Admission/Final Diagnosis: MULTINODULAR COLLOID GOITER WITH INTRATHORACIC EXTENSION I. HEALTH HISTORY A. DEMOGRAPHIC DATA (BIOGRAPHICAL DATA) 1. Client’s name or initial: M.G.F. 2. Gender (Sex): Female 3. Age: 43 years old Birthdate: August 21, 1967 Birthplace: Manila 4. Marital (Civil) Status: Married 5. Race and Nationality: Filipino 6. Religion: Catholic 7. Address: General Trias, Cavite Telephone Number: N/A E-mail address: N/A 8. Educational Background / Other Significant Framing: 3 rd year college 9. Occupation: Midwife 10. Usual Source of Medical Care: Contreras Medical Clinic 11. Date of Admission: Sept. 15, 2010 B. SOURE AND RELIABILITY OF INFORMATION Client herself seems reliable
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Admission/Final Diagnosis:
MULTINODULAR COLLOID GOITER WITH INTRATHORACIC EXTENSION
I. HEALTH HISTORY
A. DEMOGRAPHIC DATA (BIOGRAPHICAL DATA)
1. Client’s name or initial: M.G.F.
2. Gender (Sex): Female
3. Age: 43 years old
Birthdate: August 21, 1967
Birthplace: Manila
4. Marital (Civil) Status: Married
5. Race and Nationality: Filipino
6. Religion: Catholic
7. Address: General Trias, Cavite
Telephone Number: N/A
E-mail address: N/A
8. Educational Background / Other Significant Framing: 3rd year college
9. Occupation: Midwife
10.Usual Source of Medical Care: Contreras Medical Clinic
11.Date of Admission: Sept. 15, 2010
B. SOURE AND RELIABILITY OF INFORMATION
Client herself seems reliable
C. REASONS FOR SEEKING CARE
“Malakas ang kabog ng dibdib ko”
“Para akong nasasakal”
“Parang may nagbabara kapag kumakain ako”
D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH
The pt. was apparently well until 2 yrs. ago, when she got pregnant, her doctor
advised her to undergo UTZ of her neck & check for goiter. She presented with increased
perspiration, anxiety, nervousness, tachypnea, and thick, tingling, feeling on the right hand.
Without noted aggravating or relieving factors. No consult was done and no medications
were taken.
One year prior to admission, there was persistence of symptoms and the pt. noted a
neck mass sensation. She began folding her pillow to elevate her head when sleeping
because of the neck discomfort.
Four months prior to admission, she experienced heat intolerance and felt an
obstruction on the neck area when swallowing even without food. There was persistence of
symptoms but the thick tingling sensation was felt from the fingertips of the right hand to the
forearm. Palpitations were also noted. No consult was done and no medications were taken.
Tremors on the right hand were noted.
Two months prior to admission, there was persistence of symptoms that prompted
her consult to a physician who referred her to an ENT doctor. She was advised to undergo
an operation ad no medications were prescribed. UTZ of the neck, CT Scan, CBC, X-ray
(Chest), FT4, TSH, ECG was done to prepare for the operation.
On the day of consult, there was persistence of symptoms and she was admitted in
DLS-UMC at around 3:00pm.
E. PAST MEDICAL HISTORY OR PAST HEALTH
Client stated that she had common illnesses in the past like fever, cough and
common cold. She had no serious illnesses experienced aside from these. The
client is not hypertensive and has no history of diabetes mellitus, bronchial asthma
and seizure. She has not experienced any serious injuries or accident.
The client had already undergone 2 operations before she was admitted in the
hospital. According to the client, her first operation was done on 1990’s which is
appendectomy along with unilateral oophorectomy due to a cyst found on her right
ovary. After 2 years, she underwent another operation which is cholecystectomy.
There were no complications reported from any of her operations.
The client’s OB score is G6P4 40240 which indicates that she became
pregnant six times and gave birth at term four times, all under normal delivery. She
currently has four living children. Unfortunately, she also had two spontaneous
abortions. Her age at menarche was 12 years old, her LMP was September 7, 2010
and her menstrual cycle is regular, usually lasting for 4-5 days. The client sometimes
experience heavy menstrual periods in which she uses diapers and change 3 times
in day. She had also experienced dysmenorrhea during her adolescence.
