Rubric: Care Plan & Care Map
Category Full Credit
Patient data+3 Complete.
Notes on +10 Complete. Summary of physiologic
patho processes that occurred leading to this
hospitalization. Information is accurate.
Labs & +20 Complete. Labs are defined. Abnormal
Tests values are identified. Student is able to
articulate reasoning employed to determine
significance. Appropriate relationships are
identified among different labs through
correlation of values and concepts.
Medications +15 Complete. Plain language is used to
explain action, purpose, and side effects.
Information is accurate. Appropriate additional
teaching included.
NDs +20 Complete. Appropriately prioritized. Data
provided as evidence supports the chosen ND
accurately. Variety of NDs demonstrate novice
understanding of patient condition.
NIC +20 Complete. Student demonstrates use of
ADPIE by discussing interventions, evaluating
patient response, and determining whether
additional interventions are needed.
SBAR +7 Complete. Student demonstrates clear
attempt to include appropriate information in
situation and background. Use of terms and
abbreviations are accurate.
Overall +5 Complete. Evidence of incorporating
instructor’s feedback as applicable.
Total:
/100
CLINICAL CARE PLAN & CARE MAP
Revised: Medical Surgical Committee 5/17/19
Partial credit (needs improvement)
+1.5 Some data omitted.
+5 Some data omitted. Unclear whether student
understands physiology related to patient.
+10 Some data omitted. Labs are defined. Student
demonstrates inaccurate understanding of
foundational physiology related to some lab values.
Abnormal values are identified. Student is unable to
clearly articulate reasoning employed to determine
significance (illogical).
+7.5 Some data omitted. Medical jargon used to
explain action, purpose, and/or side effects. Some
additional teaching is missing, or is not appropriate
for the patient.
+10 Some data omitted. Not appropriately
prioritized (out of order). Data provided as evidence
does not accurately support the chosen ND. Lack of
variety demonstrates limited understanding of
patient condition.
+10 Some data omitted. Student’s use of ADPIE
unclear, i.e. not discussing evaluation of patient
response and/or whether additional interventions are
needed.
+3.5 Some data omitted. Information included in
situation and/or background that belongs in the
assessment. Terms or abbreviations in review of
systems not accurate.
+2.5 Incomplete. Some data omitted. Discussions
are lacking in one or more areas.
No credit (unacceptable)
+0 Significant omissions.
+0 Significant omissions. List of
definitions. No connections made between
concepts. Information inaccurate.
+0 Significant omissions. Labs are not
defined. Student demonstrates inaccurate
understanding of foundational physiology
related to all lab values. Student does not
provide explanation of significance of
some or all lab values.
+0 Significant omissions. Action, purpose,
and/or side effects are in medical jargon
only. There is no additional teaching, or it
is not accurate.
+0 Significant omissions. Too little data to
determine whether there is evidence to
support ND. Limited NDs; total lack of
understanding of patient condition.
+0 Significant omissions. Unclear
discussion of interventions. Total lack of
evaluation of patient response to
interventions.
+0 Significant omissions.
+0 Significant omissions. Includes
mistakes previously corrected by
instructor, as applicable.
1
 Patient Data

Student: Shaylee Date of Care:__3/18 Patient initials:_ Admit date:_3/17__Floor/room #_MT RM 326 Allergies: _NKDA___Code Status:_Full code____

Demographics Gender: M Age: 61 Height: 177.8cm Weight: 98.4kg Primary language: English Spirituality: Christian
Vital signs T: 36.5 HR: 71 RR: 18 BP: 104/67 O2sat: 96% Pain: 0 Pain scale type: Number
Admitting Dx Umbilical drainage, seroma
PMHx HTN, umbilical hernia SAC, depression

PSHx Laparoscopic cholecystectomy, anterior lumbar interbody fusion, transfer right & left abdomen muscle, incisional hernia repair

Surgery Surgery this admission: drainage of abdomen POD: 1

Advance directive: no Isolation: contact- wound cx VS Frequency: q4h
Diet order: heart healthy (los sodium, Activity order: bed rest w/ ambulatory Vascular access: peripheral, LAC IVF: Lactated Ringers
salt, cholesterol, fat)
Oxygen therapy: room air Foley: no Feeding tube: no Glucose checks: none
VTE prophylaxis: SCD’s Drains/tubes: none Wounds/dressings: umbilical wound Telemetry: continuous
Restraints: no Safety issues: none Braden: 21 D/C plan: home

