Case: Location: Medical-Surgical Unit Time: 0800 Report from night shift charge nurse: Situation: Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today. Background: Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive. Assessment: Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing early this morning. The incision is closed with staples; the edges are well approximated and only slightly reddened, with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and the drain was pulled this morning. A small amount of bleeding was present; no further bleeding is noted. She had her first small soft brown stool since surgery this morning. Recommendation: You will have to transition Sara to oral antibiotics and pain medication. She last had pain medication 4 hours ago. You will need to provide discharge patient education related to incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up. Upon further assessment, the nurse learns that the client's pain is 6/10, sharp, and located at the incision site. The pain increases with coughing and deep breathing. Which of the following would be the nurse's priority action(s)? (Select all that apply from the answers below.) Only need the answers no explanation is necessary Educating the client on the importance of coughing and deep breathing Reviewing the provider orders to initiate pain medication Administering 5 mg IV morphine Assisting with incentive spirometry Assessing the incision site Calling the provider to report findings
Case:
Location: Medical-Surgical Unit
Time: 0800
Report from night shift charge nurse:
Situation:
Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.
Background:
Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.
Assessment:
Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing early this morning. The incision is closed with staples; the edges are well approximated and only slightly reddened, with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and the drain was pulled this morning. A small amount of bleeding was present; no further bleeding is noted. She had her first small soft brown stool since surgery this morning.
Recommendation:
You will have to transition Sara to oral antibiotics and pain medication. She last had pain medication 4 hours ago. You will need to provide discharge patient education related to incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up.
Trending now
This is a popular solution!
Step by step
Solved in 2 steps
