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NR 325 Adult Health PNCI F - Preoperative Cholecystectomy; Howard Reeves $16.49   Add to cart

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NR 325 Adult Health PNCI F - Preoperative Cholecystectomy; Howard Reeves

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NR 325 Adult Health PNCI F - Preoperative Cholecystectomy; Howard Reeves

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  • February 17, 2022
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  • 2021/2022
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NR 325 Adult Health PNCI F - Preoperative Cholecystectomy;
Howard Reeves

H. Reeves
Age: 67

Weight: 70 kg

Height: 175 cm



Background
Patient History
Past Medical History:
 Type II diabetes
 Coronary artery bypass graft (CABG) x4 two years ago
 Hypertension
 Chronic insomnia

Allergies:
 Penicillin

Home Medications:
 Insulin glargine 16 units SUBCUT at bedtime

Code Status:
 Full code

Social/Family History:
 Retired mail carrier
 Lives with spouse
 Three children who do not live nearby

Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment findings where
appropriate and necessary.

The report should follow the SBAR format and include:

Situation:
 The patient is a 67-year-old individual who was admitted to the Medical-Surgical Unit
for monitoring prior to undergoing an open cholecystectomy tomorrow morning




Fundamentals - PNCI v6
This sPturdeyospoeurrcaetiwvaes Cdohwonlelocaydsetdebcyto10m0y000826556894 from CourseHero.com on
02-17-2022 08:14:04 GMT -06:00 1
© 2018 CAE Healthcare

https://www.coursehero.com/file/73006107/H-Reeves-scenario-pdf/

, PNCI F - Preoperative
CholecystectomyFundamentals (F) - Learner

Handoff Report Continued
 The patient’s spouse is at the bedside
 The patient’s bowel sounds are hypoactive and his abdomen is firm and painful to light
palpation
 The patient is complaining of abdominal pain radiating to the right shoulder, and rates
the pain 6/10
 The patient has a fever and episodes of nausea and vomiting
 The patient states “abdomen feels full” and is requesting “something for pain.”

Background:
 The patient has been experiencing intermittent abdominal pain and nausea for the
last several weeks
 In the last two days, the patient has suffered several bouts of vomiting that relieved
the abdominal pain
 The patient saw a gastroenterologist, who ordered an abdominal ultrasound that
revealed multiple stones in the gallbladder and partial obstruction of the cystic duct by
a stone
 The patient has been diagnosed with symptomatic cholelithiasis and cholecystitis
 The patient has been scheduled for an open cholecystectomy tomorrow morning, but
has been admitted to the hospital today so he can be monitored
 The surgeon explained the pateint prefers to do an open cholecystectomy rather
than a laparoscopic procedure to explore the common bile duct for possible stones
 The patient signed the surgical consent form after speaking to the surgeon
 The Cardiologist has cleared the patient for surgery

Assessment:
Vital Signs:
 HR 88
 BP 126/68
 RR 24
 SpO2 98% on room air
 Temperature
37.7C General
Appearance:
 Alert
 Anxious
 Grimacing with
pain Cardiovascular:
 Normal sinus
rhythm Respiratory:
 Lung sounds are clear
GI:
 Hypoactive bowel sounds
 Abdomen firm and painful to light palpation
 Complains of abdominal fullness




Fundamentals - PNCI v6
This sPturdeyospoeurrcaetiwvaes Cdohwonlelocaydsetdebcyto10m0y000826556894 from CourseHero.com on
02-17-2022 08:14:04 GMT -06:00 2
© 2018 CAE Healthcare

https://www.coursehero.com/file/73006107/H-Reeves-scenario-pdf/

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