Medical-surgical unit after having an emergency right colectomy due to cancer
Scenario
You are the nurse caring for a 64-year-old male client who is postoperative day four on the medical-surgical unit after having an emergency right colectomy due to cancer. The client is NPO with a nasogastric (NG) tube to low intermittent suction. The client has a history of smoking and no other health problems.
Vital signs:
Temperature: 99.2° F
Heart rate: 91 beats/min
Respirations: 20 breaths/minute
O2 saturation: 93% on 2L oxygen via nasal cannula
Blood pressure: 110/68 mm Hg
Pain: "6/10"
Focused assessment findings:
Alert and oriented to person, place, and time
Moves all four extremities, refuses to ambulate
Apical pulse is regular at 91 beats/minute
Lungs clear to auscultation, diminished bilaterally
Bowel sounds hypoactive, abdomen soft, tender in all four quadrants
Midline abdominal incision well approximated with staples intact, no erythema, Penrose drain intact with scant serous drainage
Right lower quadrant Jackson-Pratt drain with sutures intact, no erythema, 30 mL of serosanguineous drainage
Instructions
Using the information from the scenario, create a care plan using the attached template.
Sample Solution
Client: 64-year-old male Diagnosis: Cancer of the right colon Surgery: Emergency right colectomy Postoperative Day: 4 Vital signs:- Temperature: 99.2° F
- Heart rate: 91 beats/min
- Respirations: 20 breaths/minute
- O2 saturation: 93% on 2L oxygen via nasal cannula
- Blood pressure: 110/68 mm Hg
- Pain: "6/10"
Full Answer Section
Focused assessment findings:- Alert and oriented to person, place, and time
- Moves all four extremities, refuses to ambulate
- Apical pulse is regular at 91 beats/minute
- Lungs clear to auscultation, diminished bilaterally
- Bowel sounds hypoactive, abdomen soft, tender in all four quadrants
- Midline abdominal incision well approximated with staples intact, no erythema, Penrose drain intact with scant serous drainage
- Right lower quadrant Jackson-Pratt drain with sutures intact, no erythema, 30 mL of serosanguineous drainage
- Pain (acute) related to surgical incision as evidenced by self-report of pain at 6/10 on a scale of 0-10
- Risk for infection related to surgical incision and drains as evidenced by presence of incision and drains
- Constipation related to decreased peristalsis after surgery as evidenced by hypoactive bowel sounds and abdominal distension
- Deficient knowledge related to post-surgical care as evidenced by questions about incision care and diet
- Administer pain medication as prescribed.
- Monitor incision for signs of infection, such as redness, swelling, or drainage.
- Maintain patency of drains.
- Encourage ambulation and activity as tolerated.
- Provide a high-fiber diet and encourage fluids.
- Teach the client about incision care, diet, and activity restrictions.
- The client reports pain relief after receiving pain medication.
- The incision is clean, dry, and intact.
- The drains are draining clear fluid.
- The client is ambulating with assistance.
- The client has a bowel movement.
- The client verbalizes understanding of incision care, diet, and activity restrictions.
- Document the client's vital signs, pain level, and assessment findings.
- Document the administration of pain medication and any adverse reactions.
- Document the appearance of the incision and drains.
- Document the client's activity level and bowel status.
- Document the teaching that was provided to the client and the client's understanding of the information.