Question

M.C. is a 36-year-old female who had a Laparoscopic cholecystectomy.

She was under general anesthesia and required a fluid bolus during the intraoperative phase.

Post -Op Vitals- 98.8 Temp

                          86 HR

                          16 RR

                          104/65 BP

                          O2 Sat 94% on 4 liters NC

Surgical Incisions - 4 small incisions on her abdomen with glue and steri-strips

Allergies – none

Home medications- Aspirin

                                Metformin

                                Omeprazole

Medical History - DM

                            HTN

                            GERD

M.C. lives at home with her husband and 3 children between the ages of 6-12.

M.C. is a stay at home mom and her husband runs his own business at the home.

Develop a care plan for this patient which will include:

1. Diagnostics needed for patient

2. What will your assessment include for the patient

3. Education will include disease, medications, and at home teaching

4. What specialists should be added to the patient’s care plan?

Answer 1

1.The diagnostics whochbeill be neede for tre patient are

Preoperative

• CBC
• TZripls H (HIV,HCV,HepatitisB)
• Coagulation profile
• Liver function test
• Renal function test
• Blood group
• Urine analysis
• ECG
• Chest X ray
• USG Abdomen

Postoperatively

• CBC

2.The assessment which will be needed for this patient are

• Subjective data: Collecting information about the postoperative status
• Objective data:
  • Inspection:Assessing the dressing site for any signs of infection or pain
  • Monitor vital signs
  • Assess intake and output
  • Monitor vitals
  • Assess for any surgical complications
  • Assess the blood glucose levels

3.Medication

• Restarting the oral antiglycemic drug
• To complete the course of antibiotics

Home teaching

• Medication adherence
• Proper follow up
• Do not drive if taking any narcotic pain killers
• No heavy weight lift for atleast six weeks
• Mild exercise is allowed no straining or strenuous exercise
• Keep wound dry and clean
• Report in case of diarrhea, constipation ,pain or any abnormal symptoms

Disease

• To follow a low fat diet to prevent recurrence

4.The specialist who can be added in the care are

• Dietitian or a nutritionist to plan for appropriate diet
• Physiotherapists to ensure physical exercise if needed
• Diabetologist to control his blood glucose levels
• Gastroenterologist to look out for gastrointestinal problems
• Cardiologist to tracknznd maintain his blood pressure under control.