Her immunization status was unrecalled by the client. She has no allergies to
any foods or medications but stated that she has seasonal allergies in which the skin
below her lower lip becomes swollen and reddened.
The client was not a drinker but admits that she smokes whenever she wants
to defecate. According to her, this helps her to feel the urge to defecate and have an
easy bowel movement. The client also admitted that she sometimes consume
carbonated drinks.
F. FAMILY HISTORY
60 y/oDM
UnrecalledStroke
DM
89 Y/OHeart attack
63 y/o A&W
57 y/oDM
HPN-Gouty
Arthritis
50 y/oA&W
49 y/ounrecalled
48 y/oSkin
Asthma
47 y/oHTN
46 y/oHTN
44 y/oKidneydisease
60y/oHTN
56 y/oHTN
53 y/oHTN
48 y/oHTN
45y/oA&W
40y/oHTN
unrecalledTB
UnrecalledGI problem
43y/o 1y/o 33y/o 24y/o
Interpretation:
On her father side, they have a history of hypertension, tuberculosis and
asthma. Her grandfather died due to tuberculosis, unrecalled age while her
grandmother died due to gastrointestinal problem according to patient, unrecalled
specific gastrointestinal disease an age of death. Her father is the eldest among the
six, is sixty years old and is hypertensive. Most of her father’s siblings are
hypertensive except for the fifth child.
On her mother side, they have history of heart problems, Diabetes Mellitus,
skin asthma, gouty arthritis and renal problems. Her grandmother died at the age of
89 due to heart attack while her grandfather died at the age of sixty due to stroke,
also her grandfather had diabetes mellitus. Her mother is the second among the
nine children. The eldest died at the age of sixty years old due to Diabetes
complication. Her mother is sixty three years old. The third child has diabetes
mellitus and hypertension. The fourth child is fifty years old, has hypertension and
with gouty arthritis. The fifth child died at forty nine years old with unrecalled cause
of death. The sixth child is forty eight years old with skin asthma. The seventh and
eight child aged forty seven and forty six respectively, have hypertension, and the
youngest child aged fort four has kidney disease and is undergoing hemodialysis
twice a week for six years.
G. SOCIO ECONOMIC
The client stated that she does not work at present. She lives in three
different houses: her mother’s, her husband’s and her uncle’s house. This is
because she does not have any source of income to support her and her children’s
basic needs. Her 2 children are living with her mother and the other two are living
with her uncle. Her husband works as a security guard and earns 4,000 pesos every
15th of the month but his income is not enough to support their needs. Additional
taxes would still be subtracted from her husband’s income. The client’s brother
sometimes helps in paying for the expenses of the family. The client’s mother also
shares in paying the expenses because she works in a small grocery and has a
small apartment. Their other relatives abroad offer financial support to them and they
also help in paying for her hospitalization and other expenses they incur. Due to lack
of the sources of income of the client, her family experiences financial problems but
stated that they were lucky because they can still manage to pay for their basic
needs at present.
H. DEVELOPMENTAL HISTORY
According to Erik Erikson’s Developmental Theory, patient is in middle
adulthood stage with an ego development task of Generativity vs. Self absorption or
Stagnation and with the basic strengths of production and care
Now work is most crucial. Erikson observed that middle-age is when we tend
to be occupied with creative and meaningful work and with issues surrounding our
family. Also, middle adulthood is when we can expect to "be in charge," the role
we've longer envied. The significant task is to perpetuate culture and transmit values
of the culture through the family-like taming the kids and working to establish a
stable environment. Strength comes through care of others and production of
something that contributes to the betterment of society, which Erikson calls
generativity, so when we're in this stage we often fear inactivity and
meaninglessness.
As our children leave home, or our relationships or goals change, we may be
faced with major life changes—the mid-life crisis—and struggle with finding new
meanings and purposes. If we don't get through this stage successfully, we can
become self-absorbed and stagnate. Significant relationships are within the
workplace, the community and the family.
