PACU Endorsement

PARREÑO, MITZI
PASAQUIAN, MAREFIL JANE
PATEÑA, PRINCESS BRIGITTE
PEDIANGCO, JEWELLYN IMEE
PERUCHO, PAULINE JOY

2nd Rotation 10/19/2021

Operating Room BSN 4F
I PUT PATIENT FIRST
Patient’s past medical history (medical, surgical, social)
Patient’s name is Felicia Riego, 75 years old, Female from
OR with Chart no. 0188 under Dr. Magsino. She was
indicated for surgery due to swelling and pain in the left
hip after having a fall.

Underlying X-ray of Right hip, APL

result revels a Shenton’s line
diagnosis and disruption: loss of contour
procedure between normally
continuous line from medial
edge of femoral neck and
inferior edge of the superior
pubic ramus

Total Hip
Replacement
Technique Patient was under General
Anesthesia and Anesthesiologist was
(general
Dr. Quilantang.
anesthesia,
neuraxial,
regional)
Peripheral IVs, The patient’s IV line is placed on the
left cephalic vein. I have already
arterial lines,
regulated the patient’s present IVF
central lines, to 30gtts/min as ordered and be
drains followed by D5LR 1L and PLR 1L to
run for 8 hours.
Allergies The patient has no known allergies
Therapeutic Dr. Magsino ordered Antibiotic
interventions Cefazolin to be given every 6 hours
and I have already given the first
(pain medications, dose of Cefazolin 1 gm at 12 PM. You
antibiotics) can give the patient this antibiotic at
6PM for patient’s 2nd dose. I also
have started Nubain 5mgs at 12:30
PM and it is also given every 6 hours
for 4 doses only and if patient
complains of moderate pain,
Tramadol 50 mgs as PRN medication
is ordered.
Intubation (very o NONE
difficult, moderately
difficult, easy)
Extubation likelihood NONE
(already extubated, very
likely, unlikely, definitely
no extubation planned)
Need for drips NONE
(epinephrine,
vasopressin,
norepinephrine,
insulin, propofol, etc.)
 Transfer patient to PACU (S/P Total
Hip Replacement, left)
Treatment plan Keep flat on bed until fully awake
for postoperative VS q 15 mins x 4 hours then q 1 next 4

care (blood hours then q 2 hours next 4 hours till

stable
pressure goals, NPO till further order
ventilator settings) Encourage deep breathing exercises
For Daily Change dressing starting
tom
Maintain Foley catheter tom AM.
Measure I and O and record
Kept patient comfortable
Please refer accordingly
 Request for the following:
1. Repeat x-ray of the left hip

Treatment plan 2. CBC

Regulate present IVF to 30 gtts./min
for postoperative IVF to follow as follow
3. D5LR 1 L x 8 hours
care (blood 4. PLR 1 L x 8 hours

pressure goals, Start cefazolin I gm q 6 hours

Tramadol 50 mgs IV q 6 PRN for moderate pain
ventilator settings) Nubain 5mgs q6 hours for 4 doses only
Observe Post hip prosthesis precaution (leg
movement)
Encourage deep breathing exercise
For Daily Change dressing starting tom
Maintain Foley catheter tom AM.
Measure I and O and record
Kept patient comfortable
Please refer accordingly
Signs (vital signs The patient’s vital signs are to be
checked every 15 mins in the first 4
during case and
hours and be taken every 1 hour in
most recent) the next 4 hours, then every 2 hours
for the next 4 hours until stable. I
have already checked the vital signs
at 1:00 PM and the BP is 130/90
mmHg, pulse rate is 83bpm,
respiratory rate is 19 bpm and
temperature is 36.4 ̊C.
Fluids (In’s and I also have already measured and
recorded the patient’s intake and
Outs’s, blood
output.
product(s)
administered)
Intraoperative NONE
Events (if any)
Recent labs Dr. Magsino also ordered to request
to repeat X-Ray of the left Hip and
(Hemoglobin,
CBC. I already have notified the staff
glucose, etc.) please follow-up if necessary.
 For positioning please place the
Suggestions for
patient flat on bed until fully awake
immediate postop and also please observe the patient’s
care (ex: special post hip prosthesis precaution and
positioning, pain encourage the patient to use deep
control, need for breathing exercises. The patient is
pumps, etc.) placed NPO until there is further
order from Dr. Magsino and the
dressing will be changed daily
starting tomorrow and the foley
catheter is maintained until
tomorrow morning.
Timing/expected The patient is already made
comfortable in the stretcher ready
time of arrival to
for transfer in PACU.
ICU
THANK YOU!
PARREÑO, MITZI
PASAQUIAN, MAREFIL JANE
PATEÑA, PRINCESS BRIGITTE
PEDIANGCO, JEWELLYN IMEE
PERUCHO, PAULINE JOY

2nd Rotation 11/27/2021

Operating Room BSN 4F