Order 1103231: Clinical Case study post op

RN: Lisa Leonard

Item Number (s)

YES

INFECTION STATUS

CLEAN

Dressings INFECTED

Drain Tubes POTENTIALLY INFECTED

DATE:

Operation Performed:

Post Operative Orders (Please print or write clearly)

- RPAO

- IV therapy as charted

Laprascopic +/- Open Cholecystectomy

Details of Operation (including incision, organs removed and findings)

URN

SURNAME

GIVEN NAME

ADDRESS

DATE OF BIRTH

Reece Latham

5th March 2018

John Smith

Chronic Cholecystitis

75486

ROBERTS

Darren

25 Happy Street

CAIRNS 4860

23/11/1968 John SmithOPERATION REPORT

Simulated Hospital

DOCTOR

Date of Operation:

Surgeon:

Operative Diagnosis:

Assistant:

- Pain relief as charted

- Diet and fluids as tolerated once bowel sounds present

- Ambulate as tolerated

Speciman to Pathology

- Dressing to remain intact for 7 days

- Follow up with local GP if any concerns post discharge

SURGEONS SIGNATURE John Smith

Original Copy to remain with Hospital Duplicate Copy for Surgeons records

REASON

Steri Strips and Gauze

Drug and I.V Therapy - As charted arts

5th March 2018

P

Patient placed on standard operating table in supine surgical position and sites of compression well padded. Patient prepared with iodine solution and draped in a sterile fashion. A paramedian incison was made approximately 5cm in lenght wiht a #10 blade scalpel, Next haemostasis was obtained using electro Bovie cautery. Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped and the abdomen was entered. The gallbladder was immediately visualised and brought into view. It was found to be inflammed, thickened and filmy adhesions were present. Adhesions to the gallbladder taken down with sharp dissection. Contents of gallbladder were aspirated. Gallbladder disected free from liver bed, placed into specimen bag and

The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and tehn the anterior rectus fascia was clised in interrupted figure- of-eight #0 Vicryl sutures. Skin staples were used on the skin and sterile dressings were applied. The patient was transferred to recovery in a stable condition.

- VTE precautions as charted

withdrawn through the incision. Prior to closure, peritoneal cavity examined and showed complete signs of haemostasis, no bleeding from the gallbladder bed and no evidence of bowel injury.

Original Copy to remain with Hospital Duplicate Copy for Surgeons records

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