When performing an initial assessment on Ms. Lin, the nurse understands which of the following finding(s) would indicate the need for further assessment?
Case:
Location: Medical-Surgical Unit
Time: 0800
Report from night shift charge nurse:
Situation:
Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.
Background:
Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.
Assessment:
Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing early this morning. The incision is closed with staples; the edges are well approximated and only slightly reddened, with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and the drain was pulled this morning. A small amount of bleeding was present; no further bleeding is noted. She had her first small soft brown stool since surgery this morning.
Recommendation:
You will have to transition Sara to oral antibiotics and pain medication. She last had pain medication 4 hours ago. You will need to provide discharge patient education related to incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up.
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