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

Assessment Nursing DX/Clinical Problem Problem Risk for infection Client Goals/Desired Outcomes/Objectives Long Term: Client will remain free from symptoms of infection as measured by WBC within normal limits to be evaluated before discharge. Nursing Interventions/Actions/Orders andRationale 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). 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). *I Evaluation Goals Client remained free from symptoms of infection as noted by the WBC count of 6.0. Goal met. Interventions Charted the WBC as a 6.0 and reported to oncoming nurse.

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 weekends. 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 fiance. He has been upset and concerned about his health and voices concern about dying as his father did with cancer.

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.

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

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