OR-guide (1)

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City Vision: WVSU as one of the top universities in Southeast Asia. Mission: To produce globally competitive life-long learners. ADULT NURSING PROCESS (Operating Room) I.

VITAL INFORMATION

Name: Age: Address: Religious Affiliation: Date and Time of Delivery: Educational Attainment: Civil Status: Date and time Admitted: Physician’s Initials: Chief Complaint:

Impression/ Diagnosis:

Pre-op Diagnosis: Post-op Diagnosis:

Surgical Operation Performed: Days post-op:

II. OBSTETRICAL HISTORY G_P_T_P_A_L LMP: 0 Pad counts:

EDD:

AOG:

Duration of Menses:

Discomforts:

Cesarean Section:

Others (specify):

Chronologic Story: Type of Delivery: NSVD: Episiotomy: Yes ___

No ___

Type of Incision: N/A Mediolateral

Right ___

Left ___

Median: Previous Hospitalization: Yes ___

No ___

Date of last consultation while pregnant: Did she have access to inform regarding childbirth? If yes, how? ___TV Programs

___Attendance to health classes

___reading magazines

___family members (mother)

___friends/neighbors

___others (pre natal check-up and pamphlets)

Any complications during this pregnancy / previous pregnancies: Medications taken during this pregnancy (include dosage, frequency and compliance): FAMILY PLANNING: Practicing:

Yes ___

No ___

If yes, what method of contraceptive used: If none, does she signify willingness to practice family planning? Yes ___

No ___

If yes, what method?

NURSING HISTORY 1. History of Present Illness a. Usual Health Status

b. Chronologic Story

2. Past Health Problems/Status a. Childhood Illness Chickenpox Mumps b. Immunization c. Allergies

d. Accidents and Injuries e. Hospitalization for serious illnesses f.

Medications (all currently used prescriptions and OTC’s)

3. Family History of Illness

4. Patient’s Expectation a. What does she expect to occur during this hospitalization? b. To the nurses, doctors and staffs? III.

PATTERNS OF FUNCTIONING

A. BREATHING PATTERN Respiratory Problems: Usual Remedy: Manner of Breathing: B. CIRCULATION Usual Blood Pressure: Any history of chest pain, palpitations, coldness of extremities, etc.: C. SLEEPING PATTERN Usual Bedtime: Number of pillows: Bedtime rituals: Problems regarding sleep: Usual Remedy:

D. DRINKING PATTERN Kinds of Fluid Taken in 24 hours and amount in mL: Type Water Soda (Coke) Milk

Amount

Time

E. EATING PATTERNS Usual Food Taken Breakfast Lunch Dinner Snacks Food Preferences: F. ELIMINATION PATTERNS 1. Bowel Movement Frequency:

Time

Problems or difficulties: Usual remedy: 2. Urination Frequency: Problems: Usual remedy: G. EXERCISE, REST, AND ACTIVITIES H. PERSONAL HYGIENE 1. Bath Type: Frequency: Time of day: 2. Oral Care Frequency: Care of Dentures (if any): 3. Shaving Frequency: 4. Use of cosmetics and toiletries I. RECREATION J. Health Supervision

II.B. Pre-Operative Assessment 1. Physiologic Preparation

2. Physical Preparation  Vital Signs T= PR=  Measurements Height= Weight=

3. Legal Preparation Surgical consent:

Date and Time taken: RR= BP=

4. Psychosocial Preparation a. Health Teachings:

5. Spiritual preparation

III. B. Intraoperative Preparation A. Name of procedure: B. Intraoperative Procedure

According to Textbook

Surgical Instrumentation

Actual

Instrument Kocher’s Straight

Babcock Forceps

Allis Forceps

Roundnose Forceps

Kelly Forceps Straight

Purpose

How It Was Used During Surgery

Instrument Kelly Forceps Curved

Tumbler

Poole Suction Tip

Long Thumb Forceps

Long Suture Scissors

Purpose

How It Was Used During Surgery

Instrument Suture/Mayo Scissors Straight

Metzenbaum Scissors

Mayo Scissors Curved

Needle Holder

Tissue Forceps/Adson tissue forcep with teeth

Purpose

How It Was Used During Surgery

Instrument Thumb Forceps

Blade Holder Number 4

Army-Navy Retractor

Big and Small Richardson Retractor

Balfour Self Retaining Retractor

Purpose

How It Was Used During Surgery

Instrument Narrow and Wide Deaver Retractor

Debakey Forcep

Mixter Forcep

Backhaus Towel Clips

Intestinal Clamp

Purpose

How It Was Used During Surgery

Instrument Bowl

Kidney Basin

Ovum Forceps

Rubber tubing

Vicryl 0

Purpose

How It Was Used During Surgery

Instrument Mersilk 3.0

Plain 2.0

Monocryl 3.0

Electrocautery

Purpose

How It Was Used During Surgery

Instrument

Purpose

How It Was Used During Surgery

Operating Sponges

Asepto Syringe

1. Physical Assessment General Appearance

A. Neurological System

Cranial Nerve

Function

I.

