West Visayas State University COLLEGE OF NURSING
La Paz, Iloilo City
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
0
LMP: EDD: AOG:
Pad counts: Duration of Menses: Discomforts:
Chronologic Story: Type of Delivery:
NSVD: Cesarean Section: Others (specify):
Episiotomy: Yes ___ No ___
Vision: WVSU as one of the top universities in Southeast Asia. Mission: To produce globally competitive life-long learners.
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
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 Amount Time
Water Soda (Coke) Milk
E. EATING PATTERNS
Usual Food Taken Time
Breakfast Lunch Dinner Snacks Food Preferences: F. ELIMINATION PATTERNS 1. Bowel Movement Frequency:
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 Date and Time taken:
T= RR= PR= BP= Measurements Height= Weight= 3. Legal Preparation Surgical consent:
4. Psychosocial Preparation a. Health Teachings:
5. Spiritual preparation
III. B. Intraoperative Preparation
A. Name of procedure: B. Intraoperative Procedure
According to Textbook Actual
Instrument Purpose How It Was Used During Surgery Kocher’s Straight Babcock Forceps Allis Forceps Roundnose Forceps
Instrument Purpose How It Was Used During Surgery Kelly Forceps Curved
Tumbler
Poole Suction Tip
Long Thumb Forceps
Instrument Purpose How It Was Used During Surgery Suture/Mayo Scissors Straight
Metzenbaum Scissors
Mayo Scissors Curved
Needle Holder
Tissue Forceps/Adson tissue forcep with teeth
Instrument Purpose How It Was Used During Surgery Thumb Forceps
Blade Holder Number 4
Army-Navy Retractor
Big and Small Richardson Retractor
Instrument Purpose How It Was Used During Surgery Narrow and Wide Deaver
Retractor
Debakey Forcep
Mixter Forcep
Backhaus Towel Clips
Instrument Purpose How It Was Used During Surgery Bowl Kidney Basin Ovum Forceps Rubber tubing Vicryl 0
Instrument Purpose How It Was Used During Surgery Mersilk 3.0 Plain 2.0 Monocryl 3.0 Electrocautery
Instrument Purpose How It Was Used During Surgery Operating Sponges Asepto Syringe 1. Physical Assessment General Appearance A. Neurological System
Cranial Nerve Function How Elicited Clients Response
I . Olfactory contributes in the sense of smell in the client
Occlude the nostril while the patient closes eyes; let the patient smell the scent. Repeat with other nostril.
II. Optic transforms information about vision to the brain
Ask the patient about a certain letter in the Snellen’s chart at twenty feet
testing for her visual acuity.
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
IV. Trochlear handling the eye muscles and turning the eye
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,
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
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.
VI. Abducens function of turning eye laterally
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.
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, swallowing food.helping in
Using tongue
depressor, tests for gag reflex
X. Vagus it contributes in thetasting ability of the client
Instruct the patient to close her eyes, let the patient taste the condiments.
XI. Spinal Accessory
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.
XII. Hypoglossal motor nerve that deals with the muscles of tongue
Tongue movement and strength using the tongue
depressor put resistance on the tongue and observe the strength. 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
DATE/
TIME FOCUS DATA ACTION
DATE/ TIME RESPONSE 9/9/16 2:30 pm Pre-operative care 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 9/9/16 2:30 pm Baseline VS BP= 130/80 mmHg RR= 20 bpm PR= 88 bpm O2 SAT= 100% Urine output 200 cc 9/9/16 2:52 Intra-operative care 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 4:29 pm Immediate post-operative care s/P total abdominal hysterectomy with bilateral salphingo-oophorectomy, 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.
4:39 pm Latest vital signs BP= 120/80 PR= 77 bpm RR= 20 bpm 02 sat= 99%
catheter.
V. LIST OF NURSING PROBLEMS IDENTIFIED (according to priority) 1.
2. 3.. 4. 5.
