Care Plan 2 male client

 

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. The client has a history of smoking and no other health problems.  

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 clear to auscultation, diminished bilaterally 
  • 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. 

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