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?