I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION
1. ROS AND PE
Date: Sept, 16, 2010
System ROS PE
a. General/overall health
status
“Nabawasan ang
timbang ko ng 4 kilos”
“Init na init yung
pakiramdam ko, gusto
ko na maligo”
“Hindi ako
nakakaramdam ng
panghihina ngayon”
Received patient
sitting on bed,
conscious,
awake and
communicative
Patient appears F/N
With heplock at right
metacarpal vein
V/S:
BP: 130/60mmHg
PR: 80 bpm
RR: 32cpm
Temp: 36.0°C
Good capillary refill (3
secs.)
large-size body build
Diet is DAT
b. Integument “Pakiramdam ko
parang may
tumutusok tusok sa
kamay ko, minsan
nawawala”
“Wala naman akong
sakit sa balat”
“Hindi naman ako
nangangati ngayon,
init na init lang ang
pakiramdam ko”
SKIN
Inspection
soft, smooth, dark
colored skin
(+) dark nuccal
(-) erythema
>(-) hyperpigmentation
on the skin
>(+)pruritus
Palpation
normothermic
(-) edema
HAIR
Inspection
gray-white colored hair
usual for age
(-) patches or lesions
on areas with hair
(-) parasites
Palpation
(+) thin hair strands
(+) dry hair
NAILS
Inspection
Nail surface are
smooth and slightly
curved w/ elongated
dirty nail edges
Convex shape
Pale pink nail beds w.
no linear pigmentation
Palpation
Smooth and rounded
posterior and lateral
nail folds
Good capillary refill for
3 secs.
Good skin turgor and
mobility
c. Head “Hindi naman palaging
sumasakit ang ulo ko,
hindi naman ako
nahihilo”
INSPECTION
>short black hair, well
to distributed
>Proportion to the body
>Bilateral symmetric
facial features
>(-) dandruff
>normocephalic
Palpation
>(-) tenderness
>(-) lumps observed
and palpated
d. Eyes “Medyo malabo na
ang mata ko”
“Nakakabasa ako sa
malayo pero kapag
sobrang lapit, medyo
malabo na”
“May salamin ako
kaya lang limang taon
ko na hindi nagamit
kasi hindi ko na
kasukat”
EYEBROWS
Inspection
Eyebrows evenly
distributed on both
sides
(-) lesions
(-) scaling
Both are bilaterally
equal and maintains
symmetry even after
movement
EYELIDS
Inspection
Completely close when
clients sleeps
With baggy eyelids
SCLERA:
Inspection:
White sclera
EYELAHES:
Inspection
>Lids close
symmetrically
>Pink palpebral
conjunctiva
Palpation:
>Skin intact
>Nodules or lesions
EYEBALLS:
Inspection:
>(-) protusion or
sunken
>Aligned normally in
their sockets
>Bilaterally
symmetrical
>(+) parallel eye
movements
CONJUNCTIVA:
Inspection:
>Pallor
>Shiny, smooth
>(+) parallel eye
movement
>(-) discharge
>(-) redness
CORNEA
Inspection:
>(+) corneal reflex
>transparent
PUPILS:
Inspection:
>Black in color
>(+) PERRLA
e. Ears “Nagkaroon ng
impeksyon yung
kaliwang tenga ko
dati, two years ago na.
Namaga tapos
pinacheck-up ko sa
doktor, binigyan ako
ng pampatak pati ng
antibiotic”
“Minsan sa isang
linggo ko lang nililinis
ang tenga ko kasi sabi
ng doktor hindi dapat
araw araw ang
paglilinis noon”
Inspection:
>Both ears are
bilaterally equal and
inline with the eyes
>Color same as facial
skin
>No discharge
>(+) cerumen
>(-) lesions
>(-)Swelling
Palpation:
>Pinna recoils after it is
folded
>Firm
>No tenderness on the
auricle and tragus
>(-) masses
f. Nose “Hindi naman ako
madalas magkasipon.
Pag nagkasipon ako
hindi naman barado”
Inspection:
>Symmetric and at the
midline
>Nasal septum intact
at midline of the head
without perforations
>(-) nasal flaring
>(-) nasal discharge
>(-) lesions
>(-) swelling of sinuses
>(-) nasal congestion
>(-) epistaxis
Palpation:
>(-) tenderness upon
palpation of the
maxillary and frontal
sinuses
>Both nasal airways
patent
g. Mouth & throat “Minsan sumasakit
ang lalamunan ko
kapag lumulunok at
kapag namamaga
yung tonsil ko”
“Medyo namamalat
din yung boses ko”
“Last year pa ako
nagpunta sa dentist.
