Operating room observation paper

Topics: Anesthesia, Surgery, Post anesthesia care unit Pages: 5 (1052 words) Published: October 18, 2014

Patient: J.D.

Age: 39 year-old.

Gender: Female.

Marital status: Married.

Chief complaint:

Left tendoachilles pain for 5 years.

Patient rates pain to 10/10. Patient said she had a Platelet-Rich Plasma

(PRP) injection 2 years ago as a treatment intervention for this condition and had some relief but over time, the pain came back and got worse.

Name of surgical procedure:

Endoscopic Gastrocnemius Recession.


Left leg Gastrocnemius Recession. This procedure is to release a tight calf muscle that is pulling the heel upward. To improve ROM(Range Of Motion), the tendon connecting to the tight calf muscle will be cut, this will release the heel from the upward pull allowing the patient to stand with foot flat on ground.

Gastrocnemius Recession is commonly performed to correct an equinus contracture of the ankle that may accompany foot and ankle pathology in adults. (An equinus deformity is basically one in which the achilles tendon is shorter than needed to allow adequate dorsiflexion during the gait cycle. If the foot is perpendicular to the leg and put through a range of motion where the foot cannot dorsiflex (move upward) more than 10 degrees this is thought of as an equinus deformity). The equinus deformity leads to excessive pressure and pain that manifests as plantar fasciitis, metatarsalgia, posterior tibial tendon insufficiency, osteoarthritis, and foot ulcers. The procedure is also performed on individuals who have limited ankle dorsiflexion.

Preoperative phase.

In the preoperative phase, many informations are obtained, a full history from the client, including allergies, medication usage, and pre-existing medical

conditions. Any previous experiences with sedation or anesthesia should to be reported, especially any adverse reactions. Note the last dose of each of the client's prescribed medications, especially if it could alter the client's response (diuretic, antihypertensive, narcotic). Provide education about the procedure and the medications to be used. Perform a full assessment on the client, including baseline vital signs, cardiac rhythm, and level of consciousness. Determine the last time the client ate or drank (generally NPO for 6 hrs or more before the procedure). The client may have clear liquids up to 2 hrs before the surgery or procedure. Instruct the client to adhere to the instructions to remain NPO, or the surgery or procedure may be cancelled. Establish IV access and administer fluids as prescribed. Verify that the client signed the informed consent. Attach monitoring equipment to the client. Remove dentures (in case intubation would become necessary). Anxiety level is also assessed regarding the procedure, and coping mechanisms.

Diagnostic test.

Usually many diagnostic test are performed, including Urinalysis, CBC, ECG, chest X-ray for heart and lung status and also for this case since my assignment patient was a female, a pregnancy test was performed, which came out negative.

Informed consent.

Usually once surgery has been discussed as treatment with the client and significant other, family member, informed consent is obtained after discussing the risks and benefits of the procedure.

To obtain informed consent, the provider must give the client a complete description of the treatment/procedure. A description of the professionals who will be performing and participating in the treatment Information on the risks of anesthesia. A description of the potential harm, pain, and/or discomfort that may occur. Options for other treatments and the right to refuse treatment. The patient must give informed consent voluntarily. And the nurse is to witness the patient sign the consent papers.

The procedure/Intraoperative.

The nurse remains with the client at all times. Allow other staff to assist the provider with the procedure, if indicated. Continually assess and monitor level of consciousness, cardiac rhythm,...
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