Pathophysiology:
The pt came in after a recent hernia repair with purulent drainage from the surgical site and along with pain.
This pt received an anterior lumbar interbody fusion, which means that an incision was made in the abdomen, through the skin and muscles, to fuse
lumbar vertebrae together. An incisional hernia can occur from excessive or premature physical activity after surgery or increase abdominal pressure in
any other way before the incision is fully healed.
I believe that the anterior approach to the lumbar surgery caused this pt to develop an umbilical hernia at the incision site. This means that
tissue/intestines bulged out through at the opening in the muscles from the incision site. The pt could have easily resumed somewhat-normal physical
activity after surgery or even strained the abdomen during bowel movement as the cause of this hernia.
The pt then received another surgery to fix this, where another incision is made near the hernia site, and tissue is inserted back to its normal place. Then,
sutures are used to close the abdominal muscles. This surgery causes damage to the blood and lymph vessels and surrounding tissue and organs. An
inflammatory response aslo occurs, and the severed vessels and tissues will produce clear fluid in response. This fluid is composed of blood plasma that
has seeped out of ruptured small blood vessels, and the inflammatory fluid is produced by injured/dying cells.
In some cases, like with this pt, the fluid forms a pocket, which leads to the formation of a seroma. A seroma is a collection of this blood plasma and
inflammatory fluid that builds up under the surface of the skin, usually at the site of the surgical incision. The buildup of fluid in the peritoneum caused
excess pressure that is not normal, which explains the patient’s pain. This fluid can also seep out of the surgical incision if it is not fully healed yet, which
Revised: Medical Surgical Committee 5/17/19 2
 is why the pt experienced purulent drainage.
This pt did not have any abnormal lab values, which is a good thing, but that means there are no values except for the pt’s symptoms to add to this
explanation.

Lab and Diagnostic Test Data

LABS Normal RESULT 1 RESULT 2 RESULT 3 1. Use plain language to explain what the lab is measuring (every
Range single lab should be explained)
(date & time) (date & time) (date & time)
(Fill in Hospital
Norms) 3/17 1534 2. Reason for abnormal lab values related to patient care &
nursing implications (where applicable; only discuss resulted labs)

CBC

 WBC 4.8-10.8 7.1 This pt has normal WBC levels. WBC measures the total amount of
white blood cells in the pt’s blood which can help detect infection.
Elevated levels of WBC’s indicate that the body is fighting off an
infection. Decreased levels of WBC’s could indicate an autoimmune
disorder or a severe infection.
 RBC 4.4-6 4.72 RBC Is the total amount of red blood cells which help assess
circulation and oxygen/nutrient transportation. Elevated levels of
RBC’s can be an indicator of dehydration or even a more serious
disease such as heart failure. Decreased levels of RBC’s could
indicate anemia, this could cause the pt to feel fatigued because
the body has to work harder to get enough oxygen to the cells of
the body.
Hemoglobin (Hgb) 13.5-18 13.7 This pt has normal hemoglobin levels which means the body has
the correct amount of protein molecules carrying oxygen
throughout the body and to the lungs. A decreased hemoglobin
level could indicate low RBC’s or anemia. An increases hemoglobin
level could be due to lung disease, heavy smoking, living at a high
altitude, or extreme physical exercise because the body is trying to
get as much oxygen as it can in a condition or environment where
there is not ample oxygen.
Revised: Medical Surgical Committee 5/17/19 3
 Hematocrit (Hct) 40-54 41.8 Hematocrit measures the total percentage of red blood cells
compared to the total volume of blood. A low hematocrit may
indicate anemia but is common after an injury with blood loss or
surgery. Elevated levels of hematocrit indicate dehydration.
 MCV 81-99 88.6 MCV monitors the average size and volume of an RBC, this test
differentiates between the different types of anemia and what
deficiencies are causing it. Menstruation and gastrointestinal
bleeding may cause low levels of MCV.
 MCH 27-32 29 MCH indicates the amount of hemoglobin, the molecule that carries
oxygen, in a RBC. This would also be an indicator of how much
oxygen the cell is able to carry and distribute to the body. Low
levels of MCH could indicate anemia related to low iron levels while
high levels of MCH could indicate inadequate intake of Vitamin B
and folate.
 MCHC 32-37 32.7 MCHC indicates the average concentration of hemoglobin in all
your RBC’s. This again assesses the blood’s ability to carry O2
throughout the body. Low levels could indicate anemia related to
iron deficiencies and high levels could indicate anemia related to
vitamin B and folate deficiencies.
 RDW 11.5-15.5 15.2 RDW measures the size of RBCs along with the volume of RBCs.
High RDW could be an indicator of iron deficiency, or decreased B-
12 or folate levels, anemia, or thalassemia. Low RDW indicates that
the RBCs are all the same size.
PLT COUNT 130-400 223 Platelet counts measure the number of platelets in the blood which
are responsible for clotting of the blood. Platelets are essential as
the body’s natural cessation of blood loss. High platelet counts
could indicate an increased risk for blood clots which could be
potentially dangerous by occluding arteries and causing a cessation
of blood flow to certain areas of the body. Low platelet counts can
lead to an increase risk of bleeding because the body is unable to
properly form clots to stop blood loss.
WBC DIFF

