Question

. Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient has a colostomy on her left (descending colon) abdomen. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson--Pratt drain intact with minimal serous sanguineous drainage present. The colostomy is not functioning at this time. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. The patient’s cardiac assessment is within normal limits. The patient is receiving O₂ at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate, 110 bpm; respiratory rate, 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time.

After receiving report on this patient, what are the two most significant nursing priorities?

What is missing from this report and needs to be known and addressed?

Answer 1

Ans) Postoperative delirium – This is a temporary condition that causes the patient to be confused, disoriented, unaware of their surroundings, and have problems with memory and paying attention. It may not start until a few days after surgery, comes and goes, and usually disappears after about a week.

Nursing Interventions:

- Orient the patient, try to stabilize.

- Keep one relative/ care taker with the patient so that unnecessary behaviour of patient is btought to the notice of the health care provider at once.

- Monitoring the patient every hourly.

- Notify any deviations to the physician.

- Carry out all due orders of the physician as prescribed.

Teaching colostomy care- patient may need support.