PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
PREOP CHARGE SHEET DATE / TIME IN: ___________________________ DATE / TIME OUT: _________________________ MINUTES OF NURSING CARE: _____________________
MINOR PROCEDURE PACU 0216 Includes only central line insertions, Vas Cath insertions/removals CSR CART STOCK CHARGES PREOP KIT 5161 Secondary Med 5084 LR 5492 500 mL 0.9% NaCl 5570 500 mL D5W 5378 Basic Solution Set 5013 Pump Set N/C 5012 Gel Cap N/C 5015 Pharmaseal/Epidural 3279 Extension set 5024 Dial−A−Flow 5129 Twin Cath 0217
The following charges are entered under Sterile Processing charges. Jelcos/Cathions 6731 Braun Tray 7094 Abbott/Epidural 7135 Arrow Tray−CVL Single Lumen 6529 Double Lumen 6520 Triple Lumen 0146 Pediatric 7409 Arrow Spring Wire Guide 6550 Arrow Radial Catheter 6519 Hand Aid Wrist Support 0104
Central Distribution Order Compression Pump Rental Thigh Sleeves Standard 2835 Large 2833 Knee High 2836 TED Hose Small short 1558 Regular 1552 Long 1546 Medium short 1534 Regular 1528 Long 1522 Large Short 1518 Regular 1510 Long 1504
SURGERY CHARGE Mini drip 5002
THE FOLLOWING CHARGES ARE ENTERED UNDER PACU CHARGES Blood patch 0049 Epidural Block 0048 Occipital Block 0047 Stellate Block 0044 Trigger Point Inj. 0042 Intercostal Block 0043 Sympathetic Block 0051 Interscalene Block 36500522 Femoral (3 in 1) Block 36500573 Supraclavicular Block 36500603 All blocks include nurse time but minutes of Nursing care are needed for monthly report. Trays and meds are charged seperately. UCG Test − BST Clipper Venipuncture
0001 0215 0013
SITE RITE − PF6−PF8 Code 0999
Lab BG Inpatient Outpatient Date Printed:
$71.28
9973 0330 PREOP001
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Anesthesia Record Date OR No. Surgeon(s) Anesthestist/Anesthesiologist
Lithotomy R Axillary roll Out Lubed Goggles Hot line
Surgery start Surgery end Anesthesia end
of
Name of Operation
INDUCTION
MONITORS & LINES
REGIONAL
❏ Pre−oxygenation ❏ Intravenous ❏ Inhalation ❏ Cricoid pressure ❏ Rapid sequence Antibiotic and time dosed:
❏ Anesthesia machine checked out ❏ Pulse oximeter ❏ EKG BP cuff: ❏ L ❏ R Stethoscope:❏ Esoph ❏ Precord ❏ Temp: ____________________________ ❏ ET CO2 ❏ Gas analyzer ❏ Nerve stimulator ❏ EEG ❏ A−Line: ___________________________ ❏ CVL: _____________________________ ❏ Swan: ___________________________ ❏ PIVs: ____________________________
❏ Spinal ❏ Epidural ❏ Ankle ❏ Interscalene ❏ Axillary ❏ Bier ❏ Other: _______________________________ Position: _______________________________ Needle gauge & type: ____________________ Level inserted: __________________________ ❏ Midline ❏ Paramedian Attempt x _______ ❏ Catheter ______ cm ❏ CSF ❏ Blood ❏ Paresthesia Level: _________________________________ Drugs & Doses
INTUBATION
TIMES Discontinuous time Start (if applicable) End Anesthesia start
OP1123
Page
POSITIONING ❏ Supine ❏ Prone ❏ ❏ Lateral: ❏ L ❏ ❏ Pressure point pads ❏ Arms: ❏ Tucked ❏ Eyes: ❏ Taped ❏ ❏ Pads ❏ ❏ Warming blanket ❏
r*OP123*r
❏ Oral ❏ Nasal ❏ Trach ❏ Direct ❏ Fiberoptic ❏ LMA ❏ Blade: _______________________ TOURNIQUET Tube: ___________________________ : _____________ ❏ Arm ❏ Leg Secured @ ______cm ❏ Cuff : _____________ ❏ L ❏ R ❏ ET CO2 ❏ BBS ❏ Teeth intact ❏ Stylette __________ mmHg Time: _____________ Block performed by (initials): _______________ ❏ Difficult ⇒ see remarks
Time: Oxygen(L/min) ❏ N2O ❏ Air TOTALS 1 2 3 4 5 6 7 8 9 10 11 12
(ET%) 1 2 3 4 5 6 7 8 9 10 11 12 EKG FiO2 SaO2 ET co2 Temp EBL Urine output Anesthesiologist in room (initials) 220
220
❏ Pt re−evaluated 200
200
immediately before anesthesia 180 induction
180
Induction
160
160
140
140
HR ∨ ∧
120
120
BP
100
100
80
80
60
60
40
40
20
20
Respiratory Rate 10
10
•
Emergence
Cont. available
Available for RR
Ventiliations ( S/A/V )
Tidal Volume
Peak Inspiratory Press
Remarks:
REV 10/02 NSG00047
PRE−ANESTHESIA EVALUATION Height Vital Signs NPO after: Previous anesthesia/surgeries ❏ None ❏ No Problems ❏ Problems
Date: Diagnosis: Medications ❏ None
Allergies NKA
Weight
Family history of anesthesia No Problems ❏ Problems ❏
❏
HISTORY AIRWAY ❏ ❏ ❏ ❏
Loose teeth Caps/crowns Dentures Difficult intubation
❏ ❏ ❏ ❏
HTN PVD CAD/Angina Arrhytmias
❏ neck extension ❏ thyromental distance ❏ mouth opening
CARDIOVASCULAR ❏ ❏ ❏ ❏
TESTS & LABS (if blank, none needed)
COMMENTS Mallampati class: ❏ I ❏ II ❏ III ❏ IV ❏ No problems
CHF Pacemaker Previous MI Previous CABG ❏ No problems
RESPIRATORY ❏ Asthma ❏ Smoker ❏ Emphysema/COPD ❏ Pneumonia/bronchitis ❏ Sleep apnea/CPAP
NEURO/MUSCULOSKELETAL ❏ Stroke/CVA ❏ TIA ❏ Dementia
❏ No problems
❏ Paralysis ❏ Seizures ❏ Neuromuscular dz
RENAL/ENDOCRINE
OTHER
❏ No acute disease
HCG
❏ NA ❏ Neg ❏ Pos
❏ No problems
PTT Other
❏ No problems
❏ Bleeding disorder ❏ Sickle Cell ❏ Joint problems
Planned anesthetic/special monitors ❏ General ❏ A−line ❏ Spinal ❏ CVP ❏ Epidural ❏ Swan−Ganz ❏ Block ❏ MAC
❏ Risks, benefits, and alternatives of anesthetic plan discussed with patient/family.
Signature:
Date:
RECOVERY ROOM Admission time: BP P RR FiO2 Sat Temp
CXR
PT (INR)
❏ Renal insufficiency ❏ CRF/dialysis
❏ Anemia ❏ Pregnancy ❏ Eye disorders
❏ NL
❏ No problems
GI/LIVER ❏ Nausea & vomiting ❏ Jaundice/hepatitis ❏ Bowel obstruction ❏ Hiatal hernia/reflux ❏ ETOH ❏ Obesity ❏ NIDDM ❏ IDDM ❏ Thyroid disease
EKG
INS Crystalloid Colloid PRBC OUTS EBLUrine
Airway: ❏ None ❏ Oral ❏ Nasal ❏ Other:
ASA CLASS ❏ I ❏ II ❏ III ❏ IV ❏ V
❏ E
Time:
POST − ANESTHESIA DATA Sensorium: ❏ Awake Seen ❏ Reactive Cardiopulmonary status: ❏ Non−reactive Condition ❏ Satisfactory ❏ Guarded
❏ No Anesthesia Complication ❏ Comments if Complications:
Anesthetist: ___________________________________________________________
ANESTHESIA RECORD Signature / Date / Time
r*HP201*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
HP2021
H&P
Pre−op Diagnosis:
Proposed Procedure:
Proposed Anesthesia:
Deep Sedation
None
Minimal Sedation
Moderate Sedation / Conscious Sedation
Local
Regional
General
Per Anesthesia
Plan for Anesthesia/Sedation Discussed:
Yes No Risks VS Benefits, Potential Complications, Alternative Options Discussed:
Stroke
Seizures
Heart Disease
Diabetes
Kidney Disease
Respiratory Disease
Hypertension
HX Bleeding
Other:
No
PHYSICAL EXAMINATION
RELEVANT MEDICAL HISTORY
Mark All Applicable:
Yes
HEENT:
Heart:
Explanation:
Lungs:
Comorbid Conditions: ABD: Allergies: Extremities: Medications: Mental Status:
Other Pertinent Findings: Family/Social History:
Notes:
Physicians Signature:
Date:
Date Printed:
Time:
REV 03/11 NSG00010
r*HP201*r HP2021
ELEMENT
GENERAL
DOCUMENTATION GUIDELINES FOR PROCEDURES DOCUMENTATION
A current H&P must be completed and documented no more than 30 days before or 24 hours after patient admission or registration. The referring physician, the attending physician, or an assistant who may be authorized by state law to perform an examination may perform the history and physical. If H&P is performed within the past 30 days, a durable, legible copy of the report may be used, provided a preoperative examination addressing the patient’s interim and current medical status is: a) performed within 24 hours after admission or registration and b) documented in the medical record prior to surgery. The extent of the physical examination required on the H&P will depend upon the procedure to be performed and the anesthesia used. The following guidelines will assist you in making this determination: 1. No anesthesia, or topical−local or regional block: a. Assessment of mental status, vital signs; b. An examination specific to the procedure proposed to be performed and any comorbid condition. 2. I.V. Sedation: a. Assessment of mental status, vital signs; b. An examination specific to the procedure proposed to be performed and any comorbid condition. c. Examination of heart and lung by auscultation. 3. General, spinal, or epidural anesthesia: a. Assessment of mental status, vital signs; b. An examination specific to the procedure proposed to be performed and any comorbid condition. c. Examination of heart and lung by auscultation. e. A complete examination. Pre−procedure notes on patients undergoing spinal or general anesthesia should include an anesthesia examination including the anesthesia planned and risk of anesthesia by person qualified to administer anesthesia. This information may be included in the operative note.
