Using the information from the scenario, create a care plan using the attached template. 

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.  

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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. 

Sample Solution

Care Plan for a 64-Year-Old Male Client Postoperative Day 4

Assessment Data:

• 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, Moves all four extremities, Refuses to ambulate, Apical pulse 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

Nursing Diagnoses:

1. Impaired Gas Exchange related to decreased lung sounds and decreased oxygen saturation
2. Acute Pain related to surgical incision and presence of drains
3. Risk for Infection related to presence of surgical incision and drains

Goals:

1. Maintain adequate oxygenation with oxygen saturation above 95%.
2. Manage pain and discomfort to achieve a pain level of ≤4/10.
3. Prevent infection and promote wound healing.

Interventions:

1. Impaired Gas Exchange:

• Monitor oxygen saturation and respiratory status regularly.
• Administer supplemental oxygen as prescribed to maintain oxygen saturation above 95%.
• Encourage deep breathing exercises and use of incentive spirometer to promote lung expansion.
• Assist the client with turning, repositioning, and mobilization to promote lung ventilation.

2. Acute Pain:

• Assess pain level using a standardized pain scale and document pain characteristics.
• Administer analgesic medication as prescribed to manage pain effectively.
• Apply cold or warm compresses to the incision site as appropriate.
• Encourage relaxation techniques, such as deep breathing and guided imagery, to help alleviate pain.

3. Risk for Infection:

• Monitor vital signs and assess the incision site and drains regularly for signs of infection (e.g., redness, swelling, increased drainage, warmth).
• Maintain aseptic technique during dressing changes and drain care.
• Administer prophylactic antibiotic …ORDER CUSTOMIZED ANSWER HERE

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