On postoperative day 2, R.O. continues to improve and is tolerating ice chips. Breath sounds are clear, and
she is performing her pulmonary hygiene. NGT has minimal drainage.
The Foley catheter and Penrose
drain have been removed, and her urine output is adequate. Her IV line is saline locked. The incision is well
approximated with no drainage or redness. Her pain is 4 to 6 out of 10 with pain medication every 4 hours.
Later that evening your assessment shows that R.O. is pale and listless; bowel sounds are absent;
abdomen is distended and tender to the touch; the NGT is draining an increased amount of dark, green-
ish black fluid. Her lung sounds are moist bilaterally, and her temperature has spiked to 40.2 ° C (104.4 °
F), O2 saturation is 97% on room air. she rates her pain at 10 out of 10 and is having difficulty taking deep
breaths because of the pain, which she says "hurts over my whole stomach."
What actions would you take?
Obtain additional assessment data, including VS, pulmonary status (Spo2, respiratory rate), bowel
sounds; check for abdominal distention; clearly identify characteristics of pain (location, intensity,
duration); monitor intake and output (calculate hourly urinary output to assist in ascertaining
hydration status); determine time of last bowel movement. Contact the surgeon and provide the data.
You might also like to view...
A child who is able to use a systematic, scientific problem-solving approach is in which of the Piaget stages of cognitive development?
a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought
The patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The nurse knows that the systems to be assessed include what?
A) Hepatic B) Gastrointestinal C) Musculoskeletal D) Neurologic
The nurse is considering enrolling in an online program to achieve a baccalaureate degree in nursing. What should the nurse consider as an advantage of taking the program online? Select all that apply.
A) Easy B) Flexible C) Consistent D) Convenient E) Cost effective
The nurse is discussing respiratory and metabolic acids and bases
Which statements would the nurse supervisor evaluate as indicating that the nurse needs more information? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "When water combines with carbon dioxide, carbonic acid is produced." 2. "Carbon dioxide is a potential acid that is excreted through the lungs." 3. "Body metabolism produces lactic acids, which are constantly eliminated in the lungs." 4. "Sodium bicarbonate buffers the blood by removing hydrogen ions from the blood." 5. "Carbonic acid dissociates into sodium and bicarbonate.".