PRE−OP EVALUATION
PHYSICAL
In additional to the above noted documentation requirements, a pre−operative assessment should include: • Indications / symptoms to justify procedures • Informed consent • List of current medications and dosage of each • Known allergies / medication reactions • Existing comorbid conditions (if any) • (Consultation when indicated − clearing patient for surgery) The physical examination required is most often based on the extent of the surgical procedure and the anesthesia used. The information above under "GENERAL" provides a baseline for the extent of the examinations required. A preoperative temperature is not required for colonoscopy or UGI endoscopy and, in general, for procedures of short duration, i.e., 20 minutes.
LAB & X−RAY
• Testing according to facility standards and appropriate to the procedure to be preformed. • All results should be normal or addressed. • All reports should have date and time documented.
ANESTHESIA
• Anesthesia risk considerations and anesthesia planned should be recorded.
SURGICAL REPORT (OP NOTE)
• A post op note is required. [Surgeon(s), descriptions, findings, procedures and post op diagnosis,
POST−OP DISCHARGE AND EDUCATION
specimens removed and path report if available, are recommended]. • The discharge note may be included with the operative note. • Documentation of intervention or explanation of abnormalities, which occurred intra−operatively or
post−operatively should be noted. • Statement of medical stability and mental assessment. • Care arrangements and to whom related. • Instructions − medications − follow−up visits − transfers to another care setting or admission should be noted.
r*PO104*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
PO1004
DATE HOUR
Page 1 of 1
PHYSICIAN’S ORDERS ORDERS FOR PACU ONLY
ANESTHESIA SOLUTIONS
1. Maintain normothermia: Apply forced air warming blanket to maintain temperature above or equal to 96.8° F. Once temperature reaches 98.8°F, may switch to warm blankets.
2. Analgesia: (Circle one) a.) morphine 2 mg to 5 mg IV PRN every 5 minutes up to a maximum of 20 mg if respiratory rate greater than 8. b.) hydromorphone (DILAUDID) 0.1 mg to 0.5 mg IV every 5 minutes PRN to a maximum of 2 mg if respiratory rate greater than 8. c.) ____________________________________________ IV every 5 minutes PRN x _____ doses.
d.) Consult anesthesiologist before giving any prescription pain medication. 3. Nausea: (Use sequentially only if circled) a.) ondansetron (ZOFRAN) 4 mg IV PRN x 1 b.) promethazine (PHENERGAN) 6.25 mg to 12.5 mg IV PRN x 1 c.) dexamethasone (DECADRON) 8 mg IV PRN x 1 d.) Notify Anesthesia Solutions for persistent nausea. 4. Post Op blood glucose on all diabetic patients and notify anesthesiologist if greater than 200 or less than 70. 5. Oxygen: Titrate to maintain oxygen Saturation greater than 95% 6. When the following criteria are met, call the anesthesiologist for postop evaluation and PACU discharge. a.) Awake, alert, able to maintain airway. b.) No unretractable nausea and vomiting. c.) If SAB, able to move legs. d.) PAR score greater than or equal to 9. e.) Patients receiving naloxone (NARCAN) will remain in unit for at least 4 hours and must be evaluated by anesthesiologist prior to discharge. 7. lidocaine 1% (plain) 0.2 mL to 2 mL intradermal PRN for IV insertion. 8. ❑ scopolamine (TRANSDERM SCOP) 1.5 mg patch applied in PreOp. Instruct patient and/or nursing staff to remove the patch within 24 to 72 hours depending on patient’s nausea level.
RN Signature: ______________________________ Date: _________ Time: _______ ANESTHESIOLOGIST’S SIGNATURE: __________________________ Date: _______ Time: ______ Developed: Revised: Revised: Revised:
AS−PACU−0211PH
March 1991 November 2008 March 2010 February 2011
DATE PRINTED:
PHY00347 ANES0004
r*PO104*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Page 1 of 2
PO1004
Pre−Admit Testing Standing Orders
DATE HOUR
ANESTHESIA SOLUTIONS
To be ordered if results are not on the chart or have not already been ordered.
Do not duplicate orders from other sources.
F
R
O
N
T
1. CBC without diff: Previous study acceptable if less than1 month and no interval change. ♦ Age greater than 60 ♦ Diabetes ♦ Significant pre−operative bleeding ♦ warfarin (COUMADIN) or heparin prescription or order ♦ Chemotherapy or radiation treatment within 6 months ♦ Unresolved cardiac, pulmonary, renal disease or malignancy ♦ Procedures associated with significant blood loss (see list) 2. H&H: Previous study acceptable if less than 1 month and no interval change. ♦ Age less than 6 months 3. T&S − Must be drawn within 72 H of need. ♦ Procedures associated with significant blood loss (see list) 4. Basic Metabolic Profile: Previous study if less than 1 month and no interval change. Complete Metabolic Profile for all Laparoscopic Cholecystectomy. ♦ Hypertension ♦ Diabetes ♦ Steriod Rx ♦ Unresolved cardiac, pulmonary, renal disease or malignancy Potassium level: For repeat of high or low Potassium level on previous study. 5. Liver Function Tests: Previous study acceptable if < 1 month and no interval change ♦ Hepatitis or other hepatic disease 6. PT, PTT, INR: ♦ warfarin (COUMADIN), heparin, or low molecular weight heparin (i.e. enoxaparin (LOVENOX)) prescription or order ♦ Hepatitis or other hepatic disease ♦ Bleeding tendency 7. Pregnancy Test: ♦ Females less than 1 year post menopause unless surgical (tubal ligation not a contraindication) 8. EKG: Previous study acceptable if less than 3 months and no interval. ♦ Obesity ♦ Male greater than 50 ♦ Female age greater than 55 ♦ Chest pain, SOB, diminished exercise tolerance ♦ Diabetes, hypertension, peripheral vascular disease (especially carotid) ♦ Radiation treatment to chest 9. Chest X Ray: Previous study acceptable if less than 6 months and no interval change. ♦ Chest pain, SOB, newly diminished exercise tolerance ♦ Bronchospasm, productive cough, fever or chills ♦ Expected prolonged intubation and ventilation
NURSE SIGNATURE
Date
Time
ANESTHESIOLOGIST’S SIGNATURE
Date
Time
Developed: March 2009 PH−ANES−0309PH
DATE PRINTED:
PHY00354
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Page 2 of 2
Patient Education for Preoperative Medication
DATE HOUR
Anesthesia Solutions of Mobile
1.
Discontinue these medications 24 hours before surgery and 48 hours after: metformin plus rosiglitazone (AVANDAMET) metformin extended release (GLUCOPHAGE XR) metformin plus glipizide (METAGLIP) metformin extended release (FORTAMET) metformin (GLUCOPHAGE) metformin plus glyburide (GLUCOVANCE) metformin plus sitagliptin (JANUMET) Do NOT take insulin or diabetic medications the morning of surgery. EXCEPTION: Basal or long acting insulin ( i.e. detemir (LEVEMIR) or glargine (LANTUS). Instruct patient to take their full dose of their (LANTUS) or (LEVEMIR) insulin the night before surgery.
3.
Instruct the patient to obtain specific instructions by the physician that ordered any of the medications below:
C
K
2.
A
warfarin (COUMADIN) pentoxifyllin (TRENTAL) ticlopidine (TICLID) cilostazol (PLETAL) aspirin including baby aspirin clopidogrel (PLAVIX) enoxaparin (LOVENOX) prasugrel (EFFIENT)
Discontinue diet pills 2 weeks before surgery.
B
4. 5.
Discontinue herbals 2 weeks before surgery.
6.
Take these medications as previously prescribed the morning of surgery with a sip of water.
Blood pressure meds * Parkinson’s meds Thyroid meds Eye drops Steroids Organ transplant meds
Seizure meds Pulmonary meds Cardiac meds Stomach meds (anti−reflux) Anxiety meds Pain meds
7. * If the patient is taking rasagiline (AZILECT), discontinue the rasagiline (AZILECT) 2 weeks prior to surgery. Please instruct the patient to contact their physician to obtain an alternate prescription for their Parkinson’s. 8. ❑ Patient verbalized understanding of above instructions during their Pre−Admit testing phone interview.
Approved: Anesthesia Solutions of Mobile August 2008 Patient education provided by: ______________________ Nurse Signature Developed: August 2008 Revised: May 2009 Revised: November 2009 AS−SOPO−1109PH
DATE PRINTED:
________ Date
_______ Time
PHY00354pg2
r*PO104*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Page 1 of 3
PO1004
PRE−OP STANDING ORDERS
DATE HOUR
To be ordered if results are not on the chart or have not already been ordered.
Do not duplicate orders from other sources.
