PN1 Mod5 Care plan

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