Patient R.E. 2 year old female
by Amanda Reid
1. chest port removed, patient started on antibiotics
2. peri-orbital cellulitis from pseudomonas infection in chest port
3. Sepsis related to infected chest port
4. Porta-cath inserted
5. Febrile Neutropenia
6. Nursing Interventions
6.1. Most important is education focusing on adequate oral intake, proper nutrition and hand hygiene to prevent spread of infection
6.1.1. monitor infected port site on R chest
6.1.2. Maintain patent IV sites and monitor for signs of infection
6.1.3. Obtain bloodwork to monitor for signs of infection and pseudumonas
6.1.4. Keep patient comfortable and assist with ADL's
7. Medications
7.1. 2mg oral morphine
7.2. 1548mg Piperacillin-Tazobactam
7.3. 200mg oral Imatinib
8. Patient History
8.1. Philadelphia Chromosome positive acute lymphoblastic leukemia (Ph+ALL) - December 2018
9. Diagnosis
9.1. Sepsis
9.1.1. Pseudomonas infection in chest port and left eye
10. Diagnostic Tests
10.1. Nursing Intervention: Lubricate the distal portion of the catheter before insertion Rationale: Decrease friction to facilitate catheter insertion (Potter & Perry, 2015)
10.2. Nursing Intervention: Ask client to bear down prior to insertion of catheter Rationale: Release of tension in urethral sphincter & pelvic floor muscles aids in catheter insertion. (Potter & Perry, 2015)
10.3. Nursing Intervention: Select appropriate size of catheter for patient. Rationale: Prevent damage to urethra and client pain upon insertion. (Potter & Perry, 2015)
10.4. Nursing Intervention: Once urine is flowing, advance the catheter an additional 2.5-5cm before inflating the balloon. Rationale: Prevents trauma to urethra and ensures balloon placement in bladder (Potter & Perry, 2015)
10.5. Nursing Intervention: Wipe perineal area of any remaining lubricant and return client to a comfortable position. Rationale: Avoid irritation of perineal skin. (Potter & Perry, 2015)
10.6. Nursing Intervention: Position client in supine position with legs spread and feet together. Rationale: Comfortable position for client, reduces muscle tension and allows nurse to visualize the urethra. (Potter & Perry, 2015)