F
R
O
N
T
1. No narcotics or sedatives prior to anesthesia interview. 2. CBC without diff: Previous study acceptable if less than1 month and no interval change. ♦ Age greater than 60 ♦ Diabetes ♦ Significant pre−operative bleeding ♦ warfarin (COUMADIN) or heparin prescription or order ♦ Chemotherapy or radiation treatment within 6 months ♦ Unresolved cardiac, pulmonary, renal disease or malignancy ♦ Procedures associated with significant blood loss (see list) 3. H&H: Previous study acceptable if less than 1 month and no interval change. ♦ Age less than 6 months 4. T&S − Must be drawn within 72 H of need. ♦ Procedures associated with significant blood loss (see list) 5. Basic Metabolic Profile: Previous study if less than 1 month and no interval change. Complete Metabolic Profile for all laparocsopic cholecystectomy ♦ Hypertension ♦ Diabetes ♦ Steriod Rx ♦ Unresolved cardiac, pulmonary, renal disease or malignancy Potassium level: For repeat of high or low Potassium level on previous study. 6. Liver Function Tests: Previous study acceptable if < 1 month and no interval change ♦ Hepatitis or other hepatic disease 7. PT, PTT, INR: ♦ warfarin (COUMADIN), heparin, or low molecular weight heparin (i.e. enoxaparin (LOVENOX)) prescription or order ♦ Hepatitis or other hepatic disease ♦ Bleeding tendency 8. Pregnancy Test: ♦ Females less than 1 year post menopause unless surgical (tubal ligation not a contraindication) 9. AM Glucose, if above 150, consult anesthesia. 10. PreOp Antibiotic: Administer surgeon ordered antibiotic within 1−60 minutes prior to incision. (1−120 minutes for vancomycin or quinolones). As directed, in accordance, with the guidelines developed to comply with SCIP protocols. If the surgeon orders antibiotics per hospital protocol, refer to Table 2 for selection. 11. Beta Blockers: Continue beta blocker peri−operatively. If the patient did not receive their regular dose the night before or morning of surgery notify anesthesia and administer unless there are contraindications. ❑ Beta Blocker to be given in PreOp: __________________________________________ Contraindications: ❑ History of adverse reaction/allergy to beta blocker ❑ 2nd or 3rd degree AV heart block ❑ Acute bronchospasm (caution with asthma or COPD) ❑ Congestive heart failure exacerbation ❑ Heart Rate less than 50 bpm ❑ Systolic blood pressure less than 100 mmHg ❑ Acute hemodynamic instability (See Table 1 for a list of beta blockers) 12. IV Orders: ❑ 1000 mL Ringers Lactate, Regular drip ❑ 500 mL 0.9% Sodium Chloride, Renal Failure Patients, Mini Drip ❑ 500 mL Ringers Lactate, Children, Mini Drip
PH−ANES−0111PH
DATE PRINTED:
PHY00337
r*PO104*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Page 2 of 3
PO1004
PRE−OP STANDING ORDERS
DATE HOUR
K
13. Medications: lidocaine (XYLOCAINE) 1% 0.2 mL to 1 mL intradermal PRN for IV insertion ❑ scopolamine (TRANSDERM SCOP) 1.5 mg patch applied behind the ear in preop ❑ midazolam (VERSED) 2 mg IV x 1 may repeat once ❑ metoclopramide (REGLAN) 10 mg IV x 1 ❑ famotidine (PEPCID) 20 mg IV x 1 ❑ ondansetron (ZOFRAN) 4 mg IV x 1 ❑ hydromorphone (DILAUDID) 0.2 mg IV Q 5 to 10 minutes PRN pain or headache. Maximum dose: 1mg. ❑ morphine 1 mg to 2 mg Q 5 to 10 minutes PRN pain or headache. Maximum dose: 10 mg. 14. EKG: Previous study acceptable if less than 3 months and no interval. ♦ Obesity ♦ Male greater than 50 ♦ Female age greater than 55 ♦ Chest pain, SOB, diminished exercise tolerance ♦ Diabetes, hypertension, peripheral vascular disease (especially carotid) ♦ Radiation treatment to chest 15. Chest X Ray: Previous study acceptable if less than 6 months and no interval change. ♦ Chest pain, SOB, newly diminished exercise tolerance ♦ Bronchospasm, productive cough, fever or chills ♦ Expected prolonged intubation and ventilation 16. Apply forced air warming blanket to all open abdominal procedures and laparoscopic colorectal procedures. Offer to other types of cases and apply PRN.
C
RN Signature:___________________________________________Date:_______ Time:______ ANESTHESIOLOGIST’S SIGNATURE: ______________________ Date: _______ Time: _____
A
atenolol (TENORMIN) PO or IV esmolol (BREVIBLOC) metoprolol (LOPRESSOR) PO or IV metoprolol (TOPROL XL)
Table 1 BETA BLOCKERS bisoprolol (ZEBETA) labetalol (TRANDATE) PO or IV nadolol (CORGARD)
carvedilol (COREG) propranolol (INDERAL) nebivolol (BYSTOLIC) sotalol (BETAPACE)
Table 2 ANTIBIOTIC PROTOCOL PROPHYLAXIS RECOMMENDATIONS BY SURGICAL PROCEDURE Patients < 18 years of age are excluded from recommendations
B
1. Head and Neck, involving incisions through oral or pharyngeal mucosa 2. Craniotomy 3. Spine 4. Cardio−thoracic (see Table 3) 5. Intra abdominal except colorectal (see below) 6. Vascular 7. Orthopedic 8. Hernia with mesh 1. 2. 3. 4. 5.
Appendectomy Colorectal Hysterectomy vaginal, abdominal, or radical Vaginal Sling Procedure Genitourinary
1. Penile prosthesis
cefazolin (ANCEF) 1 g IVP **If allergic: vancomycin 1 g IV in 250 mL NS over 2 hours or clindamycin (CLEOCIN) 600 mg IV over 60 min
cefoxitin (MEFOXIN) 1 g IVP **If allergic: metronidazole (FLAGYL) 500 mg IVPB over 30 min PLUS gentamicin 100 mg IVPB over 30 min gentamicin 100 mg IVPB over 30 minutes PLUS cefazolin (ANCEF) 1 g IVP **If allergic: gentamicin 100 mg IVPB over 30 min PLUS vancomycin 1 g IV in 250 mL NS over 2 hours
**ALLERGIC to cefazolin (ANCEF) or a life threatening reaction to ANY cephalosporin or penicillin PH−ANES−0111PH
DATE PRINTED:
PHY00337−ANES0003−PREOP002
r*PO104*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
PO1004
DATE
HOUR
PHYSICIAN’S ORDERS DATE, TIME AND SIGN QC
Revised 11/06
NSG00025
r*PO104*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
NURSING PROTOCOL
ADMITTING NURSE SHOULD REVIEW WITH THE PATIENT THE OPPORTUNITY TO RECEIVE THE PNEUMOCOCCAL AND/OR INFLUENZA VACCINE IF ELIGIBLE ACCORDING TO THE FOLLOWING CRITERIA:
❒
Pneumococcal Polysaccharide Vaccine (offered year round)
Influenza Vaccine (offered October through end of March)
HIGH RISK CRITERIA (High Risk Patients should receive vaccine)
HIGH RISK CRITERIA (High Risk Patients should receive vaccine)
Age 65 or older − OR −
❒ Adult patients with chronic illness such as chronic cardiovascular disease (CHF, Cardiomyopathies), chronic pulmonary disease, COPD, emphysema, diabetes, alcoholism, chronic liver disease (cirrhosis), CSF leak, sickle cell or spleenectomy −OR− ❒ Conditions associated with decreased immunological function (HIV infection, cancer, chronic renal failure or nephrotic syndrome, candidate for or recipient of cochlear implant) If any of above criteria checked, complete PATIENT EXCLUSION SECTION BELOW. ❒ No high risk criteria identified −− No further action necessary; sign criteria completed by; place in chart.
❒ Age 50 or older − OR − ❒ Children less than 6 months −OR− ❒ Adult patients with chronic illness such as chronic cardiovascular disease (CHF, Cardiomyopathies), chronic pulmonary disease, COPD, asthma, emphysema, diabetes, alcoholism, chronic liver disease (cirrhosis), CSF leak, sickle cell or spleenectomy −OR− ❒ Conditions associated with decreased immunological function (HIV infection, cancer, chronic renal failure or nephrotic syndrome) ❒
Pregnancy will be in 2nd or 3rd trimester during influenza season
If any of above Criteria checked, complete PATIENT EXCLUSION SECTION BELOW. ❒ No high risk criteria identified −− NO further action necessary; sign criteria completed by; place in chart.
PATIENT EXCLUSION CRITERIA (If any box below is checked, DO NOT administer vaccine)
PATIENT EXCLUSION CRITERIA (If any box below is checked, DO NOT administer vaccine) ❒ ❒ ❒ ❒ ❒ ❒
Age 18 or under Already Vaccinated since age 65 Already Vaccinated within past 5 years Year ____ Reported severe reaction to the vaccine or component Post CABG within 3 weeks or less Received shingles vaccine (ZOSTAVAX) within the past 4 weeks. Bone Marrow Transplant within the past 12 months. Currently receiving chemotherapy and/or radiation or have had in the past 2 weeks. Consult physician
❒ ❒ ❒
❒ ❒ ❒ ❒ ❒ ❒ ❒
Already vaccinated this season Date: _______________ Reported serious reaction to the influenza vaccine Reported serious allergy to eggs History of Guillain−Barre Syndrome Post CABG within 3 weeks or less Bone Marrow Transplant within the past 12 months Currently receiving chemotherapy and/or radiation or have had in the past 2 weeks. Consult physician.
Smoking Cessation Education given to patient.
Criteria completed by _______________________________________ Nurse Signature
_____________ Date
____________ Time
PATIENT REFUSAL
VACCINES
Check box(es) below if patient is to receive a vaccine. ❒ Patient requests the vaccine and no exclusion criteria identified. ❒ Patients on MED/SURG or TELE receive vaccine(s) in AM on first full day of admission. ❒ Patients in ICU receive vaccine(s) on day transfer from unit order is written. ❒ Document vaccinations(s) on MAR and staple Patient Immunization card to Discharge Plan Sheet. ❒ Complete vaccine immunization information in HED. If vaccine history is unknown, there is no contraindication to revaccination. Pneumococcal and influenza vaccines can be administered to different sites on the same day. If no exclusion criteria were identified during assessment of the patient, complete Order Set below, then scan to Pharmacy.
❒ Pneumococcal vaccine 0.5 mL IM in deltoid muscle.
❒ Influenza vaccine 0.5 mL IM in deltoid muscle.
