Postoperative Care of the Patient with
Complications: Pneumonia
PNCI® - Learner
Leo Halgren
Age: 55
Weight: 80 kg
Location: Surgical Unit
Background
Patient History
Past Medical History: No significant medical history
Allergies: No known allergies
Medications: None
Code Status: Full code
Social/Family History: : Plumber works 40 hours a week. Divorced with three
independent adult children and two grandchildren. Recently engaged and plans to be
married within the next six months. Lives with his fiancée. His father died of colon
cancer before the age 60. Patient has smoked 2 packs a day for most of his adult life
Handoff Report
Situation:
The patient is a 55-year-old male who is one day postoperative after an abdominal-
perineal (A-P) resection for colorectal cancer, colostomy, lymph nodes dissection and
liver biopsy. His surgical dressings are dry and intact, his nasogastric tube is draining
minimal secretions and he has been resting comfortably since returning from surgery.
Background:
He presented to his healthcare provider with complaints of fatigue, rectal
bleeding and a change in bowel patterns (constipation alternating with diarrhea).
Initial diagnostic testing revealed anemia, a carcinoembryonic antigen level of 22
and a positive CT scan showing a mass in the sigmoid rectal region. He has had
no other significant medical history.
Assessment:
Vital signs: HR 92, BP 144/80, RR 24, and SpO2 95% on room air. Temperature 37.7C
General Appearance: Well-nourished, appears stated age
Cardiovascular: Sinus rhythm
Program for Nursing Curriculum Integration (PNCI®) 1
© 2012 CAE Healthcare, Sarasota, FL v.5
This study source was downloaded by 100000840858457 from CourseHero.com on 02-26-2022 19:25:11 GMT -06:00
https://www.coursehero.com/file/69107907/Human20Sim20Post20Op20Pneumonia20Leo20Halgren20Student20Version20REVISED202019docx/
Complications: Pneumonia
PNCI® - Learner
Leo Halgren
Age: 55
Weight: 80 kg
Location: Surgical Unit
Background
Patient History
Past Medical History: No significant medical history
Allergies: No known allergies
Medications: None
Code Status: Full code
Social/Family History: : Plumber works 40 hours a week. Divorced with three
independent adult children and two grandchildren. Recently engaged and plans to be
married within the next six months. Lives with his fiancée. His father died of colon
cancer before the age 60. Patient has smoked 2 packs a day for most of his adult life
Handoff Report
Situation:
The patient is a 55-year-old male who is one day postoperative after an abdominal-
perineal (A-P) resection for colorectal cancer, colostomy, lymph nodes dissection and
liver biopsy. His surgical dressings are dry and intact, his nasogastric tube is draining
minimal secretions and he has been resting comfortably since returning from surgery.
Background:
He presented to his healthcare provider with complaints of fatigue, rectal
bleeding and a change in bowel patterns (constipation alternating with diarrhea).
Initial diagnostic testing revealed anemia, a carcinoembryonic antigen level of 22
and a positive CT scan showing a mass in the sigmoid rectal region. He has had
no other significant medical history.
Assessment:
Vital signs: HR 92, BP 144/80, RR 24, and SpO2 95% on room air. Temperature 37.7C
General Appearance: Well-nourished, appears stated age
Cardiovascular: Sinus rhythm
Program for Nursing Curriculum Integration (PNCI®) 1
© 2012 CAE Healthcare, Sarasota, FL v.5
This study source was downloaded by 100000840858457 from CourseHero.com on 02-26-2022 19:25:11 GMT -06:00
https://www.coursehero.com/file/69107907/Human20Sim20Post20Op20Pneumonia20Leo20Halgren20Student20Version20REVISED202019docx/