Revised: Medical Surgical Committee 5/17/19 4

 NEUTROPHIL % 42-75 57 The neutrophil lab test measures the amount of neutrophils in the
blood. Neutrophils make up the largest number of white blood
cells. They move to the area of damaged or infected tissue and
engulf bacteria or fungi. Neutrophil percentage grows if there is an
infection, inflammation, or a disease like cancer because the
immune system is trying to rid the body of the intruding
bacteria/cells. Neutrophil percentage would be low in cases of an
overwhelming infection, during an acute episode of inflammation
before neutrophils have time to replenish, reaction to drugs, an
autoimmune disorder, and chemotherapy.
LYMPHOCYTE% 16-50 30.2 A lymphocyte lab test measures the amount of lymphocytes in the
blood. Lymphocytes are made in the bone marrow and found in the
blood and lymph. Lymphocytes produce antibodies, control the
immune response, and attack and kill abnormal cells. The
lymphocyte percentage may be high if the patient has an acute viral
or bacterial infection or lymphoma. Lymphocyte percentage may be
low during an inflammatory response, if the patient has an
autoimmune disorder, bone marrow damage, or a serious infection
like TB or hepatitis.
MONOCYTE % 2-12 9.5 A monocyte lab test measures the amount of monocytes in the
blood. Monocytes move to chronic infections to engulf and destroy
the bacteria as well as repairing damaged tissues. Monocyte
percentage may be high if the patient has chronic infections, IBD, a
heart infection, leukemia, lupus, or rheumatoid arthritis. Monocyte
percentage may be low if the patient has bone marrow damage.
EOSINOPHILS % 0-5 3 An eosinophil lab test measures the amount of eosinophils in the
blood. Eosinophils move to inflamed areas, kill cells, trap harmful
substances, play a role in immediate allergic reactions. Elevated
eosinophils may indicate a parasitic infection, an allergic reaction,
or cancer. Although low eosinophils are normal, it can also be
caused from Cushing syndrome, treatment with corticosteroids,
and bloodstream infections.
BASOPHILS % 0-1 0.3 A basophil lab test measures the amount of basophils, a white
blood cell that fights fungal or bacterial infections, viruses, and
Revised: Medical Surgical Committee 5/17/19 5
 helps mediate allergic reactions. A high basophil level can be
caused by inflammation like in IBD or rheumatoid arthritis, allergies
like food allergies or hay fever, infections like chickenpox or
tuberculosis, or conditions that cause the bone marrow to make
too many white blood cells like myelofibrosis. Although basophil
levels are low in normal circumstances, they can become extremely
low in cases of severe infection.
CHEMISTRY

