SY 2021 - 2022

COLLEGE OF NURSING
Silliman University
Dumaguete City

LAPAROTOMY, APPENDECTOMY

Submitted to:
Asst. Prof. Veveca V. Bustamante RN, MN

Submitted by:
Parreñas, Maria Angel Lou
Perigua, Andrea Paz
Poligrates, Jannah Mae

BSN III - D3
May 26, 2022
 SUMMARY

NAMES & ROLES Circulating Nurse Poligrates, Jannah Mae

1st Scrub Nurse Perigua, Andrea Paz T.
2nd Scrub Nurse Parreñas, Maria Angel Lou
CASE #73077
PATIENT’S NAME Fonollera, Charter Kenn Jadraque
DATE OF OPERATION May 26, 2022
 DEMOGRAPHIC DATA

Name: Fonellera, Charter Kenn Jadraque Civil Status: Single Sex: Male Age: 23 years old DOB: 9/5/1998
Educational Attainment: Undergraduate Address: Tubtubon, Sibulan, Sibulan Negros Oriental Religion: Roman Catholic
Occupation: On and off work Nationality: Filipino Date & Time of Admission: 5/25/2022 at 8:05 PM
Doctor(s) in charge: Dr. Balbon
Chief Complaint(s): Abdominal pain
Diagnosis(es): Acute Supprative Appendectomy
Admitting Diagnosis: Acute Appendicitis
Past Medical History: No surgical history
History of Present Illness: 5 days prior to admission, onset epigastric pain with subsequent right lowe quadrant pain. Consulted at Holy Child Hospital.
Ultrasound done.
General Impression of client (appearance upon first contact): Patient was lying on the operating table, conscious and having conversation to the
anesthesiologist.
SURGICAL TEAM & OPERATION
Case #: 73077
Operation: Laparotomy, Appendectomy Date: May 26, 2022
Surgeon: Dr. Balbon Time started: 9:01 A.M
Anesthesiologist: Dr. Villegas Time ended: 9:29 A.M
Anesthesia: Subarachnoid Spinal Block (Regional Anesthesia)
OR Scrub Nurse: Octave Von Estravela
OR Circulating Nurse: Riesary Icao
Post-op Diagnosis: Acute Complicated Appendicitis

NURSE NOTES
TIME ACTION/REMARKS
8:37 AM ● Received patient, he was already in the operating table
● Checked the patient’s chart for the informed consent
● Jewelries and dentures removed
● At left metacarpal vein: 5% Dextrose in Lactated Ringer’s
● At right metacarpal vein: 0.9% Sodium Chloride
● VS:
○ BP= 128/80 mmHg
○ Temperature= 36.1° C
○ PR=97 bpm
○ RR=16 cpm
○ Spo2= 100%
● NPO started on May 25, 2022 around 2-3 pm in the afternoon
● Urine drained at 200 mL; Dark yellow
8:45 AM ● Administered Anesthesia SAB by Dr. Villegas
8:47 AM ● Changed of IV 5% Dextrose in Lactated Ringer’s
8:50 AM ● Skin preparation on surgical site (beginning from umbilicus outward, in a circular motion, including the
groin and the perineum)
8:59 AM ● Skin preparation done
9:01 AM ● Operation started
INSTRUMENTS:
➔ 7 - straight
 ➔ 8 - curve
➔ 3 - allis
➔ 3 - bobcocks
➔ 2 - Needle holders
➔ 2 - Tissue forceps with teeth
➔ 1- Tissue forcep without teeth
➔ 2 - mayo scissors
➔ 2-Metzenbaum scissor
➔ 2- Army navy retractor
➔ 2-Richardson retractor
➔ 4- Packs
➔ 3- ATR
➔ 3-Actual Needle
Extra:
➔ 4 - Mixter Forceps
➔ 2 Metzenbaum scissor
➔ 1-Debakey Forcep
9:05 AM BP- 113/62 mmHg
RR - 17 cpm
SaO2 - 99%

