Care Plan

Care Plan

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Module 05 Content


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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


Using the information from the scenario, create a care plan using the attached template.