Observe patient for 20 minutes after injection. ● Vaccination Information of 4/16/10 given to patient
● Vaccine Information of 8/10/10 given to patient
Observe patient for 20 minutes after injection.
________________________________________ _________________ _________________ Order Set Review Nurse Signature Date Time Patient Refusal: I have been offered the vaccine but choose not to get it at this time. ❒ Pneumococcal Vaccine ❒ Influenza Vaccine
Patient Signature
Date
Time
Nurse Signature
Date
Time
PH−VACC−0411PH
Date Printed:
PHY00325
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Admit Status I have verified that this patient has a written Admit Status Order: (Inpatient), (Observation), or (Outpatient), (circle one of the above)
and has been admitted to the correct Physician. I have verified the status on the HEV screen is the same as the written order (Green = Inpatient, Teal = Observation, Orange = Outpatient). If different, a message needs to be sent to Admitting and a copy of the written order faxed to Admitting. If there is no written Admit Status order, notify the RN taking care of the patient to obtain status order from physician.
Secretary Signature_________________________ Date_______ Time_____ −or− RN Signature______________________________ Date_______ Time_____ IMPORTANT: ***There MUST be an Admit Status order written on the chart before the MD writes Discharge orders, or the hospital cannot bill Medicare or the Insurance Company for this pt’s entire hospitalization.*** If you have any questions concerning status orders, call the Case Management Office at 633−1340, Monday−Friday, 0800−1630. After hours & weekends, call the Admitting MD. Place this form under the Discharge Planning tab. Clarification of Admit Status Orders Admit = Inpatient Admit to Dr._________ = Inpatient Admit to Tele, ICU, Med−Surg = Inpatient. Admit to Observation = Observation (RN Case Manager will clarify status) Admit to Outpatient = Outpatient (RN Case Manager will clarify status) *This is not a part of the permanent record". LEAVE ON CHART AT DISCHARGE; MEDICAL RECORDS WILL DISCARD.
Created: 04/2011 Revised: 05/2011
Date Printed:
nsg00204
r*HP1094*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
HP1094
DATE
PROGRESS NOTES
TIME
POST−OP / POST−PROCEDURE NOTES
1. Pre−Operative Diagnosis:
2. Post−Operative Diagnosis:
3. Procedure:
* Implant information on reverse side, if applicable 4. Physician / Surgeon: 5. Anesthesia: 6. EBL: 7. Specimen: 8. Complications:
9. Condition:
10. Findings: ❏ Same as post−operative diagnosis
CONDITION / PROGNOSIS ON DISCHARGE:
Rev: 3/11
Physician Signature Date Printed:
Date
Time PACU0002
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Perioperative Nursing Care Plan EVALUATION / SUMMARY OF NURSING PLAN Nursing Intervention 1. O.R. protocol explained to patient (using age specific language). 2. Patient/Family encouraged to ask questions and verbalize concerns. 3. Patient/Significant Other questions answered. 4. Unhurried, calm approach to care provided. 5. Instructed on use of pain scale. 6. Patient Right−To−Privacy is maintained. 7. Fun and game playing approach used to orient child to O.R.
Expected Outcome 1. Patient will manage anxiety by discussing feelings about surgery, anesthesia, and hospitalization. 2. Patient/Family/Significant Other verbalized understanding of pre−op/intra−op and post−op activities, and participated in decisions affecting his/her plan of care.
1. Potential for impaired tissue integrity and injury (nerve damage, foreign body in wound), related to length of surgery, positioning during surgery, use of sharps, sponges, instruments, and electrosurgical unit during surgery.
1. Skin prep solutions will not pool around or under patient. 2. Apply eletrosurgical grounding pad securley to appropriate area. 3. Insure that electrosurgical equipment functioning properly prior to use. 4. Patient arms on arm boards at less than 90° angle to body. 5. Insure that pressure areas padded appropriately. 6. Insure the equipment, personnel and instrumentation are not placing pressure on patient. 7. Counts as appropriate for case. 8. Safety strap applied. 9. Side rails up during transport.
1. Patient is free from signs and symptoms of electrical/chemical injury. 2. Patient will sustain no nerve injury during surgery, and will demonstrate no loss of movement or sensation post−op due to complications. 3. Patient will be free of foreign body at end of procedure as evidence by a correct count. 4. Patient’s skin exhibits no redness or tissue breakdown post−op.
2. Potential for infection related to surgical incision and possible wound contamination during surgery.
1. Strict aseptic technique maintained throughout procedure. 2. Surgical site prepared with appropriate antiseptic. 3 O.R. door closed. 4. Traffic in and out of O.R. kept to a minimum. 5. Antibiotics given per physician request. 6. Document wound classification. 7. If break occurs, take action to correct.
1. Patient will be free of wound infection.
Nursing Diagnosis 1. Anxiety related to impending surgical intervention and anesthesia.
2. Knowledge deficit related to surgical procedure.
r*OP127*r OP1127 − Perioperative Care Plan
SGY00004A
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Post Operative Care Plan 1. Potential for inadequate ventilation related to anesthesia or airway.
1. Assess continuously for signs of inadequate ventilation. 2. Record respiratory rate every fifteen minutes. 3. Stimulate patient by shaking or verbal stimulus. 4. Administer and document oxygen/ stimulant agents as ordered by anesthesiologist. 5. Suction patient as indicated. 6. Insert oral or nasal airway. 7. Hyper−extend neck if no contraindications. 8. Jaw thrust. 9. Notify M.D. if unable to correct. 10. Provide mechanical ventilation.
1. Patient respiratory function is consistent with or improved from baseline levels established pre−operatively.
2. Potential for alteration and comfort; pain related to surgical procedure.
1. Evaluate intensity of pain. 2. Check anesthesia record for stimulants or narcotic antagonist given in O.R. 3. Administer and record analgesics. 4. Reinforce pain scale education.
2. Patient demonstrates reasonable comfort and knowledge of pain management.
3. Potential for altered hemo−dynamic status; related to anesthesia or hypovolemia.
1. Monitor and record B/P, pulse and respirations every 15 minutes or more frequently as necessary. 2. Observe dressings and drains for drainage. 3. Administer fluids and blood products as ordered. 4. Monitor urine output every hour or more frequently as necessary. 5. Adjust position of patient appropriate to hemo−dynamic status.
3. Patient remains hemo− dynamically stable, fluid, electrolyte, cardiovascular function are consistent with or improved from baseline levels established pre−operatively.
COMMENTS:
Pre−Op: AM Admit
RN Signature
Date / Time
RN Signature
Date / Time
RN Signature
Date / Time
Surgery:
PACU: SGY00004p2
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
PHYSICIAN’S ORDERS
Page 1 of 1
Intraoperative Orders
DATE HOUR
QC
1.
LABS:
2.
ADMIN:
❑ CBC with diff ❑ CBC without diff ❑ Hematocrit ❑ Hemoglobin ❑ Glucose ❑ Type & Screen ❑ Type & Crossmatch _____units ❑ ABG’s ❑ PRBC ____ units ❑ Platelets ____ units ❑ FFP ____ units
3.
X−RAY:
❑ Portable ________
4.
CULTURE: ❑ Routine ❑ Anaerobic ❑ Acid Fast ❑ Gram Stain ❑ Fungus ❑ Cytology ❑ Pelvic Washings ❑ Other ____________________
5.
FOLEY CATHETER: Insert with
6.
SPECIMEN: ❑ To Lab
7.
WARMING BLANKET: ❑ Upper Body ❑ Lower Body ❑ Other ______________ Apply forced air warming blanket to all open abdominal procedures and laparoscopic colorectal procedures. IMMOBILIZER: ❑ Knee ❑ Shoulder
8. 9.
❑ C−Arm
❑ Dye Type
❑ regular catheter bag
❑ Frozen Section
❑ urimeter bag
❑ Other _________________
SCDs: Apply SCD’s, to all surgical patients, unless a contraindication is documented. ❑ Severe heart failure or pulmonary edema ❑ Severe arterial occlusion disease ❑ Postop vein ligation ❑ Deformity of the limb ❑ Gangrene or infected leg wounds ❑ Recent skin grafts
❑ Immobilized for greater than 72 hours without DVT prophylaxis 10.
❑ Dermatitis
MEDICATIONS: ❑ bacitracin 50,000 units in ______ mL Normal Saline ❑ kanamycin (KANTREX) 1 g in 3 mL Normal Saline ❑ neomycin and polymyxin B (NEOSPORIN G.U.) irrigant ______ mL Normal Saline ❑ heparin ______ units in _______ mL of ___________________________ ❑ papaverine 30 mg per mL in _______ mL of ___________________________ ❑ topical thrombin ______ units ❑ lidocaine topical 2% jelly or 2% uroject ❑ Anesthetic Pain Pump ropivacaine (NAROPIN) 0.2% ❑ 100 mL ❑ 270mL ● Inpatients require use of separate Pain Pump orderset ❑ gelatin sponge (GELFOAM) ❑ Fibrillar _________ ❑ Nu Knit __________ ❑ Local ____________________________________ Blood & Body Fluid Exposure ❑ sodium bicarbonate _____ mL (for local) ❑ 8900 HBs Ag ❑ Other ❑ 8902 HCAB ❑ 8903 HIV AB (with consent) message "rapid HIV"
V.O.V. Dr.___________________________________ / ___________________________ RN Noted __________________________ / RN Time __________ / Date _____ / ______ / ______ SURGEON SIGNATURE: _____________________________ Date: ____/____/____ Time: ______ Developed: Revised: Revised: Revised:
PH−PHIO−0910PH
December 2005 February 2010 March 2010 September 2010
DATE PRINTED:
PHY00173
r*OP124*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
OP1124
INTRAOPERATIVE REPORT PAGE 1 OF 2 DATE
O.R.#
PREOPERATIVE DIAGNOSIS:
PRE−OP: START
END
O.R. ROOM TIME: START
END
ANESTHESIA TIME: START
END
SURGERY TIME: START
END
OPERATION:
PACU IN TIME:
UNIT TIME:
PACU OUT TIME: ON BYPASS:
OFF BYPASS:
POST−OP DIAGNOSIS
WOUND CLASSIFICATION:
I
II
III
IV
SURGEON:
ASA:
1
2
3
4
5
6
Pt. Identified by:
Pt. Name
Date of Birth
Account #
ASSISTANT:
2ND PRIMARY SURGEON: ANESTHESIOLOGIST:
RELIEVED BY:
TIME:
ANESTHETIST:
RELIEVED BY:
TIME:
SCRUB NURSE:
RELIEVED BY:
TIME:
RETRACTOR NURSE:
RELIEVED BY:
TIME:
CIRCULATING NURSE.
