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Objective: Management of a post-operative patient after laparoscopic cholecystectomy.

Objective: Management of a post-operative patient after laparoscopic cholecystectomy.

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Patient Information

NAME: Chad Jones

AGE: 40

DOB: March 18, 1978

WEIGHT: 195 lbs. (88.6 kg)

HEIGHT: 67 inches (170 cm)

Past Medical History: Chad Jones is 40 years old. He lived in Poland until he was 12 years old and relocated with his mother and sister to the US at that time. He is currently married. Chad works as a grocery produce manager. He is approximately 40 lbs. overweight. Besides his activity being a produce manager, he does not participate in organized exercise.

He is being treated for hypertension, but otherwise healthy.

He is now status post laparoscopic cholecystectomy.

Situation: Mr. Jones had surgery very early this am. He is still somewhat sedated. He is complaining of upper right chest/shoulder pain that is pretty intense. He is alert and oriented x4. His wife has arrived and is visiting at this time.

Current Plan: Patient is experiencing post-operative pain. He has 4 incisions. Three located in the right upper quadrant and one is distal to the umbilicus. Current plan is to control pain and report any new findings to provider.

Provider Orders:

Foley catheter in place

0.9% Sodium Chloride infusing at 200 mL/hr.

Monitor SpO2 – Oxygen to maintain Sp02 greater than 94%

Start clear liquids once bowel sounds heard or passing gas.

Medications as per MAR.

Post Op Vital Signs

2 x 15 min

4 x 30 min

2 x 60 min, then Q 4hours

Sequential Compression Devices while in bed.

 

 

Medication Drug Classification, expected action, indication for use Possible Adverse Effects Medication or Food Interactions Nursing Considerations Client Education and Evaluation Client Education and Evaluation of Effectiveness Effectiveness
Aspirin
Hydrochlorothiazide
Lisinopril
Ondansetron
NS at 200 mL/hr
Dilaudid 1-2 mg Q2hr IVP as needed for pain

You do not have to look these up again as it was completed last week.

Pre-Simulation Questions: (3-5 full sentences detailing needs of this patient)

1.    What would be pertinent questions to ask this client during the assessment?

2.    What are the anticipated needs of this patient?

3.    What tasks need to be completed for this patient?

4.    How would you prioritize your assessment with this patient?

Expert Answer


1. a) Tell how you feel the pain? b) where is the pain? c) is it radiating to anywhere? d) how often it occur? e) is it occur in a sudden manner or here before? f) is this pain occur associated with any action? g) do you have fever before? h) how is …

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