Question

Ms. Huang is a 72- year- old Asian female who was admitted for an exploratory laparotomy. She underwent surgery and was found to have a perforated bowel secondary to a ruptured appendix. She currently is receiving chemotherapy for severe rheumatoid arthritis. Ms. Huang is POD (post-op day) #2 and the AM assessment reveals the following: B/P 144/86, P 92, R 26, T 38 C. The client has an N/G to 20 cm. suction, foley catheter, O2 at 3 l/min via NC to maintain sats > 92% and a JP drain from her abdominal incision draining mod. amt serosanguinous drainage. Ms. Huang rates her pain at an “8” on a 1-10 scale.

She appears slightly confused and has developed a productive cough of thick, light brown sputum. Lung assessment reveals diminished breath sounds with course wheezes in left lower lobe. Her respirations are shallow and fairly rapid. Her urine is clear and her output was 1400 ml. in the last 24 hours.

Ms. Huang’s WBC’s are 13,000 and her ANC is 700 mm.

1.I What precautions is the nurse going to take while caring for this client?

2.Identify 3 nursing diagnoses appropriate for this client.

3. Identify 6 nursing interventions appropriate for this client.

4. Identify 2 additional infections that Ms. Huang is at risk for developing. Include rationale and nursing precautions.

Answer 1