Course in the Ward

Date 2/ 8/ 13 @ 11am Order Admit under the care of Dr. Batucan Rationale Admitted under the care of Dr. Batucan, a surgeon, for his specialties on surgical procedures (Laparoscopic cholecystectomy) Secure consent to care Consent is an agreement between client and health care provider to give proper quality care. It is also to protect the client from harmful procedures and the institution from law suits Low Salt, Low fat diet Doctors were not sure whether the gallstones are either cholesterol or pigment stones. Thus, this is done to prevent any further damage to the gallbladder. Monitor VSqShift and record Monitoring vital signs is important in order to note any unusualities and to refer these as follows. Labs: Done Done Remarks Done. Patient was placed in ROOM 345 Pre Op Ward Done

CBC

A complete blood count (CBC) is a series of tests used to evaluate the

Done

composition and concentration of the cellular components of blood. It consists of the following tests: red blood cell (RBC) count, white blood cell (WBC) count, and platelet count; measurement of hemoglobin and mean red cell volume; classification of white blood cells (WBC differential); and calculation of hematocrit and red blood cell

Platelet

Platelet count is to determine the number of platelets; If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form (thrombosis), which may obstruct blood vessels.

Done

Urinalysis

It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances

Done

PNSS 1L @ 100cc/hr PNSS is an isotonic solution

Done. IVF

for 2 cycles

to provide hydration since it was found out that the specific gravity for urine is in the borderline (1.010). It is also to provide electrolytes, and as a medium for IVTT meds

infusing well at right metacarpal vein.

Meds:

Nalbuphine 10 mg IV now then prn for abdominal pain

Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation for relief of moderate to severe pain

Given

HNBB (Hyoscine NButyl Bromide) 20mg 1amp IVTT now

It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists causing smooth muscle relaxation indicated for her abdominal pain

Given

Omeprazole (Prilosec) 40 mg IV MHBR Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. This is also to prevent ascending infection that could be caused by Done

possible rupture of the gallbladder. Refer any unusualities: severe abdominal pain, vomiting 02/ 09/ 13 @8:30 Start Ciprofloxacin(Ciprob ay) 200 mg IV q8 ANST In order for the patient to be assessed and evaluated properly and be managed accordingly. Ciprofloxacin inhibits synthesis of bacterial cell wall causing cell death which acts Done. Result for skin test is negative. Done

as a perioperative prophylaxis Ciprofloxacin for surgical procedures. ANST or after negative skin test is to check whether the client is not allergic to the antibiotic. may be given to the patient.

For ultrasound tomorrow morning

This is done to visualize internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. This is also to know the condition of the gallbladder whether it ruptured or not.

Not able to comply. Patient had her ultrasound on February 10/ 13

For total bilirubin,

Bilirubin is elvated if hepatocytes are injured and cannot metabolize or excrete bilirubin

Done. Results are normal

Direct bilirubin,

Increases in conjugated bilirubin are highly specific for disease of the liver or bile

ducts

Indirect bilirubin

Increase in unconjugated bilirubin may be caused by hepatic disease, cholestasis, and hemolysis

SGPT (Serum glutamic pyruvic transaminase)

SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver function. Elevation of this may possibly mean liver problems AST (aspartate aminotransferase) or SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. It is also found in lesser amounts in other tissues. Elevated levels may be caused by liver or heart disease

Done. Patients SGPT results are normal

SGOT (Serum glutamic oxaloacetic transaminase)

Done. SGOT results are also slightly high

Schedule for laparoscopic cholecystectomy on February 10, 3 pm, Sunday Secure consent/AC

Lap Chole was to surgically remove the gallbladder with only a small incision.

