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Mr. Johnson is a 60-year-old African American construction worker who is seen in the physician’s office with complaints of dull chest pain, shortness of breath, swelling of his hands and feet, weight loss, fatigue, and weakness. On physical assessment, vital signs are temperature 99.8°F, pulse 84, respirations 24, blood pressure 168/92. His height is 5′11″ and weight is 175 pounds. Mr. Johnson states this is a loss of 35 pounds during the past 3 months. Wheezing is heard when breath sounds are auscultated. Coughing is noted with deep breathing. The remainder of the physical assessment is unremarkable. He has a medical history of high blood pressure for which he takes diltiazem and ramipril. He has a history of smoking one to two packs of cigarettes a day since he was 15 years old. He states he has been exposed to asbestos in his employment. Mr. Johnson’s nutrition assessment indicates that his diet consists of fried meats (especially chicken), green vegetables cooked in fatback, eggs and bacon for breakfast, and at breaktime he eats doughnuts or cookies. His fluid intake consists of coffee for breakfast and breaktime, soda at lunch, and three to four beers at night.
Blood is drawn for a complete blood count, electrolytes, blood glucose, calcitonin, CEA, haptoglobulin, GGT, and creatinine. A sputum specimen is sent to the laboratory. A chest x-ray and CT scan are done. Based on the results of the chest x-ray, bronchoscopy and needle aspiration biopsies are performed to confirm the diagnosis of lung cancer. The oncologist recommends an initial treatment plan of radiation therapy followed by combination chemotherapy to reduce the tumor size followed by surgical resection of the tumor.
Based on Mr. Johnson’s medical diagnosis and treatment plan, Readiness for Enhanced Therapeutic Regimen Management is identified as the priority nursing diagnosis at this time.