Reference no: EM133704897

Question

Nurses' Notes DAY 1 1200: Admitted to the surgical unit after an L2-L4 laminectomy with Jackson Pratt (JP) drain placement. Has a history of Type II diabetes and back pain for 10 years that was unrelieved with pharmacologic pain management. Jackson Pratt (JP) drain has 30 mL of output upon arrival to floor and is emptied. Bloodwork sent to lab after surgery. She is alert and oriented x4, pupils are 3 cm bilaterally, denies numbness or tingling in extremities, 5/5 strength in all extremities. Pain rated 6/10. Foley removed before arrival to floor around 1100 and she is due to void. The surgical dressing is clean, dry, and intact. Day 1 1330: Pain level 3/10 after oxycodone administration Day 1 1600: The client's neurologic status remains stable. The client reports her back feels "wet". There is 0 mL of output from the JP drain, the drain is uncompressed, and the surgical dressing is saturated with dark red blood. She reports bending over to get her call bell from the floor. She has not voided since Foley catheter was removed but reports the urge to go. Reports her last bowel movement was two days before surgery.