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Howard Reeves Preoperative Care of the Patient Scheduled for a Cholecystectomy
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Howard Reeves Preoperative Care of the Patient Scheduled for a Cholecystectomy
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Preoperative Care of the Patient Scheduledfor a Cholecystectomy
PNCI® - Learner
Howard Reeves
Age: 67
Weight: 70 kg
Location: Medical-Surgical
Unit
Background
Patient History
Past Medical History: His past medical and surgical history includes type II diabetes, coronary artery
bypass graf x4 two years ago, hypertension and chronic insomnia.
Allergies: Penicillin
Medications: Insulin glargine 16 units SUBCUT at bedtime
Code Status: Full code
Social/Family History: Retired mail carrier. Lives with his wife. Has three children who do not live nearby.
Handof Report
Situation:
The patient is a 67-year-old male who was admitted to the Medical-Surgical Unit for monitoring prior
to undergoing an open cholecystectomy tomorrow morning. His wife is at the bedside. The patient’s
bowel sounds are hypoactive and his abdomen is firm and painful to light palpation. He complains of
abdominal pain radiating to the right shoulder, fever and episodes of nausea and vomiting. He states
his abdomen feels full and is requesting “something for pain.” He rates his pain as 6 out of 10.
Background:
The patient has been experiencing intermittent abdominal pain and nausea for the last several
weeks. In the last two days, he has suffered several bouts of vomiting that relieved the abdominal
pain. He 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. He has been diagnosed
with symptomatic cholelithiasis and cholecystitis. The patient has been scheduled for an open
cholecystectomy tomorrow morning, but he has been admitted to the hospital today so he can be
monitored. The surgeon explained he prefers to do an open cholecystectomy rather than a laparoscopic
procedure in order to explore the common bile duct for possible stones. The patient signed the surgical
consent form afer speaking to the surgeon. His cardiologist has cleared him for surgery.
Program for Nursing Curriculum Integration
1
(PNCI®)
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, PNCI® - Learner
Handof Report Continued
Assessment:
Vital signs: HR 88, BP 126/68, RR 24, SpO2 98% on room air and temperature 37.7C
General Appearance: Alert and anxious. Grimacing wtih pain
Cardiovascular: Sinus rhythm
Respiratory: Breath sounds are clear
GI: Hypoactive bowel sounds. Abdomen firm and painful to light palpation. Complains of abdominal
fullness
GU: Voided 100 mL/hour clear amber urine
Extremities: Pink and warm. Movement equal in all four extremities
Skin: Pink, warm and dry
Neurological: Alert and oriented to person, place and time. Pupils equal, round and reactive to light
and accommodation. No neurological deficits
IVs: Saline lock in the right forearm
Labs: Admission labs need to be drawn
Fall Risk: Low risk for falls
Pain: Sharp abdominal pain in right upper quadrant radiating to back. Rates pain 6 out of 10 and
requesting something for pain.
Recommendations:
Admit patient to Medical-Surgical Unit, implement orders and monitor for instability
This study source was downloaded by 100000836551366 from CourseHero.com on 02-21-2022 10:17:09 GMT -06:00
https://www.coursehero.com/file/25397972/Learner-Howard-Reeves-preop-choledocx/
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