​​​​​​Patient Data

Exhibits

Review H and P, nurse's notes, and laboratory results.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Rationale

A. An elevated neutrophil count suggests an active immune response to infection, supporting the clinical findings of purulent drainage. This information is crucial for the healthcare provider to assess the severity of the infection and guide treatment.

B. Hematocrit changes are more related to blood volume, fluid shifts, or bleeding rather than infection. While it may be monitored postoperatively, it does not provide specific information about infection.

C. Platelet count is important for assessing clotting function but does not directly indicate infection or purulent drainage.

D. Serum sodium levels are part of electrolyte balance and hydration status monitoring but do not directly relate to the presence of infection.

Rationale

A. Monitoring intake and output closely is essential to assess fluid balance and ensure adequate hydration. Replacing fluids intravenously based on this assessment helps maintain hemodynamic stability and prevent dehydration, electrolyte imbalances, and hypovolemia.

B. After surgery for fistula repair, it is important to monitor wound drainage to assess for complications such as infection or delayed healing. Excessive drainage may indicate issues with wound healing or ongoing inflammation, requiring timely intervention.

C. Turning the client every 2 hours helps prevent complications such as pressure ulcers and respiratory complications. It promotes circulation, prevents skin breakdown, and aids in lung expansion. However, while important, this intervention is more focused on preventing physical complications rather than directly addressing the client's immediate medical needs post-surgery.

D. Clients with inflammatory bowel disease, especially those undergoing surgery and critically ill, are at increased risk for skin breakdown due to factors such as decreased mobility, medication effects, and overall health status. Regular skin assessments help detect early signs of breakdown and allow for prompt intervention to prevent pressure ulcers or skin complications.