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Book/movie review
22/08/2022
Post-op Cholecystectomy
Background Info:
42-year-old female patient presented to the emergency room after experiencing two weeks of nausea, dyspepsia, fever, and upper abdominal pain. A HIDA scan was completed confirming the diagnosis of acute cholecystitis. The pt. underwent a laparoscopic cholecystectomy late this morning and just returned to the floor from the PACU 1 hr. ago. She received a total of 1500ml LR during the procedure, and 6mg Morphine and 4 mg Zofran in the PACU. Her last set of vitals in the PACU: P-88, R-20, BP-122/76, and O2Sat 95% on 2L of O2 via NC. The pt. is a full code, allergic to latex, adhesive tape, and bees. She lives alone with one cat, she’s overweight but currently working on weight loss, denies smoking and drinks a few glasses of wine a week. Additional past medical and surgical history considerations include routine mammogram (2020), tonsillectomy (1987), wisdom tooth removal (1998), high cholesterol and non-insulin dependent diabetes managed with Metformin.
Ignatavicius, D.D. (2021).
Nutrition: Cholecystitis/Cholecystectomy. St. Louis, MO: Elsevier.
Current Assessment/Facts:
· T- 98.9 F, P-89, R-18, BP- 135/75
· O2 sat- 96% on 2L NC.
· Abdomen is soft and round
· Significant nausea present
· Lungs clear
· Heart rate regular
· NPO
· Alert and oriented x 4
· Abdominal pain of 7/10
· 20 gauge peripheral IV in her right lower arm
· FSBG- 190
· NS @ 100ML per hour
· 2MG of morphine was administered 45 minutes ago
· Wean O2 to keep Sat’s above 90%
· Bruising on her right arm from IV attempts
· SCD’s and TEDS on
· 4 lap incisions to the abdomen clean, dry, and intact
· IV Zosyn q6h ordered.
· WBC- 15,000
Critical Thinking:
1. What’s missing from your report?
2. What should you remain on alert for with this patient?
3. What are the important assessments to make?
4. What complications could occur with this patient?
The writer is very fast, professional and responded to the review request fast also. Thank you.
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