UPMC Shadyside Surgical Patient Preparation Checklist

Transcription

1 UPMC Shadyside Surgical Patient Preparation Checklist Critical Elements 1. Accesses the Nursing Dashboard (M page) in erecord during shift to view if any of the patients on today s assignment are scheduled for surgery in next 24 hours. a. Clicks on the flow tab to view the columns titled OR Next 24 hrs and Diagnostics. b. If an indicator is located in the diagnostics column, opens the indicator to view the details. 2. Locates the Surgical Preparation Resource binder on the unit and reviews for reference content. 3. Initiates a pre op checklist in erecord via Ad Hoc pre op checklist form, if an assigned patient is scheduled for surgery. If a pre op checklist already exists, then modifies the existing one. States that only 1 pre op checklist should exist per surgical procedure encounter. 4. Beta Blockers a. Opens the Beta Blockers field in erecord. b. Gives pre op dose if within parameters. c. States Beta Blocker exceptions and documents appropriately if Beta Blockers not given. Holds Beta Blockers for systolic blood pressure 100 or heart rate 50. d. Refers to surgical preparation resource binder for Surgical Care Improvement Project (SCIP) Core Measure details. 5. Consents a. Verifies that required consents are completed including physician and patient signatures. b. States that as a nurse, they are only witnessing the signature, not the patient s understanding. c. Signs, dates, and times the consent form as the witness. d. Refers to the Consent Decision Tree Flow Chart in reference binder when uncertain. Blood Product Consent a. If the patient has cultural/religious beliefs against receiving blood products (ex. Jehovah s Witness), locates the Release From Liability For Failure To Administer Blood Transfusion (Adult) form from print on demand. b. Ensures patient completes and signs the form and places form in paper chart. c. States when unsure, they can contact the UPMC Center for Bloodless Medicine and Surgery office at Blood Products a. Determines whether the patient requires a type and screen (T&S) or a type and cross (T&C). b. If so, checks if it is ordered/completed. If samples are already completed checks that the sample is current <72 hours old. States that samples expire in 72hrs. c. If T&S/T&C are needed, but not ordered, properly orders and specifies ASAP for OR in the order details. States that orders for T&S/T&C must specify for OR in order to get results quickly. d. States that missing samples or unordered blood will result in a surgical delay. e. When unsure, checks with the blood bank at extension

2 7. Pacemaker/ICD a. Documents Make/Model/Serial Number in AdHoc Charting: ICD/Pacemaker Vendor form. b. Refers to reference binder for vendor details. c. Notifies O.R. Front Desk of existence of patient s Pacemaker/ICD at extension from the hours of 5am 5pm, or O.R. Charge nurse at extension between the hours of 5pm 5am. 8. Vital signs a. Records recent vitals. b. Addresses any abnormal findings. 9. Hygiene a. Gives the patient an antimicrobial bath the evening before and morning of procedure (depending on time of shift). b. Performs proper oral hygiene. States the importance in preventing Ventilator Associated Pneumonia (VAPs). 10. Medications a. Refers to the reference binder for the list of appropriate medications to administer. b. Administers medications with sips of water only. c. If an antibiotic is ordered, sends antibiotic with the patient to pre op holding. States that the anesthesia staff will administer the antibiotic due to this being a SCIP Core Measure. 11. Checks for NPO orders/status. Ensures patient has had nothing by mouth except for medications with sips of water only. 12. Lab Work a. Ensures all necessary lab work is completed. b. If patient has diabetes, checks capillary blood sugar (CBS) prior to sending patient to pre op holding. 13. CJD (Creutzfeldt Jacob Disease) a. Completes the CJD (Creutzfeldt Jacob Disease) section. b. States that CJD screening must be completed on every patient. c. If the patient screens positive, notifies the attending and OR charge nurse. d. States CJD positive patients must be the last case of the day due to special cleaning procedures. 14. Removes all valuables, including clothing and jewelry, and gives valuables to family or sends to security prior to sending patient to pre op holding. 15. Transportation to Pre op holding a. Locates the Ticket to Ride form from either print on demand or reports in erecord. b. Prints and completes the form. Ensures that Transport receives the form along with the patient chart. c. States that the Ticket to Ride form MUST be completed for transport to pre op holding. 16. erecord Downtime (see form attached on following page) a. Locates the pre op checklist in print on demand. b. States that all sections must be completed on the paper downtime form.

3 erecord Downtime Form

4

5