Case Study:
The nurse is caring for a 48-year-old client who had abdominal surgery to remove a portion of their bowel due to cancer. The client is three days postoperative and preparing to go home the next day. However, the nurse notes the client's lung sounds are coarse, and the client has been reluctant to ambulate and use the incentive spirometer for 2 days; the nurse is concerned about atelectasis. The client reports pain of 6 out of 10 on the numerical pain scale and is due for a scheduled dose of an oral pain medication. The surgical wound appears to be intact with slight redness along the edges, no drainage is present, and sutures are intact. The client refuses to wear sequential compression devices, stating they are "too hot".
Assessment Questions:
1. Identify the relevant subjective and objective assessment information related to the client's condition and place the findings in the assessment data box below. (Recognizing Cues; Assessment)
2. Based upon assessment information, identify and prioritize the top 3 client problems. Write one client problem in each of the Client Problem boxes below. (Analyze Cues; Analysis and Prioritize Hypothesis; Planning)
3. Below each client problem, determine and enter the relevant assessment information that supports the identified client problem. (Analyze Cues; Analysis and Prioritize Hypothesis; Planning)
4. Identify important nursing interventions that should be taken to address each client problem and enter them in the related intervention box for the associated client problem. (Take Action; Implementation)