Question

A 70-year-old female is admitted to your unit for changes in bowel/bladder function. Her initial lab work was WNL. Her baseline vital signs were BP 124/62, HR 84, RR 20, Temp 98.4. The MD performed a bowel resection after it was determined that the pt has colon cancer. Post-operatively the pt is taken to a medical/surgical unit. She has an IV of NS at 100ml/hr., and an NGT to intermittent suction, a foley catheter, and a midline abdominal dressing that is dry and intact.  

You are assigned the patient post-op day one. Her VS @ 0700, BP 100/60, HR 104, RR 24, Temp. 99.2 orally. the pt is alert and oriented; her color is pale. the NGT is draining brownish-green mucous, the abdominal dressing is D/I, and the IV is at 100 ml/hr. The pt says, "I'm so tired and I feel so nauseous, and it hurts to move."

The physician ordered the pt to be out of bed. When sitting at the bedside at 1000, the pt states, "I don't feel very well." after waiting 30 seconds, the nurse assists the pt to the chair. The pt becomes dizzy and her bp is 90/64, HR 114, and the urine output has been 70 ml since 0600.

1) What would you do first with this pt? List 3 priority interventions you would implement at this time?

2) List 2 categories of medications that you may be administering to this pt and give an example in each category? (remember, the pt has an ng tube)

3) State 2 priority nursing diagnoses?

Answer 1

1 Immediately after recieving the patient observe the generall ondition the give her proper position and psychological supports

will explain the recovery process about the IV placed in her arms for the medications and the iv fluid theraphy it should be till you start drinking fluid through mouth.then cathether for the urination and about the dressing and drinage will remove when you able to walk.then give the purpose of keeping NGtube it will assist and remove the abdominal discomfort. check the vitals every second hourly ,abdiminal girth to observe the distention and swelling .then measure the drains also The main  interventions are minitor vitals 2 advance diet as tolerate 3 decrease cramping 4 monitor drain 4 Reduce pain 5 prevent Thrombophlebitis

2 Medication ; Patient controlled analgesia or morphine 2 Antibiotics for the prevention of infection 3 Antacids 4 laxatives

NURSING DIAGNOSIS

1Risk for injury; the post of patients are at the risk of post of complications

2 Imbalanced nutrition less the boby requirements;Related to impaired absorption of nutrient

3 Anxiety; Related to psychological factors likes change in the life style socio -economic status etc