Case No: Circulating Major 1

Name of Student: Salazar, Nica Sharmaine C.

Year/Section & RLE: 3NUR8 RLE4

Name of Patient: Rustom Cervantes Luego Age: 58 Sex: M Civil Status: Married
Date of Admission: 10/16/17 Time Started & Ended: 3:40-4:15 PM
Date of Surgery: 10/19/17
Bed #: 3014 Hospital No: 17-120000086326 Admission No: 17J00519

Surgeon: Dr. P. Purino Jr. Anesthesiologist: Dr.E. Guerrero

Assistant Surgeon: Dr. J. Lopez Scrub Nurse: Arnold Jeff S. Cadiang R.N.
Circulating Nurse: Jo Francesca B. Fernando, R.N.
Chief Complaint: Difficulty of breathing
Rationale/Definition:There are a number of lung conditions that can causebreathing difficulty. All of these require immediate
medical attention. Asthma is an inflammation and narrowing of the airways that can cause shortness of breath, wheezing,
chest tightness, and coughing.

Post-Operative Diagnosis: Pericardial Effusion

Rationale/Definition:is an abnormal accumulation of fluid in the pericardialcavity. Because of the limited amount of space in
thepericardial cavity, fluid accumulation leads to an increased intrapericardial pressure which can negatively affect heart
function.

Complete Surgical Procedure: Pleuropericardial Window

Definition/Indication:is used diagnostically and, more often, therapeutically for drainage of accumulated pericardial fluid (a
condition that most often occurs after cardiac surgery but has many other possible causes). The pericardium envelops the
heart like a cocoon; its cardiac filling can be impaired when this cavity fills with excess fluid. When the limited space
between the noncompliant pericardium and heart is acutely filled with blood or fluid, cardiac compression and tamponade
may result.
Type of Anesthesia: General Anesthesia
Specific Technique: GA-LMA (Laryngeal Mask Airway)
Skin preparation/ Assistance done: Use of Lubricating jelly
Items used to Administer Anesthesia: General Anesthetic Machine
Main Anesthetic Agent: Sevoflourane
Mechanism of Action: Used as an inhalational anaesthetic for induction and maintenance of general anesthesia.
Other Medications:
Propofol
Mechanism of Action:
involves a positive modulation of the inhibitory function of the neurotransmitter gama-aminobutyric acid (GABA) through
GABA-A receptors.
Medazolam
Mechanism of Action: Benzodiazepines increase the activity of GABA, thereby producing a calming effect, relaxing
skeletal muscles, and inducing sleep. Benzodiazepines bind to the benzodiazepine site on GABA-A receptors, which
potentiates the effects of GABA by increasing the frequency of chloride channel opening.
Morphine Sulfate
Mechanism of Action:
The principal alkaloid in opium and the prototype opiate analgesic and narcotic. Morphine has widespread effects in the
central nervous system and on smooth muscle
Position: Supine
Equipment used for Positioning: pillow; sandbag; and safetybelt
Incision: small subxiphoid incision, thoracoscopically, or via a thoracotomy.
Skin Preparation: whole anterior chest
Disinfectant Used: Betadine
Draping: 4 small towel sheets, Laparotomy sheet
 Sign In Time Out Sign Out
Is the patients identity, YES Time Out: 3:40 PM Nurse verbally
site, procedure and confirms: YES
consent CONFIRMED? Patient Rustom Cervantes Luego The name of
Is the surgical site YES Constantino Legaspi, age 58, the procedure
marked? scheduled for Pleuropericardial to be YES
Is the anesthesia machine YES Window under general anesthesia. recorded
and medication chart If
checked? Surgeon is Dr. Purino assisted by Dr. instruments,
Is the pulse oximeter YES Lopez, sponges,
attached and working? Anesthesiologist is Dr.E. Guerrero sharps and
Equipment needed YES needle counts
available and working? Scrub Nurse, Sir Arnold Jeff S. are complete
Does the patient has any: Cadiang and Circulating Nurse Maam Has the specimen been YES
Known allergies NO Jo Francesca B. Fernando labeled correctly?
Difficult Counting of instruments complete, (including patients
airway/aspiration risk? Time out is done, the procedure may name)
now be started.
Risk of blood Specimen: Pleural
loss pericardial
Has the Surgical Site NO left
Infection (SSI) bundle Pathologist: Dr. Lopez
been undertaken? Any equipment NONE
Antibiotic problems identified?
prophylaxis within the Any concerns for NONE
60 minutes transfer to recovery
Patient warming and management
Hair issues
 removal/shave site
Glycemic
control- NO
Has venous NO
thromboembolism
prophylaxis been
undertaken?
Is essential imaging NO
displayed?
Is the initial count done NO
and recorded?

FDAR
Date and Time Focus
10/16/2017 Risk for falls D: Patient is sedated and disoriented; patient have
sensory/perceptual disturbances due to anesthesia
A: >Secure patient on OR table with safety belt as
appropriate
> placed sandbag below patients arm to prevent muscle
complications
>Reposition slowly at transfer from table and in bed

R: amendable; avoided falls during and after the procedure.