0700 Handoff Report: S Mr. A, a 72-year-old male, is 2 days postop small bowel

0700 Handoff Report:
S Mr. A, a 72-year-old male, is 2 days postop small bowel resection. His NG tube is connected to continuous low wall suction and has drained 75 mL of tan-colored fluid. Vital signs at 0600: T 99.6° F, P 90, R 28, BP 160/94, pulse ox 94%. He has D5/0.45% NS with 20 mEq KCl infusing at 125 mL in the right forearm, 300 mL are left. He is using the PCA with relief, pain level 2.
B History and physical indicate that Mr. A has a history of Crohn’s disease, experiencing watery bloody diarrhea.
A Abd soft, faint bowel sounds present ×2 quadrants. He slept most of the night and is now sitting in a chair. SOB was noted when he was transferred to the chair. Lung sounds diminished in the right lower lung.
1200 nursing assessment: Oriented ×3, skin WNL, capillary refill less than 3 sec, turgor good, mucous mem-branes moist, pinkish, T 99°F, P 88 and slightly irregular, R 20, BP 164/94, pulse ox 96%. NG draining brownish fluid 100 mL since 0800. Bowel sounds present ×4, abd soft. Foley catheter draining clear yellow urine.
Mr. A has minimal complaints and is visited by the physician at 1200. The physician writes the following orders:
-Remove Foley now
-Encourage incentive spirometer every hour ×10
-Discontinue NG tube
-Discontinue furosemide
-Discontinue IV digoxin
-Start digoxin 0.25 mg PO
-Daily Hgb & Hct today
-Clear liquid diet
Identify the nursing interventions that require immediate follow-up.
Identify the nursing actions that you can delegate/assign to unlicenced personnel