Exam (elaborations)
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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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
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© 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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