SAINT LOUIS UNIVERSITY

School Of Nursing
OR WRITE-UP

NAME OF STUDENT: Tamayo, Teanu Jose G. Year & Sec. III-D Group D4
NAME OF PATIENT: XXXXXX, XXXX
Date of Admission: June 20, 2018 Ward: OB Ward
Age: 38 years old Sex: Female Civil Status: Married Religion: Roman Catholic
Address: Bakakeng, Baguio City Occupation: Housekeeper
Operation Proposed: Repeat LSCS
Working Diagnosis:
Type of Anesthesia: caudal epidural anaesthesia (CEA) with bupivacaine Position: sitting; to L4-L5
History of Present Illness:
G4P2 (2-0-1-2)
2oo4, delivered under cesarean delivery due to breech presentation
2oo5, delivered under cesarean delivery due to breech presentation.
Present pregnancy at 38 weeks AOG.. Prenatal check-up done in SLUHSH physician assessed mother of failure of descent hence was advised for repeat LSCS.

Special Considerations of client: (in terms of surgery)

Past Medical History:
Hx of 2 deliveries under CS

Pathophysiology: Repeat LSCS

Brief Discussion of Proposed Operation:

Patient was identified in holding area and brought the the OR table. Patient Positioned in sitting position, bupivacaine administered at L4-L5 level. Placed in Supine. Skin prepped and
draped. Paused for accomplishment of anesthesia. First cut made to the skin then to the fat, superficial fascia, deep fascia, muscle, peritoneum and uterus. Bleeders controlled. Baby
delivered, amniotic fluid suctioned delivery 0f the placenta. Sutured layer by layer. Counting done during closure and after procedure. Towels removed, skin cleaned., patient transferred
out of OR to PACU. Instruments cleaned.

Instruments: (Place at the back of this sheet)

 SURGICAL INSTRUMENTS 7. Army-Navy Retractor 13. Mixter Forceps
1. Straight Forceps

2. Curved Forceps 14. Ochsner Forceps

8. Mayo Scissors

3. Allis Forceps
9. Curve Metzenbaum Scissors
15. Pean Forceps

10. Blade Handles

4. Towel Clip

16. Bobcock Forceps

11. Richardson Retractor

5. Tissue Forceps
17. Plastic Umbilical Cord Clamp

12. Balfour Self-Retaining Retractor

6. Needle Holder