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Case No: Circulating Major 1

Name of Student: Clarice Gabrielle B. Sanchez

Year/Section & RLE: 3NUR8 RLE4

Name of Patient: M.A.G.B. Age: 30 Sex: F Civil Status: Single

Date of Admission: 9/25/17 Time Started & Ended: 2:05 PM 3:20PM
Date of Surgery: 10/5/17
Bed #: 4020 Hospital No: 17-020000079878 Admission No: 17100742

Surgeon: Gerald T. Alcid M.D. Anesthesiologist: Dr. V. Jamora

Assistant Surgeon: Dr. Umil Scrub Nurse: Arnold Jeff S. Cadian R.N.
Dr. Lira Montalbo Circulating Nurse: Clarisse V. Hernandez R.N.

Chief Complaint: Difficulty of Breathing


Post-Operative Diagnosis: Pulmonary Metastasis, Pancreatic Adenocarcinoma Stage IV (Lung Metastasis)


Complete Surgical Procedure: Knee Arthroscopy Left Knee


Type of Anesthesia: General & Regional

Specific Technique: Continuous Thoracic Epidural Anesthesia (CTEA) + GAOT ( Double Lumen Endotacheal Tube |DLT)
Items used to Administer Anesthesia: Stimuplex 20Gx4.30, Terumo G21 (5cc&10cc), Terumo G23 (3cc), Spinocan 27Gx 3 ,
needle 25G, Spinocan 25Gx3 , KY lubricant, Stimuplex HNS12
Main Anesthetic Agent: Ropivacaine
Mechanism of Action:
Other Medications: Rocorium
Morphine Sulfate
Mechanism of Action:
Position: Lateral
Equipment used for Positioning: N/A
Incision: postero lateral thoracotomy
Skin Preparation: Thoracic preparation
Disinfectant Used: Cutasept
Draping: 4 small towel sheets, Laparotomy sheet

Sign In Time Out Sign Out

Is the patients identity, YES Time Out: 2:00 PM Nurse verbally confirms:
site, procedure and The name of the YES
consent CONFIRMED? Patient Buraga Mary Ann Gonzales, procedure to be
Is the surgical site YES age 30, scheduled for Mini recorded
marked? Thoracotomy under general If instruments, YES
Is the anesthesia machine YES anesthesia. sponges, sharps
and medication chart and needle
checked? Surgeon is Dr. Gerald Alcid, assisted counts are
Is the pulse oximeter YES by Dr. Umil. complete
attached and working? Anesthesiologist is Dr. V. Jamora. Has the specimen been YES
Equipment needed YES labeled correctly?
available and working? Scrub Nurse is Arnold Jeff Cadian. And (including patients name)
Does the patient has any: Circulating Nurse is Clarisse
Known allergies NA Hernandez. Patient was given
Difficult airway/aspiration Specimen: Pleural
risk? Tissue
Risk of blood loss / Fluid
Has the Surgical Site NA Pathologist: Dr.
Infection (SSI) bundle Lopez
been undertaken? Any equipment problems NONE
Antibiotic prophylaxis identified?
within the 60 minutes Any concerns for transfer NONE
Patient warming to recovery and
Hair removal/shave site management issues
Glycemic control
Has venous YES
prophylaxis been
Is essential imaging YES
Is the initial count done YES
and recorded?

Date and Time Focus
8/31/2017 Risk for Falls D: Patient was sedated, is groggy and mutters incoherent
Ensure proper positioning of the patient.
Lower the level of the OR table
Ensure that straps are secured
Decrease environmental stimulation by dimming the lights.
Support and assist patient right after the procedure.

R: Prevented falls during and after the procedure.