Question

Dorothy Payne (D. P.) is a 76-year-old female who was admitted to the hospital 2 days earlier with complaints of right lower quadrant abdominal pain. Her medical history includes type 2 diabetes mellitus. She was evaluated in the emergency department and sent to the operating room for an appendectomy 8 hours after coming to the hospital.

D. P.'s vital signs are: temperature 38.4° C (101.2° F), P 96 and regular, R 22 and unlabored, BP 130/72, and pulse oximetry of 96% on room air. She rates pain in her right lower abdomen as 3 of 10, but with movement the pain level increases to 8 of 10. She reports sharp, stabbing pain in the abdominal area around her incision site. Pain medication and position change relieve the pain. The skin around the incision is warm and red, and the area is tender to the touch. Laboratory results are WBC 20,000 (cells/mm³), Hgb 16 g/dL, Hct 47%, BUN 25 mg/dL, creatinine 0.8 mg/dL, K 4.0 mEq/L, blood glucose 150 mg/dL, and Na 142 mEq/L.

Treatment orders are as follows:

• Vital signs q 4 h and as needed (PRN)

• Regular diet with supplements twice daily

• Intake and output (I&O)

• Activity: Up with assist of one

• Right abdominal dressing: Dry sterile dressing, cleanse incision with sterile saline solution, change q 8 h

• Turn, cough, and deep breathe q 4 h while awake

• Incentive spirometry q 2 h while awake

• Antiembolism stockings while out of bed

• Sequential compression devices (SCDs) while in bed

• Complete blood count (CBC) every morning

• Fall precautions

• Physical therapy (PT) for ambulation daily

Medication orders are as follows:

• Continuous intravenous 5% dextrose in 0.45% normal saline (D₅/0.45 NS) at 50 mL/h

• Enoxaparin 40 mg subcutaneously daily

• Metformin 500 mg PO twice daily

• Hydrocodone 5 mg and acetaminophen 500 mg PO q 4 h PRN for pain

• Cefuroxime 750 mg IV q 8 h

Question 1:

List four concerns or consideration when evaluating DP and her risk for infection.

Question 2: List four assessments necessary to evaluate for signs and symptoms of a possible developing infection.

Question 3: Write a complete nursing diagnosis for DP.

Question 4: Identify at least three nursing interventions with rationales for the nursing diagnosis from Question 3.

Answer 1

1) DP is an elderly woman of 76 years old who has undergone appendectomy. The concerns when eveluating DP are as follows.

• She is a know case of Diabetis type 2.
• She is above 65 years which is vulnerable age.
• She is febrile now with the wbc count of 20,000
• Her incision site is red, warm and tender to touch which shows ahe may have infection at the incision site.

2) To know the possible signs and symptoms of developing infection,

The assessment required for knowing the signs an symptoms are

• Physical assessment
• Assessing the pain at the site
• Inspection of the incision site
• Assessing the blood works and vital signs

the following points to be noticed which shows signs of infection

• Fever and chills is one of the signs of developing infection
• Increasing pain(sharp and stabing pain) which is reduced only with medications. Pain reoccurs
• Blood count is increasing
• Incision site is red and warm
• Incision site is tender and painful to touch

3) Nursing Diagnosis for DP

In the above case the main concern ofthe pateint is acute pain

Acute pain at the incision site related to the surgery secondary to the infection.

4) The interventions an the rationals for the above diagnosis of pain ae as follows.

Interventions Rational

1. Assess the intensity of pain by using the pain scale 1. Prescribed medications to be given and reassess the pain.

2. Encourage early ambulation. 2. Early ambulation is encouraged and physiotherapist assisstance is provided

3. Provide diversional therapy 3. Comfortable position is provided and encourage watching TV, listening to musics and reading books will help in pain relieve

4. Watch closely for possible sugical complications 4. Fever and continuing pain is a sign of infection. Notify to the physician if observed.