Wala akong pustiso
kasi natatakot ako sa
dentista, masakit kasi
yung tusok ng
injection”
MOUTH, TEETH & GUMS,
PLATES, UVULA, THROAT
AND TONSILS:
Inspection:
unable to perform,
patient cannot open
her mouth still.
LIPS:
Inspection:
>(+) chapped lips
>(-)pallor
>(-) lesions
h. Neck “Nangangalay yung
batok ko”
“May goiter ako kaya
ako inoperahan, buti
natanggal na”
“Hindi ko masyado
magalaw pa ngayon
yung leeg ko, masakit
kasi”
Inspection:
post surgical operation
– thyroidectomy
Slow, limited
movements
>Positioned in midline
>Accessory neck
muscle are
symmetrical
>Head position is
centered in the midline
i. Breast & Axillary “Kinakapa ko yung
dede ko kung kailan
ko lang maisipan,
wala namang bukol”
“Lahat ng anak ko
breastfeed talaga sila,
mahal kasi yung
gatas”
Inspection:
>equal size of breast
>dark brown nipples
>(-)discharge
>small montgomery
tubercles present
j. Respiratory “Wala naman akong
sakit sa baga kasi
minsan lang ako
manigarilyo kapag
gusto ko lang
dumumi”
“Kanina may dugo
yung dura ko pero
ngayon wala na”
Inspection:
>RR=32 cpm
>(+) difficulty of breathing
>Thorax is symmetric,
Elliptical in shape
>(+) symmetrical chest
expansion
>AP diameter of the chest 1:2
>(+) cough; non-productive
Palpation:
>(+) equal tactile fremitus on
both lungs
Percussion:
>(+) resonant in both lung
fields
Auscultation:
>(-) adventitious sound
k. Cardiovascular Mabilis ako mapagod
lalo na kapag
umaakyat sa hagdan
kaya kapag umaalis
ako ng bahay lagi
akong sumasakay ng
tricycle”
“Nagpalpitate ako
bago ako maospital,
ngayon meron pa rin
pero konti na lang”
“Lagi akong
pinupulikat”
Inspection:
>(-) Cyanosis
>(-) Varicose veins
>(-) edema
Palpation:
>BP= 130/60 mmHg
>PR= 80 bpm
>(-) chest pain
>(-) palpitations
>Carotid artery pulsation
>(-) jugular vein distention
Auscultation:
(-) heart murmur
(-) tachycardia
(+)dyspnea
l. Gastrointestinal and
Abdomen
“Kahit ano kinakain
ko, medyo hirap nga
lang akong kumain
ngayon”
“Hindi ako umiinom ng
Inspection:
two incisions –
(previous
cholecystectomy and
appendectomy)
pampadumi”
“Regular naman ako
dumumi kasi pag
kumain ako, dudumi
ako pagkatapos”
(-) rahes
>+) striae
Ausculation:
15 Bowel
sounds/minutes
Palpation:
(+) dry skin
Percussion:
(+) tympanic sound
m. Urinary “Madami yung iniihi
ko, madilaw yung
kulay”
“Nagkaroon ako ng
UTI noong nagbuntis
ako”
Inspection:
>UO= 150 cc from 2-10pm
>Amber yellow urine
Palpation:
>(-)low back pain
>(-) umbilical area tenderness
n. Genitalia “12 years old ako
unang nagkaroon,
irregular pa dati pero
regular na ngayon”
“Minsan nagsusuot
ako ng diaper kapag
malakas yung period
ko”
Client refused to be
examined
o. Muscoloskeletal “Medyo masakit yung
likod ko pati balikat
ko”
Inspection:
Elbows, wrists, hands,
fingers, and feet are
“Yung kanang binti ko
medyo masakit din,
parang nangalay”
bilaterally symmetrical
(+) tremors
(+) Chvostek’s sign
(+) Trousseau sign
full range of motion of
hands and feet, as well
as wrists and ankles,
elbows, and knees but
limited range of motion
of neck
>Both sides of the
body are symmetrical
Palpation:
(-) joint stiffness
(-) joint swelling
(-) bone pain
(-) lethargy
p. Neurologic “Maayos pa naman
yung memorya ko”
“Hindi pa ako
nakaranas
mahimatay. Wag
naman sana”
“Minsan nerbyosa ako
pero depende rin sa
sitwasyon”
Inspection:
>Conscious and cohisent
Alert and oriented to person,
place and time
> Able to speak
>(-) tremors
>(-)depression
>CNS I = without difficulty in
smeling aromatic substances
>CNS II = equality responsive
to light, (+) pulpillary reflex,
bilateral eyeballs
>CNS III, IV, VI = EOMs
>CNS V = good temporalic
tone, with corneal reflex