RELIEVED BY:
TIME:
ANCILLARY PERSONNEL:
RELIEVED BY:
TIME:
PERFUSION:
IT:
LAB:
ANESTHESIA TYPE:
X−RAY:
General
Date Collection Assessment
General Appearance:
Emotional/Mental Status:
Spinal
Normal Obese Alert
Epidural
Bier Block
Pale Cyanotic Emaciated Other Oriented
Unresponsive Calm Other
Jaundiced
Confused
Anxious Crying
Axillary Block
Sedated
Agitated
Behavior Observed:
Cooperative Talkative
Withdrawn
History & Physical
Complete Risk, Benefits and Alternatives Dictated and Verified
Chart Reviewed: O.R. Criteria Complete and Reports Available: Yes No Comments: NKA Latex Allergies No Blood Available: Direct Donor
Yes # of units: T&C Exp. Date Autologus T&S Exp. Date
Local
Ankle Block Mac Sur/Sed PREOPERATIVE ASSESSMENT
Nursing Diagnosis: Expected Outcome:
Anxiety/Knowledge deficit related to surgical procedure. Patient exhibits decreased anxiety level/verbalizes understanding of surgical procedure.
Data Base I Reviewed For:
Chronic Health Problems MH Impairments Skin Integrity DVT Potential Yes No Time Out by Patient: Confirmation of Surgical Site & Side Yes No In OR by Consent: Rt Lt by Surgeon: Yes No Other Drains & Catheters on Arrival: None Yes − Type Foley I.V. Levine Endotracheal Chest Tube Other Swan A−Line Family/Significant Other Waiting: Yes No Patient Complaints:
Banked Blood
None Other
NPO Since AM Admit Status: Surgery Type:
Add on
Thirsty/Hungry
Inpatient Elective
Nauseated
Pain
Outpatient Emergency
Urgent REV 02/08 NSG00063
r*OP124*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
OP1124
INTRAOPERATIVE REPORT PAGE 2 OF 2
Nursing Diagnosis: Potential injury to positioning, electrical agents, retained objects. Expected outcome: Patient will remain free of injury. Gauge checked Pading under cuff Unit # Prone Lithotomy Sitting Jacknife Beach Chair Tourniquet: Arm Rt. Lt. Thigh Rt. Lt. Calf Rt. Lt. Rt. Side ↑ Lt. Side ↑ Knee Chest Other Pressure (mmHg) Olympus Pillow Kambin SP Frame Wilson Frame Positional Aides: Skin Condition Post−Op: No change *Comments N/A Acromed Chest Rolls Pegboard Tape Bean Bag 1st Time Up Time Down Total Min. Pillows x ___ ↓ Head Between Legs Between Arms ↓ Legs 2nd Time Up Time Down Total Min. N/A Kidney Rest Rt. Lt. DePuy Pos Stulberg Pos U L Serial # Model Forced Air Warming Blanket Alvarado Leg Hldr Rt. Lt. Sandbag Rt. Lt. Site __ Hemotherm Warm Blankets Temp Setting N/A Shoulder Roll Rt. Lt. Axillary Roll Rt. Lt. C−Arm Ionizing Model # Yellow Fin Laser: Type Shoulder Boom Rt. Lt. Stirrups type J Radiation: Model # Exposure Time Wattage M/Sec. Mayfield Headrest Skull Pins Horseshoe Allen Shoulder Pos Continuous Intermittent Portable N/A Pressure Points Padded: Heels Elbows Knees Popliteal Ankles Other N/A Laser safety precautions instituted N/A Gel Pad To: Entire Table Arms Axillary Roll Headrest Counts: N/A Code Correct = 1 Incorrect = 2 Leg Rt. Lt. To Pt. Positioners Soft roll Towels Foam Pillows Other Padded c Counts 1st 2nd 3rd Counts 1st 2nd 3rd Ace wrapped TED Anti−thrombic device Feet uncrossed X−Ray 4x4 Legs: Suture Boots Flexed Rt. Lt. Straight Rt. Lt. Froglegged N/A X−Ray 2x2 Dura Hooks Bil. knee drop Other Laps Initial Count: Circulator: Extended on arm board Rt. Lt. Secured at side Rt. Lt. Arms: Mini Laps Scrub: Extended on Mayo Stand Rt. Lt. Across chest Rt. Lt. N/A Extended on hand table Rt. Lt. Other Cottonnoid 2" ↑Knees Posterior thighs Other Safety Straps: N/a Dissectors Final Count: Circulator: Positioning:
Supine Lateral
Tables:
Regular Chick Jackson Table
Aamsco Andrews Neuro Chair Cysto Tonsils Other _________________________________ Bovie Tips Unit # Bipolar Blades Lot # Exp. Date Needles Mode P S Coag Cutting Blend
Scrub:
Yes Electrosurgical Unit: Pad: Type Lead: Type N/A Rt. Lt. Anterior Posterior Medial Lateral Instruments Pad Positions: Thigh Abdomen Other Rt. Lt. Arm Retractor Tapes Rt. Lt. Buttocks Hypoderms Hair at site removed with clipper Yes No Skin condition Post−Op No Change *Comments
Nursing Diagnosis: Potential for infection.
Hair Removal:
Yes, Clipper
Count Resolved by X−Ray
Yes
No
N/A
Radiologist: Surgeon Notified:
Yes
No
Expected outcome: Aseptic technique will be maintained throughout the surgical procedure.
Yes, Depilatory
No
in Preop
in O.R.
Nursing Unit
Per Surgeon
Foley inserted at _________ by ___________ Foley on arrival Urinary Drainage: Surgical Prep: Cida Stat Betadine S + S Alcohol Phisohex Dura. Prep Size _____ Fr 2−way 3−way 5mL 30mL Temp Foley Other N/A PCMX Location Other Initial Output mL Total Output mL Chloraprep Performed by Surgeon N/A Emptied Yes No Foley removed Irrigation Solutions: Lactated Ringers Glycine _____ mL NaCl _____ mL Continuous Irrigation Leg Strap Urine Appearance: N/A Warmed IV Saline _____ mL Ureter R L Supra Pubic Stent Size H2O Irrig _____ mL H2O Splash Drains: Hemovac Penrose Gastrostomy J−vac Chest Tube Rt. Lt. Mediastinal Rt. Lt. Specimen: Yes No Exempt F/S N/A Pleurovac to suction size site Description: Autotransfusion lot # Packing: Iodoform Gelfoam Avitene Surgical Vaginal Anaerobic Acid−Fast Fungus Cytology N/A Routine C + S Cultures Kling Kerlix Fibrillar Location: Gram Stain N/A Site Dressings: Telfa Adaptic Xeroform Vaseline Gauze Tegaderm Steri−Strips 4x4’s 2x2’s ABD Ace Kling Kerlix Peri Pad Immobilizer N/A COMMENTS: Paper Foam Adhesive Silk Elasticon Abductor Pillow Tape: Softroll Eye Pad/Shield Splint Cast Bandaid Cottonballs C−Collar Indermil Dermabond Unit Rm. # ER Other Disposition: PACU O2 Transport Lifepack Side Rails ↑ Anesthesia Present Estimated Blood Loss: mL N/A CL ET Tube IV NG Swan A Line ICP Sub Arach Post−Op Report to Patient’s Family Notified Yes No TIme: Intubated Extubated Awake Disposition of Video Tape/CD: Tamper tabs pulled Date Printed:
Page 2 REV 06/10 NSG000020−SGY00008
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
SURGERY QA ➨
CASE DATE: ____________________________
➨ RN: ______________________________
➨
CASE TIME: ______________________ ❒ TF
➨ SURGEON ARRIVED AT: ____________
➨
WAS THE CASE DELAYED?
YES / NO
❒ CASE CANCELLED:
YES / NO
!!!If answered YES, complete the next section!!! ❒
❒
STAFF/UNIT: ❒
PATIENT:
❒
INTRAOP: ❒
❒
POST OP: PACU FULL
❒ LATE ❒
REASON FOR THE CASE DELAY? Choose one.
PREOP: EXPLANATION CASE CONTAMINATION
❒
❒
EQUIPMENT
❒ PT ATE ❒ WANTED TO SEE FAMILY/SURGEON
STAFFING
❒ FAILED TO PREOP
CONDITION WARRANTS FURTHER TESTING/TREATMENT
❒
SURGEON:
❒
LATE: OFFICE
❒
ANESTH:
❒
MD_______________
CRNA_______________
❒
N/A
❒
PREOP PROCEDURE__________________________
❒
UNAVAILABLE
❒
LAB NOT DRAWN / REPORTED TIMELY
❒
INPATIENT NOT READY FOR TRANSPORT TO SURGERY
❒
PREVIOUS CASE RAN OVER
❒
EMERGENCY PRECEDENCE
❒
❒
HOSPITAL:
OTHER:
/
ER
/ ❒
ROUNDS
❒
/ OTHER:
❒
RADIOLOGY AVAILABILITY
OR POSTING ERROR
COMMENTS:
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• REPORTABLE EVENTS: COMPLETE ONLINE ERS REPORTING FOR ALL OF THE FOLLOWING: ❒ INCORRECT COUNT
❒ RETURN TO SURGERY
❒ CHANGE IN PROCEDURE
❒ INTRA−OP DEATH
❒ CASE CANCELLED ON O.R. TABLE
❒ INTRA−OP TIME GREATER THAN 6 HOURS
❒ UNPLANNED ADMISSION TO INTENSIVE CARE POST−OP ❒ REMOVAL/INJURY OR REPAIR OF ORGAN DURING OPERATIVE PROCEDURE ❒ ANY OTHER QUESTIONABLE EVENT COMMENTS:
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• IMPLANT INFORMATION (handwritten or stickers sufficient): REQUIRED DATA:
REQUIRED LOCATIONS:
1. MANUFACTURER
1. POST−OP SURGEON NOTE
2. MODEL #
2. CHARGES
3. LOT #
3. IMPLANT TRACKER (IMPLANT MOTION)
4. SIZE
4. IMPLANT BOOK
5. CATALOG # 6. QUANTITY *If the implant contained an identification card to be returned to the supplier, please complete and forward to secretary.
