Health Assessment

LC is a 65 y/o caucasian female diagnosed with small cell carcinoma of lung. Introduced self to patient, explained assessment procedure to patient. Patient awake alert, oriented x 3, pleasant and follows commands. PERL, mucus membranes pale, lips dry and cracked. Multiple small bruises on bilateral arms and on legs. No further skin breakdown observed. Port-a-cath left upper chest under skin, no redness around site, port is not accessed at this time. No JVD observed. Patient states she has been coughing up small amounts of blood, lungs with bilateral crackers and diminished sounds in left lower lobe of lung. Respirations unlabored 18 rpm, no use of accessory muscles.Patient states she has to use 2 pillows at night to sleep. Oxygen @ 2L per nasal cannula, patient wears 24/7. Heart rate and rhythm regular, S1/S2 auscultated, apical pulse 68, no gallops noted, no murmurs auscultated. Abdomen soft, nontender to palpation, scar from belly button to pelvis (patient has history of C-section and hysterectomy), Bowel sounds present and active x 4 quadrants, patient states that last BM was normal earlier this AM. Patient states that she has frequent nausea and vomiting. Patient voiding without difficulty, at times has stress incontinence. Urine dark. No edema observed. Patient moves all extremities with weakness bilaterally. Patient's gait unsteady, states she just doesn't have good balance. Patient walks with cane. Patient walks less than 50 feet and becomes short of breath. Education given on signs and symptoms of dehydration and the need to increase fluid intake and notify doctor if unable to void. Patient verbalizes understanding.