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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