9:10 AM BP- 108/56 mmHg

RR - 16 cpm
SaO2 - 99%

9:15 AM BP- 108/58 mmHg

 RR - 18 cpm
SaO2 - 99%

9:20 AM BP- 112/65 mmHg

RR - 18 cpm
SaO2 - 99%

9:25 AM BP- 115/70 mmHg

RR - 19 cpm
SaO2 - 100%

9:29 AM BP- 115/70 mmHg

RR - 19 cpm
SaO2 - 100%

9:35 AM ● Done cleaning the patient and preparing for transporting the patient to Post Anethesia Care Unit
BP- 122/67 mmHg
RR - 16 cpm
SaO2 - 100%

9:46 AM ● Arrived to PACU

9:47 AM ● O2 Therapy Insertion
9:50 AM ● Lying flat in bed
● Checking the incision site: No odor, redness, pus, or drainage noted.
● Upon assessment, patient verbalized feel dizzy.
● Rated pain 5 out of 10.

9:52 AM ● Administered antibiotic

BP- 124/76 mmHg
RR - 17 cpm
PR - 71 bpm
SaO2 - 99%

10:07 AM BP- 128/84 mmHg

RR - 17 cpm
PR - 73 bpm
SaO2 - 99%

10:22 AM BP- 128/84 mmHg

RR - 17 cpm
PR - 73 bpm
SaO2 - 99%
10:37 AM BP- 131/78 mmHg
RR - 18 cpm
PR - 67 bpm
SaO2 - 98%
10:52 AM BP- 139/84 mmHg
RR - 16 cpm
PR - 83 bpm
SaO2 - 98%
11:07 AM BP- 139/84 mmHg
RR - 16 cpm
PR - 78 bpm
SaO2 - 98%
11:22 AM BP- 131/82 mmHg
RR - 16 cpm
PR - 75 bpm
SaO2 - 98%
11:37 AM BP- 131/82 mmHg
RR - 16 cpm
PR - 83 bpm
SaO2 - 98%
 NURSING CARE PLANS
PART I: PREOPERATIVE PHASE

CUES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Data Anxiety related to Within my 8 hour care, INDEPENDENT After my 8 hour care,
● Verbalized surgical procedure the patient will have the goal was fully met,
“nakuyawan reduced anxiety as Provide quiet Speaking in a calm, the patient will have
rako gamay” evidenced by: environment. reassuring tone reduced anxiety as
increases comfort and evidenced by:
Objective Data 1. Acknowledge helps to alleviate
● Appeared to be feelings and anxiety. 1. Acknowledge
anxious identify healthy feelings and
● Unable to ways to deal Establish rapport To gain patient’s trust identify healthy
maintain eye with them ways to deal
contact 2. Appear relaxed Encourage Enables pt to express with them
and be able to verbalization of thoughts and opinions 2. Appear relaxed
rest feelings and actively and alleviates anxiety. and be able to
appropriately listen to patient rest
3. Report anxiety appropriately
reduced to a Assure patient Reduces concerns that 3. Report anxiety
manageable anticipating conscious client may “see” the reduced to a
level sedation or spinal procedure. manageable
4. Verbalize anesthesia that level
understanding of drowsiness or sleep 4. Verbalize
distraction occurs understanding of
techniques like distraction
deep breathing Provide preoperative Can provide techniques like
and guided education on the reassurance and to deep breathing
imagery procedure. alleviate patient's and guided
anxiety. imagery

Discuss routine Acknowledges that

procedures and foreign environment
processes that may may be frightening and
frighten or concern alleviates associated
such as putting on fears.
oxygen masks and
anesthesia.

Teach proper deep These are helpful

 breathing technique distraction methods to
and introduce guided relieve the patient’s
imagery to patient. anxiety.
Subjective Data Deficient knowledge Within my 8 hour care, INDEPENDENT After my 8 hour care,
● Verbalized related to postoperative the patient will have the goal was fully met,
“maunsa diay ko outcomes increased knowledge Assess patient’s level Facilitates planning of the patient had
ani inig human and understanding as of understanding. preoperative teaching increased knowledge
Ma’am?” evidenced by: program, identifies and understanding as
1. Verbalization of content needs. evidenced by:
Objective Data understanding of 1. Verbalization of
● First time to postoperative Provide education on Enhances patient’s understanding of
undergo a outcomes preoperative or understanding or disease process
surgical 2. Verbalization of postoperative control and can relieve and surgical
procedure expected procedures and stress related to the procedure
postoperative expectations, urinary unknown or 2. Understanding
outcomes and bowel changes, unexpected. expected
dietary considerations, postoperative
activity levels/ outcomes
transfers, respiratory/ 3. Verbalization of
cardiovascular expected
exercises postoperative
outcomes
Explain to patient Enables the patient to
anticipated IV lines and know what to expect.
tubes.

