NR 446 SIMULATION 3 ILEUS Care
Ileus Postoperative Care of the Patient
with Complications
HomeDocumentsPostoperative 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
m
er as
Background
co
Patient History
eH w
Past Medical History: Patient had an uneventful laparoscopic cholecystectomy two days ago. She was in
o.
good health prior to her surgery
rs e
ou urc
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
o
6 hours prn for pain Code Status: Full code
aC s
Social/Family History: She is recently widowed; her husband of 50 years died unexpectedly. She has one
vi y re
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.
ed d
Handoff Report
ar stu
Situation:
The patient is a 72-year-old female who had a laparoscopic cholecystectomy. She was discharged to
is
return home with a home health nurse care.
Th
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.
sh
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
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:50:40 GMT -05:00
https://www.coursehero.com/file/40671006/Simulation-3-Ileusdocx/
, 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
m
er as
environment
co
Orders
eH w
Initial Healthcare Provider’s Orders:
o.
Admit to home health rs e
ou urc
Diet as tolerated
Activity as tolerated and encouraged
o
aC s
Call healthcare provider office for increased pain or fever
vi y re
Monitor incisions for redness, drainage, warmth and odor
Schedule 2- week postoperative appointment with healthcare provider’s office
ed d
Discharge medications include: HYDROcodone 5 mg/acetaminophen 325 mg 2 tablets PO every 6 hours
ar stu
prn for pain
is
Th
sh
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:50:40 GMT -05:00
https://www.coursehero.com/file/40671006/Simulation-3-Ileusdocx/
Ileus Postoperative Care of the Patient
with Complications
HomeDocumentsPostoperative 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
m
er as
Background
co
Patient History
eH w
Past Medical History: Patient had an uneventful laparoscopic cholecystectomy two days ago. She was in
o.
good health prior to her surgery
rs e
ou urc
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
o
6 hours prn for pain Code Status: Full code
aC s
Social/Family History: She is recently widowed; her husband of 50 years died unexpectedly. She has one
vi y re
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.
ed d
Handoff Report
ar stu
Situation:
The patient is a 72-year-old female who had a laparoscopic cholecystectomy. She was discharged to
is
return home with a home health nurse care.
Th
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.
sh
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
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:50:40 GMT -05:00
https://www.coursehero.com/file/40671006/Simulation-3-Ileusdocx/
, 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
m
er as
environment
co
Orders
eH w
Initial Healthcare Provider’s Orders:
o.
Admit to home health rs e
ou urc
Diet as tolerated
Activity as tolerated and encouraged
o
aC s
Call healthcare provider office for increased pain or fever
vi y re
Monitor incisions for redness, drainage, warmth and odor
Schedule 2- week postoperative appointment with healthcare provider’s office
ed d
Discharge medications include: HYDROcodone 5 mg/acetaminophen 325 mg 2 tablets PO every 6 hours
ar stu
prn for pain
is
Th
sh
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:50:40 GMT -05:00
https://www.coursehero.com/file/40671006/Simulation-3-Ileusdocx/
