Care Plan
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Module 05 Content
1.
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Scenario
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
Instructions
Using the information from the scenario, create a care plan using the attached template.