Date Printed:
Developed 10/2001 Revised: 4/2010 SGY00005
r*PO104*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Page 3 of 3
PO1004
Prophylactic Antibiotic Dosing Protocol for Cardiac Surgery
DATE HOUR
Table 3
Antibiotic Selection
1. First Choice: cefazolin (ANCEF) see dosing below 2. Second Choice: vancomycin (VANCOCIN) see dosing below. a. Recommended for patients ● genuinely allergic to cefazolin (ANCEF) ● presumed or known Staphylococcal colonization ● high institutional presence of MRSA ● preop hospitalization more than 3 days ● transferred from another inpatient facillity or SNF ● already on antibiotics other than vancomycin ● prosthetic valve or vascular graft insertion b. If vancomycin is selected additional gram negative coverage with gentamicin is strongly recommended. Initial Dosing of Antibiotics
1. cefazolin (ANCEF) ● dosing for any serum creatinine or GFR ● give cefazolin within 60 minutes of first incision (preferably within 30 to 60 minutes of incision) ● actual weight is less than 80 kg give cefazolin 2 g IV x 1 dose preop ● weight greater than or equal to 80 kg: 80 kg to 89 kg give cefazolin 2.5 g IV 90 kg to 109 kg give cefazolin 3 g IV 110 kg to 124 kg give cefazolin 3.5 g IV greater than 125 kg give cefazolin 4 g IV 2. vancomycin (VANCOCIN) ● dosing for any serum creatinine or GFR ● start infusion within 2 hours of first surgical incision with completion recommended before incision. ● actual weight less than 80 kg give vancomycin 1000 mg IV over 2 hours x 1 dose preop ● actual weight greater than or equal to 80 kg 80 kg to 99 kg give vancomycin 1250 mg IV over 2 hours greater than 100 kg give vancomycin 1500 mg IV over 2 hours 3. gentamicin ● dosing for any serum creatinine or GFR ● start infusion within 60 minutes of first surgical incision (preferably within 30 to 60 minutes of incision) ● For any weight give gentamicin 4 mg per kg IV over 60 minutes, up to a maximum dose of 500 mg Redosing of Antibiotic during Surgery 1. cefazolin (ANCEF) ● Redose within 3 to 4 hours of initial PreOp dose ● actual weight less than 80 kg give cefazolin 1 g ● actual weight greater than or equal to 80 kg 80 kg to 89 kg give cefazolin 1.5 g IV push greater than 90 kg give cefazolin 2 g IV push 2. vancomycin (VANCOCIN) ● Redose within 6 to 8 hours of initial PreOp dose ● actual weight less than 60 kg give vancomycin 500 mg IF over 1 hour ● actual weight 60 kg to 79 kg give vancomycin 750 mg IV over 2 hours ● actual weight greater than 80 kg give vancomycin 1000 mg IV over 2 hours 3. gentamicin ● No Redosing Recommended Developed: March 2003 Revised: January 2011
PH−ANES−0111PH
DATE PRINTED:
PHY00337pg3
r*PM139*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000 PM1139 − MARs
INIT/ISIGNATURE/TITLE
OMISSION CODES R N U D I H O
LD RD LG RG LL RL LV RV LA RA
PAIN SCALE
LT DELTOID RT DELTOID LT GLUTEUS RT GLUTEUS LT VASTUS LATERALIS RT VASTUS LATERALIS LT VENTRAGLUTEAL RT VENTRAGLUTEAL LT ABDOMEN RT ABDOMEN
0
No Pain
(0−10 SCALE)
10 UNBEARABL
PAIN
Location/Size: ALLERGIES:
: :− 1500 0701 TIME : ID : COMMENTS
CHECKED BY:
PreOp
PATIENT REFUSED NPO OFF UNIT DIALYSIS IV OUT HOLD PER ORDER OTHER−NURSESNOTES
INJECTION CODES
(Page 1 of 2)
PreOp Antibiotic given per Anesthesia ❑ Yes See Anesthesia Record
0.9% Sodium Chloride 500 mL Renal Failure Patients/Mini Drip Ringers Lactate 500 mL Children/Mini Drip
R
lidocaine (XYLOCAINE) 1% 0.2 mL to 1 mL intradermal PRN for IV insertion
F
scoplamine (TRANSDERM SCOP) 1.5 mg patch applied behind the ear in preop
midazolam (VERSED) 2 mg IV x 1 may repeat once metoclopramide (REGLAN) 10 mg IV x 1 ondansetron (ZOFRAN) 4 mg IV x 1 famotidine (PEPCID) 20 mg IV x 1 hydromorphone (DILAUDID) 0.2 mg IV Q 5 to 10 minutes PRN pain or headache Maximum dose: 1 mg morphine 1 mg to 2 mg Q 5 to 10 minutes PRN pain or headache Maximum dose: 10 mg Dev:7/08 Rev: 12/10
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
O
Ringers Lactate 1000 mL Regular Drip
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : Date Printed:
T
DATE:
INIT/SIGNATURE/TITLE
: :− 2300 1501 TIME : ID : COMMENTS
N
IV: Date
Perioperative MAR
: : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : :
: : : :
2301 : :− 0700 TIME : ID :COMMENTS : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : PHY00337PG4
r*PM139*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000 PM1139 − MARs
INIT/ISIGNATURE/TITLE
INIT/SIGNATURE/TITLE
OMISSION CODES R N U D I H O
PATIENT REFUSED NPO OFF UNIT DIALYSIS IV OUT HOLD PER ORDER OTHER−NURSESNOTES
INJECTION CODES
PAIN SCALE
LT DELTOID RT DELTOID LT GLUTEUS RT GLUTEUS LT VASTUS LATERALIS RT VASTUS LATERALIS LT VENTRAGLUTEAL RT VENTRAGLUTEAL LT ABDOMEN RT ABDOMEN
0
No Pain
(0−10 SCALE)
10 UNBEARABL
PAIN
ALLERGIES:
0701: − 1500 TIME : ID : COMMENTS
CHECKED BY:
PreOp (Page 2 of 2) vancomycin 1 g IV over 2 hours x 1 in preop
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : ::
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : ::
C
gentamicin 80 mg (premixed) IV over 60 minutes x 1 in preop
A
ciprofloxacin (CIPRO) 400 mg IV over 2 hours x 1 in preop
B
oxycodone extended release (OXYCONTIN) ______ mg PO x 1 in preop
warfarin (COUMADIN) _____ mg PO x 1 in preop
celecoxib (CELEBREX) 200 mg PO x 1 in preop
Dev: 7/08
LD RD LG RG LL RL LV RV LA RA
Rev: 12/10
Date Printed:
: 1501: − 2300 TIME : ID : COMMENTS
K
DATE:
Perioperative MAR
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: :− 0700 2301 TIME : ID :COMMENTS
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : PHY00337PG5
r*PM139*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000 PM1139 − MARs
INIT/ISIGNATURE/TITLE
INIT/SIGNATURE/TITLE
OMISSION CODES R N U D I H O
PATIENT REFUSED NPO OFF UNIT DIALYSIS IV OUT HOLD PER ORDER OTHER−NURSESNOTES
LD RD LG RG LL RL LV RV LA RA
INJECTION CODES
PAIN SCALE
LT DELTOID RT DELTOID LT GLUTEUS RT GLUTEUS LT VASTUS LATERALIS RT VASTUS LATERALIS LT VENTRAGLUTEAL RT VENTRAGLUTEAL LT ABDOMEN RT ABDOMEN
0
No Pain
(0−10 SCALE)
10 UNBEARABL
PAIN
:0701: − 1500 TIME : ID : COMMENTS
CHECKED BY:
IntraOp (Page 1 of 2) gelatin sponge (GELFOAM)
microfibrillar collagen (AVITENE) topical thrombin ____________ units
R
bacitracin 50,000 units ___________ units in ___________mL NaCl betadine Ointment
F
kanamycin (KANTREX) 1 g in 3 mL ________ g in _________mL NaCl
neomycin and polymyxin B (NEOSPORIN G.U) Irrigant _________mL in _________mL NaCl heparin ________units in _________mL NaCl in _________mL Plasmalyte in _________mL LR papavarin 30 mg per mL ___________mg in ___________mL plasmalyte in ___________mL LR betadine solution _____________________ betadine soap _____________________ Dev: 7/08 Rev: 12/10
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
O
fibrillar
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Date Printed:
T
ALLERGIES:
: 1501: − 2300 TIME : ID : COMMENTS
N
DATE:
Perioperative MAR
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: :− 0700 2301 TIME : ID :COMMENTS
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : PHY00337PG6
r*PM139*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000 PM1139 − MARs
DATE:
INIT/SIGNATURE/TITLE
OMISSION CODES R N U D I H O
PATIENT REFUSED NPO OFF UNIT DIALYSIS IV OUT HOLD PER ORDER OTHER−NURSESNOTES
PAIN SCALE
LT DELTOID RT DELTOID LT GLUTEUS RT GLUTEUS LT VASTUS LATERALIS RT VASTUS LATERALIS LT VENTRAGLUTEAL RT VENTRAGLUTEAL LT ABDOMEN RT ABDOMEN
0
No Pain
(0−10 SCALE)
10 UNBEARABL
PAIN
ALLERGIES:
: :− 1500 0701 TIME : ID : COMMENTS
CHECKED BY:
IntraOp (Page 2 of 2)
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Date Printed:
C
lidocaine (XYLOCAINE) 2% topical jelly _____________mL used lidocaine (XYLOCAINE) _____% ❒ with epinephrine ❒ without epi with ______mL Sodium Bicarb. _______Total Volume Injected
B
A
bupivacaine (MARCAINE) _________% ❒ with epinephrine ❒ without epi with _______mL Sodium Bicarb. _______ Total Volume Injected
Dev: 7/08 Rev: 12/10
LD RD LG RG LL RL LV RV LA RA
INJECTION CODES
:1501:− 2300 TIME : ID : COMMENTS
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
K
INIT/ISIGNATURE/TITLE
Perioperative MAR
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
2301 : :− 0700 TIME : ID :COMMENTS : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
PHY00337PG7
r*PM139*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000 PM1139 − MARs
OMISSION CODES R N U D I H O
ALLERGIES:
: :− 1500 0701 TIME : ID : COMMENTS
CHECKED BY:
PostOp
PATIENT REFUSED NPO OFF UNIT DIALYSIS IV OUT HOLD PER ORDER OTHER−NURSESNOTES
(Page 1 of 2)
R
hydromorphone (DILAUDID) 0.1 mg to 0.5 mg IV every 5 minutes PRN to a maximum of 2 mg if respiratory rate is greater than 8
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
O
morphine 2 mg to 5 mg IV PRN every 5 minutes up to a maximum of 20 mg if respiratory rate is greater than 8
