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evital - NrC Realth
RN Alterations in Mobility Assessment
Question:
4 of 30
Time Elapsed: 02:10:20
A nurse is caring for a client who is postoperative following a laminectomy.
Exhibit
1 Exhibit.
2 Exhibit
3 Exhibit
4 History and Physical
One year ago: 39 - year - old client seen in office for low back pain. Conservative treatment recommended.
One month ago:
Client reports conservative treatment no longer managing back pain. MRI ordered.
One week ago:
Plan for laminectomy of
L^2 -L^4.
Today: 40 -year-old client who has chronic low back pain admitted for laminectomy.
A nurse is caring for a client who is postoperative following a laminectomy.
Click to highlight the findings that require immediate follow-up.
To deselect a finding, click on the finding again.
Head of bed elevated at
60°.
Bilateral dorsalis pedal pulses 1 +.
Lumbar dressing wet with clear drainage. Hypoactive bowel sounds in all four quadrants. Bladder distended. Client reports uable to initiate urination.
10 months agoReport content
Answer
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Step 1:: Identify the issues that require immediate follow-up.
- The lumbar dressing is wet with clear drainage, which may indicate excessive post-surgical bleeding or leakage from the surgical site. - The client's bladder is distended, and they are unable to initiate urination, which suggests a possible urinary retention issue.
Step 2:: Address the wet lumbar dressing.
- Notify the healthcare team about the wet dressing to evaluate the cause and address any potential complications. Additional interventions might include applying a new, dry dressing and monitoring the client's vital signs and drainage.
Step 3:: Address the urinary retention issue.
- Assess the client for other symptoms of urinary retention, such as discomfort or pain in the lower abdomen. - Encourage the client to attempt to void, and provide privacy and support as needed. - If the client is unable to void, a bladder scan may be performed to assess bladder volume and the need for catheterization. If a catheter is required, ensure that it is inserted aseptically, and the client is monitored for any signs of infection or discomfort.
Final Answer
The wet lumbar dressing and the client's inability to initiate urination are the primary issues that require immediate follow-up. It is essential to notify the healthcare team about the wet dressing and monitor the client's vital signs. Addressing the urinary retention issue may involve assessing the client for other symptoms, encouraging voiding, and potentially performing a bladder scan or catheterization.
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