Provide opportunity to Enhances learning of

 practice coughing, postop exercises ahead
deep-breathing. of time.
Objective Data Readiness for Within my 8 hour care, INDEPENDENT After my 8 hour care,
● Nodded his head Enhanced Health the patient will express the goal was fully met,
when asked if he Management r/t desire his grief as evidenced Determine amount and Studies have shown patient had expressed
wanted to learn to learn about by: type of information that certain aspects of his grief as evidenced
how to manage postoperative condition 1. Verbalize desired postoperative care are by:
his condition understanding of important to clients 1. Verbalized
after surgery therapeutic Emphasize avoidance Reduces potential for understanding of
needs. of environmental risk acquired infections. therapeutic
2. Verbalize home factors, including needs.
care exposure to crowds or 2. Verbalized home
responsibilities persons with infections. care
after surgery responsibilities
Identify specific Prevents undue strain after surgery
activity limitations. on operative site.

Review importance of Provides elements

nutritious diet and necessary for tissue
adequate fluid intake. regeneration and
healing and support of
tissue perfusion and
organ function.

Encourage cessation of Smoking increases risk

smoking. of pulmonary
infections, causes
 vasoconstriction, and
reduces
oxygen-binding
capacity of blood,
affecting cellular
perfusion and
potentially impairing
healing.

PART II: INTRAOPERATIVE PHASE

CUES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Objective: Disturbed sensory Within my 1 hour the Independent Independent The goal was fully
● Vital signs at: process related to use patient will regain his ● Reorient patient ● As patient met as evidenced by:
○ BP- of pharmaceutical sensory as evidenced continuously regains
113/62 agents in the body by: when emerging consciousness,
mmHg from anesthesia; support and
○ RR - 17 ● Regain usual confirm that assurance will ● Regain
cpm level of surgery is help alleviate consciousness in
○ SaO2 - consciousness completed anxiety the PACU
99%

● Given spinal ● Vital signs ● Vital signs:

within normal ○ BP-
anesthesia block
range ● Speak in normal, ● It is thought that 122/67
by Dr. Nuique clear voice the sense of mmHg
 without hearing returns ○ RR - 16
shouting, being before the cpm
aware of what patient appears ○ SaO2 -
you are saying. fully awake, so it 100%
Minimize is important not
discussion of to say things that
negatives within may be ● Proper transfer
● Recognize his patient’s hearing. misinterpreted. and transporting
limits and seek Explain Providing with the use of
assistance as procedures, even information bed rails to
necessary if patient does helps patient ensure his
not seem aware preserve dignity safetiness
and prepare for
activity

● Evaluate ● Return of
sensation and/or function
movement of following local
extremities and or spinal nerve
trunk as blocks depends
appropriate on type or
amount of agent
used and
duration of
procedure

● Use bedrail ● Provides for

padding, patient safety
 restraints as during
necessary emergence state.
Prevents injury
to head and
extremities if
patient becomes
combative while
disoriented

● Disoriented
● Secure parenteral patient may pull
lines, ET tube, on lines and
catheters, if drainage
present, and systems,
check for disconnecting or
patency kinking them
Objective: Risk for injury related Within my 1 hour care, Independent Independent The goal was fully met
● Vital signs at: to intraoperative the patient will be from ● Monitor vital signs ● To provide a as evidenced by:
○ BP- surgical invasive injury as evidenced by: baseline data for
113/62 procedure: laparotomy monitoring ● Patient
mmHg appendectomy ● Maintain during the maintained
○ RR - 17 position in the intraoperative supine position
cpm operating table phase with abdomen
○ SaO2 - during ● Assume patient in ● To provide being visible to
99% intraoperative the correct position optimal the surgeon
● Underwent phase visualization of, during surgical
Laparotomy, and access to, operation
Appendectomy the surgical site ● Vital signs at 10
by Dr. Balbon that causes the am:
least ○ BP-
● Normal vital physiological 122/67
signs compromise of mmHg
the patient, while ○ RR - 16
also protecting cpm
the skin and ○ SaO2 -
joints 100%