Done. Surgery was done on 4/11/10 @ 4pm

Patient has the right to be

Done.

consented in all procedures to be done, and for legal purposes. Anesthesia clearance is for the patient to be evaluated whether he/she is fit to undergo the operation. It is also for the anaesthesiologist to predict the operative risk and the appropriateness of the anaesthesia to be induced during operation. Inform OR For the OR to know that such case will be performed and to prepare the necessary instruments and room. This is also to coordinate availability of staff and surgeon Refer In order for the patient to be assessed and evaluated properly and be managed accordingly. May have ultrasound on Feb 10, 2013 This was to visualize internal organs, to capture their size, Done. Ultrasound Done Done

structure and any pathological result lesions with real time tomographic images. It is also to know whether the gallbladder has ruptured or not. retrieved on 02/10/13. Impression: Cholelithiasi s; Sonographic

ally normal liver and pancreas

02/11/13 @ 8 Am

IVF TF: PNSS 1L @ KVO

PNSS is an isotonic solution for hydration and as a medium for IVTT meds; KVO was done since patients hydration was good. AC is to assess patients rate of survival and check for what anesthetics is right for the patient, making sure that the patient isnt allergic to the anesthetic

Done

Please facilitate AC

Done

For Lap Chole today 3 pm

This was to surgically remove the gallbladder with only a small incision. Patient can undergo laparoscopic cholecystectomy since gallbladder has not ruptured yet as seen on the ultrasound result.

Done.

For hematology. and Ultrasound tom

Blood tests are used to determine physiological and biochemical states, such as disease, mineral content, drug effectiveness, and organ function.

Done.

9:30pm

Pre-op orders:

NPO after light breakfast (8am)

NPO is to prevent peristalsis, aspiration and injury during surgery

Done

Assess VS prior to OR

as baseline data and to detect Done any unusualities

General oral hygiene

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.

Done

IVF: D5NSS 1L @ 120cc/hr

Intravenous solutions with reduced saline concentrations typically have dextrose added to maintain a safe osmolality while providing less sodium chloride; to hydrate before surgery in preparation for disruption of homeostasis

Done

Meds:

Diazepam 10mg 1 tab 2am

Potentiates the effects of GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; it is also used as adjunct to General anesthesia

Given

Given Ranitidine 150mg 1tab 2am Inhibits basal gastric acid secretion and gastric acid secretion; patient was placed on NPO

Vitamin K

For the liver to activate clotting factors such as prothrombin, proconvertin, thromboplasstin, and stuart factor.

Given

02/12/13 1:30pm

NPO

NPO is to prevent peristalsis, aspiration and injury to the GI tract during surgery.

Done

Post op orders:

To RR then to room

Patient must first be stabilized Done before transfer to the ward; RRis a place with complete gadgets and staff for emergency purposes after post op.

NPO for 4 hrs then may have SD Patient not yet fully conscious due to anesthetics, thus this is to prevent aspiration. Monitor VS q15 until stable then q30 for 2hrs then q2 Monitoring vital signs is to detect any unusualities after the operation. Done Done

Meds:

Etoricoxib 120mg PO 12mn

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Given

Tramadol 100mg 1tab 12mn

Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Given

Inhibits synthesis of bacterial cell wall causing Cefuroxime 500 md 1 cell death; this was tab mg PO TID indicated due to possible intra abdominal infections O2 inhalation @ 4pm until fully awake This ensures optimum oxygenation of cells gearing towards achieving balance or homeostasis. Also this was for optimum respiratory level; prevents lung collapse. MHBR Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. Deep breathing Post op exercise is indicated Done Done Done Given

exercises for 15mins TID

To prevent lung collapse and to eliminate anesthetic gases introduced to the body

02/13/13 11:15am

May have DAT

Patient may eat anything as long as it cant harm her current condition

Done.

Continue meds

For the patient to complete the medication regimen and for continuity of care

Done

Wound care

Daily routine wound care is indicated in order to promote healing and/or prevent infection

Done

02/14/13 11:30 AM Continue present management

May Remove Foley Catheter Now After Bladder Training 02/15/13 9:00am MGH Patient may go home after the doctor decides if unusualities are absent Home meds:

Removed at 1 pm

Done

Etoricoxib 90mg PO BID

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Done. Patient was informed

Tramadol 100mg tab PO BID

Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Cefuroxime 500 mg Po

Inhibits synthesis of bacterial cell wall causing cell death

C/D IVF

Terminate IVF when IVF is about 50cc

IVF discontinued Patient to come back at 5/18/10

ff. up check at 5/18/10

Follow up check up is for the patient to be assessed and evaluated properly and be managed accordingly.