Post Operative Case Scenario

Post Operative Case ScenarioKelly Patel is 65-year-old client admitted to through the emergency department 5 days ago with abdominal pain, abdominal distention, nausea, and vomiting x 3 days. The patient/client was diagnosed with a small bowel obstruction and underwent a small bowel resection. The patient/client is postoperative day (POD) # 3. The patient/client’s condition was complicated post-operatively with an ileus which has since resolved.

Previous Medical History: Hypertension.

Ht./Wt.: 5’8″/ 185 lbs.

Allergies: Iodine

Resuscitation: Full Code

Fall Risk: High

Language: English

 

Most recent vital signs were 99.9 Tympanic, Pulse 80 bpm and regular, Resp Rate 18 breaths/min, BP 140/80 mm Hg Right Arm, Lying, 93% SpO2 on Room Air.

Pain: 4/10, was medicated with prn oral pain medication for incisional pain.

Neurological: Alert and oriented x 4

Cardiac: S1 and S2 auscultation. TED hose and SCDs in use.

Respiratory: Diminished breath sounds to bases bilaterally.  Weak ineffective cough noted.

Gastrointestinal: Bowel sounds hypoactive; client is tolerating a low sodium diet. Passing flatus.

Genitourinary: Up to the bathroom with minimal assistance

Musculoskeletal: Ambulates with 1-person standby assist

Integumentary: Skin dry and intact. Abdominal incision is approximated with staples/sutures. Abdominal binder in place.

Diagnostic Testing: This morning’s labs

Lab Value	Normal Range	Result
WBC		11 000 mm3
Hgb/Hct		11g/dL and 33%

 

Complete the following activities:

1.What would you include in a focused assessment of the client/patient.  Identify expected versus unexpected findings for this post-operative client/patient.

We should always listen to the heart and the lungs.

2.Include 3 nursing interventions.

3. Include 2 orders you would anticipate from the HCP.

4.Complete patient/client teaching to prevent operative complications (hint see Table 16-4).