Problem:
Sarah Katheryn Horton is a 25-year-old client who had a hysterectomy 1 day ago. Their vital signs have been stable, and they are alert and oriented to time, place, and person. The client has a lower abdominal incision and a Jackson Pratt drain in the lower right quadrant. The dressing over the incision is intact with a small amount of bloody drainage visible. Their abdomen is soft and tender with no audible bowel sounds. They have not passed any flatus since surgery but are tolerating clear liquids. Lungs are clear and they have an incentive spirometer at the bedside. Sarah verbalizes adequate pain control with IV opioids and was last medicated 4 hours ago. They are out of bed independently to the bathroom. Lactated Ringers is infusing at 75 mL/hr to the left forearm. The nurse enters the client's room, performs hand hygiene, and introduces themselves. The client's vital signs are temperature 37.3° C (99.2°F), pulse 68/min, respirations 18/min, blood pressure 118/64, and pulse oximeter 95% on room air. Skin is warm and dry. Lips and mucus membranes are pink and moist. Lung sounds are clear to auscultation but diminished in the bases. Abdomen is soft and non-distended with hypoactive bowel sounds. Client denies passing flatus. Dressing to the surgical site is intact with a small amount of sanguineous drainage noted. A Jackson-Pratt UP) drain is intact and draining sanguineous fluid. Client reports a pain level of 5 on a scale of 0 to 10 the lower abdomen. Client denies pain elsewhere. Lower extremities warm with no peripheral edema noted. Lactated Ringers is infusing at 75 m. Need Assignment Help?