Reference no: EM133848503

Question

Ms. S. is a 66-year-old female patient whom you just received report from the PACU nurse. She has just finished the recovery room phase of her laparoscopic gallbladder surgery. Her only known medical history is diabetes mellitus type 2. The patient has not taken any of her home medications today. The PACU nurse reports to you that her blood pressure is 100/62, pulse 74, respirations 16, SpO2 sat 97% on 2 liters of oxygen, and temperature 99.0 orally. She had 4 mg of morphine per IV for abdominal pain at 1530 with good relief. She has an order for morphine 4mg IVP q3h prn.

Ms. S. comes to the floor at 1600 in good condition. You as the nurse do the admission assessment and find her vitals to be stable, with little changes in values noted from the set of vital signs the PACU nurse reported to you. Her post-op bandage is clean, dry and intact, with no apparent drainage noted on bandages. Lung sounds are clear in all lobes. Patient states her abdominal pain is "minimal", rated a 2 out of 10 on the numeric pain scale. Patient lab values from this morning reveal a hemoglobin level of 12.6 and a WBC count of 9,000. Her last blood sugar level was 118. Despite her pain being controlled, Ms. S. refuses to get out of bed to sit in the chair because she is "too tired". Ms. S. also notes that she has not voided since 0700 that morning before her scheduled surgery. She states her last BM was 3 days ago and she says her stomach "feels tight". She has not eaten or drank anything since before midnight last night.

At 1730, Ms. S. is now complaining of sharp, throbbing pain rated a 9 out of 10 on the numeric pain scale in her incision site, and she also has a headache rated 7 out of 10. Ms. S. is also moaning, grimacing, and holding her hands over her abdomen. She is requesting pain medication. You note that she is also having shortness of breath. You recheck her vital signs and her RR is now 26 bpm and her SpO2 sat is 87% on 2L of O2. Her temperature is 101.2 degrees. Her BP is 88/50 and her HR is 116 bpm. You auscultate her lung sounds and you hear crackles in the right lower lung lobe. Her abdomen is distended. Ms. S. states she is nauseous and starts vomiting bright green bile into the emesis basin. You assess her incision dressing site and you notice bright red blood seeping through the bandage. When you remove the soiled bandage, you also see that her incision site is very red and inflamed. Stat labs are drawn for the patient, including blood cultures, and you notice that her hemoglobin level is now 7 and her WBC count is 22,000. Her blood glucose level is now 66.

Using your critical thinking abilities, what specific changes have occurred in this patient that make you concerned? What could be going on with this patient?

Based on your new assessment findings of your patient at 1730, and apart from immediately calling the physician, what would be the first thing that you as the nurse would do for this patient?

Come up with 3 nursing diagnoses for this patient and place them in priority order. Include 'related to' and 'as evidenced by' statements. You can only include 1 'Risk for' diagnosis.