Southern Luzon State University

College of Allied Medicine

Lucban, Quezon

CESAREAN SECTION OPERATION

In Completion to the Requirements of the CATCH-UP Plan of the

Operating Room Area

Submitted to:

Mrs. Thelma Babia RN, MAN

Submitted by:

Lagata Denise P.
Raymundo, Krizzia Mari C.

Group 2
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

I. SCRIPT OF ROLE-PLAYING

CESAREAN SECTION – BREECH CASE SCENARIO

DEFINITION

RISKS AND COMPLICATIONS OF INTERNAL FIXATION

INDICATIONS FOR INTERNAL FIXATION

DIAGNOSTIC IMAGING
LABORATORY
POSSIBLE NURSING DIAGNOSES:

CASE SCENARIO
Scenario: The patient is a 36 years old female, gravida 2, para 1 with 41 weeks of high-risk
pregnancy, and late prenatal care. According to the patient’s medical chart, she reported
abdominal pain, edema in the feet and legs, and no contraception use prior to conception.

The patient’s principal diagnosis was breech presentation - footling. Secondary diagnosis and
concerns expressed by the patient’s physician were the possibility that the umbilical cord was
wrapped around the baby’s neck, the patient’s weight, the potential for fetal or placental
problems, and previous cesarean section.
SCENES:
--------------------------------------PREOPERATIVE------------------------------------------

---------------------------------------INTRAOPERATIVE PHASE------------------------------------

END OF OPERATION
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

PRE-OPERATIVE CHECKLIST

1. Patient’s Name: Patient Fluffy Bear Date: 07/12/21

Height: 189 cm Weight: 60 kg
Identification Band Present: Patient Fluffy, May 1, 1994
2. Informed Consent signed: Yes
3. Surgical Site: Right Arm Mid Humerus
4. History & Physical Examination report present:
Patient Fluffy Bear, a 27-year-old, fell down some stairs at school yesterday, landing on
his outstretched right hand. His GP arranged an X-ray the same day, which showed no fracture.
He had significant arm pain overnight and was referred for an MRI this morning. It showed an
open fracture of his arm.
Physical examination reveals that he was conscious and oriented to time and place,
afebrile, has an arm pain, skin is smooth and with ecchymosis noted on the right arm, with
swelling and erythema, with crepitus noted upon moving the affected arm, with a visible
deformity noted on the right arm.
Date: 07/13/21
5. Laboratory records present:
CBC:
● WBC: 12,000
● RBC: 4.9 mcl
● PTT: 28
● PT: 12 sec.
● INR: 0.9%
Hgb: 16 g/dL
UA: Negative
Hct: 46%

6. Item Present Removed

a. Natural teeth /
Dentures: upper, /
lower, partial
bridge, fixed;
crown

b. Contact lenses /
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

c. Other Prosthesis /

d. Jewelry: /
Wedding ring
Earrings: Pierced,
Clipped-on
Neck chains /
Any other body
piercings

e. Make up /
Nail polish
7. Clothing:
a. Clean patient /
gown
b. Cap /
c. Sanitary pad etc.

8. Family instructed where to wait? Waiting Area outside OR complex

9. Valuables secured? Yes within wife of patient
10. Blood Available? Yes
11. Pre-anesthesia medications given: Ativan
Type: intravenously Time: 8:20 am
12. Voided: 5 times Amount: 154 ml Time: 7:15 am Catheter: Foley
Catheter
13. Vital signs:
Temperature: 36.9 degrees C PR: 95 bpm RR: 21 bpm BP: 110/70 mmHg
14. Special problems/precautions (Allergies, deafness, etc): None
15. Area of skin prep: Right anterior mid humerus

16. Christine Jane C. Estangco 07/13/21 9:00 am

Signature: Nurse releasing patient Date Time
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

SURGICAL MEMO FORM

Name: Fluffy A. Bear DOB: January 19, 1994

Phone: 09162427912 Email: fluffy@gmail.com

Address: IbabangIyamLucena City, Quezon Province

Pre - Op Date: 07/07/21 Surgery Date:07/07/21

Diagnosis: Right Humeral Fracture

Surgery Rec: Right Arm

Anesthesia: Regional Nerve Block Anesthesia Dosage:4.5mg

PATIENT HISTORY

Medical History:Patient Fluffy fell down some stairs at school yesterday, landing on his
outstretched right hand. His GP arranged an X-ray the same day, which showed fracture. He had
significant arm pain overnight and was referred for an MRI this morning. It showed a fracture of
his arm.