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
ondansetron (ZOFRAN) 4 mg IV PRN nausea x 1
F
promethazine (PHENERGAN) 6.25 mg to 12.5 mg IV PRN nausea x 1
dexamethasone (DECADRON) 8 mg IV PRN nausea x 1 lidocaine 1% (plain) 0.2mL to 2mL intradermal PRN for IV insertion scopolamine (TRANSDERMSCOP) 1.5 mg patch applied in PreOp Instruct patient and/or nursing staff to remove the patch within 24 to 72 hours depending on patients nausea level. VTE prophylaxis ❑ enoxaparin (LOVENOX) 40 mg SUBQ daily ❑ enoxaparin (LOVENOX) 30 mg SUBQ Q 12 H ❑ heparin 5000 units SUBQ Q 8 H ❑ warfarin (COUMADIN) ______ mg PO daily ❑ none Dev: 7/08 Rev: 12/10
LD RD LG RG LL RL LV RV LA RA
INJECTION CODES
PAIN SCALE
LT DELTOID RT DELTOID LT GLUTEUS RT GLUTEUS LT VASTUS LATERALIS RT VASTUS LATERALIS LT VENTRAGLUTEAL RT VENTRAGLUTEAL LT ABDOMEN RT ABDOMEN
0
:1501:− 2300 TIME : ID : COMMENTS
N
DATE:
INIT/SIGNATURE/TITLE
T
INIT/ISIGNATURE/TITLE
Perioperative MAR
Date Printed:
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
No Pain
(0−10 SCALE)
10 UNBEARABL
PAIN
2301 : :− 0700 TIME : ID :COMMENTS : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
PHY00337PG8
r*PM139*r
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000 PM1139 − MARs
INIT/ISIGNATURE/TITLE
INIT/SIGNATURE/TITLE R N U D I H O
PATIENT REFUSED NPO OFF UNIT DIALYSIS IV OUT HOLD PER ORDER OTHER−NURSESNOTES
LD RD LG RG LL RL LV RV LA RA
INJECTION CODES
PAIN SCALE
LT DELTOID RT DELTOID LT GLUTEUS RT GLUTEUS LT VASTUS LATERALIS RT VASTUS LATERALIS LT VENTRAGLUTEAL RT VENTRAGLUTEAL LT ABDOMEN RT ABDOMEN
0
No Pain
(0−10 SCALE)
10 UNBEARABL
PAIN
ALLERGIES:
: :− 1500 0701 TIME : ID : COMMENTS
CHECKED BY:
PostOp
OMISSION CODES
(Page 2 of 2)
B
A
cefazolin (ANCEF) 1 g IV over 30 minutes
Dev: 7/08 Rev: 12/10
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
C
cefoxitin (MEFOXIN) 1 g IV over 30 minutes
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Date Printed:
:1501:− 2300 TIME : ID : COMMENTS
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : ::
K
DATE:
Perioperative MAR
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : ::
2301 : :− 0700 TIME : ID :COMMENTS : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : ::
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : ::
PHY00337PG9
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
UNIVERSAL PROTOCOL FOR SURGICAL PROCEDURES Ht __________ Wt __________ Allergies ❒ YES, see Med Reconciliation for listing ❒ NO BP __________ P __________ R__________ T__________ SpO2__________ TO BE COMPLETED BY PRE−OP RN
TO BE COMPLETED BY CIRCULATING RN
Completed prior to rolling to OR Pre−Op Time In: ____________ Pre−Op Time Out: ____________ Correct patient, ID band present/verified
❒ YES
Correct procedure
❒ YES
Correct site
❒ YES
Site marked by surgeon
❒ YES ❒ NO ❒ N/A
Correct side
❒ RIGHT ❒ LEFT ❒ N/A
Informed consent
❒ YES
H&P, present and updated
❒ YES
Labs resulted as ordered
❒ YES ❒ N/A
Blood products are available (if ordered)
❒ YES ❒ NO ❒ N/A
Dial Soap or Hibiclens bath, PM or AM
❒ YES ❒ NO ❒ N/A
Cholorhex wipe
❒ YES ❒ NO ❒ N/A
S S
Bactroban in pre−op
❒ YES ❒ NO ❒ N/A
Hair clipped
❒ YES ❒ NO ❒ N/A
A P
Correct procedure
❒ YES
Site marked by surgeon
❒ YES ❒ N/A
Correct side
❒ RIGHT ❒ LEFT ❒ N/A
Informed consent H&P, present and updated
O P
Skin Integrity Issues Reported_________ ❒ YES ❒ NO Chlorohex rinse
❒ YES
Labs resulted as ordered
❒ POS ❒ NEG ❒ PENDING ❒ NA
MRSA results
Completed prior to rolling to OR Correct patient, ID band present/verified
T R
❒ YES ❒ NO ❒ N/A ❒ YES
❒ YES ❒ N/A
Blood products are available (if ordered)
❒ YES ❒ N/A
Risks reviewed
❒ YES ❒ NO ❒ N/A
Difficult airway identified by anesthesia
❒ YES ❒ NO ❒ N/A
Equipment ready, on correct side
❒ YES ❒ NO ❒ N/A
Correct patient’s radiology reports in OR
❒ YES ❒ N/A
Instrument sterility verified
❒ YES ❒ N/A
Correct implants
❒ YES ❒ N/A
Skin Integrity Issues Reported
❒ YES ❒ NO ❒ N/A
Radiology ready
❒ YES ❒ NO
❒ YES ❒ NO ❒ N/A
Pre−op pain scale _________
Does patient take Beta Blocker Glucose _________
❒ YES ❒ NO
Antibiotic selection appropriate
❒ N/A ❒ YES ❒ N/A
Warming blanket
❒ YES ❒ NO
Clothing/prosthesis/valuables removed
❒ YES ❒ N/A
PRE−OP RN __________________________/_________/_____ Signature Date Time PRE−OP RN __________________________/_________/______ Signature Date Time Disposition:_________________
CIRCULATING RN ________________________/_______/_____ Signature Date Time CIRCULATING RN ________________________/_______/_____ Signature Date Time Date Printed:
SGY00010pg1
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
TO BE COMPLETED BY CIRCULATING NURSE
TO BE COMPLETED BY CIRCULATING NURSE
CIRCULATOR: (Time−Out in the OR prior to incision (Surgeon must be present)**) Site:_____________________________________ Time: _____:_____
Procedure verified
❒ YES
Counts correct
❒ YES ❒ N/A
Specimen labels verified
❒ YES ❒ N/A
Correct patient, ID verified
❒ YES
Equipment issues reported
❒ YES ❒ NO ❒ N/A
Correct procedure
❒ YES
Post−op risks identified by anesthesia or surgeon
❒ YES ❒ NO
Correct site
❒ YES
Site marked by surgeon
❒ YES
Correct side
❒ RIGHT ❒ LEFT ❒ N/A
Correct position / Pressure areas padded
❒ YES
❒ NO
Antibiotic selection appropriate
❒ YES
❒ N/A
Antibiotic given within 1 hour prior to incision
❒ YES
❒ N/A
Warming blanket
❒ YES
❒ NO
Irrigation fluids required
❒ YES
❒ NO ❒ N/A
SCD’s
❒ YES
❒ NO ❒ N/A
Skin Integrity Issues _____________________
❒ YES
❒ NO
❒ NO ❒ N/A
TO BE COMPLETED BY PACU RN Correct patient, ID band present/verified
❒ YES
Risks reviewed
❒ YES
Warming blanket
❒ YES ❒ NO
SCD’s
❒ YES ❒ NO ❒ N/A
Order for VTE prophylaxis within 24 hours of surgery ❒ YES ❒ NO ❒ N/A Order to d/c prophlactic antibiotic within 24 hours (48 hours for cardiac)
POA U/A obtained if patient leaves with foley
**PARTICIPANTS IN TIME−OUT PRIOR TO PROCEDURE Surgeon: __________________________________________ Anesthesia:________________________________________ PA :______________________________________________ Nurse/ORT:________________________________________ Nurse/ORT:________________________________________ Nurse/ORT:________________________________________
❒ N/A
❒ YES ❒ N/A
No Reported or Visible Changes on Skin Integrity_____________ Additional site: __________________________________________ Time: _____:_____ Correct patient, ID verified ❒ YES Correct procedure ❒ YES Correct site ❒ YES Site marked by surgeon ❒ YES ❒ NO ❒ N/A Correct side ❒ RIGHT ❒ LEFT ❒ N/A Correct position ❒ YES
❒ YES
❒ YES ❒ NO
CIRCULATING RN ________________________/_______/_____ Signature Date Time CIRCULATING RN ________________________/_______/_____ Signature Date Time PACU RN __________________________/_________/_______ Signature Date Time PACU RN __________________________/_________/________ Signature Date Time
Date Printed:
SGY00010pg2
r*CONSET*r
2−6−2011
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
CONSENT
Request and Permission for Operation/Procedure 1. I ask and allow Dr. ________________________________________________________________ and/or associates or assistants of his/her choice to perform at Providence Hospital on: ,
(Type or Print)
Name of Patient
the following operation/procedure:
Left
Right
N/A
Check Which Apply
2. Dr. ____________________________________________ has explained to me the operation/procedure, how it will help me, and the risks and possible discomfort that I may feel. The doctor has also discussed other choices for the proposed operation/procedure and the risks and consequences of no treatment. I understand that there is no guarantee of the outcome/result of the operation/procedure. 3. I understand that during the operation/procedure, unplanned medical conditions may come up which would require procedures different from the ones that are planned. I agree to allow those procedures to be done which the doctor or his/her associates or assistants may recommend. 4. I understand and consent to any testing necessary to proceed with my surgery, including testing for reportable diseases such as, but not limited to, Hepatitis, HIV, etc. These tests may be required by the surgeon and/or the anesthesia personnel. Pre−operative testing may include a urine pregnancy test. For females of childbearing age, Providence Hospital requires mandatory pregnancy testing prior to any surgery that involves the female reproductive system. I do not consent to pregnancy testing. If I am pregnant, I acknowledge and understand surgery has been associated with a higher than expected likelihood of spontaneous miscarriage. I have had an opportunity to ask questions and they have been answered to my satisfaction. 5. I agree to be given anesthetics/sedation as may be recommended by or under the direction of: Anesthesia Solutions of Mobile
