UNIVERSITY OF BOHOL

0186 Dr. Cecilio Putong Street

Tagbilaran City, Bohol,
Philippines Telefax No.
(038)411-3101
www.universityofbohol.com
College of Nursing

POST-OPERATIVE VISIT REPORT

Student’s Name: MARIA CHARMIN M. MEJIA Level/Section: BSN 3- RUBY

Dates of Exposure: Dec 10-12, 2020 Name of Patient:
_____JA________________Ward/Bed No.: PACU

Age/Sex/Civil Status: 18 yrs. Old/female/Single Date of Visit: Dec 10-12, 2020

Date of Operation: ___________________________

Surgeon: ___________________________________
Assistant Surgeon: ____________________________
Anesthesiologist:______________________________
Scrub Nurse: __Maria Charmin M. Mejia_

I. Post-Operative Diagnosis: ____ Ruptured of the appendix ________________

a. Definition: Is a surgical operation in which the vermiform appendix is removed.

b. Indication for procedure: is generally indicated for patients with a history of

persistent abdominal pain, fever,and clinical signs of localized or diffuse peritonitis,
the lower abdomen and subsequently localized to the RLQ, open appendecromy has
bee the most common approach.

III. System and Organ Involved for

Operation
a. ( ): CNS: ____________________________________________________
b. ( ) EENT: __________________________________________________
c. ( ): Cardio: __________________________________________________
d. ( ): Respi: ___________________________________________________
e. ( ): GI: Intestinal and appendix
f. ( ): Endo: ____________________________________________________
g. ( ): Renal: ____________________________________________________
h. ( ): Urinary: ________________________________________________
i. ( ): Repro: ________________________________________________
j. ( ): Musculo-Skeletal: ____________________________________________
 k. ( ): Skin: _____________________________________________________

IV. Skin Preparation

Manner:
a. [ ]: Bathing:
b. [ ]: Shaving:
c. [ ]: Area:

d. Other Preparation:
_________________________________________________________________
___________________________________________________________________
________________________________________________________________

V. Operative Position
a. [ ]: Dorsal/Supine Position
b. [ ]: Trendelenburg’s Position
c. [ ]: Reverse Trendelenburg’s Position
 d. [ ]: Fowler’s/Sitting Position
e. [ ]: Prone Position
f. [ ]: Knee-Chest Position
g. [ ]: Jackknife/Kraske Position
h. [ ]: Lateral Position
i. [ ]: Lithotomy Position
j. [ ]: Others:____________________________________________

VI. Incision
a. Abdominal Incisions and
Applications
i. [ ]: Right Subcostal (Gallbladder, Biliary System)
ii. [ ]: Left Subcostal (Spleen)
iii. [ ]: Median Upper Abdominal (Stomach, Duodenum, Pancreas)
iv. [ ]: Right Upper Paramedian (Stomach, Duodenum, Pancreas)
v. [ ]: Left Lower Paramedian (Pelvic Structures, Colon)
vi. [ ]: Median Lower Abdominal (Uterus, Adnexia, Bladder)
vii. [ ]: McBurney (Appendix)
viii. [ ]: Left Oblique Inguinal (hernia repair)
ix. [ ]: Lower Transverse “Pfannensteil” (Uterus, Ovaries, Tubes, CS)
x. [ ]: Others: ________________________________________________

VII. Anesthesia

a.Type
i. [ ]: Local
ii. [ ]: Regional Nerve Block
iii. [ ]: Spinal Anesthesia
iv. [ ]: Epidural Anesthesia
v. [ ]: Balanced Anesthesia
vi. [ ]: General Anesthesia
vii. [ ]: ( ) Others/
( ) None: _________________________________________________

b. Position for Induction

i. [ ]: Dorsal/Supine Position
ii. [ ]: Trendelenburg’s Position
iii. [ ]: Reverse Trendelenburg’s
Position
iv. [ ]: Fowler’s/Sitting Position
v. [ ]: Prone Position
 vi. [ ]: Knee-Chest Position
vii. [ ]: Jackknife/krasfe Position
viii. [ ]: Lateral Position
ix. [ ]: Lithotomy Position
x. [ ]: Others

