Preoperative Care of the Patient Scheduled for a Cholecystectomy

Questions:

Students should be prepared to describe the provision and patient care management of the following case(s) consistent with the course student learning outcomes (SLOs).

Apply complex skills and knowledge of assessment, diagnosis, planning, intervention, and evaluation in utilization of the nursing process with acutely ill patients and families. 

Demonstrate the ability to set appropriate priorities of care for acutely ill patients  including scientific/theoretical rationale for clinical decisions. 

Discuss research findings related to the care of acutely ill patients in the assignments. 

Demonstrate leadership in collaboration with preceptors and members of the health care team in coordinating services to patients, families and aggregates.

Analyze clinical situations and individual performance through reflective journaling and  student self-evaluation. 

History/Information: A 67-year-old male has been complaining of intermittent abdominal pain and nausea for the last several weeks. In the last two days, he suffered several bouts of vomiting that relieved the abdominal pain. He does not show signs of jaundice. An abdominal sonogram revealed multiple stones in the gallbladder and partial obstruction of the cystic duct by a stone, and the gastroenterologist diagnosed symptomatic cholelithiasis and cholecystitis. He scheduled the patient for a traditional cholecystectomy tomorrow morning. The surgeon explains to the patient and his wife he prefers to do an open cholecystectomy rather than a laparoscopic procedure in order to explore the common bile duct for possible stones. He tells the patient it is necessary for him to be admitted to the hospital today so his condition can be monitored. The patient signs the surgical consent form after speaking with his physician. On admission to the hospital, the patient exhibits abdominal pain radiating to right shoulder, fever and episodes of nausea and vomiting. His medical and surgical history includes Type II Diabetes, Coronary Artery Bypass Graft x4 two years ago, hypertension, chronic insomnia and a penicillin allergy. His cardiologist has cleared him for surgery. He is a retired post offi ce carrier. He and his wife have three children, none of whom live in close proximity. 

Admit for cholecystectomy; NPO with ice chips  IV 0.9% NS at 75mL/hour. Insert nasogastric tube to low continuous suction insert urinary catheter. Portable Chest x-ray 12-lead ECG.

Lab: UA, CBC, Electrolytes, BUN, Creatinine, Glucose, Bilirubin with Differentiation, INR, Liver Function Tests 

Ticarcillin 3.1g IVPB every 6 hours 

Meperidine 75mg IM every 6 hours prn pain 

Dicyclomine hydrochloride 2Omg IM every 6 hours 

Promethazine hydrochloride 12.5mg IV or IM every 6 hours prn nausea apply nitroglycerine 0.4g/hour transdermal at 0500 day of surgery Lovenox 40mg SQ daily.

Insulin glargine injectable 16 units SQ at bedtime 

Finger stick blood sugar AC and HS

Sliding scale regular insulin coverage: 

1. Blood sugar less than 80 notify healthcare provider 

2. Blood sugar 81 – 149 no coverage 

3. Blood sugar 150 – 200 5 units SQ 

4. Blood sugar 201 – 250 10 units SQ 

5. Blood sugar 251 – 300 15 units SQ 

6. Blood sugar greater than 300 notify healthcare provider 

7. Systemic Compression Device (SCD) or Intermittent Compression Device (ICD) when patient in bed.