Assignment task:
Nurse's Notes: 0930: The continue to report a non-productive cough and a popping feeling at the abdominal incision. Serious anginous drainage is noted on surgical dressing. Wound visualized surgical site is open with abdominal content protruding.
Vital Signs: BP-110/66, HR 110, RR 24, T- 99.8o F temporally, SpO2 94% on 2L/NC.
Part I: Take Actions (Implementation)
a. What actions should the nurse take to care for Vanessa Fredrick?
b. What should the client be monitored for based on the nursing actions performed?
Part II: Evaluate Outcomes (Evaluation)
a. Explain whether the client met, partially met, or did not meet the expected outcome. Support your response with client information provided.
b. Will the nurse need to revise the plan of care? If yes, describe how the plan of care should be modified.