Severe cases of cellulitis may not respond to oral antibiotics. Assessing pain before, during, and after the dressing change may provide vital information for further wound management and dressing selection. Dressings that cover/ compliment primary dressings and support the surrounding skin. Place Your Order to Get Custom-Written Paper. https://digital.nhs.uk/catalogue/PUB19124 [Accessed 9 April 2017]. Applying an antibiotic ointment on your wounds or sores. We cannot define the best treatment for cellulitis and most recommendations are made on single trials. Specific situations, such as infections associated with human or animal bites, may require broader spectrum antimicrobial cover and should be discussed with an infection specialist, as should cellulitis involving atypical sites such as the face, torso and upper limb. Cleveland Clinic Children's is dedicated to the medical, surgical and rehabilitative care of infants, children and adolescents. MHF4U is a grade 12 mathematics course in Ontario, Canada, and it covers advanced functions. Two authors independently assessed trial quality and extracted data. Nursing management for Cellulitis Assess for pain, noting quality, characteristics, location, swelling, redness, increased body temperature. We are not able to define the best treatment for cellulitis and our limited conclusions are mostly based on single trials. Nursing Interventions Relieving Pain Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed. Nursing outcomes ad goals for people at risk of cellulitis. Cellulitis presents as redness and swelling initially. I present the illustration to differentiate between normal skin and skin affected by cellulitis. Pat dry the area gently with a piece of clean cloth. We had insufficient data to give meaningful results for adverse events. Scratching the skin and rubbing it in response to the itchiness makes the irritation to the skin to increase. The patient will prevent the spread of infection to the rest of the bodyby following a treatment regimen for cellulitis. The goal of wound management: to clean debris and prevent infection. Samples should be sent for bacterial culture and consideration given to systemic antibiotics in patients with systemic signs of infection.12, Non-purulent skin and soft tissue infections generally require treatment with systemic antimicrobials. WebCellulitis affects structures that are deeper than areas affected by impetigo or erysipelas. Select personal protective equipment (PPE) where appropriate. The skin is the bodys largest organ and is responsible for protection, sensation, thermoregulation, metabolism, excretion and cosmetic. is an expectation that all aspects of wound care, including assessment,
Poorly managed wounds are one of the
These contents are not intended to be used as a substitute for professional medical advice or practice guidelines. Wound management follow up should be arranged with families prior to discharge (e.g. However, Streptococcus (strep) and Staphylococcus (staph) cause most cases of cellulitis. Cellulitis and erysipelas are now usually considered manifestations of the same condition, a skin infection associated with severe pain and systemic symptoms. Order Now, NURSING CARE PLAN FOR DIABETES MELLITUS 4, Who can do my nursing assignment in United States of America. The read-only self-assessment questionnaire (SAQ) can be found after the CME section in each edition of Clinical Medicine. Desired Nursing outcomes and goals for risk of infection related to cellulitis. Elsevier Health Sciences. WebPediculosis Capitis (Head Lice) NCLEX Review and Nursing Care Plans Pediculosis capitis, commonly known as head lice, is a common contagious infection due to human head lice. Ignatavicius, D., Workman, M., Blair, M., Rebar, C., & Winkleman, C. (2016). Assist patient to ambulate to obtain some pain relief. 2. Who can do my nursing assignment in USA ? Assess the surrounding skin (peri wound) for the following: Pain is an essential indicator of poor wound healing and should not be underestimated. WebThe goal of wound management: to stop bleeding. Cellulitis is a bacterial infection that occurs when bacteria enter a wound area without skin. The fastest way to get rid of cellulitis is to take your full course of antibiotics. We are going to prepare FIVE nursing care plans and diagnoses for patients with Cellulitis, namely: Nursing diagnosis: Impaired skin integrity linked to infection of the skin ancillary to cellulitis as shown by erythema, warmness, and swelling of the infected leg. It most commonly affects the lower part of your body, including your legs, feet and toes. This will ensure the healthcare teams have the information to deliver safe and effective patient care for cellulitis infections. Assess the skin. The SEWS is a standardised form of early warning score, calculated from the patient's