Description
Age: 68 years
Gender: Female
Diagnosis: Post-operative care following Total Abdominal Hysterectomy (TAH)
Medical History: Hypertension, Type 2 Diabetes Mellitus, Obesity (BMI: 32), Hyperlipidemia
Surgical History: Total Abdominal Hysterectomy performed 24 hours ago due to uterine fibroids and abnormal bleeding
Current Medications:
Lisinopril 10 mg daily (for hypertension)
Metformin 500 mg twice daily (for Type 2 diabetes)
Atorvastatin 20 mg daily (for hyperlipidemia)
Acetaminophen as needed for pain
Background Information:
Mrs. Lewis was admitted to the hospital for a scheduled Total Abdominal Hysterectomy due to persistent uterine fibroids and abnormal uterine bleeding. She underwent the surgery yesterday with no intraoperative complications. She was transferred to the medical-surgical floor post-operatively.
Current Situation:
It is now post-op day 1. Mrs. Lewis is alert but reports moderate abdominal pain (6/10) at the surgical site. She has been reluctant to ambulate due to pain, and her urine output has decreased slightly. Her abdominal dressing is dry and intact, but there is slight redness around the incision site. Vital signs are stable except for a slightly elevated temperature of 100.2°F. She has not had a bowel movement since surgery and is experiencing some nausea.
She has an IV of 0.9% normal saline running at 75 mL/hr. Her most recent blood glucose was 172 mg/dL, and her blood pressure was 142/86 mmHg. The patient has not ambulated since the surgery.
Nursing Assessment:
Pain: Abdominal pain rated 6/10 at the surgical site, worsens with movement.
Mobility: Limited due to pain and fear of movement.
Elimination: Slight decrease in urine output; no bowel movement post-operatively.
Skin Integrity: Slight redness around the incision site.
Fluid Balance: Patient on IV fluids, urine output slightly decreased.
Nutrition: Patient is tolerating a clear liquid diet but reports some nausea.
Infection Control: Slightly elevated temperature (100.2°F), redness around the incision site, potential risk for infection.
Blood Glucose: Slightly elevated blood glucose (172 mg/dL).