solved

You are RN working on a surgical unit and just received end of shift report about M.J. a 36-year-old man who is two days post-op after a ruptured appendix. The report includes the following information:
Vital signs: 101.4 F Pulse 118 Respiration 28 BP 97/54 O2 90% (previous Spo2 98% RA)
Assessment:
Neuro: Alert and Orientated x 4, moving all extremities
Respiratory: fine crackles heard throughout lungs, non-productive cough
GI: Bowel sounds present, brown purulent drainage from wound drain
Treatment:
O2 at 2L NC
Antibiotics: Vancomycin and Ceftriaxone IV
Labs:
WBC: 24,000/mm Hemoglobin: 10.5g/dL Hematocrit: 37%
Vancomycin trough level ordered
Patient denies any past pertinent medical history, no allergies.
Social History: Drinks less than weekly – denies use of illicit drug use, never smoker
Disease/patho: Based on the case study, list the main diagnosis and explain the pathophysiology.
Assessment: Explain what would you expect to focus your assessment on for this disease? Why?
Vitals: What would you expect vitals to look like in this patient? What may be affected? Why?
Labs: What labs would we be concerned about for this disease? Why?
Meds: What medications would you expect to give to treat or manage this disease? Explain drug action.
Tests/procedures: What tests or procedures are used to manage, diagnose or treat this disease? Why?
Psychosocial: What are some psychosocial considerations for this disease?
Discharge: Explain possible discharge concerns or needs for this disease.
Nursing diagnoses: List 4 possible nursing diagnoses for this disease.
Differences for age/gender/race/socioeconomic status? Explain if the treatment or care would differ if the patient was of a different gender, race, age, or socioeconomic status. Are certain populations at higher risk?

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