[Verified Answer]: PATIENT UNDERGOING SURGERY 0700 Handoff…

PATIENT UNDERGOING SURGERY 0700 Handoff Report S Mr. H, age 60, was admitted for persistent abdominal pain. He is diagnosed with gastric cancer and is scheduled for a partial gastrectomy later this morning. Mr. H is very anxious after speaking with his wife and indicates that he will not sign the surgical consent. He just told me that he is having abdominal pain and “wants his pain shot right now.” He has an NPO order starting at 0800. B He states he has had nausea and vomiting and has noticed a 10-lb weight loss within the past 2 months. A He has an intact and patent IV of 0.9% sodium chloride at 125 mL/hr in the right forearm. He has morphine sulfate 10 mg every 3 hours IV prn, ondansetron hydrochloride 4 mg IV every 8 hours prn nausea, and aluminum hydroxide 30 mL PO every 2 hours prn abdominal pain. It is just about 3 hours since his last pain medication and the aluminum hydroxide was given 2 hours ago. Baseline vital signs are: T 98.8deg F, P 98, R 20, BP 148/92, pulse ox 96%, pain level 7. R The following nursing interventions are recommended: Prioritize the following five recommended nursing interventions as you, the nurse, would do them to initially take care of Mr. H. write a number in the box to identify the order of your interventions (#1 = first intervention, #2 = second intervention, etc.), and state a rationale for each intervention. INTERVENTIONS PRIORITY # RATIONALE * Administer IV Pain Med * Sit and talk with patient * Give aluminum Hydroxide 30 ml * Offer to call a family member * Notify Physician Mr. H does consent to have surgery and returns to the medical unit postoperatively. He has an IV of Lactated Ringer’s solution infusing at 125 mL/hr and you assess the following: P 90, R 20, BP 130/76, pulse ox 94%, pain level 2 He is alert and oriented and his skin is warm and dry NG tube draining brown reddish drainage (300 mL in the past 4 hours) Indwelling urinary catheter draining light yellow urine (700 mL in the past 4 hours) Abdominal dressing intact and dry Do the following: (1) on the basis of the current assessment, select the one nursing diagnosis that is a priority at this time, (2) provide a rationale for your selection, and (3) list three nursing interventions that meet the needs of Mr. H. All of the following nursing diagnoses may apply to Mr. H: Risk for infection, Acute pain, Anxiety, Ineffective airway clearance, Fatigue, Impaired physical mobility, Imbalanced nutrition: less than body requirements, Deficient knowledge, Risk for deficient fluid volume, Fear Nursing Diagnosis Rationale Nursing Interventions Several hours after surgery you note that Mr. H is very restless and you assess: R 32, P 130, BP 108/70, pulse ox 90%, NG drainage 200 mL bright red drainage, skin cool, c/o a dull constant pain in the abdomen with a pain level of 8 Based on the situation, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing interventions for this situation and identify your plan for follow-up care for Mr. H. Nursing Interventions: Priority Problem (from above list) # Action Plan in Order of Priority Monitor P, R, BP, and pulse oximetry 2. Record assessment/Nursing care 3. Plan to start oxygen therapy 4. Stay with Mr. H. 5. Notify physician