Perioperative Care Record

Transcription

1 Perioperative Care Reord BAGH DMH UHND Admission Ward: Post Theatre Ward: Walking Wheelhair Trolley Other: Patient s Name: Address: Patient s preferred name:... ADDRESSOGRAPH Date of operation:... Date of Birth: Consultant:... Staff Register (ALL STAFF MUST FULLY COMPLETE THE STAFF REGISTER) Name (PRINT) Position Signature (to be used throughout doument) Observations Pulse: Height (m): CJD risk assessed? Blood Pressure: Respiration Rate: Blood Gluose Index (if appliable): Date of LMP: Has the patient had MRSA in the past? SaO 2 : Early Warning Sore: Is the patient s name inluded on the Trust MRSA patient list? Temperature ( o C): Waterlow Sore: Religious beliefs and/or ultural requirements? Weight (kgs): Consent for skin donation? Consent for bone donation? 1 LP48971

2 Handover given l l l Ward staff must omplete the Pre-operative hek before the patient is given pre-operative mediation AND before the patient is transferred to theatre. Theatre Staff must onfirm the heklist on arrival at theatre reeption. On the day of surgery the patient should NOT leave the ward unless the following have been ompleted: Ward Pre-operative Confirmation Medial Notes present and orret Wristband orret and in situ Patient has valid onsent Is the Surgial Site marked Yes Yes Yes Yes N/A Theatre onfirmation Blood has been Group and saved Available Cross mathed Patient last ate: Patient last drank:... hours on... (date)... hours on... (date)) VIP Doumentation if annulated on ward Yes Theatre Pre-operative Chek Ward Sign Theatre Sign Drug Kardex Allergies Yes N/A ne known Pre Med given Disabilities Caps / Crowns / Loose Teeth (indiate) Right Left Hearing Impaired / aid in situ Glasses / Contat lenses Jewellery / Body Piering / Hair ornaments Removed / Taped Prostheses / Implants / Paemaker Possibility of pregnany Time last passed urine: Consent gained for shave Consent gained for retal mediation ne known Dentures Plate N/A Removed In situ Upper Lower Both Left Right Both N/A Removed In situ N/A hours Consent obtained for peri-operative photography Consent obtained for observers (other than Student Nurse / ODPs to be present) Consent gained for insertion of urinary atheter Theatre Personnel sign: 2

3 Intra Operative Care Reord Monitoring (tik all that apply) Eye Protetion N/A Blood Pressure Cuff Pulse Oxymetry Arterial Line Other: ECG BIS Monitor CVP Line Type: Nasto Gastri Tube Size: Anaestheti General Regional Epidural IV Sedation Hypothermia Protetion N/A Airway ET Tube Size: IGel Size: Laryngeal Mask Size: Throat Pak Warming Devie Temperature Monitor Temperature at Indution = Arm Position Left Arm At side On Board Aross hest Other: Fluid Warmer Right Arm At side On Board Aross hest Other: Fae Mask and/or Oropharyngeal Airway Size: Medial Devie Numbers Autologous Blood Colletion System Yes No Comments: Handover given by: 3

4 Position Positioning Aids Additional Comments Supine None Prone Pillows Lithotomy Bolsters Lloyd Davis Sandbags Left Lateral Head Ring Right Lateral Arm Supports Trendelenberg Trauma Table Reverse Trendelenberg Other: Pressure Area Care and Anti-embolism Therapy Mehanial prophylaxis N/A Gel Heel Pads N/A Gel Pads N/A Diathermy N/A Monopolar Bipolar Tripolar Site shaved R L Indiate position of diathermy plate with a X L R Applied by: Removed by: Indiate position of tourniquet with a T Tourniquet 1: Inflate Time: Deflate Time: Pressure: Applied by: Total Inflation Time: Tourniquet 2: Inflate Time: Deflate Time: Pressure: Applied by: Total Inflation Time: Condition of skin sites where applianes plaed satisfatory Skin Prep Used Speimens obtained Number: Details: Operation Performed See Surgeon s Operation Notes 4

5 Paks in situ Drains N/A Drain No.1 Type: Drain Opened: Loation: Time: Drain No.2 Type: Drain Opened: Loation: Time: Drain ut or altered wtih ut setion disarded: Seured with: Dressing Suture Tape Abdominal Irrigation / Washout Invasive aess routes Fluid Type: Amount in: Amount out: (mls) (mls) Traheostomy Tube N/A Hikman Line N/A Type: Grommet or Ventilation Tube Right Left N/A Skin Closure N/A Absorbable Non-absorbable Clips Other (speify): Dressings / Ostomy Dressing N/A Ointment and Creams N/A Infiltration Drug Used (Type / Amount / Route) Catheter Pathway Bladder Irrigation Fluid Type: Amount in: mls Amount out: Catheter Type: Urinary Suprapubi Ureteri Stent N/A mls attah produt stiker Bath Number: Expiry date: Catheter inserted as per agreed Trust poliy Inserted at:... hours Sign: Sterile water inserted into balloon (As manufaturer instrutions) Evidene of uring drainage following insertion Attahed orret drainage bag with tap... Print: Catheter to be removed at:... on: Medial Devie Number 5

