Xavier University-Ateneo de Cagayan

COLLEGE OF NURSING
4th Floor, Faber Hall

73 Corrales Avenue, Cagayan de Oro city

Case analysis WEEK 1 & 2 OR Rotation

Case in Focus:
Equivalent to:
✓ 27.2 RLE hours for 4 days
✓ 6.8 RLE hours per day (Synchronous and Asynchronous)

Learning Outcomes:
a. Integrate relevant principles of social, physical, natural and health science
and humanities into the care of patients undergoing surgery.
b. Apply appropriate nursing concepts and actions holistically and
comprehensively.
c. Interpret necessary information regarding the patient and her condition.
d. Analyze the patients’ health status based on data provided.

Day 1 - Situationer: OR case

✔ We are on our first day of the 2-day OR-duty week-1. We receive a case of a 47-
year-old married female (SL) who was admitted in the emergency room at 8:00 am
with a chief complaint of multiple stab wound penetrating to pleural area. She was
then referred to the Surgery department for further management at 8:02 am.
✔ At 8:11 am, client SL is seen & examined by Dr. K (Surgeon) who made an
impression of HEMOTHORAX LEFT LUNGFIELDS and wrote the following
orders:

- Schedule for Emergency thoracostomy left.

- Secure Clearance and Consent.
- Inform Dr. L for Anesthesia
- May start Venoclysis of PNNS 1-liter fast drip the first 200cc then
regulate at 30 gtts/min.
- Strictly on NPO
- Secure 3 Unit Fresh Whole Blood of patient’s blood type and crossmatch
on STANDBY.
- Monitor V/S every 30 minutes
- Refer for signs of cardiopulmonary problem
Patients Profile:
Name: Client SL
Age: 52 Sex: Female
Civil Status: Married
Date and Time of admission: September 20,2021 @ 8:00am
Chief complaint: Multiple Stab would.

Baseline Vital Signs:

T – 36 C
PR – 96
RR – 40
BP – RU – 140/100 mmhg
LU - 130/90 mmhg
O2 sat – 89 %

Laboratory Result:

CBC CHEST X_RAY

WBC
18,000/mm3
RBC 3x 10/UI
Hgb 8.5 g/dl Massive Hemothorax
Hct 40 %
WBC Differential count
Neutophils 52%
Lymphocytes 42%
Monocytes 2%
Eosinophils 2%
Basophils 1%

Platelet Count
200,000/mm3
Guide Questions:

1.Discuss the clinical manifestations supporting the diagnosis?

(Aside from what the client manifests, consider other Signs and Symptoms
associated with the condition).
2. Analyze the laboratory results and draw inferences/interpretations.
3. As an OR nurse, gather a complete and accurate endorsement information form
the ER nurse.

✔ At 10:20 am patient SL was wheeled and endorsed directly to OR via stretcher.

Case scenario:

Intraoperatively, Patient had cardiopulmonary arrest. The Anesthesiologist inserted the

endotracheal tube. Multiple premature ventricular contractions noted on the monitor, the
staff Circulating nurse administers Cardiac medications. After the operation Patient then
transferred directly to Surgical ICU.

4. Identify the responsibility of a Scrub nurse & Circulating Nurse for the
whole procedure.
6. Make a Pathophysiology of the case.
7. Discuss at least 3 priority nursing diagnoses intraoperatively and explain the
appropriate interventions with rationale?
 8. Narrate the activities from the moment you received the client from the ER until her
endorsement to the SICU.
9. Document the nursing care provided to the client intraoperatively in a narrative
Format.

NCM 114 – Week

10. If your patient is 80 - year-old, what are the clinical considerations before, during
and after surgery.
11. Make a justification why older people undergoing surgery are at higher risk of
postoperative complications?
12. Discuss briefly what type of anesthesia might be used during surgery of an older
person?

3. Setting: Surgical ICU

14. What are the important endorsement in general that you give to the SICU
nurse?

Direction:

1. Answer the guide questions and use A4, Arial 11.

2. Individual output but submit it by group.
3. Date of submission will be on or before September 27 ,2021

Prepared by:
JESUSA C. GABULE, RN MN
09177931972