JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

Case History:
Admission Date: November 11, 2021 at 7pm.
Mr. Jack was driving his car to visit his mother, through the intersection he was
struck by a ten wheelers truck. He was a 34 year old, male patient brought by an
ambulance in the Emergency room due to a road traffic accident (RTA) resulted to blunt
trauma in his abdomen due to sharp force injury.
He was aware of his surroundings and a bit drowsy due to moderate blood loss from the
sharp force injury. Mr. Jack is posted for emergency Exploratory Laparoscopy after the
physical examination of the ER doctor and after consultation with a General Surgeon.
Administered Normal saline 1 liter, fast drip as an initial Intravenous Fluid resuscitation
to prevent hemorrhagic shock while preparing him to be shifted to Operating theatre.
The General Surgeon ordered to prepare 8 units of PRBC and 12 units of Fresh frozen
plasma to be administered during the surgery. Blood sample was sent to the blood bank
for typing and Cross matching.
While still in Emergency department, Mr. Jack received 1 unit of PRBC as ordered.

The initial Vital signs taken were the following:

Temp- 36.0 C O2 sat- 94%
PR- 115bpm Pain= 8
RR- 28 cpm
BP- 100/70mmHg

The doctor on duty ordered for urgent several laboratory investigations such as CBC,
Basic Chemistry (S. K+, Na+, RFT) + LFT, Coagulation profile (PT, PTT, INR), D-dimer,
blood alcohol test and an abdominal X-ray, it’s all carried out.

The abdominal x-ray showed the extent of the injury of the sharp object that penetrated
to his abdomen.
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

After 30 minutes, the ordered laboratory investigations revealed the following results:

WBC- 16.5 x 10/L D-dimer- negative

Hgb- 7.5 g/dl
PT- 12.5
INR- 1.0

At around 7:30pm, a Ringer lactate 1000ml was administered as fast drip per doctor’s
order.
Latest Vital signs:

Temp- 36.8 C Sat- 95%

PR- 113 bpm Pain- 8
RR- 27 cpm
BP- 105/70 mmHg

At 8:45pm, Mr. Jack was shifted to Operating Theatre for emergency Exploratory
Laparotomy.
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

After 4 hours of surgery, the patient was admitted to Surgical ICU for close observation
and further treatment.

Mr. Jack had following contraptions after surgery:

Nasogastric Tube attached to Uro bag- freely draining
3 Barovac on negative pressure
IFC connected to Urine Bag

On Oxygen 5 lpm via simple mask

Date: 11/12/21
Time BP PR RR Temp O2Sat Pain
0100H 110/72mmHg 89bpm 20cpm 36.8 C 99% 0
0115H 112/75mmHg 86bpm 20cpm 36.8 C 99% 0
0130H 112/80mmHg 83bpm 22cpm 37.0 C 100% 0
0145H 120/82mmHg 84bpm 19cpm 37.0 C 100% 0
0215H 125/80mmHg 88bpm 20cpm 37.5 C 100% 3
0245H 118/79mmHg 85bpm 18cpm 37.8 C 99% 3
0315H 128/85mmHg 102bpm 25cpm 38.2 C 99% 5
0415H 130/90mmHg 110bpm 28cpm 38.4 C 97% 4
0515H 135/92mmHg 112bpm 26cpm 37.8 C 96% 6

.
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
11/11/21 1930H T- 36.8 C Please admit under the service of Dr.
/ Lee
PR: 113bpm Secure consent for admission
RR: 27cpm Start PNSS 1L, fast drip
BP: 105/70 mmHg Administer Oxygen 6lpm via simple
mask
O2 sat: 95% Insert IFC

Pain: 8 Prepare 8 units of PRBC AND 12

units of FFP- for surgery use
Monitor Vital signs q 30 30 mins
Refer the patient to Surgeon on call
Prepare the patient for emergency
Explor Lap
Secure surgical consent
Laboratories:
CBC, Basic Chemistry (S. K+, Na+,
RFT) LFT, Coagulation profile (PT,
PTT, INR) D-dimer, blood alcohol
test
Abdominal X-ray
Medications:
Inj. Cefazolin 2 grams IV 30 mins
before surgery
Inj. Morphine 10mg subcut Stat
Inj. Perfalgan 1g IV stat
1950H Additional order: Transfuse 1 unit of PRBC to run for 2
hours stat
Refer for unusualities
Dr. Bright
ER Specialist
Post- Op Orders:
11/12/21 0100H T- 36.8 C Transfer the patient to SICU
PR- 89bpm Keep Baro Vac in negative pressure
RR- 20cpm Keep the IFC and NGT- freely
draining
BP-110/72mmHg To be seen during the surgical
rounds tomorrow
Sat- 99% Continue on D5NSS 100ml/hr
Repeat laboratory investigations in
AM.
Start Incentive Spirometer once
patient is fully conscious
Apply Embolic stocking and start
Pneumatic pump
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

Post Op meds:
Continue on Cefazolin IV
Mophine 10 mg subcut every 6H for
pain
Inj Pantoprazole 40mg IV OD
Inj Enoxaparin 40 mg Subcut OD
Refer for unusualities
Dr. Lee
Consultant, Surgery

Legend: C – Carried Out A – Administered R – Requested E – Endorsed D-

Discontinued

Patient’s Name: _______________ Age/Sex:____________ Hospital No: 21-06187

Attending Physician:_______ Room No.: 101