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 (LIS). 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 diminished bilaterallyin the bases
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.
NUR2349 Professional Nursing I
Module 05 Written Assignment – Care Plan
Student Name:
__________________________
Date: ______________________
Client Gender: ____________ Client Age: ________
Client Diagnosis: __________________________________________________________________________________________________
Assessment data for Nursing Diagnosis
Nursing Diagnosis (3)
Expected Outcomes with Indicators
(1 per Nursing Diagnosis)
Nursing Interventions
(2 per Expected Outcome)
Evidence-based Rationale for each Nursing Intervention (Cited/referenced)
Evaluation
(How do you know it worked?)
Respond to this critical thinking question:
Describe evidence-based precautions to prevent this client from obtaining a nosocomial infection. Provide supporting rationales.
Support your response with evidence from credible sources.
