Question

Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient has a colostomy on her left (descending colon) abdomen. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson--Pratt drain intact with minimal serous sanguineous drainage present. The colostomy is not functioning at this time. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. The patient’s cardiac assessment is within normal limits. The patient is receiving O₂ at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate, 110 bpm; respiratory rate, 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time.

After receiving report on this patient, what are the two most significant nursing priorities? (4 POINTS)

What is missing from this report and needs to be known and addressed?

(4 POINTS)

Perform a complete assessment addressing each system. Under ASSESSMENT for each system list the findings in the case study (both normal& abnormal). Under CRITICAL THINKING list (1) factors which may be contributing to the findings in ASSESSMENT (2) your interpretation of what these findings mean is happening physiologically (3) nursing interventions (independent or dependent) you want to implement as a result of (1) & (2) (28 POINTS/4 FOR EACH SYSTEM)

SYSTEM                         ASSESSMENT                 CRITICAL THINKING

Neuro
Resp
Cardiac
GI		.
GU
Integumentary
Pain

What gerontologic postoperative assessments should the nurse note and why? Example: Teaching colostomy care- patient may need support (4 POINTS)

After four hours under your care, the patient develops a fever of 99.9F and is difficult to arouse. You were able to get a doctor’s order for an IV of LR to run at 50ml/hr. Urine output is improving and the Foley is draining 40ml/hr. Lung sounds unchanged and pulse ox is 92%. RR 14 and BP 110/60, HR 90. O2 at 2L NC intact. The colostomy is not functioning and there are no bowel sounds. Incision site clean and dry. Jackson Pratt intact draining a small amount of fluid. You assessed her abdominal pain at an 8/10 and administered 2mg morphine sulfate IVP 30 minutes ago. What is the next nursing action? (8 POINTS)

How would you assess bowel sounds for this patient? (2 POINTS)

How would you assess, measure and apply the wafer on the new colostomy?

(10 POINTS)

After 8 hours on your unit, Ms. Schmidt is attempting to get out of bed and speaking about random things with an inability to focus on your questions. Her skin is hot, RR is 32, pulse is 102 and her BP is 140/78. The pulse ox alarm is going off and reads 89%. She keeps trying to take off her oxygen and the pulse ox probe. Her lungs have crackles bibasilar and in the right middle lobe. She has a nonproductive cough. She is not able to give a subjective pain level. Urine output is sufficient and her IV is intact. What is your next nursing intervention and what MD orders do you anticipate? (15 POINTS)

The following day you are assigned the same patient and receive her sitting in her chair with a tray of clear liquids in front of her. What assessment leads you to feel comfortable with this diet choice? (5 POINTS)

What would you look for next in your GI assessment? (5 POINTS)

You notice that Mrs. Schmidt is wearing oxygen at 2L NC and breathing comfortably at 16 breaths/minute. She is being treated with IV antibiotics for a RML pneumonia. Alert and oriented X 3. She c/o slight pain on inspiration. Lungs with scattered crackles R>L. She is answering questions coherently and asks you when she is being discharged. What is your response? (10 POINTS)

.

What medications do you anticipate Mrs. Schmidt to have ordered during this hospitalization? (5 POINTS)

Answer 1

#. The two most significant nursing priorities after receiving this report based on the altered organ functions are :-

- Ensuring safety of the patient ,making the patient oriented to time , place and person .

- Maintaining adequate respiratory function.

#. The additional information needed are :-

- any history of allergy

- history of any other metabolic disease and medicines being taken

- by what time colostomy has to be made functional