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Case No: Major Circulating 1 CI: Sir JN Paat

Name of Student: John Raphael Sanchez Date of Submission: October 13, 2017
Year and Section: 3NUR-8
OR Preference Cards
Name of Patient: T.M.L. Age: 19 Sex: Male Civil Status: Single
Date of Admission: October 12, 2017 Date of Surgery: October 12, 2017 Time Started/Ended: 2:25pm-3:00pm
Bed #: 4029 Hospital No: 17-120000022244 Admission No: 17J00375
Surgeon: Dr. Rodriguez Montenegro, MD Assistant Surgeon: Dr. P. Quinto, MD Anesthesiologist: Dr. E. Tan, MD
Scrub Nurse: Algem Paul V. Lagunsad, RN Circulating Nurse: Christopher James Z. Ruiz, RN
Chief Complaint: Patient had epigastric pain radiating to hypogastric pain accompanied by vomiting previously ingested food.
Abdominal Pain (8/10)
Pre-Operative Diagnosis: Appendicitis

Rationale/Definition: Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spead to its other
parts. It may be due to a seedling that is stuck inside the appendix which causes inflammation.

Pathophysiology: Appendicitis is caused by obstruction of the appendiceal lumen by feces, seedling, etc. The obtruction then causes
an increase in pressure in the lumen. This also results to accumulation of secretions and causing the bacteria to multiply leading to
recruitment of white blood cells and formation of pus and increase pressuure.

Obstruction in the Pressure increases within

Risk factors Accumulation of secretion
appendiceal lumen the lumen
Formation of pus Increase WBC Bacteria multiplies

Post-Operative Diagnosis: Acute Congestive Appendicitis

Rationale/Definition: It is the acute inflammation of the appendix, a small organ that is attached to the cecum.

Complete Surgical Procedure: Appendectomy “E”

Rationale/Define: Appendectomy is the surgical removal of the appendix. It is a common emergency surgery that is performed to treat
appendicitis, an inflammatory condition of the appendix.
Type of Anesthesia: Local regional anesthesia
Specific Technique: Items Used to Administer Anesthesia: Anesthesia machine, syringe
Main Anesthetic Agent: Bupivocaine
Mechanism of Action: Bupivacaine is indicated for local infiltration, peripheral nerve block, sympathetic nerve block, and epidural and
caudal blocks
Other Medications Used: N/A
Position: Supine
Equipments Used for Positioning: Surgical table, Body strap, arm rest with strap
Incision: Righ lower quadrant incision
Skin Preparation: Disinfectant spraying of all quadrants of the abdomen
Disinfectant Used: Cutasept
Draping: Disposable sterile towels and laparotomy sheet

Surgical Safety Checklist:

Regular Richardson Mayo Straight Babcock Two-thirds gauze
Baby Richardson Kelly Curve/Straight Army Navy Swabs
Metz scissors Knife/holder Needle holder
Mayo Curve Needle Allis
Sign Out
Sign In Sign In
Nurse verbally confirms:
Is the patient’s identity, site, Has the Surgical Site YES
• The name of the
procedure and consent YES Infection (SSI) bundle been procedure to be
CONFIRMED? undertaken? YES recorded
• Antibiotic prophylaxis • If instruments,
Is the surgical site marked? YES YES
within the 60 mins sponges, sharps, and YES
Is the anesthesia machine and • Patient warming YES needle counts are
medication chart checked? • Hair removal/shave site complete
• Glycemic control NO
Is the pulse oximeter attached Has the specimen been
YES Has venous
and working? labeled correctly? YES
thromboembolism (including patient’s name)
Equipment needed available NO
YES prophylaxis been undertaken?
and checked Specimen: APPENDIX
Does the patient has any: Is essential imaging displayed Pathologist: Dr. Peralta

• Known allergies NO Any equipment problems

Is the initial count done and NONE
• Difficult airway or NO recorded?
aspiration risk Any concerns for transfer
• Risk of blood loss NO to recovery and NONE
management issues
Time Out
Confirm if all team members Focus Progress Notes
introduced themselves and YES
their roles?

Patient’s identity and Pain Data: When asked about how he was
procedure to be done and site YES feeling, he verbalized, “ang sakit ng tiyan
of operation confirmed ko, pain scale 8/10”
Action: Pain scale was assessed and the
To surgeon: any anticipated data was relayed to the physician for
NONE orders.
critical events

To anesthesiologist: any
NONE Anxiety Data: Patient showed silence and is very
patient specific concerns
and pale with shaking feeling.
To scrub nurse: any Sterile and Nervousne
instruments/suture concerns complete ss

To perfusion/technician: any
equipment issues?