You are caring for a 6 year old female patient name Rita in the hospital. She is 2 hours post-op from acute appendicitis. She had a laparoscopic appendectomy. She is sleepy but arousable and can answer short questions.
Her last set of vital signs are:
b/p 100/68, p 90, r 26, t 98.1, sats 96%.
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Her vitals 30 minutes before that were:
b/p 120/79, p 74 r 20, t 98.3, sats 99%.
You check her abdomen and there are 4 well approximated incisions on her abdomen, closed with surgical glue. One incision on her lower left quadrant appears to be swollen and appears to have some red drainage seeping from under the surgical glue. Rita is moaning and grimacing with her eyes closed in the bed.
She has a 20g IV in her left forearm and is running LR at 100ml/hr, she has 02 at 2l/m via NC in place. She has an indwelling Foley catheter and you have drained 40ml of urine in the 2 hours she has been in your care.
Rita’s mom and dad are anxiously sitting in her room, asking questions regarding her recovery from surgery and when she will be discharged.
- What are your thoughts regarding Rita’s condition? Is she progressing normally post operatively?
- What is your priority in regard to her condition?
- Is Rita giving you cause to worry? If yes, what do you anticipate happening?
- What nursing diagnosis would you apply to Rita? To her family