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    Appendectomy Nurses' Notes

    Uploaded by

    Cymargox
    FDAR Documentation. of course you need to fill in the A with what you really witnessed. This is just a guide.

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    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd

    Appendectomy Nurses' Notes

    Uploaded by

    Cymargox
    10K views1 page
    FDAR Documentation. of course you need to fill in the A with what you really witnessed. This is just a guide.

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

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    FDAR Documentation. of course you need to fill in the A with what you really witnessed. This is just a guide.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    10K views1 page

    Appendectomy Nurses' Notes

    Uploaded by

    Cymargox
    FDAR Documentation. of course you need to fill in the A with what you really witnessed. This is just a guide.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Date and Time

    Focus Pre-operative Preparation Anesthesia Induction Anesthesia Evaluation

    Operation started

    Data- Action- Response D>Into OR per _______________ accompanied by _______________ with ongoing IVF of ______at ____ cc level infusing well at ___ arm, consent for surgery signed and attached to chart, confirmed identity, site, procedure and consent A>Ushered to ___ OR ambulatory and positioned comfortably on ________, monitors attached; initial vital signs taken as follows: BP= _____mmHg CR=____bpm RR=____cpm SPO2=____% A>Repositioned to ________ with arms extended on arm boards, arm straps applied; anesthetic effect assessed by anesthesiologist (Dr. _____________); electro-surgical pad placed under buttocks; ________________ skin prep done by _____________; draped aseptically by Dr. ____________; initial sponge and instrument count done, Time-out completed A>(Specify what was done)

    Specimen out

    D>____________ out (please include description of specimen)

    End of operation Unit Transfer

    A>Final sponge , needles, and instrument count done and verified correct by ________________, sign out completed, wound closure by layers done by surgeon _____________ A>Skin closure completed by same surgeon, antiseptic solution and top dressing applied and secured A>Immediate post-op care done, arm straps and electrosurgical pad removed, kept warm with blankets, transferred to RR bed, ensured safety, brought to recovery room per RR bed with IVF of ____ at _____ cc level, last BP= _______, CR=________,RR=_______, SPO2=______, surgical checklist, OR tech and anesthesia record attached to chart, specimen labeled and given to watcher with ______________ request, endorsed to RR nurse.

    Date and Time

    Focus Pre-operative Preparation Anesthesia Induction Anesthesia Evaluation

    Operation started

    Data- Action- Response D>Into OR per _______________ accompanied by _______________ with ongoing IVF of ______at ____ cc level infusing well at ___ arm, consent for surgery signed and attached to chart, confirmed identity, site, procedure and consent A>Ushered to ___ OR ambulatory and positioned comfortably on ________, monitors attached; initial vital signs taken as follows: BP= _____mmHg CR=____bpm RR=____cpm SPO2=____% A>Repositioned to ________ with arms extended on arm boards, arm straps applied; anesthetic effect assessed by anesthesiologist (Dr. _____________); electro-surgical pad placed under buttocks; ________________ skin prep done by _____________; draped aseptically by Dr. ____________; initial sponge and instrument count done, Time-out completed A>(Specify what was done)

    Specimen out

    D>____________ out (please include description of specimen)

    End of operation Unit Transfer

    A>Final sponge , needles, and instrument count done and verified correct by ________________, sign out completed, wound closure by layers done by surgeon _____________ A>Skin closure completed by same surgeon, antiseptic solution and top dressing applied and secured A>Immediate post-op care done, arm straps and electrosurgical pad removed, kept warm with blankets, transferred to RR bed, ensured safety, brought to recovery room per RR bed with IVF of ____ at _____ cc level, last BP= _______, CR=________,RR=_______, SPO2=______, surgical checklist, OR tech and anesthesia record attached to chart, specimen labeled and given to watcher with ______________ request, endorsed to RR nurse.

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