Alternative Learning System

Related Learning Experience

Operating Room

CASE SCENARIO:
PRE-OPERATIVE PHASE
 A 30-year-old male patient was brought to the Emergency Room this morning with chief
complaint of abdominal pain in the right lower quadrant accompanied by loss of appetite,
nausea and vomiting. Upon assessment by the surgical resident, the patient verbalized
that he initially felt mild discomfort around the umbilicus the night prior. After extensive
examination and laboratory tests, the patient was diagnosed with acute appendicitis and
was ordered for STAT appendectomy. Abdominal Ultrasound suggest early signs of
localized peritonitis. Patient’s symptoms of having high fever (Temp: 39C) and pain were
initially managed in the Emergency Room prior to transport to the Operating Room.
Antibiotic skin-testing was endorsed to the Operating Room Nurse for orders of giving
IV Cefuroxime 750mg before induction of anesthesia (RA-SAB).
IMMEDIATE POST-OPERATIVE (PACU):
 After an hour of surgery (Appendectomy), the patient is transferred to the Post-
Anesthesia Care Unit for immediate monitoring. Patient is arousable upon calling and an
hour later the patient is fully awake, is capable of moving both upper extremities only.
Patient is able to breathe spontaneously and cough two times with vital signs of BP:
110/70mmhg, RR= 20bpm, PR= 89bpm, Temp: 35.9, and 02SAT: 96% with oxygen
inhalation at 2L/min via nasal cannula.
Table 1.0 Laboratory Results
Examinations Patient’s Result Normal Value Indication
Blood Exam
1. RBC 5.0 x 1,000,000/mm3 4.3-5.9 million/mm3 Normal
2. Hemoglobin 14.0 g/dL 13-17 g/dL Normal
3. WBC 25.2 x 1000/mm3 4-10 x 10*9/L Abnormal
4. Platelets 250 x109/L 150-400 x 10*9/L Normal

5. Appearance Clear Clear Normal

6. Color Dark yellow Pale yellow-yellow Abnormal (dehydrated)
6. pH 5.0 5,5-6 Normal
7. Protein Negative Negative Normal
8. Sp. Gravity 1.040 1.010-1.030 Abnormal (dehydrated)
9. Glucose Negative Negative Normal
Casts None 0-2 hyaline Normal
 WBC 1–2 0-4 rbc/hpf Normal
RBC 0–1 2-5 wbc.hpf Normal

Color Light Brown Brown Normal

Consistency Watery Soft and well-formed Abnormal (diarrhea)
Occult blood Negative Negative Normal
Ova & parasites None seen Negative Normal
Bacteria ++++ Negative Normal
Stool Analysis: Negative
Laboratory findings are indicated above in Table 1.0, wherein the attending physician concludes
to proceed with antibiotic regimen via intravenously.
Medications on Board:
1. Metoclopramide 10mg IV q8 prn for vomiting
2. Paracetamol 300mg IV prn for temp >37.8
3. Cefuroxime 750mg IV ANST ( ) prior to induction of anesthesia
4. Metronidazole 500mh/100ml (5mg/ml) IV drip q8

CASE STUDY QUESTIONS:

1. What is the Hallmark Sign of Appendicitis?
The hallmark sign of Appendicitis is as follows, abdominal pain specifically in the
peri-umbilical region that radiates in the right lower quadrant (RLQ). Pain becomes localized
and sharp when the inflammation extends to the parietal peritoneum. Other signs may occur
such as anorexia, nausea, and emesis.
2. What are the other obstructive signs of appendicitis?

Obstructive signs of Appendicitis may be caused by a virus, bacterial and parasitic

infections in the digestive tract, and when a stool is trapped in the tube of the large
intestine and appendix. Another obstructive sign of appendicitis is when there is an
inflammation around the ileum that may cause close or open-loop obstructions.

3. Major complication/s of untreated appendicitis?

Untreated appendicitis may lead to a life-threatening situation. One is an infection,

a ruptured appendix may spread in the abdominal cavity and may cause peritonitis.
Peritonitis may cause damage to the internal organs and may cause death if left
untreated.

4. Classify the client’s surgery based on the following categories (next page)

Categories Description Rationale

 1. According to Urgency Immediate/Emergent:
performed immediately or as
soon as possible
It requires immediate medical
treatment. If left untreated, it
can cause your appendix to
rupture. This can be a serious
and even fatal complication

2. According to Risk Low risk It requires a shorter hospital

time, shorter recovery time
and shorter infection rates.

3. According to Purpose Corrective or Curative To take away or cut off, refers

(ablative) to the removal of diseased
organs

4. Post-operative nursing consideration/s for patients who have undergone Spinal

Anesthesia (RA-SAB).

 Continuous monitoring of heart rate, rhythm and pulse oximetry

 Monitor vital signs every 5-15 minutes (until stable)
 Assess the level of anesthesia
 Evaluate return of motor function
 Assess motor function
 Evaluation of level sensory blockade
 Flat on bed

5. Based on the Aldrete Score in the PACU, is the patient eligible for discharge and to be
transported back to the Surgical Ward?
Yes, because the patient’s Aldrete score is 9.

6. Immediate post-operative care involves monitoring vital signs frequently, the nurse
notices that there is a sudden drop in Blood Pressure from 110/70mmHg to 80/40mmHg.
There is a standing order for starting a dopamine drip. Please compute for the following:

 10:00-Start uptitrating Dopamine 400mg/250ml at 15mcg/kg/min by 5ml/2hrs to titrate

SBP greater or equal to 100mmHg. Patient weight is 70kgs. Compute for the actual dose
of the following time:
a. 12:00: 15.77 mcg/kg/min
b. 14:00: 16.53 mcg/kg/min
c. 16:00: 17.29 mcg/kg/min
References:

Laboratory Values. Available at http://www.globalrph.com/labs.htm.

Laboratory Testing Normal Values retrieved at https://www.imop.gr/en/urotools-normal-values

HealthwiseStaff,, 2020 retrieved at https://myhealth.alberta.ca/Health/Pages/conditions.aspx?

hwid=aa80714#:~:text=The%20pH%20of%20the%20stool%20is%20less%20than
%207.0%20or,results%20of%20a%20stool%20analysis.