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Medical Diagnoses: Risk for Infection, immunosuppression, Invasive procedures and tissue destruction

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Complaints of fatigue, rectal bleeding and a change in bowel patterns (constipation alternating with diarrhea. The patient has no other significant medical history. He has smoked for most of his adult life; he has an 80 pack/year history. He admits to drinking “several” beers on the week-ends. He denies the use of drugs. The patient is divorced and has 3 independent adult children and 2 grandchildren. Recently he became engaged and plans to be married within 6 months. His father had colon cancer and died before he was

60 years of age. The patient is a plumber and works 40 hours/week. He currently lives with his fiancée. He has been upset and concerned about his health and voices concern about dying as his father did with cancer.

     

     

     

Objective

Temp 99.86

Heart Rate 83

Respirations 20

Output 400cc

Intake 0cc- NPO

Post AR surgery

Lesion on abdoment 6cmX8cm

An initial work-up revealed anemia, a carcinoembryonic antigen

(CEA) level of 22mg/dl, and a positive computerized technology (CT) scan showing a mass in the sigmoid rectal region

No family at bedside

CBC, electrolytes, BUN, creatinine, glucose-pending

Problem

Risk for infection

    

    

    



Long Term:

Client will remain free from symptoms of infection as measured by WBC within normal limits to be evaluated before  discharge.

Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). EB: The white blood cell count and the automated absolute neutrophil count are better diagnostic tests for adults and most children (Cornbleet, 2002).

    

Client remained free from symptoms of infection as noted by the WBC count of 6.0. Goal met.

Charted the WBC as a 6.0 and reported to oncoming nurse.

Risk factors: immunosuppression; invasive procedures tissue destruction

    

    

 

Short Term:

Client will demonstrate appropriate care of infection-prone site  to be evaluated by end of shift on [date] at 1430.

Use careful sterile technique wherever there is a loss of skin integrity. EB: Extensive literature search revealed that sterile gloves should be used for postoperative wound dressing changes (St. Clair & Larrabee, 2002).

    



 

Client was able to verbalize that the dressing change would stay on during hospital stay and will be taught how to change dressing on home upon discharge. Goal partially met.

Used sterile technique while changing dressing and demonstrated apporpriate care of site.

AEB

    

    

 

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