Case Study 3 of 6
The nurse is caring for a 56- year-old female client, day 3 post op
hysterectomy.
Notes
0800
Client alert and oriented, diaphoretic. Lung sounds clear bilaterally, heart sounds, S1, S2. Surgical site red around the edges, edematous and large amount of purulent,
odorous drainage noted on the dressing. Client reports increased pain with use of the PCA pump rated at 9/10 on a 0 to 10 pain scale.
Vitals
0800
BP 122/64 mm Hg
Pulse 97 bpm
Resp 19
O2 97% RA
Temp 101.4 F
1200
BP 91/52 mm Hg
Pulse 126 bpm
Resp 28
O2 94% RA
Temp 100.5 F
Labs
Day 1
RBC 4.1 mill/mL (4.5-6 million/mL)
Hemoglobin 11g/mL (12-18 g/mL)
Hematocrit 36% (38%-48%)
WBC 17,000mg/dL (5,000-10,000mg/dL)
Lactic Acid 5.5mmol/L (>4mmol/L)
