The nurse whо is cаring fоr а 70-yeаr-оld male client admitted to the ICU for an elective lobectomy of the right middle and lower lobe. History and Physical: The client was not due to have the lobectomy for another two weeks, but after his appt with the thoracic surgeon, the became a direct admission to the unit with plans to have the surgery in the am. Past medical history for lung cancer of the right middle and right lower lobe, COPD, hypertension, and CAD. Denies illicit drug use. Prior smoker of 2 packs per day x 30 years. Quit smoking within the last year with lung cancer diagnosis. The client is retired for the past 5 years, previously worked as an auto mechanic for all his adult life. Within the last year, he past ownership of the auto shop to his son. He visits the shop several times a week and helps his son. Family history of lung cancer with his brother that passed away over 10 years ago. All the men in his family have been smokers, including his son. The client has been in and out of the hospital in the last six months due to reoccurring upper respiratory infections. The client voices complaints of shortness of breath (SOB) and pain with deep breaths that has been going on for the past week. Appetite has been poor, but usually he is a “meat and potato” guy. Nurses Note: 8/20/24 at 1000: Client is alert and oriented x 3. The client is obese. Height 6’0”, weight 136 kg. Client placed on telemetry monitor. Vital signs: 99.1*F, P 94, RR 20, BP 140/56, SpO2 90% on room air. Lung sounds diminished bilaterally. Occasional moist cough, with small amount of light-yellow sputum production. Breathing is labored at times. Skin is warm with poor skin turgor. Capillary refill 3 seconds. No edema to bilateral lower extremities (BLE). Pedal and posterior tibial pulses are present, equal, and weak. Abdomen is large, nontender with bowel sounds present to all quadrants. 8/20/24 at 1030: Admission orders obtained. HOB elevated. O2 via NC applied at 2L/min. Client voiced sitting upright helped being able to breathe. SpO2 improved to 93% on 2L/min O2 via NC. Pre-op labs drawn and portable CXR obtained. 8/20/24 at 1040: Client started on broad spectrum antibiotic. Pre-op teaching with incentive spirometer and cough deep breathing completed at this time. 8/20/24 at 1100: CXR results showing pulmonary densities to the right middle and lower lobes, and bibasilar infiltrates. Laboratory Values Result Reference Range White blood cells (WBCs) 14.1 103/mm3 4-10 103/mm3 8/21/2024 at 0600: Client night was uneventful. Client prepped for surgery with report given to OR nurse. Client taken to OR at this time. 8/21/2024 at 1300: Client arrived on unit, accompanied by PACU nurse and respiratory therapist. Client is intubated and lightly sedated. Chest tube to right chest at -20 suction with 100ml of sanguineous drainage in atrium. Dressing C/D/I. Lung sounds clear to the upper lobes, slightly diminished to the lower lobes. SpO2 96% on current vent settings. Client is breathing with the vent at a RR of 20. 8/24/2024 at 0900: Client is 3 days postop, day 2 post extubation. Client has not required supplemental O2 for the last 24 hours. SpO2 94% on room air. Chest tube to right chest is to water seal with 10ml of serous drainage out last shift. Dressing to site is C/D/I. No crepitus heard or felt on examination. Lung sounds clear bilaterally. Client denies SOB. Client is up, walking arounds the unit with staff 2-3 times per shift. VS: 98.1*F, P 86, RR 20, BP 132/60. After reviewing the client information, select which finding indicates the client’s condition is improving. Select all that apply.
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