>CNS VII = symmetric facial
muscle tone
>CNS VIII = able to hear
whispered words
>CNS IX & X = present gag
reflex, able to swallow
>CNS XI = able to move/shrug
the shoulders
>CNS XII = able to move
tongue side to side
q. Hematologic “Hindi ako mabilis
magkapasa”
“Apat na beses na ako
nagdonate ng dugo”
Inspection:
>(-) hematomas
>(-) bruises
>(-) hx of clotting of bleeding
d/o
r. Endocrine “Wala akong diabetes”
“May goiter ako pero
natanggal na”
“Wala akong iniinom
na pills, hindi ako
gumagamit ng family
planning”
Inspection:
(-) diaphoresis
(+) tremors
Palpation
(-) abdominal
tenderness
2. LABORATORY STUDIES/DIAGNOSIS
Procedure date IndicationNormal values/finding
Actual findings
Nursing Responsibilities
HEMATOLOGYComplete Blood Count(August 12, 2010)
For evaluation of all blood components to discern if there are any
WBC Count:5-10x10^9/L
Hemoglobin:123-153g/L
9.9
145
PRE:-Check’s doctors order-Check whether fasting is required
Differential Count
changes in hematological condition before the patient becomes symptomatic.
To determine properties of different kinds of white cells.
Hematocrit:0.36 – 0.45 vol.
Platelet:150-400x10^9/L
Segmenters:0.36-0.66 %
Lymphocytes:0.22-0.40
Eosinophils:0.01-0.04
Stab cells:0.04-0.08
0.43
380
0.63
0.35
0.01
0.02-0.05
-Explain the patient the purpose of the procedure-if ordered, withhold medication until the blood is drawn-Explain that blood samples will be extracted-Prepare the needed equipment-observe universal precaution in collecting blood specimen
INTRA:-Practice aseptic technique-collect the specimen from the arm without an IV device, if possible.-to obtain valid result, do not fasten the tourniquet for longer than 1 minute. Prolonged tourniquet application can cause stasis % hemo-concentration.-Aspirate only the needed amt. of bld.-After the specimen is drawn, apply pressure/pressure dressing to the venipuncture site-note the time % date the blood is drawn. Hemolysis may result from vigorous shaking &
invalidate the result.
POST:-record/ document the exact time when the specimen was collected. Indicate drugs that the patient is taking-ensure that the blood tubes are correctly labeled.-secure the laboratory samples and label it accordingly-Assess the venipuncture site for redness and swelling.-reinstitute appropriate diet if fasting was done
Blood chemistry (Calcium, Albumin Creatinine,)(Sept. 10, 2010)
Assess a known or suspected disorder involving muscles in the absence of a renal disease.
Evaluate known or suspected renal function.
Determine whole body stores of sodium, predominantly extracellular.
Calcium:2.10-2.55umol/L
Albumin:35-50g/L
Creatinine:46-92umol/L
2.0
34.0
64
PRE:- Check doctor’s order.-Explain the procedure to the patient.-Tell the patient that no fasting is required.- Explain that blood samples will be extracted-Prepare the needed equipment.- Observe universal precaution in collecting blood specimen.INTRA:-practice aseptic
Monitor effectiveness of drug therapy, especially diuretics.
Assist in evaluation of electrolyte imbalances.
Evaluate response to treatment.
technique-collect approximately 5ml of blood in red tap tube-for pediatric patients, blood is usually drawn from a heel sick POST:-apply pressure or a pressure dressing to the venipuncture site-observe the venipuncture site for bleeding
THYROID FUNCTION TEST
(June 29, 2010)
It is used to evaluate the thyroid’s functioning and to diagnose and help determine the cause of thyroid diseases.
T3:
1.20-2.80nmol/L
FT4:
11.5-23.0pmol/L
TSH:
0.27-3.75µTU/ml
2.10
14.36
0.53
PRE:
-Check the doctor’s order
-Know the reason for the procedure.