6 Traeability Sheet 6

7 Traeability Sheet 7

8 Rayte Swabs 10m x 10m Rayte Swabs 5m x 5m Paks Red Tapes Atraumatis Blades Hypodermi Needles Spools / Reels Tip Cleaner Pledgets / Peanuts Tonsil Sponges Fine End Myringotome Slings / Sloops Nylon Tapes Inserts Pre-operative Count Corret with integrity of Instruments and Supplementary items onfirmed. Yes No Closure of a Cavity within a Cavity, Joint or Organ Count Corret Wound Closure Count Corret Srub Personnel Signature: Cirulating Personnel Signature: Srub Personnel Signature: Cirulating Personnel Signature: Srub Personnel Signature: Cirulating Personnel Signature: Final Count Corret with integrity of Instruments and Supplementary items onfirmed. Yes No Srub Personnel Signature: Cirulating Personnel Signature: If any of the above is answered NO please doument ation taken on the Communiation / Variane sheets. 8

9 Reovery Care Patient ondition on arrival Level of Consiousness Respirations Alert Voie Pain Unonsious Spontaneous Manual IPPV Mehanial Airway None Oropharyngeal LMA Traheostomy Nasopharyngeal IGel Other (please state): Airway removed: N/A In Reovery Sign: Time: O 2 Saturation Respirations O 2 Rate l / min Consiousness Sore Pain Sore (on movement) (at rest) Nausea Sore Temperature 9

10 Reord of Presribed Drugs Administered in Reovery (see Drug Kardex) Drug Amount Time given Drug Amount Time given SEE ADDITIONAL PCA snd EPIDURAL CHARTS WHERE APPROPRIATE (also see Drug Kardex) Irrigation Fluids Administered in Reovery (see instrutions in Operation Notes) Irrigation Fluids Amount Time given Bath Number Expiry Date Output Colour Intravenous Fluid in progress Type: To be followed by: Rate: Rate: Warming Devie in situ Yes N/A Wound Chek N/A PV Loss N/A Wound Drains in situ Time Clamp Opened: Amount of Drainage (mls) Medial Devies 1st Reovery Personnel Signature: 2nd Reovery Personnel Signature: (Only if the responsibility of are has been transferred) Information Handover to Ward Cheklist IV Fluids have been presribed Oxygen has been presribed VIP information has been ompleted PCA Chart has been ommened Epidural Chart has been ommened BM Chart has been ommeneed Blood transfusion pathwway has been ommened Intratheal Opiate hart has been ommened Cannula and/or Bionetor has been flushed with NaCl 0.9% Early Warning Sore on disharge = 10 Comments:

11 Reovery Room Disharge Criteria Patients must have an Early Warning Sore of 2 or less to be disharged from the Reovery Room. Any deviation from the riteria must be reported to the Anaesthetist and doumented on the Reord of Care Communiation / Variane Sheet. The patient must then not be disharged without medial santion. AVPU Sale Is the patient orientated and responsive to ommands up to 1 on the AVPU Sale Yes Variane Respiration The patient has unobstruted, spontaneous breathing Yes Variane Respiration rate is at least 10 breaths per minute Yes Variane Oxygen saturation should be at least 94%. Unless hroni hypoxemias exists. Yes Variane Basi Observations Blood Pressure and Pulse Rate should be approximate to normal pre-operative levels or within parameters stipulated by the Anaesthetist Yes Variane Systoli > 90 < 180 Yes Variane Dyastoli < 95 Yes Variane Pulse Yes Variane Temperature Is between 36 o C and 38.4 o C Yes Variane Neuromusular Transmission There should be no evidene of neuromusular blokade. The patient is able to: ough / support head / move limbs Catheterised Patients Yes N.B.: Any variane must be reorded on the variane sheet. Variane Is the patient passing approximately 30mls of urine per hour? Yes Variane Pain Sore Pain Sore should be 0-3 prior to disharge Yes Variane Analgesia regime should be presribed and given if required Yes Variane Nausea Anti-emetis should be presribed and given if required Yes Variane Wound Drainage No evidene of persistent bleeding Yes Variane All drains and atheters should be observed and loss doumented Yes Variane Fluids Intravenous lines must be patent and IV fluids given as per presribed regime Yes Variane Reovery Personnel Signature: 11

12 Date / Time Communiation / Variane Sheet Signature 12

13 Date / Time Communiation / Variane Sheet Signature 13

14 Date / Time Communiation / Variane Sheet Signature 14

15 Date / Time Communiation / Variane Sheet Signature 15

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