Assignment Task
Chief Complaint: Abdominal Pain and Fever History of Present Illness: Brittany is a 35-year old teacher who presented to the ER complaining of severe abdominal pain and fever x 3 days. She was also complaining of fatigue and had been home from work. She had not had a bowel movement for 3 days but stated that this is normal for her. She was taking 2 tabs of Tylenol a few times a day for the pain. The doctor ordered an abdominal ultrasound, which showed a perforated appendicitis. She was admitted to the surgical ward and started on IV antibiotics and additional pain medication pre-operatively.
This morning she had a laparoscopic appendectomy and you will be admitting her back to the surgical ward post-op at 1130.
The PACU nurse calls to give you report. The report is as follows: BP 99/60, heart rate 89, respiration rate of 14, Temp 36.4 C, sats 95%. NG tube insitu Rt. nares. On 1L O2 via NP, lungs clear to auscultation in all lobes. 3 incisions to abdomen covered with steristrips and medipore dressing, dry and intact. #14 Foley Catheter insitu draining clear yellow urine. What will you do to prepare for receiving this patient?
Based on your knowledge of post-operative care and this patient’s status, what do you anticipate to be your nursing priorities?
What would your initial assessment include?
Where will you document this?
Initial Priority Assessment and VS: Examination reveals a sleepy but cooperative female. She is pale. Vitals: Regular heart rhythm, and peripheral pulses strong. Pain described by patient as “2/10” to incision and right shoulder, increasing to “5/10 when moving”.
What would you include for a focused GI assessment?
Check the dressing and make sure it is dry and intact.
Listen to bowel sounds. Are they present? Are they absent?
Is the belly distended? Soft or firm?
Ask the patient if they have passed gas?
Any bowel movements. Not likely but still good to ask.
Questiones
1. How often would you do post-op vitals? What would your post-op vitals assessment include?
2. What is the significance of the following? What would you expect?
Temperature:
LOC:
Pain:
Diet:
fluids/rate:
BP:
Catheter:
Body image:
Wound:
Oxygen:
Ancef:
3. Heparin: is often given after surgery, particularly in patients who will remain hospitalized several days after surgery. Used to prevent blood clots from forming.
Morphine:
Acetaminophen:
Bowel sounds:
4. What would you expect the following lab values to show?
WBC
Na
K
5. Would you expect labs to be the same on POD?
6. What are your top 4 nursing priorities? How can you articulate this in Nursing diagnosis format (write in nursing diagnosis format)?
7. What are your nursing responsibilities for the remainder of the shift?
8. What health teaching/education can you provide?
9. Now, imagine this same patient was admitted to the unit at 1130 and you are arriving for afternoon shift. What would be different about the care that you would provide? What would your initial assessment include?
