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Preparing for surgery

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The document provides instructions for preparing a patient and their chart for surgery. Key steps include obtaining consent forms, completing pre-operative assessments and checklists, ensuring test results and medications are documented, labeling the chart and sending labels to the operating room. Important patient preparations include hygiene, ID bands, NPO status if required, and removing personal items. A time out is conducted immediately before and after the procedure to verify patient, site, procedure, history and test results.

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Preparing for Surgery Chart Preparation  Obtain informed consent and blood consent  Complete the paper form check List – and place on front of chart to use as a worksheet  Also complete the Pre-Operative assessment eform, which includes pre-op check list information and documentation of all pre-op medications and any medications given after midnight  All Surgery charting is now done on CPSI
Preparing for Surgery (continued) Chart Preparation (continued)  H&P must be on chart prior to patient going to OR  Label chart with patient labels and send 30 labels with the patient to OR – place in back of chart  Print Physician’s Medication Report and place under Physician’s Orders tab  VTE orders need to be placed under the Physician’s Orders tab as well
Preparing for Surgery (continued) Patient Preparation  All surgery patients should have good hygiene, including bath or shower as appropriate to decrease the risk of infection  Do not apply lotion, powder, or deodorant  All prostheses and personal belongings should be removed before sending patient to surgery  All patients should have ID bands on, but not on the operative extremities  All patients should be NPO unless otherwise ordered  Document fetal heart tones on all pregnant patients  If the patient is returning to the same room post – op…When surgery staff come to take the patient, remove telemetry and leave in room, notifying CCU that the patient went to the OR  End Shift
Preparing for Surgery (continued)  Start early - surgery schedule is subject to change and frequently does  Surgical patients and charts are to be ready and completed by 0600  Order all pre-operative tests and have results on chart  Inform OR if patient has any latex allergies, infectious processes, history or family history of malignant hyperthermia, or recent nuclear medicine radioactive procedures as soon as possible – prior to patient leaving the room
Preparing for Surgery (cont)  All patients should have a patent 18 gauge IV with the 7” extension tubing attached  Remove any IV filters – they could retain anesthetic agents  If patient has IV antibiotics ordered send the antibiotic with unopened tubing to the Holding area with the patient  Administer any pre-op medications ordered by surgeon or anesthesiologist/CRNA JUST prior to patient leaving floor  Physician marks surgical site with permanent marker with participation of the patient before transferring patient into the operating room  Make sure the family knows to report to the desk in the waiting area so they are available when the physician is ready to speak with them
Preparing for Surgery (cont) IMMEDIATELY BEFORE THE PROCEDURE Take a “TIME OUT” for safety • VERIFY PATIENT (verbal confirmation and ID band) • VERIFY PROCEDURE (check permit, check schedule, patient verbalization of procedure, and surgeon confirmation of correct procedure) • VERIFY SIDE/SITE (patient verbalization of side/site, pre-marked site/side by physician, check permit)
Preparing for Surgery (continued) “TIME OUT” for safety (continued) • VERIFY HISTORY (check history/physical and any medication considerations • VERIFY TEST RESULTS (diagnostic test results, PACS/Images in room) • VERIFY MEDICATIONS (check that all needed medications and fluids are available • VERIFY POSITION • VERIFY IMPLANTS
Preparing for Surgery (continued) IMMEDIATELY AFTER THE PROCEDURE Prepare patient’s room to receive patient • Have bed raised and made • Path cleared to bed • Needed equipment and transfer device in room Report should be nurse to nurse Surgery staff should not leave patient unattended Nurse should take first set of frequent vital signs and monitor patient during each set including inspecting all dressing, drains, and level of pain and sedation

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Preparing for surgery

  • 1. Preparing for Surgery Chart Preparation  Obtain informed consent and blood consent  Complete the paper form check List – and place on front of chart to use as a worksheet  Also complete the Pre-Operative assessment eform, which includes pre-op check list information and documentation of all pre-op medications and any medications given after midnight  All Surgery charting is now done on CPSI
  • 2. Preparing for Surgery (continued) Chart Preparation (continued)  H&P must be on chart prior to patient going to OR  Label chart with patient labels and send 30 labels with the patient to OR – place in back of chart  Print Physician’s Medication Report and place under Physician’s Orders tab  VTE orders need to be placed under the Physician’s Orders tab as well
  • 3. Preparing for Surgery (continued) Patient Preparation  All surgery patients should have good hygiene, including bath or shower as appropriate to decrease the risk of infection  Do not apply lotion, powder, or deodorant  All prostheses and personal belongings should be removed before sending patient to surgery  All patients should have ID bands on, but not on the operative extremities  All patients should be NPO unless otherwise ordered  Document fetal heart tones on all pregnant patients  If the patient is returning to the same room post – op…When surgery staff come to take the patient, remove telemetry and leave in room, notifying CCU that the patient went to the OR  End Shift
  • 4. Preparing for Surgery (continued)  Start early - surgery schedule is subject to change and frequently does  Surgical patients and charts are to be ready and completed by 0600  Order all pre-operative tests and have results on chart  Inform OR if patient has any latex allergies, infectious processes, history or family history of malignant hyperthermia, or recent nuclear medicine radioactive procedures as soon as possible – prior to patient leaving the room
  • 5. Preparing for Surgery (cont)  All patients should have a patent 18 gauge IV with the 7” extension tubing attached  Remove any IV filters – they could retain anesthetic agents  If patient has IV antibiotics ordered send the antibiotic with unopened tubing to the Holding area with the patient  Administer any pre-op medications ordered by surgeon or anesthesiologist/CRNA JUST prior to patient leaving floor  Physician marks surgical site with permanent marker with participation of the patient before transferring patient into the operating room  Make sure the family knows to report to the desk in the waiting area so they are available when the physician is ready to speak with them
  • 6. Preparing for Surgery (cont) IMMEDIATELY BEFORE THE PROCEDURE Take a “TIME OUT” for safety • VERIFY PATIENT (verbal confirmation and ID band) • VERIFY PROCEDURE (check permit, check schedule, patient verbalization of procedure, and surgeon confirmation of correct procedure) • VERIFY SIDE/SITE (patient verbalization of side/site, pre-marked site/side by physician, check permit)
  • 7. Preparing for Surgery (continued) “TIME OUT” for safety (continued) • VERIFY HISTORY (check history/physical and any medication considerations • VERIFY TEST RESULTS (diagnostic test results, PACS/Images in room) • VERIFY MEDICATIONS (check that all needed medications and fluids are available • VERIFY POSITION • VERIFY IMPLANTS
  • 8. Preparing for Surgery (continued) IMMEDIATELY AFTER THE PROCEDURE Prepare patient’s room to receive patient • Have bed raised and made • Path cleared to bed • Needed equipment and transfer device in room Report should be nurse to nurse Surgery staff should not leave patient unattended Nurse should take first set of frequent vital signs and monitor patient during each set including inspecting all dressing, drains, and level of pain and sedation