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Name of Student: John Raphael Sanchez Date of Submission: October 13, 2017
Year and Section: 3NUR-8
OR Preference Cards
Name of Patient: T.M.L. Age: 19 Sex: Male Civil Status: Single
Date of Admission: October 12, 2017 Date of Surgery: October 12, 2017 Time Started/Ended: 2:25pm-3:00pm
Bed #: 4029 Hospital No: 17-120000022244 Admission No: 17J00375
Surgeon: Dr. Rodriguez Montenegro, MD Assistant Surgeon: Dr. P. Quinto, MD Anesthesiologist: Dr. E. Tan, MD
Scrub Nurse: Algem Paul V. Lagunsad, RN Circulating Nurse: Christopher James Z. Ruiz, RN
Chief Complaint: Patient had epigastric pain radiating to hypogastric pain accompanied by vomiting previously ingested food.
Abdominal Pain (8/10)
Pre-Operative Diagnosis: Appendicitis
Rationale/Definition: Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spead to its other
parts. It may be due to a seedling that is stuck inside the appendix which causes inflammation.
Pathophysiology: Appendicitis is caused by obstruction of the appendiceal lumen by feces, seedling, etc. The obtruction then causes
an increase in pressure in the lumen. This also results to accumulation of secretions and causing the bacteria to multiply leading to
recruitment of white blood cells and formation of pus and increase pressuure.
Patient’s identity and Pain Data: When asked about how he was
procedure to be done and site YES feeling, he verbalized, “ang sakit ng tiyan
of operation confirmed ko, pain scale 8/10”
Action: Pain scale was assessed and the
To surgeon: any anticipated data was relayed to the physician for
NONE orders.
critical events
To anesthesiologist: any
NONE Anxiety Data: Patient showed silence and is very
patient specific concerns
and pale with shaking feeling.
To scrub nurse: any Sterile and Nervousne
instruments/suture concerns complete ss
To perfusion/technician: any
NONE
equipment issues?