6. To increase medical knowledge and education, I agree to videotaping, photographing, and/or televising the operation/procedure to be performed, provided my/the patient’s identity is not revealed. I also agree to allow health care personnel/student observers into the operating or procedure room. 7. If it is necessary, I agree to be given blood and/or blood products by transfusion. Known risks of transfusion include infections such as HIV (AIDS), hepatitis and immunological reactions. If I have requested autologous or directed donor blood and sufficient blood is not available, I may receive random donor blood. Other risks, benefits and alternatives for blood transfusion have been explained to me. 8. Any organs or tissues removed during the operation/procedure can be examined and kept by Providence Hospital for necessary medical, scientific, or educational purposes. I agree to let Providence Hospital dispose of these organs, or severed parts according to hospital rules. 9. I was given a chance to ask questions, and am satisfied with the answers that I was given. I have crossed out and initialed any part of this form, which does not relate to me. I understand that all information about my care will be kept confidential. (Continued) Date Printed:
DEV 8/96 Rev 12/2009 CON00004
r*CONSET*r CONSENT
10. I understand that I can change my mind and take back my permission at any time before the operation/procedure. Patient/Relative/Guardian: (circle one)
SIGNATURE | DATE | TIME
Print Name
Relationship, if signed by person other than patient:
Interpreter, if required: SIGNATURE | DATE | TIME
Print Name
Witness: SIGNATURE | DATE | TIME
PRINT NAME
SIGNATURE | DATE | TIME
PRINT NAME
Witness:
If not previously documented in medical record:
I have explained the nature, purpose, benefits, risks and alternatives to the proposed operation/procedure, expected results and possible results of nontreatment, have offered to answer any questions and have answered such questions. The patient/relative/guardian acknowledges an understanding of what I have explained and answered, and has consented to undergo the proposed operation/procedure.
Physician:
, M.D. Signature
Print Name
Date | Time: NOTE: THIS DOCUMENTATION WILL BE MADE PART OF THE PATIENTS MEDICAL RECORD.
Date Printed:
DEV 8/96 (REV 10/99, 6/2002, 3/2011) REV 10/09 CON00004
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Anesthesia Solutions of Mobile, Inc. Consent for Anesthesia
r*CONSET*r
I hereby authorize and direct Anesthesia Solutions of Mobile, Inc. and the individual anesthesia provider to care for me, and to administer general, regional, or monitored anesthesia care (intravenoussedation) for surgery . The nature, purpose, and risks of the anesthetic, the possibility of complications, as well as alternatives have been fully explained by ____________________________. I understand that although favorable results can be expected, they cannot be and are not guaranteed. It is the understanding of the undersigned that an Anesthesiologist, or a Certified Registered Nurse Anesthetist (CRNA) under the direction of the Anesthesiologist, will administer the anesthesia, andthat the administration and maintenance of anesthesia. is an independent function from the surgery
Signature of patient or guardian
Witness
Date
Date
Time
Time
CONSENT consent
Developed July, 2002 Revised March, 2011 N4/03 CON00002
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Outpatient Discharge Instructions from: ❒ Cardiology / EP Lab ❒ Day Surgery ❒ Emergency Room ❒ GI Lab ❒ Radiology ❒ Short Stay / Bronch Lab ❒ Surgery
Page 1/2
I will be receiving sedation / anesthesia for my procedure. These instructions were explained to me before I received sedation. 1.
You should not drive, operate machinery, make critical decisions, sign legal documents, or consume alcoholic beverages for 24 hours.
2.
You must have a responsible adult stay with you for 24 hours.
I understand these instructions and will receive a copy on discharge. Date
Patient Signature
Time
In the next 24 hours: 1. MY PROCEDURE: See attached information. 2. ACTIVITY:
❒ See specific anesthesia instructions ❒ As tolerated
❒ Limited for _________hours/days
❒ Other: __________________
3. DIET:
❒ See specific anesthesia instructions ❒ As tolerated ❒ Clear liquids ❒ Liquids, progress as tolerated ❒ Other: _________________________________
4. MEDICATIONS:
❒ No changes recommended to your current medications. ❒ See attached list for information on your medications (Take this list to your next doctor’s appointment).
5. EMERGENCY CONTACT:
If you experience any symptom that you are concerned is life threatening: ✓ Call 911 for an ambulance ✓ Or go to the closest Emergency Department.
6. OTHER INSTRUCTIONS:
❒
Follow−up Care: ❒ Call physician’s office for appointment ❒ Follow−up appointment(s) Date: _________ Time: __________ Doctor: _________________ Location: _________________________________ Date: _________ Time: __________ Doctor: _________________ Location: _________________________________ ❒ Other referrals: ________________________________________ ❒ N/A
Anesthesia or Sedation: You/your family member have received: ❒ None received
❒ Light/moderate/heavy sedation
❒ Local anesthesia
❒ Spinal anesthesia
❒ General anesthesia
If you (your family member) have received ANY anesthesia or sedation, the following behaviors are not unusual for the first 24 hours: ● ●
Groggy, dizzy, or less alert for the next few hours, but arousable. ● Irritable or hyperactive when awake. ●
Date Created: 3/2011
Date Printed:
An infant or toddler may have difficulty holding his/her head up. Nausea with or without vomiting; vomiting may occur 1−2 times.
OPS00074
PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000
Page 2/2
Anesthesia or Sedation (continued):
If you (your family member) have received ANY anesthesia or sedation, follow these guidelines for the next 24 hours: ACTIVITY:
■ There must be a responsible adult present for 24 hours. ■ Do NOT allow your family member to walk/crawl alone until the sedation has completely worn off. ■ Do NOT allow your family member to participate in activities that require good coordination or concentration. ■ Do NOT allow your family member to drive any type of vehicle. ■ Do NOT allow your family member operate machinery. ■ Do NOT allow your family member to make critical decisions or sign legal documents. ■ Limit your family member’s activity. Allow your family member to resume full physical activity when his/her doctor gives you permission. ✓ Special considerations for Spinal anesthesia − your family member should remain in bed or a recliner for 6−8 hours. They should only use the bathroom with assistance. Call physician for persistent severe headache or if unable to urinate 6−8 hours after arriving home.
DIET:
■ ■ ■ ■ ✓
MEDICATIONS:
■ Continue any medications prescribed by the doctor. ■ Do NOT give your family member any medication that contains alcohol (example: cough syrup) for the next six (6) hours.
SLEEPING:
■ Check your family member frequently during the ride home and throughout the day to assure he/she is able to breathe easily and has not vomited. ■ At home, place your family member on his/her side during sleep. ■ Your family member may not sleep well the first night after sedation, especially if he/she slept more than usual throughout the day. ■ When using an infant carrier/seat, observe infants closely. If your infant falls asleep in the car, do not allow his/her head to fall forward or to the side. This position may block their airway and not allow them to breathe properly.
WATCH FOR:
■ ■ ■ ■
Do NOT feed your family member until he/she is fully awake. Start with clear liquids (water, apple juice, 7−Up) and advance to their regular diet as tolerated. Do NOT allow your family member to drink alcoholic beverages for 24 hours. Nursing infants may have breast milk once awake. Special considerations for General anesthesia − your family member may have a sore throat. Use throat lozenges, warm liquids, and pain relievers as prescribed.
Frequent vomiting Difficulty breathing Skin very pale or grayish in color Unable to awaken from sleep
If any of these occur, call 911 or go to the nearest Emergency Department. The instructions above were explained to me. I understand these instructions and am the responsible adult caring for this patient.
Signature of Responsible Adult
Date
Time
Signature of Discharge Nurse
Date
Time
If you receive a survey about the service you experienced during this visit with us, please give us your opinion of our performance. We desire to make each visit an excellent visit. Your response assists us with continuous improvement. Thank you in advance for completing the survey. Date Created: 3/2011
Date Printed:
OPS00074pg2