Cancer Evolving Case Study Part 2
Two weeks after the patient received chemotherapy. The patient feels so tired and weak she has a hard
time getting out of bed each day. The HCP orders blood work and admits the patient to the hospital.
Allergies: NKDA
Vital Signs:
Temperature 100.8, pulse 112, Resp 24, BP 102/60, 92% RA
Present Data: Pt. was newly diagnosed with Diffuse Large B Cell Non-Hodgkin’s Lymphoma. Status Post
chemotherapy 2 weeks ago.
Past Medical History: Uneventful
Social History: Pt. is married for 20 years and has a son in high school. Pt. works as an accountant.
Which data from the present data and histories is relevant and has clinical significance to the nurse?
Assessment:
General appearance: Resting in bed, eyes closed, pale in appearance
Respiratory: Breath sounds clear bilateral, nonlabored respiratory effort
Cardiac: Capillary refill less than 2 seconds, bilateral hands, no edema, heart sounds regular, radial and
pedal pulses present and strong
Neuro: Lethargic drowsy, and alert and oriented x4
GI: Abdomen soft and non-tender positive bowel sounds x 4. Pt had a BM yesterday evening.
GU: Pt. voids without difficulty, “burning” with urination
Skin: Intact and dry, Port dressing dry intact
CBC:
WBC 0.8
HGB 8.2
HCT 28
PLT 24,000
ANC 450
