evelyn Reed, 82, Female, 12/03/1942, Metastatic Breast Cancer - 1 November 2024, 10:00 AM - Patient's Home Situation/ Reason for Consult: Patient experiencing increased pain, shortness of breath, and decreased appetite. Background: Patient reports increasing pain in her back and chest over the past week. She also reports feeling more short of breath with minimal exertion. Past medical history includes hypertension, osteoarthritis, and a history of breast cancer diagnosed in 2018. She had a mastectomy and completed chemotherapy and radiation. Usual GP: Dr. Eleanor Vance. Next appointment with oncologist on 15 November 2024. Medications: Morphine 10mg PO q4h prn pain, Lisinopril 10mg daily, Vitamin D 1000 IU daily. Allergies: No allergies identified on documentation: please confirm -Preferred Pharmacy: Main Street Pharmacy Psychosocial/ Carer: Patient lives with her husband, who is her primary caregiver. She has two adult children who live nearby and provide additional support. Patient reports feeling anxious about her symptoms and the progression of her illness. Advanced Care Directive: No current ACD identified on documentation: please confirm Please confirm MPOA, EPOA, MTDM, Will. Palliative Care Plan: Goals of care: To improve pain control, manage symptoms, and maintain quality of life. Ceiling of care: Comfort care. Preferred place of care: Home. Preferred place of death: Home. Community Palliative Care Plan - Follow-up home visit in 2 days. Review pain management plan. Contact social worker for support services. Assessment: Summary of the patient's condition and prognosis: Patient is experiencing worsening symptoms related to metastatic breast cancer. Prognosis is guarded. Primary and secondary diagnoses: Metastatic breast cancer, pain, shortness of breath, decreased appetite. Prioritization of patient care needs and important aspects of care or follow up voiced by care team: Pain management, symptom control, and emotional support. Palliative Performance Scale (PPS) score, RUN-PC triage, PCOC: APKS, RUG-ADL, PSS: PPS 40% - Nursing diagnosis or identified needs based on the subjective and objective data: Acute pain, impaired gas exchange, imbalanced nutrition, anxiety. Subjective: - Patient’s verbalized concerns or symptoms: Reports increased pain, shortness of breath, and loss of appetite. - Patient’s description of pain or discomfort: Pain is located in her back and chest, described as a sharp, 7/10 in intensity, and constant. - Any expressed concerns about treatment, care, continuity, or the healthcare environment: Patient expresses concern about her pain control and the ability to remain at home. - Patient’s and family’s understanding of the diagnosis, treatment plan, and care needs: Patient and family understand the diagnosis and are aware of the palliative care plan. Objective: - General appearance and overall condition: Appears weak and fatigued. Patient is in some distress. - Vitals signs: BP 130/80, HR 90, RR 24, Temp 37.0 C, Oxygen Saturation 90% on room air. - Physical assessment findings: Lungs: diminished breath sounds bilaterally. Abdomen: soft, non-tender. Skin: Warm and dry. Edema: None noted. - Palliative Review of Systems: Pain assessment, interventions, and effectiveness: Pain 7/10, Morphine 10mg given. Reassess in 30 minutes. Nausea assessment, interventions, and effectiveness: No nausea reported. Shortness of breath assessment, interventions, and effectiveness: Shortness of breath present. Oxygen administered at 2L via nasal cannula. Patient reports some relief. Mood assessment, interventions, and effectiveness: Patient appears anxious. Encouraged to discuss feelings. Appetite assessment, interventions, and effectiveness: Decreased appetite. Offered small, frequent meals. Functional status assessment, interventions, and effectiveness: Patient requires assistance with all activities of daily living. Bowel movements assessment, interventions, and effectiveness: Bowel movement yesterday. No constipation reported. Bladder function assessment, interventions, and effectiveness: Continent. - Results of any Laboratory and imaging results or monitoring: No recent labs available. - Review of medical chart for recent lab results, diagnostic tests, orders, and medication changes: Review of chart indicates no recent changes. Interventions: - Specific nursing interventions performed or initiated during the shift, including administration of medications, treatments, patient education provided, coordination of care, etc.: Administered Morphine, provided oxygen, assessed pain and respiratory status, provided emotional support. - Response to interventions: Patient reports some relief of pain and shortness of breath. Additional Notes: - Any patient or family education provided, including discharge planning or instructions for home care: Educated patient and family on pain management, oxygen use, and symptom management. - Communication with patient and family about care decisions, concerns, and preferences: Discussed goals of care and patient preferences. - Any safety concerns or incidents reported: None reported. Evaluation: - Evaluation of patient’s response to interventions and progress towards care goals: Patient's pain and shortness of breath improved with interventions. - Any changes in patient status or findings: Patient's condition remains stable. Plan: Treatment plan, including medications, therapies, and other interventions: Continue Morphine as prescribed. Continue oxygen therapy. Encourage small, frequent meals. Goals of care and advance care planning: Continue to focus on comfort care and symptom management. Review advance care plan at next visit. Follow-up plans and referrals: Schedule follow-up home visit in 2 days. Referral to social worker for support services. Patient and family education and support provided: Provided education on pain management, oxygen use, and symptom management. - Care plan adjustments or interventions planned, including medication administration, wound care, mobility assistance, patient education: Adjust pain medication as needed. Continue to monitor respiratory status. - Scheduled procedures or tests: None scheduled. - Collaboration with other healthcare team members: Communicate with Dr. Vance regarding patient's condition and plan of care.