Reference no: EM133295094
Client: Tobi Dobson - 56 year old male, diagnosis of draining of ABD abscess Goals of Care: R1 Past Medical History - Appendectomy 2006, DM, NKA.
Admitted to the hospital with an abdominal abscess. Client is post-op 4 days for I & D of abscess in ascending colon. By Laparoscopic procedure and is to be discharged home today after his last dose of IV antibiotics. He currently has a JP drain in place. Vital signs at 0600 this am were - BP 122/86, P- 74 regular and strong, RR 16 free and easy, T- 36.2, O2 sats 98% on room air. Surgical site is wellapproximated, minimal serous drainage noted, sutures x 4 intact. Drain site dry, pink approx. 1 cm in length. He reports pain at 3/10 in LLQ with movement, describes it as sharp and localized to surgical site and LLQ. Pain reduces to 1/10 with analgesic. Abdomen is soft and non-tender throughout remainder of regions. He is alert and oriented x 3. IV infusing 0.9% NS at 50mL/hr to left antecubital. CBC completed post op day 2 resulted a WBC of 16.8 and Hgb of 130. Repeat blood work from this morning resulted a WBC of 10.2 ad Hgb of 145. Medications: Morphine 10mg PO q8 hrs prn, Cefazolin 500mg IV TID x 1/52, Ranitidine 50mg IV q 8hr, Metformin 850mg PO BID.
Appropriate Nursing care plan:
Identify the priority nursing diagnosis.
A SMART goal for the DX
Identify three interventions to address this priority diagnosis o Include an intervention to address 1. Nursing care, 2. Medication Administration, & 3. Education needed o Identify the evaluation criteria that will be used to assess effectiveness of care o Identify the rationale for the priority dx, interventions, evaluation criteria, etc.