Scenario 2 Nursing Lab 3

Scenario 2: Tom Brown Your client is an 18-year-old male – 1 day post-operative following a ruptured appendix surgery. He has a 5cm. incision on the right lower quadrant closed with interrupted sutures. He has a Jackson-Pratt drain in place at the end of the incision line closest to the patients’ midline. There is a moderate amount of serosanquinious exudates in the container. His temperature has been elevated off & on over the past 24 hours and is currently 38 degrees. He has an intravenous infusion of normal saline 0.9% running at 100ml./hr. At present he has mild abdominal pain, one half hour after his Morphine. DR’s Orders: Change dressing daily Remove Jackson- Pratt today Morphine 5-10 mg IM or po q4h prn IV Ancef 1 gm Q8H Monitor Temp Q4H IV Normal Saline 0.9% @ 100ml./hr. Full fluid to Soft Diet Nursing diagnosis: 1) Infection related to surgery as evidenced by elevated temperature off and on over the past 24 hrs and currently 38 degrees. 2) Acute pain related to surgical incision as evidenced by complain of mild pain. 3) Risk for constipation related to morphine as evidenced by absence of BM 24 hrs after surgery. Nursing intervention: 1) Administer anti-infective agent (ancef) as ordered. Encourage patient to eat foods rich in vitamin c to strengthen the immune system. 2) Assess COLDSPA. Administer pain medication as ordered. 3) Increase fluid intake. Encourage patient to walk to increase peristaltic movement on the colon. Ancef Generic name: Cefazolin sodium Classification: Anti-infective, Cephalosporin, first generation Uses: Infection of the urinary tract, biliary tract, respiratory tract, bones ,joints, soft tissue and skin. prophylaxis in surgery. Side effects: extreme confusion, tonic clonic- seizures, mild hemiparesis Contraindications: Hypersensitivity to cephalosporins or related anti-biotics. Client/family teaching: 1) Immediately report any abnormal bleeding or bruising.

2) Oral meds should be taken on an empty stomach but if GI upset occurs, may be administered with meals. 3) Report any symptoms that may necessitate drug withdrawal such as vaginal itching or drainage, fever or diarrhea.

Morphine Sulfate Brand name: Duramorph, Statex, epimorph Generic name: Morphine sulfate Indications and dosages: Adult PO 10-30 mg q4h prn/ subcu:5- 15 mg prn, IV: 4-10 mg q4h prn. Classification: Narcotic Uses: decreases severe pain Adverse/Side effects: Anorexia, nausea and vomiting, constipation, drowsiness, dizziness, sedation, confusion, urinary retention, rash, flushing, bradycardia. Pruritis. Drug Interaction: Increase effect with alcohol, sedatives-hypnotics, antipsychotic drugs and muscle relaxant. Contraindications: Asthma with respiratory depression, increased intra cranial pressure and shock. Nursing Consideration/Teaching: 1) Encourage patient not to use alcohol or CNS depressants, respiratory depression can result. 2) Suggest non-pharmacologic measures to relieve pain as patient recuperates from surgery.