Case No: Circulating Major 2

Name of Student: Salazar, Nica Sharmaine C.

Year/Section & RLE: 3NUR8 RLE4

Name of Patient: Asuncion Rosas Magallanes Age: 77 Sex: F Civil Status: Married
Date of Admission: 10/13/17 Time Started & Ended: 1:18-4:00 PM
Date of Surgery: 10/13/17
Bed #: 3052 Hospital No: 17-130000065352 Admission No: 17J00405

Surgeon: Dra. C. Braganza Anesthesiologist: Dra. E. Braganza

Assistant Surgeon: Dr. Tayag Scrub Nurse: Ernest Palma, RN
Dr. Baylon Circulating Nurse: Marie Joy C. Acasio, RN

Chief Complaint: Difficulty Ambulating

Rationale/Definition: Difficulty in walking and in using necessary muscles and bones to move

Post-Operative Diagnosis: Revision of total Left hip arthroplasty

Rationale/Definition: During primary total hip replacement surgery, the hip joint is replaced with an implant or prosthesis
made of metal, plastic, and/or ceramic components.

Complete Surgical Procedure: Revision of total Left hip arthroplasty

Definition: During primary total hip replacement surgery, the hip joint is replaced with an implant or prosthesis made of
metal, plastic, and/or ceramic components.
Type of Anesthesia:Regional+ General Anesthesia
Specific Technique: Spinal Anesthesia+ Femoral Block + Through Inhalation
Skin Preparation: waist area to foot
Items Used to Administer Anesthesia: Spinal Set
Anesthetic Agent:Chriocaine
Mechanism of Action: Levobupivacaine is a member of the amino amide class of local anesthetics. Local anesthetics block
the generation and the conduction of nerve impulses by increasing the threshold for electrical excitation in the nerve, by
slowing propagation of the nerve impulse, and by reducing the rate of rise of the action potential. In general, the progression
of anesthesia is related to the diameter, myelination, and conduction velocity of affected nerve fibers.
Other Medications Used: Xylocaine
Mechanism of Action: Lidocaine HCl stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the
initiation and conduction of impulses thereby effecting local anesthetic action.

Position: Supine
Equipment Used for Positioning: Surgical table, pillow, armboards
Incision: Vertical incision
Skin Preparation: from waist area to the sole of the foot
Disinfectant used: Betadine
Drapes used: Disposable Hip Set
 Sign In Time Out Sign Out
Is the patients identity, YES Time Out: 3:40 PM Nurse verbally confirms:
site, procedure and The name of the YES
consent CONFIRMED? Patient, Asuncion Rosas Magallanes procedure to be
Is the surgical site YES scheduled for Hip Replacement recorded
marked? surgery under spinal+general If instruments, YES
Is the anesthesia machine YES anesthesia. sponges, sharps
and medication chart and needle
checked? Surgeon is Dr. Braganza, assisted by counts are
Is the pulse oximeter YES Dr. Tayag, Dr. Baylon complete
attached and working? Anesthesiologist is Dr. E. Braganza Has the specimen been YES
Equipment needed YES Scrub nurse is Ernest Palma, labeled correctly?
available and working? Circulating Nurse is Marie Joy C. (including patients name)
Acasio. Patient was given Cefoxilin. Specimen: NONE
Instruments counted and complete,
you may now proceed Pathologist: NONE
Any equipment problems NONE
identified?
Any concerns for transfer NONE
Does the patient has any: to recovery and
Known allergies NO management issues
Difficult
airway/aspiration risk?
Risk of blood
loss
Has the Surgical Site YES
Infection (SSI) bundle
been undertaken?
Antibiotic
prophylaxis within the
60 minutes
Patient warming
Hair
removal/shave site
Glycemic
control
Has venous YES
thromboembolism
prophylaxis been
undertaken?
Is essential imaging YES
displayed?
Is the initial count done YES
and recorded?
FDAR
Date and Time Focus
10/13/2017 Risk for bleeding D: Patient is to undergo hip replacement surgery
A: > Monitor Vital signs and Heart rate.
>Assess for PTT or APTT prior to surgery
> Evaluate the patients use of any medications that can
affect hemostasis(e.g, anticoagulants, salicylates, NSAIDs,
or cancer chemotherapy).

R: amendable; avoided bleeding during and after the

procedure.