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Scenario 2: Tom Brown

Your client is an 18-year-old male – 1 day post-operative following a ruptured appendix


surgery. He has a 5cm. incision on the right lower quadrant closed with interrupted
sutures.
He has a Jackson-Pratt drain in place at the end of the incision line closest to the patients’
midline. There is a moderate amount of serosanquinious exudates in the container. His
temperature has been elevated off & on over the past 24 hours and is currently 38
degrees. He has an intravenous infusion of normal saline 0.9% running at 100ml./hr. At
present he has mild abdominal pain, one half hour after his Morphine.

DR’s Orders:
Change dressing daily
Remove Jackson- Pratt today
Morphine 5-10 mg IM or po q4h prn
IV Ancef 1 gm Q8H
Monitor Temp Q4H
IV Normal Saline 0.9% @ 100ml./hr.
Full fluid to Soft Diet

Nursing diagnosis:
1) Infection related to surgery as evidenced by elevated temperature off and on over the
past 24 hrs and currently 38 degrees.
2) Acute pain related to surgical incision as evidenced by complain of mild pain.
3) Risk for constipation related to morphine as evidenced by absence of BM 24 hrs after
surgery.

Nursing intervention:
1) Administer anti-infective agent (ancef) as ordered. Encourage patient to eat foods rich
in vitamin c to strengthen the immune system.
2) Assess COLDSPA. Administer pain medication as ordered.
3) Increase fluid intake. Encourage patient to walk to increase peristaltic movement on
the colon.

Ancef
Generic name: Cefazolin sodium
Classification: Anti-infective, Cephalosporin, first generation
Uses: Infection of the urinary tract, biliary tract, respiratory tract, bones ,joints, soft tissue
and skin. prophylaxis in surgery.
Side effects: extreme confusion, tonic clonic- seizures, mild hemiparesis
Contraindications: Hypersensitivity to cephalosporins or related anti-biotics.
Client/family teaching:
1) Immediately report any abnormal bleeding or bruising.
2) Oral meds should be taken on an empty stomach but if GI upset occurs, may be
administered with meals.
3) Report any symptoms that may necessitate drug withdrawal such as vaginal
itching or drainage, fever or diarrhea.

Morphine Sulfate
Brand name: Duramorph, Statex, epimorph
Generic name: Morphine sulfate
Indications and dosages: Adult PO 10-30 mg q4h prn/ subcu:5- 15 mg prn, IV: 4-10 mg
q4h prn.
Classification: Narcotic
Uses: decreases severe pain
Adverse/Side effects: Anorexia, nausea and vomiting, constipation, drowsiness, dizziness,
sedation, confusion, urinary retention, rash, flushing, bradycardia. Pruritis.
Drug Interaction: Increase effect with alcohol, sedatives-hypnotics, antipsychotic drugs
and muscle relaxant.
Contraindications: Asthma with respiratory depression, increased intra cranial pressure
and shock.
Nursing Consideration/Teaching:
1) Encourage patient not to use alcohol or CNS depressants, respiratory depression
can result.
2) Suggest non-pharmacologic measures to relieve pain as patient recuperates from
surgery.