written care plan

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  1. 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. 
  • 3 years ago
  • 5