Sodium 136-145 138 A sodium lab measures the amount of sodium, an electrolyte which
helps keep the body hydrated and balances the acids and bases, in
the blood. Low sodium levels are referred to as hyponatremia, this
can cause an electrolyte imbalance and cause retention of water in
your cells that causes swelling in the body. An increased level of
sodium in the blood could indicate that the kidneys, which are
responsible for the elimination of excess electrolytes, are not
functioning properly, this could also be an indicator of dehydration.
Potassium 3.5-5.1 4 A potassium lab measures the amount of potassium, an electrolyte
which helps keep the body hydrated and balances the acids and
bases, in the blood. Increased levels of potassium in your blood
(hyperkalemia) is usually caused by the kidneys inability to properly
remove excess potassium which can cause an electrolyte imbalance
that can affect the hearts sodium potassium channels and cause a
myocardial infarction. A low potassium level (hypokalemia) can also
cause complications in carrying electrical signals to and from cells,
this can also lead to serious complications such as a myocardial
infarction.
Chloride 98-107 104 A chloride lab measures chloride in the blood, an electrolyte which
helps keep the body hydrated and balances the acids and bases in
the blood. An increase in chloride levels (hyperchloremia) could
indicate an imbalanced pH level in the blood. This can be caused by
severe dehydration or disease like diabetes or renal failure. Low
chloride levels (hypochloremia) may result in a change in normal pH
values and may produce no symptoms unless drastically low,
Revised: Medical Surgical Committee 5/17/19 6
 vomiting, diarrhea, sweating and high fevers could cause this
electrolyte imbalance.
CO2(bicarb) 21-31 24 A bicarb lab measures bicarbonate in the blood, an electrolyte
which helps keep the body hydrated and balances the acids and
bases in the blood. High levels of bicarbonate in the blood can be
from metabolic alkalosis which increases the pH of the body, this
can be caused by an increase of loss of acids that could occur from
dehydration or chronic vomiting. Low levels of bicarbonate can
indicate acidosis which is too much acid in the body due to
inadequate amounts of bases in the body, this is often caused by
kidney, liver and metabolic diseases.
BUN 7-25 14 BUN measures the amount of urea in the blood, which helps
evaluate kidney and liver function. Nitrogen, which is in the
ammonia that ids produced by the liver, combines with oxygen, as
well as carbon and hydrogen, to create a chemical waste called
urea. BUN lab tests can help evaluate the efficacy of dialysis
treatments or as part of a diagnostic process for determining the
cause of liver damage, heart failure, or urinary tract issues. If there
were a significant increase in BUN levels, this could indicate
decreased kidney function or even kidney failure. A decreased BUN
could be due to malnutrition or overhydration.
Creatinine 0.7-1.3 0.82 A creatinine lab measures the amount of creatinine in the blood,
which evaluates kidney function by determining how much
creatinine, a waste product, the kidney removes from the blood.
There should be almost no creatinine in the blood for healthy
kidneys. A creatinine lab can be done to evaluate general kidney
function and can also be used to test the efficacy of dialysis in
patients with kidney disease. High creatinine could indicate kidney
disease, urinary system blockage, diabetes, muscle disease, or
dehydration. Low creatinine could indicate liver disease in serious
cases, as well as muscle loss.
GFR >=60 >60 Glomerular filtration rate is a blood test that determines how well
your kidneys are functioning. This is assessed by measuring the
amount of blood that passes through the kidneys glomeruli which
Revised: Medical Surgical Committee 5/17/19 7
 act as filters. This test can help diagnose kidney disease. A below
normal GFR indicates that the glomerular filtration is not adequate
and may be indicative of kidney disease due to decreased kidney
function. An elevated level of GFR is not usually abnormal and can
indicate excellent kidney function.
Glucose 75-115 88 Glucose, or blood sugar, is a lab test that is done to monitor the
glucose levels of the blood. Glucose tests can be done to determine
if the patient has diabetes (especially in obese patients),
hyperglycemia, or hypoglycemia. Hyperglycemia may indicate that
the patient has diabetes as well, which can lead to kidney failure,
heart disease, and blindness. Hypoglycemia can progress to cause
brain damage if left unmonitored and untreated.
Calcium 8.6-10.3 9.2 Calcium lab tests are done to measure the amount of calcium in the
blood to make sure that the parathyroid is releasing hormones that
are effectively regulating calcium, and to monitor any abnormalities
of the bones, heart, nerves, kidney, and teeth, relating to the
increased break down or decreased amount of calcium in the
bloodstream. This test can also be done to help diagnose
pancreatitis and parathyroid disease. Hypocalcemia can lead to
seizures, muscle spasms, tingling sensations in the hands and feet,
or irregular heart rhythm. Hypercalcemia can cause nausea and
vomiting, constipation, and severe thirst.
Nasal Cultures Negative for COVID

Anion gap 5-15 The anion gap test is to measure the acid-base balance in the body.
High anion gap acidosis may be caused by many things including
ketoacidosis, lactic acidosis, renal failure, and toxic ingestions. Low
anion gaps are uncommon but may be caused by a lack of the
protein, albumin. Low albumin levels are indicative of malnutrition,
liver or kidney disease, heart disease, or an inflammatory disease.

