Date and F For Total Abdominal Hysterectomy Bilateral Salphingo

Time of Oophorectomy (TAHBSO)

charting
7AM D Into OR, a 60_y/o female, from ward per stretcher,
accompanied by transport aide and staff nurse. With an ongoing
IVF of D5NM 1L X8hrs infusing at the right hand. “Medyo
kinakabahan lang ako pero wala eh andito na” as stated by the
patient. With consent for surgery signed by the patient, dated
10/4/2021.

Wheeled to OR #3, positioned on supine at OR bed. Attached to

cardiac monitor. With vital signs of: BP 120/80 mmHg, PR =
80bpm, RR = 20cpm, T = 36.7°C and SpO2 of 97%O2 inhalation
administered by NOD at 1-2 lpm per nasal cannula.

8:15AM Skin preparation on lumbar area done by Dr. Purganan,

Bupivacaine anesthesia inducted by Dr. Dacumos. Then
repositioned back to supine. Initial sponge and instrument count
done by RN LIM and RN Paguel. Skin preparation on operative
site done by Dr. Purgnan. Sterile draping followed.

8:30AM Operation started whereby vertical incision at the lower

abdomen was done.

9:50AM Layer by layer suturing started. Bleeders clamped, cauterized,

sponged.
End of procedure whereby TAHBSO surgery is completed by Dr.
Purganan, assisted by Dr. Dacumos; Site painted with betadine
and covered with sterile dressing. Final sponge and instrument
count done by RN Lim and RN Paguel. Back of patient was
cleaned, dried and gown changed by OR Technician. Then
transferred to PACU bed.
A Received from ward nurse using the surgical safety checklist.
Verified name and procedure to be done. Checked for signed
consent and pre-op checklist completed. Assisted to OR
stretcher, raised side rails and put OR cap on patient. Assisted
in transferring patient to OR # 3, positioned comfortably and
safely on OR bed in supine position. Monitored VS and recorded.
Stayed with the patient while waiting for surgical team.
Assisted in repositioning for induction of anesthesia and to
surgical position ensuring safety by putting bed straps.
Regulated IVF per order. Participated in initial and final
complete sponge and instrument count. Anticipated needs of the
surgical team and observed aseptic technique all throughout the
procedure. Drained urine and measured at 150ml. Participated in
 cleaning, drying and changing gown. Assisted in transferring to
PACU bed then to PACU.
10:30AM R > To PACU per bed, accompanied by OR technician, student nurse
and OR nurse; with ongoing IVF of D5LRS 1L x 120 cc/hr at 800
ml level infusing well on right hand. With dry and intact wound
dressing, patent IFC draining to urine bag. With latest VS of: BP
= 100/80 mmHg, PR = 95 bpm, RR = 20 cpm. Endorsed to PACU
nurse for further care and evaluation.

Mr. Howard Eckman

BSN 4 - I Clinical Instructor

Date F Acute pain r/t surgical incision secondary to TAHBSO

and
Time of
charting
8AM D Received patient lying on bed with IVF of D5LRS 1LX20cc
per/hr infusing well on the right hand. “Nararamdaman ko
iyong sakit sa may hiwa ng tiyan ko” as stated by the
patient. Pain felt on the surgical site with a pain scale of
8/10, with facial grimacing and guarding behavior.
A Monitored vital signs, evaluated pain regularly noting
characteristic, location, intensity (0-10), identified specific
activity limitations, repositioned patient as indicated,
assisted patient in ADL’s, provided quiet environment,
assisted in relaxation technique and DBE, administered
analgesic medication as ordered, advised to do deep
breathing exercise, instructed patient to use supportive
materials such as binder,encouraged fluid intake,
encouraged to frequent rest periods.
2:30PM R > Medyo humupa naman na iyong sakit as stated by the
patient. Patient verbalized 4/10 pain scale with facial
grimacing.

Mr. Howard Eckman

BSN 4 - I Clinical Instructor