The nurse has just received the change-of-shift report about Mr. E, a 26-year-old man who had a ruptured appendix with emergency appendectomy 2 days ago. The report included this information about Mr. E’s vital signs, assessments, and prescribed therapies: Vital Signs: temp 101.4, pulse 118 resp 28, BP 98/56, O2 saturation 90%(decrease from 98% over past 4 hrs) Assessment: fine crackles heard throughout lungs with non-productive cough. Bowel sounds are present with brown purulent drainage from wound drain. Therapies: O2 at 2L/min per nasal cannula, Vancomycin and ceftriaxone IV. Arterial blood gases, CBC, BUN, electrolytes and glucose labs pending. Vancomycin trough level ordered. 1. Based on the information in the change-of-shift report, what is the nurse’s greatest concern about Mr. E and why? purulent abdominal drainage sinus tachycardia decreased oxygen saturation elevated temperature.
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