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<blockquote data-quote="NikkiLoveIsFIYA:ot" data-source="post: 2431476" data-attributes="member: 834172">complaints of abdominal pain.? Tests revealed a bowel obstruction, and she underwent surgery the same day for a bowel obstruction. On assessment, she has NGT to left nare on LIWS with moderate amount of dark green drainage. C/O dyspagia due to tube in the throat. A/R pulses are equal but irregular at 98 BPM. Respirations even but rapid and shallow at 24. Denies SOB. Abd distended at 53cm. with a minute amount of soft brown stool in colostomy bag. Stoma is red and moist, peristoma is without redness, swelling or drainage. States, &quot;that thing makes me gross.&quot; Refuses to look at it. 10cm linear abdominal incision abdominal staples present, healing by 1st intention and edges well approximated without redness swelling or drainage. Clear, yellow urine in the bag. Right hand grip strong, left weak. Bil fingernail beds &lt;3 secs. Bil temporal, carotid, brachial, radial DP and PT pulses 3+. Bil footstrenghts strong, toenail beds CRT&#039;s &lt; 3 secs. Neg Homans sign. Normal SAline infusing to LAC at 125ml/hr, site intact&nbsp; without redness swelling or drainage. Daily weight 124lbs (admission 130lbs), height 5&quot;6&quot;. NPO since admission. VS 140/84, 98, 24, 96, 99.6(T)AM labs:WBC&nbsp;&nbsp; 10.6RBC&nbsp; &nbsp;&nbsp; 3.8Hgb&nbsp; &nbsp; &nbsp; 9.8Hct&nbsp; &nbsp; &nbsp;&nbsp; 28Neut&nbsp; &nbsp;&nbsp; 85.8Lymph&nbsp;&nbsp; 6.4Prealbumin&nbsp;&nbsp; 11Albumin&nbsp; &nbsp; &nbsp; &nbsp;&nbsp; 2Glucose 70K+&nbsp; &nbsp; &nbsp; &nbsp; 3.2Med/surgical history: HTN, Breast cancer with right mastectomy, CVA, hyperlipidemia, cholecystectomy, CAD, MI, Osteoarthritis. What would be the primary problem and what assessment data supports the problem? What would be the goal and nursing interventions for the problem?</blockquote>

[QUOTE="NikkiLoveIsFIYA:ot, post: 2431476, member: 834172"] complaints of abdominal pain.? Tests revealed a bowel obstruction, and she underwent surgery the same day for a bowel obstruction. On assessment, she has NGT to left nare on LIWS with moderate amount of dark green drainage. C/O dyspagia due to tube in the throat. A/R pulses are equal but irregular at 98 BPM. Respirations even but rapid and shallow at 24. Denies SOB. Abd distended at 53cm. with a minute amount of soft brown stool in colostomy bag. Stoma is red and moist, peristoma is without redness, swelling or drainage. States, "that thing makes me gross." Refuses to look at it. 10cm linear abdominal incision abdominal staples present, healing by 1st intention and edges well approximated without redness swelling or drainage. Clear, yellow urine in the bag. Right hand grip strong, left weak. Bil fingernail beds <3 secs. Bil temporal, carotid, brachial, radial DP and PT pulses 3+. Bil footstrenghts strong, toenail beds CRT's < 3 secs. Neg Homans sign. Normal SAline infusing to LAC at 125ml/hr, site intact without redness swelling or drainage. Daily weight 124lbs (admission 130lbs), height 5"6". NPO since admission. VS 140/84, 98, 24, 96, 99.6(T) AM labs: WBC 10.6 RBC 3.8 Hgb 9.8 Hct 28 Neut 85.8 Lymph 6.4 Prealbumin 11 Albumin 2 Glucose 70 K+ 3.2 Med/surgical history: HTN, Breast cancer with right mastectomy, CVA, hyperlipidemia, cholecystectomy, CAD, MI, Osteoarthritis. What would be the primary problem and what assessment data supports the problem? What would be the goal and nursing interventions for the problem? [/QUOTE]

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