A nurse is caring for a 68-year-old client who is 2 days postoperative following surgical repair of a left hip fracture. Exhibit 1 Nurses' Notes 1300: Client reports intermittent abdominal pain as 5 on a scale of 0 to 10 on left side of abdomen. Last bowel movement 5 days ago. Client reports usual pattern is one bowel movement daily. Oral fluid intake 1,950 mL/24 hr. Urine output 1,820 mL/24 hr. 1900: Client reports nausea and constant abdominal pain as 5 on a scale of 0 to 10 throughout abdomen. Pain began after eating dinner. Exhibit 2 Physical Examination 1300: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in lower quadrants. Skin warm and dry to touch in trunk and all extremities. Pedal pulses strong and equal bilaterally. Capillary refill less than 3 seconds in toes bilaterally. 1900: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in all quadrants. Exhibit 3 Vital Signs 1400: Temperature 37° C(98.6°F) Heart rate 88/min and regular Respiratory rate 18/min Blood pressure 130/84 mm Hg Oxygen saturation 97% on room air Exhibit 4 Medical History History of osteoarthritis, hypertension, GERD, and iron- deficiency anemia. Exhibit 5 Medication Administration Record 0800: Ferrous sulfate 325 mg PO once daily 0900: Lisinopril 10 mg PO once daily Atorvastatin 40 mg PO once daily Docusate sodium 200 mg PO twice daily 1100: Hydrocodone 5 mg/acetaminophen 325 mg PO every 4 hr as needed for postoperative pain Exhibit 6 Diagnostic Results 0700: Hct 42%(42% to 52%) Hgb 14 g/dL (14 to 18 g/dL) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L)
A nurse is caring for a 68-year-old client who is 2 days postoperative
following surgical repair of a left hip fracture.
Exhibit 1
Nurses' Notes
1300:
Client reports intermittent abdominal pain as 5 on a scale of 0
to 10 on left side of abdomen. Last bowel movement 5 days
ago. Client reports usual pattern is one bowel movement daily.
Oral fluid intake 1,950 mL/24 hr. Urine output 1,820 mL/24 hr.
1900:
Client reports nausea and constant abdominal pain as 5 on a
scale of 0 to 10 throughout abdomen. Pain began after eating
dinner.
Exhibit 2
Physical Examination
1300:
Abdomen distended, dull to percussion, firm and nontender on
palpation. Hypoactive bowel sounds in lower quadrants. Skin
warm and dry to touch in trunk and all extremities. Pedal pulses
strong and equal bilaterally. Capillary refill less than 3 seconds
in toes bilaterally.
1900:
Abdomen distended, dull to percussion, firm and nontender on
palpation. Hypoactive bowel sounds in all quadrants.
Exhibit 3
Vital Signs
1400:
Temperature 37° C(98.6°F)
Heart rate 88/min and regular
Respiratory rate 18/min
Blood pressure 130/84 mm Hg
Oxygen saturation 97% on room air
Exhibit 4
Medical History
History of osteoarthritis, hypertension, GERD, and iron-
deficiency anemia.
Exhibit 5
Medication Administration Record
0800:
Ferrous sulfate 325 mg PO once daily
0900:
Lisinopril 10 mg PO once daily
Atorvastatin 40 mg PO once daily
Docusate sodium 200 mg PO twice daily
1100:
Hydrocodone 5 mg/acetaminophen 325 mg PO every 4 hr as
needed for postoperative pain
Exhibit 6
Diagnostic Results
0700:
Hct 42%(42% to 52%)
Hgb 14 g/dL (14 to 18 g/dL)
Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
Sodium 140 mEq/L (136 to 145 mEq/L)
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