routine clinical observations, with a threshold score of 4 selected to indicate the most severely unwell patients (class IV) in whom a clinical review was mandated at the site where the study was undertaken. We do not endorse non-Cleveland Clinic products or services. The company was founded in 1985 by Are you Seeking online help with a Physics project? Cleaning your wounds or sores with antibacterial soap and water. Washing under a shower may be appropriate after carefully considering the risks associated with contamination from pathogenic microorganisms, Surfactants or antiseptics for biofilm or infected wounds e.g. Cellulitis is a common painful skin infection, usually bacterial, that may require hospitalisation in severe cases. NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). healing. If I dont have cellulitis, what other condition might I have? This nursing care plan we are developing will increase the patients knowledge of preventive measures, treatment plans, and nursing interventions that will help alleviate the cellulitis infection and relieve pain. To analyze the effectiveness of interventions and to offer patient-centered care. I have listed the following factors that predispose individuals to cellulitis, A weak immune system allows bacteria to easily lodge in a person who is unable to fight off the infection, People with breaks in the skin, such as athlete's foot and eczema, provide points of entry for cellulitis-causing bacteria, Intravenous drug use also provides a break in the skin that could be an entry point for pathogens, Patients living with diabetes have sluggish wound healing, and extended exposure to wounds predisposes them to bacterial infections, History of cellulitis in the family or the patient, Lymphedema, a chronic localized swelling of the upper and lower extremities, Widespread tissue damage and tissue death( gangrene), Infection can spread to other body parts such as blood, bones, lymph system, heart, and nervous system, leading to shock and sometimes death ( sepsis), Septic shock-untreated cellulitis can cause unwarranted stress to body organs, causing numerous organ failure, Meningitis is an infection of the exterior cover of the brain. Nursing care plans: Diagnoses, interventions, and outcomes. Nursing Care Plan Goal. Do this gently as part You may also check nursing diagnosis for Cellulitis. Covering your skin will help it heal. Pain assessment and measurement guideline. Diverticulitis Pathophysiology for nursing students and nursing school, 20 NANDA nursing diagnosis for Chronic Kidney Disease (CKD), 5 Stages of Bone Healing Process |Fracture classification |5 Ps, 19 NANDA Nursing Diagnosis for Fracture |Nursing Priorities & Management, 25 NANDA Nursing Diagnosis for Breast Cancer, 9 NANDA nursing diagnosis for Cellulitis |Management |Patho |Pt education, Trauma, surgical incision, thermal injury, insect bites. Dundee classification markers of sepsis, Marwick et al used the Dundee criteria to grade severity and then assessed the appropriateness of the prescribed antimicrobial regimens.17 They found significant overtreatment of skin and soft tissue infections (SSTIs) (both in terms of spectrum and route of antimicrobial) particularly in the lowest severity group, where 65% of patients were deemed to have been over treated. Join NURSING.com to watch the full lesson now. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Moisture/ exudate is an essential part of the healing process. To help prevent cellulitis and other infections, take these precautions when you have a skin wound: Wash the wound daily with soap and water. Nursing interventions are centered on an antibiotic regimen while practicing proper wound care to prevent complications. By using any content on this website, you agree never to hold us legally liable for damages, harm, loss, or misinformation. WebNursing intervention care for patients at risk of cellulitis. I recommend the following nursing interventions in the tables below to reduce the risk of cellulitis. impaired skin integrity linked to infection of the skin ancillary to cellulitis, as shown by erythema, warmness, and swelling of the infected leg. Making the correct diagnosis is key to management. A warm compress, elevation, compression and NSAIDs also help relieve your symptoms. wound dehydration or maceration), Medications (including immunotherapy, chemotherapy, radiation or NSAIDs), Mental health (including stress, anxiety or depression), Patient knowledge, understanding or compliance, Frequency of dressing changes is led by the treating team or indicated by product manufacturers, Consider less frequent dressing changes in the paediatric population to promote wound healing and prevent unnecessary pain and trauma, It is advised that wounds are reviewed at least every 7 days to monitor wound healing and reassess goals of wound