Care Plan

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 bilaterally in 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.