Question

1. 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?

Answer 1

A.After receiving reports on patient two nursing priorities: Dark umber color urine indicates Dehydration ,Mid Inspiratory Crackles Branchiectasis ,Late inspiratory Crackles indicated restructive disease.Brown colour Salem tube indicate feeding may possible,Patient had no orientation to time and place.

First nursing priority should be Respiratory problem :providing position,oxygen administration etc.

Next priority :Reduce dehydration :fluid administration.and provide orientation.

B.Patient had no bowel movements want to find out the reason wether its due to surgical affect are not ,clear diagnosis about Respiratory system needs.

C.Patient Assessment:

Central nerous system :No orientation,having confused. Respiratory System:Respiratory rate:16breaths per minute,oxygen saturation 95%with oxygen at 2 liters. . Cardiovascular system: Heart rate :110 beats per minute .No abnormal sounds. Blood pressure :100/50. Digestive System:Nasogastric tube brown color,No bowel sounds. Colorectal drainage bag serous Sanguinous drinage. .Urinary system: dark umber colored urine. Urine:decresd Integumentary System: surgical incisions on skin.dry skin. Pain:8/10 . Gerontological consideration :Confused,not cooperative..

1.Factors contributing for this assessment: Post operative patient,abonoraml changes,geriatric patient.these factors.

2.Interpretation due to

Respiratory problem related to Old age and ventilation during surgery..Dehydration (dark umber coloured urine) due to decresd intake of fluid because of nil per oral.

Urinary problem due to Decreased intake of fluid. Colorectal Serous Sanginous drinage occur due to Acute inflammatory change.

Absences of Bowel sounds due to Nil per mouth and less physical movement due to surgery.

Integumentary system :incisions due to surgery. Pain 8/10 due to surgery.

3.Nursing interventions for Respiratory problem: Assess for hydration status,clearing airway secretion ,Oxygen supplement.Providing comfortable position.

Dehydration:Encourage fluid intake if allowed ,fluid administration as per orders. Skin care to reduce dehydration.

Urinary problem:Catheter care,fluid adminstration.

Acute inflammatory changes:providing personal hygiene, assess temperature continuously ,administration of antibiotics regularly, colostamy care,care of naso gatric tube,care of urine catheter.

Bowel problem: Encourage for physical movements,adviced to take liquid dire,encourage for simple movement.

Nerous system:Provide orientation,Allow family members for visit.   

You have given so many questions, I given four answers according to guidelines.Hope u get remaining answers from these. Please give me feedback.