management. There was no significant difference in antimicrobial therapy or treatment outcomes between class I and II severity patients, suggesting that these two groups could be merged, further simplifying the classification. This review looks at interventions for the skin infections 'cellulitis' and 'erysipelas'. It appears as a reddened, swollen area of the skin and is usually easily diagnosable through inspection. Antibiotics given by injection into a muscle were as effective as when given into a vein, with a lower incidence of adverse events. Symptoms have reduced, finishing the antibiotics will prevent the recurrence of infection and antibiotic resistance. Hinkle, J., & Cheever, K. (2018). Our writers have earned advanced degrees If you are still unable to access the content you require, please let us know through the 'Contact us' page. Getting medical attention right away for any deep cuts or puncture wounds. That Time I Dropped Out of Nursing School, 5 Steps to Writing a (kick ass) Nursing Care Plan, Dear Other Guys, Stop Scamming Nursing Students, The S.O.C.K. Discoloration (red, purple or slightly darker than your usual skin color) that may look like a rash. Ensure cleansing solutions are at body temperature. However, we aim to publish precise and current information. Cochrane Database of Systematic Reviews 2010, Issue 6. DOI: 10.1002/14651858.CD004299.pub2. As a nurse, I will assess subjective and objective data when assessing the patient for disease risk. Ongoing multidisciplinary assessment, clinical decision-making, intervention, and documentation must occur to facilitate optimal wound healing. Jones & Bartlett Learning. Use warm water and mild soap, The infected areas must remain clean at all times to promote healing, Encourage patient to stop itching affected skin areas, To avoid worsening the skin inflammation even further, Educate the patient on appropriate hand hygiene and cut their fingernails if they are long, Long fingernails harbor bacteria which are a risk for infections, Use skin indicators to mark the affected skin areas and check for reduction or spread of infection, To determine the effectiveness of interventions particularly the antibiotic energy and if there is need to change, Educate the patient on signs of a deteriorating infection. Careful clinical examination may reveal a portal of entry such as ulcers, trauma, eczema or cutaneous mycosis.5 The finding of bilateral lower limb erythema in an afebrile patient with normal inflammatory markers should prompt the clinician to reconsider the diagnosis of cellulitis.8 Systemic features and groin pain are common and may predate the onset of skin changes.5 Skin breaks, bullae or areas of necrotic tissue may be present in severe cellulitis. Cellulitis causes swelling and pain. The bacteria that cause cellulitis are. Parkville EMR | Nursing Documenting Wound Assessments (phs.org.au). Patient establishes healthy skin integrity after treatment regimen for cellulitis, I recommend the following nursing interventions in the table below to reduce the risk of. There are many online courses available that offer MHF4U as a part of their curriculum. Cellulitis is a bacterial subcutaneous skin infection. Perform hand hygiene and change gloves if required, 14. They produce a variety of products such as jams, jellies, marmalades, sauces, condiments, teas, and other gourmet foods. Educate the patient on proper skin hygiene and proper hand hygiene using water and mild soap, This helps maintain the cleanliness of the affected area and this promotes healing, Encourage the patient not to scratch affected areas and trim their fingernails if they are long, Long fingernails harbor bacteria and scratching can worsen skin inflammations, Use skin markers to mark the boundaries of the cellulitis area and observe for decrease or spread, To check the effectiveness of antibiotics and need to change if no changes are observed prevent prevent, Prevent shearing or further irritation especially if the patient is immobile and unable to guard against more skin breakdown, Be careful when repositioning the patient if they are immobile, To ensure they are not putting pressure on affected area worsening health outcomes. The following are the patient goals and anticipated outcomes for patients with Cellulitis. In cases of skin breaks, keep the area clean, use over-the-counter antibiotic creams, and watch out for signs of infection. Nursing intervention care for patients at risk of cellulitis. Nursing Care Plan and Diagnosis for Cellulitis Ineffective Hospital Episode Statistics for England 201415, Mandell, Douglas, and Bennett's principles and practice of infectious diseases, Use of cultures in cellulitis: when, how, and why, Erysipelas, a large retrospective study of aetiology and clinical presentation, Erysipelas: clinical and bacteriologic spectrum and