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Assessment
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Nursing DX/Clinical
Problem
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Client Goals/Desired
Outcomes/Objectives
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Nursing Interventions/Actions/Orders
and Rationale
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*I
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Evaluation
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Subjective
Unable to gather information- did not assess patient.
Objective
Unable to gather information- did not assess patient.
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Problem
Risk for infection
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Long Term:
Client will remain free of infection until discharge.
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Observe and report
signs of infection such as redness, warmth, discharge, and increased body temperature.
EB: Prospective surveillance study for nosocomial infection
on hematology-oncology units should include fever of unknown origin as the single
most common and clinically important entity (Engelhart et al, 2002).
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Unable to evaluate-
did not care for patient.
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Unable to evaluate-
did not care for patient.
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R/T
Chronic disease and
inadequate secondary defenses.
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Short Term:
Client will maintain
white blood cell count and differential within normal limits until discharge.
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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).
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Unable to evaluate-
did not care for patient.
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Unable to evaluate-
did not care for patient.
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