● Able to remove ● Maintain restraints ● Prevent potential ● Appendix was

appendix during surgical injury to the successfully
successfully procedure client removed and
incision site was
● Assess surgeon on ● To illuminate the properly closed
adjusting the operative site on using suture
surgical lighting and/or within a needles and
patient for ideal surgical staplers
visualization and
to prevent
injuries during
operation

● Proper counting of ● Eliminate the

surgical possibility of
instruments use in leaving surgical
the operating room instruments
 before, during, and behind and to
after the operation ensure the safety
of the patient
during
intraoperative
Objective: Risk for hypothermia After our 1 hour care, Independent Independent After our 1 hour care,
● Vital signs: r/t to introduction of patient will maintain a ● Note ● To provide a the goal was met as
○ BP- pharmaceutical agents normal body preoperative baseline data for evidenced by:
113/62 temperature as temperature monitoring
in the body
mmHg evidenced by: during the
○ RR - 17 intraoperative ● Vital signs:
cpm ● Vital signs are phase ○ BP- 122/67
○ SaO2 - within the mmHg
99% normal range ● Monitor vital ● Early ○ RR - 16 cpm
signs and alert recognition of ○ SaO2 - 100%
● Given spinal the nurse if the symptoms
● No signs of results are facilitates early ● No signs of
anesthesia block
cyanotic abnormal intervention to cyanotic on skin
by Dr. Nuique prevent further
● No signs of complications ● No signs of
hypothermia ● Assess hypothermia like
environment ● Aids in shivering and
temperature and maintaining the cyanosis
request patient's body
modification if temperature
needed
 ● To make sure
that only the site ● To avoid heat
of surgery is loss, as skin is
expose exposed to a
cool
environment
temperature
● To strictly follow
aseptic technique ● To maintain
in assisting the sterility and
surgery avoid giving
pathogens to the
client

PART III: POSTOPERATIVE PHASE

CUES/EVIDENCES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Objective Data: Impaired skin integrity Within our 8 hours of INDEPENDENT: At the end of my care,
● Rate pain 5 out r/t post-op surgery care, the patient will be ● Assess the site of ● Redness, the goal is partially met
of 10. able report partial impaired tissue swelling, pain, as evidenced by:
● Lying flat in bed integrity and its burning, and ● Patient reported
wound healing and
● Feeling dizzy condition. itching are no pain or
and tired as reduce pain as indications of altered sensation
 verbalized. evidenced by: inflammation at the incision
● ● Patient reports and the body’s site.
any altered immune system
VITAL SIGNS: response to ● Patient applied
sensation or pain
● BP- 124/76 localized tissue and
mmHg at the site of trauma or demonstrated
● RR - 17 cpm tissue impaired tissue some healing
● PR - 71 bpm impairment. integrity. technique to
● SaO2 - 99% avoid injury.
● Patient
demonstrates ● Assess ● These findings ● Patient
characteristics of will give described safety
understanding of
the wound, information on measures for
plan to heal including color, the extent of the protection and
tissue and size (length, impaired tissue wound healing.
prevent injury. width, depth), integrity or
drainage, and injury. Pale ● Patient wound
● Patient odor. tissue color is a decreased and
describes sign of decreased increased
oxygenation. An granulation
measures to
odor may result tissue.
protect and heal from the
the tissue, presence of
including wound infection on the
care. site; it may also
be coming from
necrotic tissue.
● Patient’s wound
decreases in size
and has ● Assess changes ● Fever is a
increased in body systemic
temperature, manifestation of
granulation
specifically inflammation
tissue. increased body and may indicate
temperature. the presence of
infection.