Olfactory

contributes in the sense of smell in the client

II.

Optic

transforms information about vision to the brain

How Elicited Occlude the nostril while the patient closes eyes; let the patient smell the scent. Repeat with other nostril. Ask the patient about a certain letter in the Snellen’s chart at twenty feet testing for her visual acuity.

Clients Response

III. Oculomotor

superiorly uplifting eyelid, superiorly rotating eyeball, construction of pupil on the exposure to light and operating several eye muscles

Assess papillary response to light and accommodation by instructing patient to look straight as penlight is shining through each pupil. PERRLA Place penlight in front of the patient and ask her to follow it with her eyes only as it moves through the 6 cardinal fields of gaze, Ask patient to clench teeth while the nurse palpates her temporal and masseter muscles for contractions, use cotton balls to stroke forehead, cheeks and chin and ash patient if she is able to feel the touch, and test for the corneal reflex. Place penlight in front of the patient and ask her to follow it with her eyes only as it moves through the 6 cardinal fields of gaze.

IV. Trochlear

handling the eye muscles and turning the eye

V. Trigeminal

Sensory functions related to nose, eyes, tongue and teeth. It basically is further divided in three branches that are ophthalmic, maxillary and mandibular nerve

VI. Abducens

function of turning eye laterally

VII. Facial

responsible for different types of facial expressions

Instruct patient to smile, frown, elevate and lower down eyebrows and puff cheeks.

VIII. Vestibulocochclear

providing information related to balance of head and sense of sound or hearing

Occlude ear and intermittently and ask client to repeat whispered words at two feet distance.

IX. Glossopharyngeal

for taste, helping in swallowing food.

Using tongue depressor, tests for gag reflex

X. Vagus

it contributes in the tasting ability of the client

Instruct the patient to close her eyes, let the patient taste the condiments.

Tests for muscle strength, provides muscle movement of the shoulders and surrounding neck

Tests for muscle strength, turn the head to one side against the resistance of a hand on each sides and shrugs shoulders against resistance of the hands.

XI. Spinal Accessory

XII. Hypoglossal

motor nerve that deals with the muscles of tongue

B. Cardiovascular System C. Respiratory System

D. Gastrointestinal System

E. Genito-Urinary System

F. Reproductive System

G. Lymphatic System

H. Endocrine System

I. Hematopoeitic System

J. Musculoskeletal System

K. Integumentary System

IV.

NURSING PROGRESS NOTES

Tongue movement and strength using the tongue depressor put resistance on the tongue and observe the strength.

DATE/ TIME

9/9/16 2:30 pm

FOCUS

Pre-operative care

DATA

Received from NOD, conscious and coherent, with IVF 0.9 NaCl x 8H and blood transfusion going on a side drip. With signed consent for Total Abdominal Hysterectomy with Bilateral Salphingo Oopherectomy.

Pre-op checklist reviewed. Brought to OR #1, O2 at 2 liters per minute, administered via nasal cannula, attached to monitors. Placed on right lateral position. Indwelling catheter inserted continuously. Final skin prep done aseptically

For induction of anesthesia, SAB inducted by Dr. G. procedure started by Dr. L assisted by Dr. S,

Continuous monitoring done of vital signs; intake and output, O2 Sat and cardiac status, IVF regulated by Dr. B. counting done before the end of procedure.

9/9/16 2:52 Intraoperative care

9/9/16 4:29 pm

Immediate postoperative care

ACTION

s/P total abdominal hysterectomy with bilateral salphingooophorectomy, under SAB, with IVF, PNSS 1 liter x 8hrs going on, with indwelling

Brought to PACU per stretcher endorsed to nurse on duty at 4:45 pm.

DATE/ TIME

9/9/16 2:30 pm

4:39 pm

RESPONSE

Baseline VS BP= 130/80 mmHg RR= 20 bpm PR= 88 bpm O2 SAT= 100% Urine output 200 cc

Latest vital signs BP= 120/80 PR= 77 bpm RR= 20 bpm 02 sat= 99% Total Urine output=

catheter.

V.

LIST OF NURSING PROBLEMS IDENTIFIED (according to priority) 1. 2. 3.. 4. 5.