You are the nurse caring for a 64-year-old male client who is postoperative day four on the medical-surgical unit after having an emergency right colectomy due to cancer. The client is NPO with a nasogastric (NG) tube to low intermittent suction. The client has a history of smoking and no other health problems.
Vital signs:
- 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”
Focused assessment findings:
- 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
Student Name: __________________________
Date: ______________________
Client Gender: ____________ Client Age: ________
Client Diagnosis: __________________________________________________________________________________________________
| Assessment data for Nursing Diagnosis | Nursing Diagnosis (3) | Expected Outcomes with Indicators
(1 per Nursing Diagnosis) |
Nursing Interventions
(2 per Expected Outcome) |
Evidence-based Rationale for each Nursing Intervention (Cited/referenced) | Evaluation
(How do you know it worked?) |
Respond to this critical thinking question:
Describe evidence-based precautions to prevent this client from obtaining a nosocomial infection. Provide supporting rationales.
Support your response with evidence from credible sources.
You are the nurse caring for a 64-year-old male client who is postoperative day four on the medical-surgical unit after having an emergency right colectomy due to cancer. The client is NPO with a nasogastric (NG) tube to low intermittent suction. The client has a history of smoking and no other health problems.
Vital signs:
- 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”
Focused assessment findings:
- 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
Student Name: __________________________
Date: ______________________
Client Gender: ____________ Client Age: ________
Client Diagnosis: __________________________________________________________________________________________________
| Assessment data for Nursing Diagnosis | Nursing Diagnosis (3) | Expected Outcomes with Indicators
(1 per Nursing Diagnosis) |
Nursing Interventions
(2 per Expected Outcome) |
Evidence-based Rationale for each Nursing Intervention (Cited/referenced) | Evaluation
(How do you know it worked?) |
Respond to this critical thinking question:
Describe evidence-based precautions to prevent this client from obtaining a nosocomial infection. Provide supporting rationales.
Support your response with evidence from credible sources.