ShelbySilvertooth

This was a test question, I went with urgency because to me that would happen before confusion. Another question was asking what is the most accurate way to assess hydration status, I&O, daily weights, or skin turgor. I went with I&O, but curious what someone else may believe. Thanks!

Patient admitted with bowel obstruction secondary to chronic diverticulitis. He had a right colectomy and a primary anastomosis between the ileum and transverse colon. Pt is a smoker, drinks several drinks on the weekend, has a desk job, and is not active including poor eating habits. 48 hours post-op his morning assessment includes an "okay" O2 stat (not specifically given), R 24, T 37.7, P 92 B/P 144/80 pain 3/10 sharp in abdomen. Urine output 200 mL clear amber. Distended abdomen, hypoactive bowel sounds, diminished and shallow lung sounds. No edema, cap refill His afternoon assessment the same day includes R 30, T 38.4, O2 91%, B/P 150/86, no nausea or vomiting, urine output: 60 mL/hr., he is awake and oriented x3, rales and fluid sounds in lungs, pain 4/10 located in R&L chest and gets worse when deep breathing, pt states pain in chest is worse than his abdominal incision. His tissue perfusion/cap refill are fine. He has a productive cough with green sputum. Hypoactive bowel sounds. No edema. It is clear to me that this patient has an infection. In the scenario our teacher says we have not concluded whether his infection is related to pneumonia or foley catheter and that we would need to have a urinalysis done to check for infection and a sputum sample be done to test for pneumonia. Without knowing what specifically is causing this infection how can i come up with a priority nursing diagnosis? It's quite clear pneumonia is more likely going on and the cause of this infection but nothing has been proven.

It doesn't say anywhere basic assessment provided that it was

I don't think a related factor can be a surgery

In my nursing diagnosis hand book related factors for the diagnosis say hypertension

My patient is an older woman who fell while grocery shopping and broke her right hip. She had a right hip replacement. It's 2 days post op and her right pedal pulse is absent, however left one is present. She has edema in right foot and her dressing from her surgery is saturated in blood. History of CHF, hypertension, and afib. She is on warfarin. I came up with the nursing diagnosis of "Ineffective peripheral tissue perfusion r/t hypertension, anemia, inactivity, and pt. taking warfarin AEB absence of pedal pulse in r foot, edema in r foot, blood saturated dressing, and lab results indicating low H&H." Does this make sense or does it need to be revised? I didn't know if her CHF could be incorporated anywhere in it? Thanks!