1930 – Assessment completed
Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema.
Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored.
Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone.
Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied.
Client reported intermittent incisional pain of 3/10 described as ‘sore’.
Oral Temperature 100.4° F (38° C)
Pulse 93/minute
Respirations 18/minute
Blood pressure 111/69 mm Hg
O2 saturation 95% on room air
The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.
➢ Select three (3) assessment and vital sign findings that are highly concerning.
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