Medications

Revised: Medical Surgical Committee 5/17/19 8

 Generic Dose/Route Frequency Action of Drug Possible Nursing Considerations related to patient care and
Trade Name Rate of Administration Purpose Side Effects teaching
Drug classification (if needed) (specific to Pt) (What to assess, when to hold, what to teach, etc.
(Therapeutic & Anything other than the side effects that the hospitalized
Pharmacologic) patient needs to know.)

G: Ringers Solution 1000mL IV Purpose: fluid Possible side effects -assess for allergies before administration
T: Lactated Ringers replacement include: -assess injection site after admin for any signs
Th: Fluid/electrolyte
75 MLS/ Action: replaces lost Allergic reaction, fever, of redness or infection
replenishment Q13h20m PRN fluid and electrolytes injection site reaction -talk to HCP before administering other drugs
Ph: Alkalinizing agents to the blood with this solution
G: ethyl alcohol I unit NA BID Purpose: decrease Possible side effects -do not exceed 4 times a day
intranasal germs spread from include: -do not use If allergic to ethyl alcohol or any
T: Nozin Nasal Sanitizer 0900, 2100 nose to hands Nose irritation, redness, ingredients in the drug (coconut, orange, jojoba)
Th: antiseptics Action: kills germs possible allergic reaction to -do not use with a history of nasal bleeding or
Ph: topical antiseptics in nose which helps other additives used for scent irritation
decrease spread of (coconut, orange, jojoba)
germs from nose to
hand transmission

G: lisinopril 20mg PO Daily Purpose: manage Possible side effects -monitor BP and pulse frequently
T: Prinivil hypertension include: -assess weight and for swelling periodically
Th: antihypertensives Action: lower BP Swelling of face, chest pain, -advise pt to take medication at the same time
Ph: ACE inhibitors tiredness, itching every day, even if feeling better
-caution pt to change positions slowly to
minimize dizziness
G: pantoprazole 40mg PO Daily Purpose: prevent Possible side effects -obtain complete medication history, including
T: Protonix ulcers include: supplements and vitamins before admin
Th: antiulcer agents
0900 Action: decreases Headache, diarrhea, -Assess for abdominal pain, bowel function, and
Ph: proton-pump stomach acid constipation, abdominal pain bloody stools after admin
inhibitors -Advise patient to take as directed, even if
feeling better
-avoid alcohol and aspirin
G: trazodone 100mg PO Purpose: treat Possible side effects -monitor BP and pulse before and during
T: Desyrel depression include: -assess for possible sexual dysfunction
Th: antidepressants
QHS Action: alters effects Drowsiness, hypotension, -assess for serotonin syndrome (nausea
Ph: of hormones that dry mouth, vomiting, mental changes)
cause depression -assess mental status frequently
Revised: Medical Surgical Committee 5/17/19 9
 - admin immediately after meals to minimize
side effects
-take medication as directed
-avoid alcohol and other CNS depressants

Concept Mapping

ND # 1 Impaired physical mobility r/t hernia and seroma

Revised: Medical Surgical Committee 5/17/19
Data to support: 10

-hernia at incision
 Chief Medical Diagnosis: umbilical seroma w/
drainage
Priority Assessments:
ND # 2 Risk for infection r/t alteration in skin integrity -assess for further fluid accumulation
Data to support: -assess bowel sounds to make sure seroma has not
impacted bowel movements
-incision into abdominal skin
-assess WBC’s and monitor vitals for signs of
-open abdominal wound
infection
-fluid accumulation containing inflammatory response fluid and plasma

ND # 3 Risk for dysfunctional gastrointestinal motility R/T hernia and prolonged abdominal
muscle healing

Data to support:

