PNCI F - Postoperative Deep Vein Thrombosis
Fundamentals (F) - Learner
T. Wang
Age: 35
Weight: 95 kg
Height: 175 cm
Background
Patient History
Past Medical History:
• The patient was in good health until the accident
• Para-surfing three days ago when the patient lost control and slammed into some rocks
off shore
• The patient was brought to the Emergency Department (ED) via ambulance with a
fractured leg
• X-rays confirmed a fracture of the left femur
• Two days ago, the patient was taken to the Operating Room (OR) for an ORIF of the left
femur
• Recovery has been unremarkable
Allergies:
• No known allergies
Medications:
• None
Code Status:
• Full Code
Social/Family History:
• Not married but lives with a companion in a two-story, single-family home
• Athletic and exercises five times a week
• Works in construction
• The patient’s mother and father are both in good health
Fundamentals - PNCI v6
Postoperative Deep Vein Thrombosis
© 2018 CAE Healthcare 1
, PNCI F - Postoperative Deep Vein Thrombosis
Fundamentals (F) - Learner
Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment findings where
appropriate and necessary.
The report should follow the SBAR format and include:
Situation:
• The patient is a 35-year-old who underwent an ORIF of the left femur three days ago
• The patient is alert and oriented to person, place and time
• Currently experiencing acute pain in the left calf and rates pain 10 out of 10
Background:
• Patient had a para-surfing accident three days ago when they lost control of the board
and slammed into some rocks off shore
• The patient was initially admitted to the ED and later transferred to the Medical-Surgical
Unit
Assessment:
Vital Signs:
• HR 92
• BP 138/86
• RR 18
• SpO2 98% on room air
• Temperature 37.5C
Cardiovascular:
• Sinus tachycardia
• Slight edema to left calf
• Left pedal pulse 1+; Right pedal pulse 2+
Respiratory:
• Breath sounds clear
GI:
• Hypoactive bowel sounds
GU:
• Voided 800 mL during previous shift
Extremities:
• Antiembolism stockings and sequential compression devices on bilaterally
• Left femur surgical site dressing dry and intact
Skin:
• Pink, warm and dry
Neurological:
• Alert and oriented to person, place and time
• Pupils equal and reactive to light and accommodation
Fundamentals - PNCI v6
Postoperative Deep Vein Thrombosis
© 2018 CAE Healthcare 2
Fundamentals (F) - Learner
T. Wang
Age: 35
Weight: 95 kg
Height: 175 cm
Background
Patient History
Past Medical History:
• The patient was in good health until the accident
• Para-surfing three days ago when the patient lost control and slammed into some rocks
off shore
• The patient was brought to the Emergency Department (ED) via ambulance with a
fractured leg
• X-rays confirmed a fracture of the left femur
• Two days ago, the patient was taken to the Operating Room (OR) for an ORIF of the left
femur
• Recovery has been unremarkable
Allergies:
• No known allergies
Medications:
• None
Code Status:
• Full Code
Social/Family History:
• Not married but lives with a companion in a two-story, single-family home
• Athletic and exercises five times a week
• Works in construction
• The patient’s mother and father are both in good health
Fundamentals - PNCI v6
Postoperative Deep Vein Thrombosis
© 2018 CAE Healthcare 1
, PNCI F - Postoperative Deep Vein Thrombosis
Fundamentals (F) - Learner
Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment findings where
appropriate and necessary.
The report should follow the SBAR format and include:
Situation:
• The patient is a 35-year-old who underwent an ORIF of the left femur three days ago
• The patient is alert and oriented to person, place and time
• Currently experiencing acute pain in the left calf and rates pain 10 out of 10
Background:
• Patient had a para-surfing accident three days ago when they lost control of the board
and slammed into some rocks off shore
• The patient was initially admitted to the ED and later transferred to the Medical-Surgical
Unit
Assessment:
Vital Signs:
• HR 92
• BP 138/86
• RR 18
• SpO2 98% on room air
• Temperature 37.5C
Cardiovascular:
• Sinus tachycardia
• Slight edema to left calf
• Left pedal pulse 1+; Right pedal pulse 2+
Respiratory:
• Breath sounds clear
GI:
• Hypoactive bowel sounds
GU:
• Voided 800 mL during previous shift
Extremities:
• Antiembolism stockings and sequential compression devices on bilaterally
• Left femur surgical site dressing dry and intact
Skin:
• Pink, warm and dry
Neurological:
• Alert and oriented to person, place and time
• Pupils equal and reactive to light and accommodation
Fundamentals - PNCI v6
Postoperative Deep Vein Thrombosis
© 2018 CAE Healthcare 2
