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NURSING DIAGNOSIS/ PROBLEM PRIORITY
Mr. Lee is a 72 year old patient who had abdominal surgery for a colon resection and removal of a tumor two days ago. His nurse, Sam, implemented pain-control strategies in an effort to help him become more mobile so recovery could proceed. Up until now, he was getting out of bed and rating his pain at a level of 6 on a scale of 0 to 10. The patient still tends to guard his incision by placing his hand over the wound when moving.
Mr. Lee weighs 250 lbs and is 5 ft 10 inches tall. He has tried to cough more during his postoperative deep-breathing exercises. Sam is caring for him for the third day in a row and begins the morning shift by inspecting his surgical wound. The wound is approximately 18 cm in length and closed with steel sutures. Sam notices separation of the wound between two sutures at the bottom of the incision. There is a small amount of serous-sanguineous drainage. The area is inflamed and she asks the patient if the incision is tender when she gently palpates around the area. Mr. Lee states, “Ow, that feels sore there. I think I pulled it when I coughed last night.” He also rates pain at this time as being at a level of 6. Sam checks Mr. Lee's vital signs and notes that his temperature of 32.2 C. Sam also inspects the intravenous access device in the patient/s left forearm. It is intact, and there are no signs of phlebitis at the IV site. Mr. Lee knows that he will have activity restrictions and his wife will be a resource to him once he returns home. His discharge has been planned tentatively. His family depends on his income. Now he begins to share concerns with Sam about being able to return to work after surgery. He does not consistently attend to nurse during instructions of his home instructions. Mr. Lee also verbalized some concern by asking Sam, “ The doctor told me that I would not be able to lift anything heavy and Im not so sure if I understand. The way my incision looks, will I need to do something to it?”
pain at surgical site
oozing from the surgical site
serosanguious discharge from the surgical site indicates infection
risk for infection
risk for imbalanced body temperature
risk for defecient fluid volume
- aseptic precaution during dressing
- encourage eating protein rich food
- encourage breathing excercises
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