VIII. Basic Operative

Procedure
a. Pack
i. [ ]: Minor Pack
ii. [ ]: Minor Pack

b. Instrument
i. [ ]: Basic Set
ii. [ ]: Minor Set
iii. [ ]: Neuro Set
iv. [ ]: OB Set
v. [ ]: Other Set:_________________________________________________

c. Additional Instruments:
i. Mayo straight scissors
ii. Kelly straight mayo scissor
iii. Metzenbaum scissor

d. Draping:
● From the longitudinal length of the sterile green towel, it is folded on-third
away from the sterile nurse.
● From the longitudinal length of the sterile green towel, it is folded one-
third away from the sterile nurse.
● Four towel clamps are used to anchor the initial drapes and are placed
properly
● Place the laparotomy sheet with opening in it directly over the skin are
outlined by the sterile green towel. The thick fold is forwards he foot part
of the patient while the thin fold is directed towards the head part.
● Drop the folds over the sides of the table.
● While the thick fold is supported by one hand, and the thin fold on
opened
Draping the head part of the patient over the anesthetic screen.
 IX. Post-Operative
Management

If the patient is restless, something is wrong.

Look out for the following in recovery:
● Airway obstruction
● Hypoxia
● Haemorrhage: internal or external
● Hypotension and/or hypertension
● Postoperative pain
● Shivering, hypothermia
● Vomiting, aspiration
● Falling on the floor
● Residual narcosis

The recovering patient is fit for the ward when:

● Awake, opens eyes
● Extubated
● Blood pressure and pulse are satisfactory
● Can lift head on command
● Not hypoxic
● Breathing quietly and comfortably
● Appropriate analgesia has been prescribed and is safely established
 X. Post-Operative
Medication

Drug Classification Indication Mechanism Intervention

of Action

Cefuroxime ● Antibiotic For treatment of Bactericidal: ● Assess any

750mg BID IV ● Cephalosporin many different Inhibits synthesis history of allergy
types of bacterial of bacterial cell with this drug.
infections such as wall, causing cell
bronchitis, death.
● Culture infection,
and arrange for
sinusitis,
sensitivity tests
tonsillitis, ear
before and during
infection, skin
therapy if
infections,
expected
gonorrhea, and
response is not
urinary tract
seen.
infection.
● Give oral drug
with food to
decrease GI
upset and
enhance
absorption.
● Have vit. K
available in case
hypoprothrombin
e-mia occurs.
● Instruct the pt to
report any
unusualities.
● Instruct pt to
avoid alcohol
while taking this
drug and for 3
days after
because severe
reactions often
occur.
 ● Monitor VS
● Explain the side
effects of the drug
● Health teachings
for the pt

Flagyl 500mg Antibiotic General Hinders growth of Before

BID IV Antibacterial Indications: selected ● assess pts.
Amebicide organisms, Infection
Antiprotozoal ● amebic including most ● watch carefully
hepatic anaerobic for edema
abscess bacteria and because it may
protozoa cause sodium
● intestinal retention
amebiasis ● assess skin for
severity areas of
● trichomoniasis local adverse
reactions
● retractory ● record number
trichomoniasis and character of
stools
● bacterial ● assess pt’s and
infection family’s
caused by knowledge of
anaerobic drug therapy
microorganis
ms During
● give drug with
● to prevent meals to minimize
postoperative GI distress
infection in ● to treat
contaminated trichomoniasis,
colorectal give drug for
surgery 7days instead of
2-g single dose
● pelvic ● use only after
inflammatory T.vaginalis has
disease been confirmed
by wet smear
 ● tablets may be
crushed for pt’s.
with difficult
swallowing
● do not use
aluminium
needles or hubs,
color will turn
orange/rust

After
● tell pt. that
metallic taste and
dark or red brown
urine may occur
● instruct pt. to take
oral form with
meals to minimize
reactions
● instruct to
complete full
course of therapy
● tell pt. not to use
alcohol or drugs
that contain
alcohol.
● may cause
dizziness/ light
headedness

Paracetamol Analgesic ( Non- To relieve Paracetamol ● Assess patient’s

opioid) mild to may cause fever or pain: type
of pain, location,
Antipyretic moderate analgesia by
intensity,
pain due to inhibiting duration,
things such CNS temperature, and
as headache, prostaglandin diaphoresis.
muscle and synthesis. ● Assess allergic
joint pain, The reactions: rash,
backache mechanism urticaria; if these
occur, drug may
and period of morphine
pains. It is is believed to have to be
also used to involve discontinued.
bring down a decreased ● Teach patient to
recognize signs
high permeability
of chronic
temperature. of the cell overdose:
membrane to bleeding,
sodium, bruising, malaise,
which results fever, sore throat.
in diminished Tell patient to
transmission notify prescriber
for pain/ fever
of pain
lasting for more
impulses than 3 days.
therefore
analgesia.
XI. Patient Status

STABLE VITAL SIGN WTH IV