-Introduce self and verify the client’s identity.
-Check the vital signs
-Explain the procedure that will be done to prepare the patient
-Provide privacy
INTRA:
-Ensure the use of standard precautions and sterile technique as appropriate
-Provide emotional
and physical support as needed
-Ensure the correct labeling, storage and transportation of specimen
POST:
-Provide nursing care for the client
-Check vital signs
3.Report the results to appropriate health team worker
CHEST X-RAY(August 12, 2010)
To visualize the internal organs and bones of the body to see if there are any deformities and abnormalities in it.
Lungs are both clear
Heart is not enlarged
Diaphragm and sinuses are intact
Findings:Lungs are clear
Heart is mildly enlarged
Aorta tortuous
Diaphragm sulci and bones are intact
Impression:Mild Cardiomegaly
Atheromatous Aorta
PRE:
- Check the doctor’s order
- Know the reason for the procedure.
- Introduce self and verify the client’s identity.
- Check the vital signs
- Explain the procedure that will be done to prepare the patient
- Provide privacy
INTRA:
- Ask the client to remove any
jewelry from her
- Give the obtained jewelry to a trustful relative and inform the client whom you have given the jewelry to
- Assist the client in going to the x-ray room
POST:
- Wait for the result and check the client for further questions
CT SCAN &MRI SECTION(August11, 2010)
To note for any remarkable structures
To look for lesions and masses
Unremarkable Impression: -Thyomegaly with intathoracic extension as described -cardiomegaly-sub centimeter pulmonary nodule, left upper lobe, as described. consider pulmonary AV malformation
PRE:-Explain the procedure to the client.-Ask the patient if she is claustrophobic -Ask to remove any jewelries and metals
INTRA:-Instruct the patient not to move when she is inside the capsule
POST:-Inform the result to patient
FNAB(July 13, 2010)
to check if the goiter is toxic or non toxic
Unremarkable Impression:-Blood and Colloid
PRE:-explain procedure to patient
POST:
-inform the result to patient
Urinalysis (September 15, 2010)
To determine urine composition and possible abnormal components (e.g., protein or glucose) or infection
Color:Light yellow amber
Trans-parency:Clear
Spec. Gravity:1.005-1.030
Albumin:Negative
Sugar:Negative
RBC:Negative
WBC:Negative
Epithelial cells:Negative
yellow
Cloudy
1.025
trace
Negative
0-2/HPF
5-8/HPF
+3
PRE:- Check doctor’s order.-Explain the procedure to the patient.-Tell the patient that no fasting is required.- Explain that blood samples will be extracted-Prepare the needed equipment.- Observe universal precaution in collecting blood specimen.
INTRA:-practice aseptic technique-collect approximately 5ml of blood in red tap tube-for pediatric patients, blood is usually drawn from a heel sick
POST:-apply pressure or a pressure dressing to the venipuncture site-observe the venipuncture site for bleeding
2. OTHER ASSESSMENT TOOLS
Date Taken Comprehensive Actual Actual Result
Content/Legend
Sept. 16, 2010 Level 0 – Full Self Care
Level 1 – Requires use of
device
Level 2 – Requires
assistance from another
person
Level 3 – Requires use of
assistance from another
person or device
Level 4 – It depends and
does not participate
Level 0 – Full self care
J. FUNCTIONAL ASSESSMENT
1. Health Perception/ Health Management Pattern
Client describes her health as good even though she was hospitalized. She rates her
general health status as 9 in the scale of 0-10 wherein 0 represents poor health status and
10 represents good health status. The most important thing that she does in order to keep
her body healthy is to eat a balanced diet. She thinks that these are also the things that
doctors and nurses would suggest to her. When asked about the cause of her illness, she
states that she failed to comply with the doctor’s advice to her that’s why her goiter
progressively increased in size before she sought consultation to the hospital. Her current
health does not interfere with desired activities of daily living. However, there is a limitation
of movement in her neck area due to thyroidectomy. The thing that is important to her while
she is in the hospital is her immediate recovery so that she can already go home and take
PRE:-give preview about the procedure to be done and let the surgeon to explain the rest-check for pre-op meds-check for the consent form-check for the right identity and procedure to be done