Surgery 1: Open Reduction Internal Fixation Date:07/07/21

Surgery 2:

Surgery 3:

Medication 1:Acetaminophen Dosage: 650 mg

Medication 2: Ativan Dosage:2 mg

Medication 3: Dosage:

Allergies: None
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

Other Medical Conditions: NONE

EXAMINATIONS

Height: 5’6’’ Weight: 63 kg BMI: 24.2 Normal

Temp: 36.9 Pulse: 175 BP: 120/80 RR: 22

HEENT: Atraumatic Neck: No Jugular Vein distension, No Mass

Heart: Regular, No Murmur Lungs: Clear Breath Sound

Abdomen: Non - Tender Extremities: Fracture on Right Upper Arm

Labs: Normal X-Rays: Humeral Fracture

EKG: U/A: Within normal range

RESULTS

 The patient is cleared for surgery

□ The patient is not cleared for surgery
□ Further test required

07/07/21
Signature Date
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

INSTRUMENT COUNT SHEET

PATIENT NO: #153

ID #153 TRAY BASIC CIRC Christine Jane Estangco

ORTHOPEDI
C TRAY
DAT 07/07/2 ASSEMBLE Daryl Joyce S. SCRU Daryl Joyce S. Tenorio
E 1 D BY: Tenorio B
QTY INSTRUMENT DESCRIPTION 1ST ADDE 2ND FINAL
COUN D COUN COUN
T T T
4 RAKE RETRACTORS 4 - 4 4
2 WEITLANER 2 - 2 2
2 ARMY NAVY RETRACTOR 2 - 2 2
2 TOOTHEDTISSUE FORCEPS 2 - 2 2
2 TOOTHEDADSON FORCEPS 2 - 2 2
2 STRAIGHT MAYO SCISSOR 2 - 2 2
2 CURVED MAYO SCISSOR 2 - 2 2
2 METZENBAUM 2 - 2 2
1 BANDAGE SCISSOR 1 - 1 1
1 WIRE CUTTER 1 - 1 1
1 PIN CUTTER 1 - 1 1
2 CURVED PEAN CLAMP 2 - 2 2
2 KOCHER LOVE LACE 2 - 2 2
5 CURVED CRILE 5 - 5 5
2 NEEDLE HOLDERS 2 - 2 2
8 TOWEL CLIPS PIERCING 8 - 8 8
8 TOWEL CLIPS NON-PIERCING 8 - 8 8
1 SPONGE FORCEP 1 - 1 1
1 YAUNKER SUCTIONTIP 1 - 1 1
3 KNIFE HANDLE 3 - 3 3
2 PLIER 2 - 2 2
2 SCREW DRIVER 2 - 2 2
1 MALLET 1 - 1 1
1 RULER 1 - 1 1
1 DEPTH GAUGE 1 - 1 1
3 GUIDE WIRE 3 - 3 3
1 RASP 1 - 1 1
1 HANDLE DRILL WITH CHUCK 1 - 1 1
3 LISTON BONE CUTTER 3 - 3 3
2 PERIOSTEAL ELEVATOR 2 - 2 2
1 JOKER CUSHING ELEVATOR 1 - 1 1
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

1 FREER DISSECTOR 1 - 1 1
6 CURETTE 6 - 6 6
1 BLUNT NERVE HOOK 1 - 1 1
1 GIGLI SAW 1 - 1 1
6 OSTEOTOMES 6 - 6 6
10 SCREWS 10 - 10 10
3 SHEET WADDING 3 - 3 3
2 BLADES 2 - 2 2
4 SUTURES 4 - 4 4
6 ALLIS FORCEP 6 - 6 6
6 KELLY FORCEP 6 - 6 6
6 STRAIGHT KELLY FORCEP 6 - 6 6
6 MOSQUITO 6 - 6 6
129 TOTAL INSTRUMENT COUNT 129 0 129 129

FINAL COUNT: 129 Total Instruments Count - COMPLETE

CIRCULATOR: Christine Jane Estangco
SCRUB: Daryl Joyce S. Tenorio
DATE/TIME: 07/07/21 – 9:00 – 11:30 am
PROBLEM: None
COMMENT:
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