-buildup of fluid/pressure due to seroma

-decreased muscle strength due incision and prolonged healing

-no bowel movement in 3 days

Revised: Medical Surgical Committee 5/17/19 11


ND
1.
Impaired physical mobility r/t
hernia and seroma AEB
hernia at incision, prolonged
muscle healing after hernia
surgery, open abdominal
wound
2.
Risk for infection r/t
alteration in skin integrity
AEB incision into abdominal
skin, open abdominal wound,
fluid accumulation containing
inflammatory response fluid
and plasma
3.
Risk for dysfunctional
gastrointestinal motility R/T
hernia and prolonged
abdominal muscle healing
AEB buildup of
fluid/pressure due to seroma,
decreased muscle strength
due incision and prolonged
healing, no bowel movement
in 3 days
Revised: Medical Surgical Committee 5/17/19
12
Nursing Interventions Classification (NIC)
Interventions
Assist pt with ADL’s and
BRP, educate pt on healing
and resting post-op, use
SCD’s instead of
ambulating, note
elimination status, assess
skin integrity and
reposition q2h
Monitor vitals q4h and
labs to check for signs of
infection, assess abdominal
wound site frequently,
apply clean dressings PRN
Frequently assess for fluid
buildup in seroma, listen to
bowel sounds and assess
bowel movements, assess
for distention, assess for
discomfort
Evaluation of Response
Assisted patient with a DL’s in order to prevent excessive or premature physical activity
after surgical incision.
Educated patient on the need to rest and heal after abdominal incision, patient
understands that he needs to remain on bedrest and avoid excessive physical activity to
prevent recurrent incisional hernia and fluid buildup.
Used SCD’s periodically to stimulate lower extremities so that patient did not have to
ambulate in order to prevent DVT.
Assessing patients elimination status to make sure that he is not straining the abdominal
muscles to void or eliminate.
Assessed skin integrity frequently and repositioned every two hours to maintain Braden
scale score and prevent decrease in skin integrity.
Vitals remained stable and normal with no increases in temperature or other signs of
infection.
Labs remained normal with no elevations or decrease in white blood cells.
Abdominal wound site was assessed frequently with no signs of erythema or edema.
Clean dressings or applied whenever dressing became saturated with drainage or as
needed.
Sterility maintained upon dressing change of abdominal incision to prevent spread of
bacteria to site.
Fluid buildup has not occurred since seroma was drained upon admission. Will continue
to monitor for fluid buildup.
Bowel sounds were assessed and slightly diminished. Nurse is talking to doctor to get a
laxative ordered.
Patient is asked about bowel movements and is assessed assisted during bathroom
privileges.
Abdomen is assessed frequently for distention and hardening with no abnormalities.
Patient is routinely asked about discomfort and understands that he needs to tell the
nurse if he is experiencing abdominal discomfort related to bowel movements.
SBAR REPORT: (What did you report off to the RN upon end of shift)
S: Pt is a 61-year-old male admitted for umbilical drainage.
B: Pt was admitted on 3/17 for drainage from the surgery site to repair an umbilical
hernia. Current pain is 0/10. Pt has PMH of HTN and depression. Pt is on a heart healthy
diet. Pt is on bed rest with frequent repositioning. BRP with assistance. Saline lock in LAC
flushed q8h and prn. Last IV flush was 1700 Braden scale score of 21. Pt currently takes
Prinivil 20mg PO daily, Protonix 40mg PO daily, Desyrel 100mg PO qhs, and is om
Lactated Ringers 1000mL IV at a rate of 75 MLS/ Q13h20m PRN.

A:
Primary Assessment
A. Airway- no obstructions
B. Breathing- no SOB, no cough, non-labored
C. Circulation- color WNL, no edema
D. Degree of consciousness/mental status- awake, fully oriented
E. Exposure/ Skin- No visible skin wounds, see integumentary
Secondary Assessment

Revised: Medical Surgical Committee 5/17/19

13
Neuro: AAOx4, PERRLA 3mm, clear speech, spontaneous motor response, calm
Resp: equal chest expansion, regular and even, lung sounds clear in all fields, pt on room
air
CV: regular heart rate & rhythm, S1/S2 sounds audible, no JVD, cap refill is < 2 sec in all
extremities, radial & pedal pulses present and +2 bilaterally, no clubbing, no cyanosis,
no edema
GI: abdomen round and soft, bowel sounds present and normal, LBM 3/15 PR
unassessed, no flatus
GU: bladder is nondistended, voiding, urine assessed
Skin: color WNL, warm & dry, abdominal wound with purulent drainage, good turgor,
Braden Scale- 21
Musculoskeletal: normal strength in all extremities

R: Monitor vitals q4h. Pt is to stay on bed rest with frequent repositioning. Allow pt BRP
with assistance. Keep pt on room air and heart healthy diet. Flush saline lock q8h and
prn. Change position q2h to: promote skin integrity, keep Braden scale at 21, and
maintain good circulation to extremities. Listen to bowel sounds to make sure seroma
Revised: Medical Surgical Committee 5/17/19
14
has not affected bowel movement. Monitor telemetry for any changes. Continue
medication administration as ordered. Encourage pt to ambulate and use SCD’s to
prevent DVT.

Revised: Medical Surgical Committee 5/17/19

15
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16