Assisting in the care of a client who is postoperative


Problem: A nurse on a medical-surgical unit is assisting in the care of a client who is postoperative following left knee arthroplasty. Exhibit 1Exhibit 2Exhibit 3Nurses' NotesPostoperative day 2, 0800:Client oriented to person, place, time, and situation, answers questions appropriately, and moves all extremities to command. Guarded with left leg movement, reports pain.Sinus rhythm, S1, S2. Pulses palpable 2 to all extremities, capillary refill less than 2 seconds.Respirations even, unlabored. Chest clear on auscultation. No cough noted.Bowel sounds in all four quadrants. Client tolerating diet with no nausea/vomiting. No bowel movement since surgery.Reports no difficulty with urination. Clear, yellow urine.Reports pain of 8 on a 0 to 10 scale in left leg. Client was last medicated for pain at 0300 with acetaminophen, states, "It didn't help at all."Left knee area edematous, serous sanguineous drainage on dressing. Dressing removed. Staples intact, edges pulling apart approximately 2 cm (0.79 in) on the top of the incision between staples. Remainder of the incision well-approximated. Incisional area irritated and warm, with purulent drainage. Client reports tenderness to area. Clean dressing reapplied. 0830:Report to provider about client's assessment and changes in vital signs.Prescriptions received

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Other Subject: Assisting in the care of a client who is postoperative
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