● Assess the ● Pain is part of

patient’s level of the normal
pain. inflammatory
process. The
extent and depth
of injury may
affect pain
sensations.

● Monitor site of ● Systematic

impaired tissue inspection can
integrity at least identify
once daily for impending
color changes, problems early.
redness,
swelling,
warmth, pain, or
 other signs of
infection.

● Instruct the ● Rubbing and

patient to avoid scratching can
rubbing and cause further
scratching. injury and delay
healing.

● Keep a sterile ● A sterile

dressing technique
technique during reduces the risk
wound care. of infection in
impaired tissue
integrity.

● Encourage the ● To prevent

use of pillows, pressure injury.
foam wedges,
and
pressure-reducin
g devices.
 DEPENDENT:
● Administer ● Intravenous
antibiotics as antibiotics may
prescribed by the be indicated,
physician. wound infections
may be managed
well and more
efficiently with
topical agents.

Subjective Data: Acute pain r/t surgical Within our 8 hours of INDEPENDENT: After 8 hours of
● Verbalized, incision. care, the client will be ● Assess pain, ● These nursing care, the goal
“Sakit -sakit pa able to relieve pain as noting location, assessments was fully met, the
siya gamay, evidenced by: characteristics, demonstrate the patient relieved from
kanang mag ● Verbalizes severity (0–10 degree and type pain, as evidenced by:
ngot-ngot pa”. reduced scale). of discomfort,
discomfort or Investigate and trend of the ● Verbalized pain
report changes in discomfort, and or discomfort
pain
Objective Data: pain as relief obtained reduced.
● Rate pain 5 out appropriate. after
of 10. ● Appears relax interventions. ● Appeared
● Lying flat in bed and can rest or relaxed and can
● Feeling dizzy as sleep ● Monitor the ● To determine sleep and rest
verbalized client’s vital baseline data appropriately.
● Demonstrates signs.
VITAL SIGNS: relaxation skills ● Demonstrated
● BP- 128/84 and diversional relaxation skills
mmHg activities as ● Encourage the ● Allow the client and diversional
● RR - 17 cpm client to to verbalize her activities as
indicated for the
● PR - 73 bpm verbalize perceptions indicated for the
● SaO2 - 98% situation. feelings about about pain and situation.
pain acknowledge the
pain experience.

● Monitor closely ● Continuing pain

for possible and presence of
surgical fever may signal
complications an abscess.

DEPENDENT: ● Relief of pain

● Administer facilitates
analgesics as cooperation with
indicated other therapeutic
interventions
(ambulation,
pulmonary
toilet).
Objective Data: Risk for infection r/t Within our 8 hours of INDEPENDENT: After 8 hours of
● Confined to surgical wound care, the client will be ● Observe for ● Surgical site nursing care, the goal
PACU free from infection as localized signs infection (SSI) was fully met, the
● Lying in bed evidenced by: occurs in up to patient is free from
of infection at
● Feel tired ● No bleeding, 11% of women infection, as evidenced
● Rate pain 5 out odor, pus, or the surgical after cesarean by:
of 10. drainage. incision site. birth and is
VITAL SIGNS: manifested as
● BP- 124/76 ● Incision wound wound infection. ● No presence of
mmHg is clean and dry Note for bleeding, pus or
● RR - 17 cpm presence of drainage noted.
● PR - 73 bpm ● Achieves timely redness,
● SaO2 - 99% wound healing swelling, pus, or
without drainage
complications.

● Is afebrile ● Instruct the ● To avoid

(temperature maceration or ● Incision wound
client to keep
below weakening of the is cleaned and
incision site dry dry.
38℃/100.4℉) incision line as it
for the first 48
becomes wet and
hours after soft
surgery.

● Tell the client the ● Achieved wound

 importance of ● Infection can healing without
wound care arise from lack complications.
during the of cleanliness of
the wound.
postoperative
period.

● Is afribile or no
● Perform wound fever is present.
care. ● Incubation
germs in the
wound area can
cause infection.

● Tell the client

how to identify ● Various clinical
signs of manifestations
infection. can be
nonspecific sign
of infection,
fever and
increased pain
may be
symptoms of
infection.