The nurse is caring for a 30-year-old client who underwent a…
The nurse is caring for a 30-year-old client who underwent an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Nursing documentation: The client is 7 hours post-op in the intensive care unit. Rates pain a 4 on the 1-to-10 pain scale. Client appears lethargic, but oriented x4 and cooperative. Lungs clear bilaterally. Abdomen is hard and distended. The nurse notes increasing drainage in the client’s abdominal drain.Vital signs are: Temp 98.1, HR 122, BP 89/50, RR 26, O2 94% on RA.