Appendectomy

Focus Notes
For Stat D- Sakit na kayo akong tiyan as verbalized by the patient. Conscious,
Appendectomy as coherent, irritable, restless, grimaced face, guarding behavior, rebound
ordered by tenderness noted. Right lower quadrant pain noted. Not in respiratory
Dr.________ distress. Bp-120//90 mmhg, PR- 98 bpm, RR-235 cpm, T- 37 C. With
ongoing D5LR I L @ 700 cc level infusing well on left cephalic vein. IV
site clean, dry and intact, C signed consent for Stat AP under the service
of Dr. Kho/ Dr. Garcia. Endorsed by Surgery ward NOD. Preoprative and
surgical checklist filled up and verified..
A- Assisted on OR table in supine position. Attached to cardiac monitor,
V/S taken and recorded, Pulse oximeter attached to left thumb. O2
administered @ 2-3 L/ min via nasal cannula. Assisted to left lateral
position. Skin prep done on lower back and draped. Gauge 25 spinal
niddle aseptically inserted between L3-L4 area c clear SCF flows noted.
Sensorcaine Heavy inducted as spinal anesthesia by Dr. Garcia. Assisted
back to supine position c arms placed on padded arm board. V/S
rechecked. Sensory and motor loss obtained Perinial pre done. Foley
catheter FIG aseptically inserted connected to urobag draining clear pale
yellow urine. Final abdomen skin pre done. Aseptically drape by scrub
team. Initial counting of sponges, instruments and needles done. Itemized
and recorded. Prayer and procedure started. Cutting time. Focky Davis
incision by Dr. Kho. Incision deepened to perineum. Bleeders clamped
and cauterized. Retractors placed .Abdomen explored, findings noted.
Abdominal organs protected with moist saline packs. Appendix grasped c
Babcock. Bloody supply to the appendix ligated and divided. Clamp
applied to appendicial placed, ligated and divided. Appendix removed.
Specimen out. Stump closed using silk 2/0 . Washing with PNSS done.
Penrose drain placed and anchored to skin. Bleeders checked- cleared.
First counting of sponges, instruments and needles done. Verified
complete and recorded. Peritoneum closed. Third counting of sponges,
instruments and needles done, verified complete and recorded.
Subcutaneous layer closed. Final counting of sponges, instruments and
needles done, verified complete nad recorded Skin closed using Silk 4/0.
Procedured ended. Incision painted c betadined OS and covered c sterile
gauze.l Betadine os removed from vagina. Post op care done. Urobag
drained. Epidural catheter removed by dr. Gracia with blue tip intact.
Latest V/S taken and recorded. Kept monitored. Forwarded back to
ward. Endorsed to NOD..
R- BP-100/80 mmhg. PR-90 bpm. RR-18 cpm. T- 35.7 C. 400 cc clear
yellow urine drained. Conscious. Not in respiratory distress. Incision site
dry and intact. O2 saturated-99%.................................K E. Lumanta, RN