OR Write-up-NSD
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Name of patient: JB Age:31 Sex: Female Civil Status: Married Religion: Roman Catholic Address: Mangatarem, Pangasinan Operation Proposed: NSD Working Diagnosis: PU 40 wks AOG, G5P4 (5,0,0,4) Type of Anesthesia: SAB Position: knee chest History of Present Illness: Prior to admission, the patient was in: - PU 40 wks AOG, G5P4 (5,0,0,4) - Pregnancy uterine delivered by NSD 2° to a live baby boy out G5P5 (2,0,0,2) Pathology: There was a sexual intercourse done by the married couple. Soon after, there was the union of egg cell & sperm cell. Then, fertilization takes place in the woman’s uterus, and then a fetus developed for 9 months. After 40 wks of pregnancy, the mother gave birth to a live baby boy Brief Discussion of Proposed Operation: 12:20 am: Brought to O.R. a 31 year old female, per stretcher, with D5LRS at 500 cc level, scheduled for NSD by Dr. Espinosa, placed at O.R. table in supine position, repositioned to knee-chest position, SAB inducted by Dr. Ordona, and skin preparation done. Draped properly, IFC inserted aseptically, connected to urine bag. Initial count of sponges, needles, and instruments done. 12:46 am: operation started by Dr. Espinosa, RMLE done. 12: 52 am: a live baby boy out 12:53 am: placenta out completely. Suturing started. 01:34 am: operation ended, Betadine swabbed. Finally, then brought to PACU per stretcher with D5LRS at 500 cc level, for further care and management. UNIVERSITY OF THE CORDILLERAS COLLEGE OF NURSING Gov. Pack Road, Baguio City
Transcript of OR Write-up-NSD
Name of patient: JB Age:31 Sex: Female Civil Status: Married Religion: Roman CatholicAddress: Mangatarem, PangasinanOperation Proposed: NSDWorking Diagnosis: PU 40 wks AOG, G5P4 (5,0,0,4)Type of Anesthesia: SAB Position: knee chest History of Present Illness:
Prior to admission, the patient was in:
- PU 40 wks AOG, G5P4 (5,0,0,4)
- Pregnancy uterine delivered by NSD 2° to a live baby boy out G5P5 (2,0,0,2)
Pathology:
There was a sexual intercourse done by the married couple. Soon after, there was the union of egg cell & sperm cell. Then, fertilization takes place in the woman’s uterus, and then a fetus developed for 9 months. After 40 wks of pregnancy, the mother gave birth to a live baby boy
Brief Discussion of Proposed Operation:
12:20 am: Brought to O.R. a 31 year old female, per stretcher, with D5LRS at 500
cc level, scheduled for NSD by Dr. Espinosa, placed at O.R. table in supine position,
repositioned to knee-chest position, SAB inducted by Dr. Ordona, and skin preparation
done. Draped properly, IFC inserted aseptically, connected to urine bag. Initial count of
sponges, needles, and instruments done.
12:46 am: operation started by Dr. Espinosa, RMLE done.
12: 52 am: a live baby boy out
12:53 am: placenta out completely. Suturing started.
01:34 am: operation ended, Betadine swabbed. Finally, then brought to PACU per
stretcher with D5LRS at 500 cc level, for further care and management.
UNIVERSITY OF THE CORDILLERASCOLLEGE OF NURSING
Gov. Pack Road, Baguio City
OR WRITE UP
INSTRUMENTS:
TISSUE FORCEPS
THUMB FORCEPS
NEEDLE HOLDER
SURGICAL NEEDLES
METZENBAUM SCISSORS
STRAIGHT MAYO SCISSORS
CURVE MAYO SCISSORS
BLADE HOLDER
SURGICAL BLADES
KELLY CURVED
KELLY STRAIGHT
BOBCOCK
ARMY NAVY RETRACTOR
RICHARDSON RETRACTOR
ABDOMINAL RETRACTOR
TOWEL CLAMP
ALLIS
CAUTERY MACHINE
