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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
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Problem
Risk for infection
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Long Term:
Client will
remain free from symptoms of infection as measured by WBC within normal limits to
be evaluated before 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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Client remained free from symptoms of infection as noted
by the WBC count of 6.0. Goal met.
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Charted the WBC as a 6.0 and reported to oncoming nurse.
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Risk factors: immunosuppression; invasive procedures tissue destruction
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Short Term:
Client will demonstrate appropriate care of infection-prone
site to be evaluated by end of shift
on [date] at 1430.
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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).
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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.
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Used sterile technique
while changing dressing and demonstrated apporpriate care of site.
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