Elimination: -Pain medication

-Constipation -Stool softeners -Low fluid intake -Immobile -Hurts to push -Uses Bedside Commode

Pain: -Spinal fusion sx T5-S1 -12 Hr Sx of spine -Wound Vac -Dilaudid PCA -PRN Oxycodone -Chest Tube

Sean Barnett Nurs 360 Queens Group Professor Rosado

Fluid Electrolyte Imbalance: -Large blood loss during 12hr sx

-Multiple blood products administered. -JP drains x 2 -NPO -LOW H&H 8.5, 25%

Chief Medical Dx: Scoliosis, Kyphosis, and Spondylothesis, Hunington Disease, Cerebral Palsy POST-OP Sx: Spinal fusion and bilateral rod placement Priority Assessment: Pain, Surgical site, Drains, I&Os, PCA.

Immobility: -Pt on Bedrest

-Fall precautions d/t IV pump, PCA, morphine -Tubes, Drains x2 -Pain -Altered Mental Status at times -Forward Wheel Walker when ambulatory

Risk for Bleeding:

-Jehovahs Witness and does not accept blood products -Coumadin/Warfarin take home Medication -Surgical incisions

Infection/Skin integrity: Anxiety: -Rt Surgery

-Temp 100.4F -Wound Vac -Surgical Dressing (Aquacell) -2 JP Drains -Immobile -Hemovac -Pulmonary Embolism -Chest Tube

-Body image -Pain -Pt says she feels ugly and that she will never be normal again. -Cries -Verbalizes pain, and anxiety. -Use of Bedside Commode -Chest Tube -Pulmonary Emoblus