serological aspects, Improvement of a clinical score for necrotizing fasciitis: Pain out of proportion and high CRP levels aid the diagnosis, Distinguishing cellulitis from its mimics, Risk factors for erysipelas of the leg (cellulitis): case-control study, Risk factors for acute cellulitis of the lower limb: a prospective case-control study, Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples, Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America, Costs and consequences associated with misdiagnosed lower extremity cellulitis, Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care, Managing skin and soft tissue infections: expert panel recommendations on key decision points, Guidelines on the management of cellulitis in adults, Severity assessment of skin and soft tissue infections: cohort study of management and outcomes for hospitalized patients, A predictive model for diagnosis of lower extremity cellulitis: A cross-sectional study, National Institute for Health and Care Excellence, Sepsis: recognition, diagnosis and early management, Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial, Flucloxacillin alone or combined with benzylpenicillin to treat lower limb cellulitis: a randomised controlled trial, Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis, Early response in cellulitis: A prospective study of dynamics and predictors, Gilchrist DM. Cellulitis is an infection that occurs when bacteria enter the skin, causing a dented appearance attributed to fatty deposits. I will assess the patient for high fever and chills. Daily review and early switch to oral therapies is optimal, In patients with recurrent episodes of cellulitis, risk factors should be addressed and consideration given to prophylaxis. We selected randomised controlled trials comparing two or more different interventions for cellulitis. Many more cases are treated in primary care.1, Gram-positive cocci such as Streptococcus spp and Staphylococcus aureus are thought to be the predominant cause of cellulitis.2, Positive blood cultures are found in less than 10% of cases. Referrals to the Stomal Therapy, Plastic Surgery, Specialist Clinics or Allied Health teams (via an EMR referral order) may also be necessary for appropriate management and dressing selection, to optimise wound
The expected nursing goals and outcomes for the individual are: Nursing assessment and diagnosis for risk for infection. In 20145, cellulitis was listed as a primary diagnosis for 114,190 completed consultant episodes in secondary care and 75,838 inpatient admissions with a median length of stay of 3days with a mean patient age of 63. WebPack the wound with saline-soaked dressings and a bandage WOUND CARE Your surgical wound may need to be cleaned and the dressing changed on a regular basis. WebAnyone can get cellulitis, but the risk is higher if you have a skin wound that allows bacteria to enter your body easily or a weakened immune system. 1 Between 13.9% and 17% 1-3 of patients seen in the ED with cellulitis are admitted, accounting for 10% of all infectious disease-related US hospitalizations. The bacteria could spread to your bloodstream (bacteremia) or heart (endocarditis), which may be fatal. Unlike many contagious bacterial infections, we must note thatcellulitis is not infectious and cannot be spread from person to person. EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 10th Floor, Southern House, Wellesley Grove, Croydon, CR0 1XG. Risk for infection related to a decrease in immune function, non-adherence to antibiotic treatment, broken skin barriers, chronic illnesses, malnutrition, and poor hygiene practices. However, if cellulitis is left untreated it can cause life-threatening complications such as sepsis. Most cases of uncomplicated cellulitis are traditionally treated with 12weeks of antimicrobial therapy.15However, evidence now exists to suggest that such prolonged courses may be unnecessary, and that 5days treatment may be sufficient in cases of uncomplicated cellulitis.26 Provided there are no concerns about absorption and there has been some clinical improvement, most patients with uncomplicated SSTIs can be safely switched to oral antibiotics after 14days of parenteral therapy.15,16 The CREST guidance suggests settling pyrexia, stable comorbidities, less intense erythema and falling inflammatory markers as criteria for an oral switch.16 Any predisposing factors (eg tinea pedis, lymphoedema etc) should be addressed to reduce the risk of recurrent cellulitis. It is essential for optimal healing to address these factors. These findings suggest the currently used severity scoring system is not a robust means of guiding empirical therapy. Pain out of proportion to the clinical signs, in particular, if accompanied by a history of rapid progression should prompt consideration of a necrotising fasciitis.7 Timing and evolution of the skin findings may differentiate cellulitis from some of the common mimics with more chronic clinical course. Kilburn SA, Featherstone P, Higgins B, Brindle R. Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas. A range of antibiotic treatments are suggested in guidelines. As a nurse, I will assess subjective and objective data when assessing the patient for disease risk. Accurate assessment of pain is essential when selecting dressings to prevent unnecessary pain, fear and anxiety associated with dressing changes. The following are the patient goals and anticipated outcomes for patients with impaired skin integrity linked to infection of the skin ancillary to cellulitis, as shown by erythema, warmness, and swelling of the infected leg. The affected skin is usually inflamed and swollen and is warm and painful even to the touch. Art. Most people feel better after seven to 10 days. Clinical images are a valuable assessment tool that should be utilised to track the progress of wound management. It can be described as: If any of the above clinical indicators are present (including fever, pain, discharge or cellulitis) a medical review should be initiated and consider a Microscopy & Culture Wound Swab (MCS). Thirty day mortality and undertreatment increased with the class of disease severity, from 1% mortality and 14% undertreatment in the class I severity group to 33% mortality and 92% undertreatment in the class IV severity group. I will evaluate any ultrasound, CT scans, and MRI results to detect abscesses, The patient should show opportune healing of wounds without any problems, Patient should be able to preserve ideal diet and physical well being, Person should partake in prevention measures and treatment programs, Patient should articulate feelings of increased self-esteem. Hospital in the Home, Specialist Clinics or GP follow up). Hypertension (HTN) is a chronic disease that requires long-term, I must conduct nursing assessments with the knowledge of the several risk factors which make the individual more susceptible to other infections, such as chronic illnesses and compromised immune systems. This merits further study. Carpenito, L. J. They include; The following is an illustration of cellulitis infection on the legs. Monitor pain closely and report promptly increases in severity. For simplicity we used the one term 'cellulitis' to refer to both conditions. Cellulitis risk factors include:Advertisementsif(typeof ez_ad_units != 'undefined'){ez_ad_units.push([[300,250],'nurseship_com-leader-4','ezslot_10',642,'0','0'])};__ez_fad_position('div-gpt-ad-nurseship_com-leader-4-0'); Usually, the prognosis of cellulitis is good when treated early stages. Royal College of Physicians 2018. I must conduct nursing assessments with the knowledge that, cellulitis infections sometimes look like common skin infections, I will assess the patient's medical history to identify the presence of comorbid illnesses that may increase the risk of cellulitis. Mild cellulitis is treated as an outpatient with oral penicillin. Cleaning and trimming your fingernails and toenails. Clean and assess the wound (wound and peri wound should be cleaned separately if washing the patient), 9. skin integrity linked to infection of the skin ancillary to cellulitis, as shown by erythema, warmness, and swelling of the infected leg. Our expert physicians and surgeons provide a full range of dermatologic, reconstructive and aesthetic treatments options at Cleveland Clinic. The Infectious Disease Society of America recommends hospitalization for patients with cellulitis under certain circumstances but there is little actual clinical evidence to guide the decision to admit. Intravenous third-class penicillin is also administered for severe cellulitis. It stands for Tissue, Infection or Inflammation, Moisture balance and Edges of the wound or Epithelial advancement. in nursing and other medical fields. WebWound care: This is an important part of treating cellulitis. Only two studies investigated treatments for severe cellulitis and these selected different antibiotics for their comparisons, so we cannot make firm conclusions. If the WBC and CRP continue increasing, it indicates a worsening infection. We identified 25 randomised controlled trials. I present the illustration to differentiate between normal skin and skin affected by cellulitis. You might need to undergo a blood test or other tests to help rule out other It can cause warmth, inflammation and swelling of the affected area. cavities. (https://www.ncbi.nlm.nih.gov/books/NBK303987/), Visitation, mask requirements and COVID-19 information, You have a long-lasting (chronic) skin condition such as. The nursing care plan also assists the nursing care team in developing appropriate interventions to mitigatedifficulties of impaired skin integrity linked to