Medical-surgical unit after having an emergency right colectomy due to cancer

Full Answer Section

• 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.

Sample Solution

• 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"