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Case NR 325 (NR325) PNCI F - Preoperative Cholecystectomy; Howard Reeves. LATEST UPDATE 2022.
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PNCI F - Preoperative Cholecystectomy; Howard Reeves.
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PNCI F - Preoperative CholecystectomyFundamentals (F) - Learner
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
Preoperative
This study source was Cholecystectomy
downloaded by 100000804166229 from CourseHero.com on 02-19-2022 13:01:11 GMT -06:00
© 2018 CAE Healthcare 1
https://www.coursehero.com/file/73006107/H-Reeves-scenario-pdf/
, PNCI F - Preoperative Cholecystectomy
Fundamentals (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
Preoperative
This study source was Cholecystectomy
downloaded by 100000804166229 from CourseHero.com on 02-19-2022 13:01:11 GMT -06:00
© 2018 CAE Healthcare 2
https://www.coursehero.com/file/73006107/H-Reeves-scenario-pdf/
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