cellulitis. The spectrum of severity ranges from localised erythema in a systemically well patient to the rapidly spreading erythema and fulminant sepsis seen with necrotising fasciitis. RCP members and fellows (using their login details for the main RCP website) are able toaccess the full SAQ with answers and are awarded 2 CPD points upon successful (8/10) completion from:https://cme.rcplondon.ac.uk, Copyright 2021 by the Royal College of Physicians, DOI: https://doi.org/10.7861/clinmedicine.18-2-160, Sign In to Email Alerts with your Email Address, Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic oedema: a randomised controlled trial protocol, NHS Digital. The goal of wound management is to understand the different stages of wound healing and treat the wound accordingly. You may learn to do this yourself, or nurses may do it for you. Elsevier/Mosby. Cellulitis can quickly progress and lead to more severe conditions. I present the following clinical manifestations that are apparent in most cellulitis infections. This nursing care plan will provide the nursing care team with sufficiently treating impaired skin integrity related to cellulitis, ensuring the patient's well-being. Many people who get cellulitis again usually have skin conditions that dont go away without treatment, such as athletes foot or impetigo. A wound is a disruption to the integrity of the skin that leaves the body vulnerable to pain and infection. Avail bestphysics assignmenthelp, andphysics homeworkhelp from nursinghelpexperts.com and boost your grades. A new approach to the National Outcomes Registry. At NURSING.com, we believe Black Lives Matter , No Human Is Illegal , Love Is Love , Women`s Rights Are Human Rights , Science Is Real , Water Is Life , Injustice Anywhere Is A Threat To Justice Everywhere . Infections of the Skin, Muscles, and Soft Tissues. The patient must finish the dose even if the symptoms heal, Educate the patient on appropriate skin sanitation. No two trials examined the same drugs, therefore we grouped similar types of drugs together. In: Kelly A, Taylor SC, Lim HW, et al., eds. EDC. Surgical removal of the necrotized tissue is always recommended in severe forms of cellulitis affecting the bone and deep tissues. No. Advertisementsif(typeof ez_ad_units != 'undefined'){ez_ad_units.push([[250,250],'nurseship_com-leader-2','ezslot_8',662,'0','0'])};__ez_fad_position('div-gpt-ad-nurseship_com-leader-2-0');Cellulitis is most commonly caused by group A streptococci (Streptococcus pyogenes). The affected skin is usually inflamed and swollen and is warm and painful even to the touch. * Dressings not available on ward imprest/more extensive dressing supplies can be sourced in hours from
), mouth, anus, and belly. Cellulitis is most common in places (limbs)where the skin was broken before by blisters, surgical wounds, cuts, insect bites or burns. c. Stainless steel scissors that do not come into contact with the wound, body or bodily fluids can be re-used for the sole purpose of cutting that patients unused dressings. In some cases of cellulitis, the entry point may not be evident as the entry may involve minute skin changes or intrusive qualities of some infectious bacteria. Patients sensitive to penicillin are prescribed.IV Lincosomides and IV glycopeptides. Cellulitis usually affects the arms and legs. I recommend the following nursing interventions in the tables below to reduce the risk of cellulitis. We know the importance of nursing assessment in identifying factors that may increase the risk of infection. Nursing interventions are centered on an antibiotic regimen while practicing proper wound care to prevent complications. Your cellulitis infection spreads to surrounding areas of your body. Get useful, helpful and relevant health + wellness information. Washing your hands regularly with soap and warm water. These two terms are now considered different presentations of the same condition by most Sample nursing care plan for hyperthermia. Severe cellulitis is a medical emergency, and treatment must be sought promptly. No single treatment was clearly superior. However, if youve got a severe case of cellulitis, your healthcare provider may recommend tests to make sure the infection hasnt spread to other parts of your body. Last reviewed by a Cleveland Clinic medical professional on 04/18/2022. Cellulitis nursing management and patient teaching are all included. To use turmeric for leg cellulitis treatment, thoroughly mix a teaspoon of turmeric powder with 1 tablespoon of raw organic honey to make a paste. Class 1: no fever and healthy; no systemic toxicity, no comorbiditiesClass 2: fever and appears ill; systemic symptoms, stable comorbiditiesClass 3: significant toxicity; at least one unstable comorbidityClass 4: Sepsis; life-threatening condition
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