PREFERENCE CARD
OR - Pay Division USTH
LIM, ELISA JOANA R. March 2009
BSN III-6.2
Name of Patient:Carlos Bayona Cojelo / Age: 85 y/oDate of Admission: March 22, 2009 / Date of Surgery: March 27, 2009
Time started:4:00 PM / Time ended:5:40 PM
Bed No.:221 / Registration/Receipt No.: 09C01068
Hospital No.: 01-65-38
Surgeon:Dr. Nelson Lim
Asst. Surgeon:Dr. Ausero
Anesthesiologist:Dr. C. Braganza
Scrub Nurse:Ross Cleofe, RN / Circulating Nurse:Ryan Guaria, RN
Chief Complaint:altered sensorium and anorexia
Rationale/Patho-physiological basis in relation to its diagnosis:
Diabetes Mellitus
Chronic hyperglycemia
Glucose toxicity Irreversible structural changes
Altered functional cell integrity Microvascular changes Macrovascular changes
Altered WBC function Neuropathy Peripheral vascular disease
Risk for infection Loss of nerve function Clogged arteries in the legs
(diffuse) Poor blood flow
Distal symmetric polyneuropathy Body cannot heal efficiently
Altered sensorium Motor alterations in
intrinsic muscles of foot
Diabetic foot infection
-Redness -Temperature -SwellingLoss of function -Pus
- Blue/black discoloration around the sight of infection
Post-operative diagnosis:diabetic foot, leftRationale/definition:Diabetic foot is an umbrella term for foot problems in patients with diabetes mellitus. Due to arterial abnormalities and diabetic neuropathy, as well as a tendency to delayed wound healing, infection or gangrene of the foot is relatively common. Ten to fifteen percent of diabetic patients develop foot ulcers at some point in their lives and foot related problems are responsible for up to 50% of diabetes related hospital admissions.
Complete Surgical Procedure:BKA, left foot (Below-knee Amputation)
Definition:Amputation is a surgical procedure that involves removal of an extremity/limb (leg or arm) or a part of a limb (such as a toe, finger, foot, or hand), usually as a result of injury, disease, infection, or surgery (to remove tumors from bones and muscles). Amputation of the leg (above and below-knee) is the most common type of amputation procedure performed.
Type of Anesthesia:General
Specific Type:Spinal
Anesthetic Agent: Bupivacane Heavy
Mechanism of Action:
Bupivacaine binds to the intracellular portion of sodium channels and blocks sodium influx into nerve cells, which prevents depolarization. Since pain transmitting nerve fibres tend to be thinner and either unmyelinated or lightly myelinated, the agent can diffuse more readily into them than into thicker and more heavily myelinated nerve fibres like touch, proprioception, etc.
Position: Supine
Incision:Closed (flap) amputation method was performed below the knee
Skin Preparation:left upper thigh to entire left foot
Draping:1 lap, 2 small sheets, and 4 towels
Sutures and Needles:
Tissue Layer / Needle / Suture Used / Suturing Technique
Visceral
Visceral
Muscle and Subcutaneous tissue
Skin / n/a
n/a
Round
Cutting / Mersilk 2-0
Mersilk 4-0
Chromic 2-0
Prolene 2-0 / Interrupted
Interrupted
Interrupted
Interrupted
Instruments:
Clamping / Retracting / Grasping / Cutting / Others
Ochsner (1)
Needle holder (2)
Kelly fine (4)
Kelly round (7)
Allis (3) / Army Navy (2) / Tissue (1)
Thumb (1)
Ronjure (1) / Mayo (1)
Metz (1)
Straight (1)
Knife handle/blade (2/2) / MC/bowl/kidney basin (1/3/1)
2/3’s gauze (20)
Asepto syringe (1)
Curette (1)
Filer (2)
Elevator (1)
Penrose drain tube (1)