Question

Ms X is a 76 year-old woman with breast cancer. She had a primary lumpectomy and recently completed her final chemotherapy treatment. She has had a poor appetite and lost 22 pounds since diagnosis. She was seen in her physician’s office earlier today with a complaint of malaise and low-grade fever. Her blood pressure on the non-operative arm was 90/50 and pulse was 110 and irregular. She has complained of intermittent diarrhea over the past few days. Upon ambulation, you note that she is a bit unsteady. She did not seek medical attention earlier because she knew she had an appointment scheduled today. Her ambulatory complete blood count (CBC) revealed WBC 2,000 cells/ cu mm. Differential included segs 46%, bands 1%, lymphocytes 16%, monocytes 15% and eosinophils 5%. Ms. X’s physician decided to admit her to the hospital and she comes to your unit.

What are your primary nursing diagnoses and what intervention would you institute?

Which of her lab results are significant and require interventions?

What safety concerns are present?

Which teaching issues should be addressed?

Answer 1

Nursing diagnosis:

I. High risk for infection

Nursing intervention;

1.insist on property hand hygiene

2.advice on vacation

3. Special precautions during invasive procedure

4. Restrict visitation

5. Use soft bristle

6.advice electric razor for shaving

Lab results:

1.Leucopenia

2.Elevated differential counts

Safety concern

1. Infection preventing

2. Well hesitated room

3. Use size rails during sleeping

4.removed obstacles on pathway

5. Use assistive device during ambulance

Teaching:

1.Safety precautions

2. Vitamin c rich diet

3. Avoid raw fruits and vegetables

4. Proper hand hygiene

5. Use soft bristle while brushing