Jim Sanderson is a 65-year-old male who is admitted for acut

Jim Sanderson is a 65-year-old male who is admitted for acute lower… Jim Sanderson is a 65-year-old male who is admitted for acute lower abdominal pain which was the result of a ruptured appendix. He had an open appendectomy and is now post-operative day three. He refuses to use the incentive spirometer or get up in the chair and requires encouragement to get out of bed and ambulate on the unit. His appetite is poor, and he eats a small portion of his meals but tolerates and drinks fluids readily. He has had 2200 mL intake to 1800 mL urine output the past 24 hours. He denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and senna tabs daily. His abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds. His incision site in his RLQ has no drainage. Swelling and mild erythema noted along the edge of the incision. Current Complaint: Jim puts on his call light. When you arrive, he states he feels nauseated. He has an order for ondansetron 4 mg IV every 4 hours PRN for nausea, and this is administered. Thirty minutes later he puts his call light on again, stating that his nausea has gotten worse. While in the room, he begins to wretch and has a small bile green emesis. What PRIORITY data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) (list 2 for each section) RELEVANT Data-Present Problem: Clinical Significance: RELEVANT Data-Current Complaint: Clinical Significance: Nursing Assessment Begins: Current VS: Most Recent VS: Current WILDA: T: 99.2 F/37.3 C (oral) T: 99.4 F/37.4 C (oral) Words: ache/cramp P: 92 (reg) P: 74 (reg) Intensity: 5/10 R: 24 (reg) R: 18 (reg) Location: generalized abdomen BP: 168/88 BP: 142/80 Duration: ongoing-started last hour O2 sat: 93% room air O2 sat: 98% room air Aggravate: movement Alleviate: rest¬†Health Science Science Nursing NURSING NUR 100

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