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 a 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.  

Perform a complete assessment addressing each system. Under ASSESSMENT for each system list the findings in the case study (both normal& abnormal). Under CRITICAL THINKING list (1) factors which may be contributing to the findings in ASSESSMENT (2) your interpretation of what these findings mean is happening physiologically (3) nursing interventions (independent or dependent) you want to implement as a result of (1) & (2) (28 POINTS/4 FOR EACH SYSTEM)

SYSTEM                         ASSESSMENT                 CRITICAL THINKING

Neuro
Resp
Cardiac
GI		.
GU
Integumentary
Pain

Answer 1

System thinking	Assessment	Critical thinking
Neuromuscular system	Disoriented to place and time.	Disorientation to place and time can be due to postoperative sedation effect or pain killers effect .
Respiratory system	Respiratory rate-16 breaths/minute. SpO2-95% on 2L nasal cannula Breath sounds - Air entry decreased bilaterally in bases and presence of inspiratory crackles.	Abdominal distention could have led to lower lobe lung Atlectasis which made the air-entry diminished. Presence of inspiratory crackles secondary to the Atlectasis. Crackles and lower lobe Atlectasis lead to oxygen requirement and desaturation.
Cardiovascular system	Heart rate-110bts/mt Blood pressure-100/mmHg Heart sounds-Normal	Mild tachycardia with borderline blood pressure reveals the patient in mild hypovolemia secondary to fluid loss or bleeding inside abdomen.
Gastrointestinal system	colostomy -not functioning Bowel sounds -Absent oral intake -npo status Nasogastric drain-brown colored small amount fluid via Salem sump tube. Surgical drain(type,color and amount)-Jackson--Pratt drain,serosanguineous drainage and minimum amount	Absence of bowel sounds could indicate bowel ischemia.
Genito urinary system	urine - via folleys catheter Urine color-dark amber Urine output-oliguric. urine consistency-no sediments noted	Concentrated small amount of urine shows the need of fluids secondary to fluid loss in abdomen postoperatively.
Integumentary system	surgical wound -present wound status -dry,intact	clear wounds suggest normal findings.

(1) factors which may be contributing to the findings in ASSESSMENT (2) your interpretation of what these findings mean is happening physiologically (3) nursing interventions (independent or dependent) you want to implement as a result of (1) & (2) (28 POINTS/4 FOR EACH SYSTEM)

Factors contributing the above abnormal clinical findings could be

1.Abdominal distention related  to bleeding in the abdomen( evidenced by absence of bowel sounds,Atlectasis etc. )

2.Hypovolemia related to the fluid loss in abdomen.(evidenced by oliguria ,tachycardia and borderline hypotension).

Nursing interventions:

1.Abdominal distention related  to bleeding in the abdomen( evidenced by absence of bowel sounds,Atlectasis etc. )

-provide comfortable supine position to reduce the abdominal pressure .

-Assess the presence of bowel sounds in all four quadrants .

-perform blood investigations to rule out lactate and Hemoglobin,which suggest the ischemia and blood loss.

-Monitor abdominal girth to see the progress .

-check the drain for any kinks or blocks.

-Inform the surgeon about the patient condition.

2.Hypovolemia related to the fluid loss in abdomen.(evidenced by oliguria ,tachycardia and borderline hypotension).

-Continuous monitoring of vitals to monitor hypovolemia.

-Maintain intake output chart to see the fluid balance.

-Administer fluids as per physicians order.