NR 446 Simulation 3 Ileus.docx - Care Ileus Postoperative Care of the Patient with Complications Ileus PNCI\u00ae Learner Alice Smythe Age 72Weight 55 kg Location Simulation 3 Ileus.docx

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NR 446Simulation 3 Ileus.docx - Care Ileus Postoperative Care of the Patient with Complications Ileus PNCI\u00ae Learner Alice Smythe Age 72Weight 55 kg Location Simulation 3 Ileus.docx HomeDocume... ntsPostoperative Care Ileus.docx Postoperative Care of the Patient with Complications: Ileus PNCI® - Learner Alice Smythe Age: 72Weight: 55 kg Location: Patient’s home/Medical-Surgical Unit Background Patient History Past Medical History: Patient had an uneventful laparoscopic cholecystectomy two days ago. She was in good health prior to her surgery Allergies: No known drug allergiesMedications: Aspirin 325 mg by mouth every day; multivitamin 1 tablet by mouth every day; HYDROcodone 5 mg/acetaminophen 325 mg 2 tablets by mouth every 6 hours prn for pain Code Status: Full code Social/Family History: She is recently widowed; her husband of 50 years died unexpectedly. She has one daughter who lives out of state. The daughter was present after her father’s death and for the surgery, but had to return home because of her career and family. The patient lives alone in a two-story house. Handoff Report Situation: The patient is a 72-year-old female who had a laparoscopic cholecystectomy. She was discharged to return home with a home health nurse care. Background: The patient had a laparoscopic cholecystectomy two days ago. She stayed overnight after the surgery for observation and then was discharged home. The patient lives alone. Assessment upon discharge from hospital one day ago: Vital signs: HR 92, BP 135/76, RR 18, SpO2 98% on room air and temperature 37.0C General appearance: Appears stated age Cardiovascular: Sinus tachycardia. Peripheral pulses strong Respiratory: Breath sounds clear and equal bilaterally GI: Bowel sounds absent. Abdomen soft with mild tenderness upon palpation GU: Voids spontaneously Extremities: Equal movement bilaterally Skin: Pink, warm and dry. Abdominal incisions sites intact with small amount of redness and no drainage Neurological: Alert and oriented to person, place and time. Pupils equal and reactive to light and accommodation IV: None Fall Risk: Low riskPain: Complains of minimal pain, rated 2/10 Recommendations: Perform physical assessment, including assessing incisions; Monitor for postoperative complications and assess home environment Orders Initial Healthcare Provider’s Orders: Admit to home health Diet as tolerated Activity as tolerated and encouraged Call healthcare provider office for increased pain or fever Monitor incisions for redness, drainage, warmth and odor Schedule 2- week postoperative appointment with healthcare provider’s office Discharge medications include: HYDROcodone 5 mg/acetaminophen 325 mg 2 tablets PO every 6 hours prn for pain Transcript Postoperative Care of the Patient with Complications: Ileus PNCI - Learner Alice Smythe Age: 72Weight: 55 kg Location: Patients home/Medical-Surgical Unit Background Patient History Past Medical History: Patient had an uneventful laparoscopic cholecystectomy two days ago. She was in good health prior to her surgery Allergies: No known drug allergies Medications: Aspirin 325 mg by mouth every day; multivitamin 1 tablet by mouth every day; HYDROcodone 5 mg/acetaminophen 325 mg 2 tablets by mouth every 6 hours prn for pain Code Status: Full code Social/Family History: She is recently widowed; her husband of 50 years died unexpectedly. She has one daughter who lives out of state. The daughter was present after her fathers death and for the surgery, but had to return home because of her career and family. The patient lives alone in a two-story house. Handoff Report Situation: The patient is a 72-year-old female who had a laparoscopic cholecystectomy. She was discharged to return home with a home health nurse care. Background: The patient had a laparoscopic cholecystectomy two days ago. She stayed overnight after the surgery for observation and then was discharged home. The patient lives alone. Assessment upon discharge from hospital one day ago: Vital signs: HR 92, BP 135/76, RR 18, SpO2 98% on room air and temperature 37.0C General appearance: Appears stated age Cardiovascular: Sinus tachycardia. Peripheral pulses strong Respiratory: Breath sounds clear and equal bilaterally GI: Bowel sounds absent. Abdomen soft with mild tenderness upon palpation GU: Voids spontaneously Extremities: Equal movement bilaterally Program for Nursing Curriculum Integration (PNCI) 2012 CAE Healthcare, Sarasota, FL v.5 1 Postoperative Care of the Patient with Complications: Skin: Pink, warm and dry. Abdominal incisions sites intact with small amount of redness and no drainage Neurological: Alert and oriented to person, place and time. Pupils equal and reactive to light and accommodation IV: None Fall Risk: Low risk Pain: Complains of minimal pain, rated 2/10 [Show More]

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