FDAR SAMPLE CHARTING IN OR

Time Focus 6-2 pm

7:30 am Open D> Received into the operating room per stretcher accompanied by
Reduction NOD and nursing assistant with ongoing IVF Lactating Ringer’s
Internal Solution 1L inserted at left cephalic vein at 800 cc level, infusing
Fixation of the well, conscious, and coherent, with informed consent signed for
right mid ORIF, operative site marked by Dr. Valdez, pre-anesthetic
humerus medsgiven, Ativan 2 mg intravenously, Acetaminophen 650 mg IV,
8:00 am fracture with NPO diet
------------------------------------------------------------------------
A> Preoperative interview done, preoperative and post-operative
instructions given such as pain relief measures, verified patients’
identity, and given psychological support, preoperative checklist
completed, prepared, and follow up blood bag and hard copy of CT
8:30 am scan imaging results, secured availability of plates and pins to be used
during the operation.----------------------------------------------------------
>Ushered to the OR table in supine position, with preoperative vital
8:45 am signs BP: 110/70 mmHg, PR: 95 bpm, RR: 21 bpm, T: 36.9 C, O2
Sat: 98%, O2 inhalation administered @ 2 LPM per nasal cannula
>Given regional nerve block 4.5 mg anesthesia by Dr. Valdez, no
9:12 am adverse reactions were noted during the induction of anesthesia.
>Skin prepped in the right arm, then draped by Scrub Nurse Daryl.
>Time out was initiated, Dr. Valdez as surgeon, Nurse Daryl as scrub
nurse, Nurse Christine as circulating nurse, Dr. Karen as
9:15 am anesthesiologist, initial count of instruments were done, verification
of patient, operation and operative site was done.------------------------
9:55 am >Time of operation started where an incision was done by Dr. Valdez,
10:03 am assisted by Nurse Daryl.-----------------------------------------------------
>Plates were placed and screwed in place.-------------------------------
>Final counting of instruments was initiated before closing, and
10:12 am informed the surgeon about the results, sponges, needles, and
10:20 am instruments count were complete.------------------------------------------
>Operation was finished.----------------------------------------------------
>Application of dressing and cast was done, post-op care was done,
10:40 am post operative vital signs were recorded, BP: 100/70 mmHg, PR: 91
bpm, RR: 23 bpm, T: 37.3 C, O2 Sat: 99%-------------------------------
>Into recovery room per stretcher with IVF of LRS @ 400 cc
level.----------

Christine Jane C. Estangco

BSN III-SLSU CAM
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

NARRATIVE REPORT

OPERATION:ORIF

DESCRIPTION: 
□ Open reduction internal fixation (ORIF) with irrigation and debridement of open
fracture.

PREOP DIAGNOSIS:

□ Right open humeral fracture

POSTOP DIAGNOSIS:
□ Right open humeral fracture.

INTRAVENOUS FLUIDS: 

□ 650 packed red blood cells.

TOURNIQUET TIME: 
□ 2 hours.

URINE OUTPUT: 
□ 1600 cubic centimeters.

ESTIMATED BLOOD LOSS: 

□ 250 cubic centimeters.

COMPLICATIONS: 
□ None.

PLAN:
□ Non-weightbearing right lower extremity, clindamycin x 48 hours.

OPERATIVE NARRATIVE:
 Southern Luzon State University
College of Allied Medicine
Lucban, Quezon

 The patient is a 27-year-old female who fell down some stairs at school yesterday,
landing on his outstretched right hand. She sustained a right open humeral fracture. Given the
emergent nature of the right humeral fracture and her young age as well as the open fracture, it
was decided to proceed with an urgent operative intervention. The risks of surgery were
discussed in detail and the consents were signed. The operative site was marked. The patient
was taken to the operating room where she was given preoperative clindamycin. The patient had
then general anesthetic performed by anesthesia.
A well-padded side tourniquet was placed. Attention was turned to the right humerus.
The large medical laceration was extended, and the tissues were debrided. All dirty of the all-
injured bone, muscle, and tissues were debrided. Wound was then copiously irrigated with 8
liters of normal saline. At this point, the medial malleolus fracture was identified and was
reduced. This was then fixed in with two 4.5 mm cannulated Synthes screws.
Next, the patient was then placed in the fracture table and all extremities were well
padded. All prominences were padded. The right arm was then prepped and draped in usual
sterile fashion. A 2-cm incision was made just distal to the greater trochanter. This was carried
down sharply through the skin to the fascia. The femur was identified. The guidewire for a
striker Asnis 6.5 mm screw was placed in the appropriate position. The triangle guide was then
used to ensure appropriate triangular formation of the remainder of the screws. A reduction of
the fracture was performed prior to placing all the guide wires. A single 8 mm Asnis screw was
placed inferiorly followed by two 6.5 mm screws superiorly.
Next, the abrasions on the right elbow were copiously irrigated. The necrotic and dead
tissue was removed. The abrasions did not appear to enter the joints. They were wrapped with
Xeroform 4 x 4 x 4 Kerlix and Ace wrap.
The patient was placed in the AO splints for the right arm. The wounds were dressed in
Xeroform 4 x 4 x 4s and IO band. The care was then transferred for the patient to Halstead
Service.
The plan will be non-weightbearing right upper extremity and antibiotics for 48 hours.
Dr. Valdez was present and scrubbed for the entirety of the procedure.