PNCI F - Preoperative Cholecystectomy
Fundamentals (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 whereappropriate 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 formonitoring prior to
undergoing an open cholecystectomy tomorrow morning
1
, 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 lastseveral 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 revealedmultiple 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 hasbeen admitted to
the hospital today so he can be monitored
The surgeon explained the pateint prefers to do an open cholecystectomy rather than alaparoscopic
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
2
Fundamentals (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 whereappropriate 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 formonitoring prior to
undergoing an open cholecystectomy tomorrow morning
1
, 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 lastseveral 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 revealedmultiple 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 hasbeen admitted to
the hospital today so he can be monitored
The surgeon explained the pateint prefers to do an open cholecystectomy rather than alaparoscopic
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
2
