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

The nursing diagnosis for the patient are as follows :

1. Imbalanced nutrition less than body requirement related to chemotherapy treatment as evidenced patient verbalise loss of appetite

2. Risk for fluid volume deficit related to diarrhea

3. Risk for injury related to hypotension induced dizziness

4. Fatigue related to weightloss as evidenced by chemotherapy treatment and loss of appetite

The interventions which could be done are as follws:

* Monitoring the vital signs

* maintain intake and output chart

* assist the patient to mobile and during walk to prevent falls and injuries

* provide small and frequent diet to improve the nutritional status

* provide adequate rest to reduce malaise

* provide fluids to improve fluid status

* provide vitamin c rich foods to boost up the immunity and to reduce the infection and promote wound healing

The lab reports such as WBC and differential counts has to be takeb into consideration wereby it is sign of infection and low immunity

The safety concerns present are vulnerable for other infections, complications and malnutrition with hypovolemic shock.

The teaching should consider:

* importance of nutrition

* maintenance of fluid balance

* vitamin supplemnts

* drug compliance and the follow up care.