DEFINITION OF TERMS

• Operating Room- room in a heath care facility in which patients are prepared for surgery, undergo surgical
procedures and recover from anesthetic procedures required fur surgery.
• Peri operative nursing- total surgical experience that encompasses pre operative, intra operative, and post
operative phases of patient care.
• Operating room nurse- duly registered nurse legally responsible for the nature and quality of the nursing
care patients.
• Surgical conscience- awareness which develops from a knowledge base on the importance of strict
adherence to principles of aseptic and sterile technique.
• Asepsis- freedom from infection or absence of microorganism.
• Sepsis- general reaction from the action of bacteria or their products.
• Aseptic technique- methods by which contamination of microorganism is prevented.
• Antiseptic- substance which combats sepsis and cause bacteriostasis.
• Disinfection- process of destroying microorganisms except pore bearing ones.
• Anesthesia- insensibility to pain and trauma with or without loss of consciousness.
• Operating room attire- consists of the scrub dress, head cover, mask and shoes or shoe cover.
• Surgical scrub- is the removal of as many bacteria as possible from the hands and arms by mechanical
washing and chemical disinfection before participating in an operation.
• Gowning- to exclude skin as a possible contaminant and to create a barrier between sterile and non sterile
areas, to permit the wearer to come within the sterile field and to carry out sterile techniques during an
operative procedure.
• Gloving- to exclude skin as a possible contaminant, to create a barrier between sterile and unsterile areas
and to permit the wearer to handle sterile supplies or tissues of the operative wound.
• Draping- is the procedure of covering patient and surrounding areas with a sterile barrier to create and
maintain an adequate sterile field during operation.

ROLES OF THE OPERATING ROOM TEAM MEMBERS

• Surgeon- responsible to perform the operative procedure safely and correctly. He is also responsible for
being certain that all necessary equipment and instruments are available.
• Assistant surgeon- responsible to help the surgeon in any way requested. He may close the incision and help
with the placement of dressings.
• Anesthesiologist- is the person who administers the anesthetic to the patient. He is responsible for being
certain that all equipment and supplies necessary for the induction of anesthesia are available and checks the
patient and the chart for any last minute changes. He monitors the patiet’s vital signs and responsible for
keeping the surgeon aware of the patient’s condition. He checks the fluids and blood transfusion needed
during surgery and checks the patient’s airway and vital signs before taking the patient in post anesthesia
recovery room.
• Scrub nurse- must be properly attired, scrubbed, gowned and gloved. He is responsible in setting up the
back table, mayo tray, sponges, needles and instruments. He assists the surgeon throughout the procedure as
required and anticipates the needs for the surgeon.
• Circulating nurse- responsible for the overall running of the operating room before, during, and after the
operative procedure.

PRINCIPLES OF STERILE TECHNIQUE

• Sterile persons have scrubbed and are gowned and gloved; unsterile persons have not.
• Only sterile items are used within sterile field.
• If you are in doubt about the sterility of anything, consider it unsterile.
• Gowns are considered sterile only from the waist to shoulder level and in front of the sleeves.
• Tables are sterile at table level.
• Persons who are sterile touch only sterile items or areas; persons who are not sterile touch only unsterile
items or areas.
• Unsterile persons avoid reaching over a sterile field; persons avoid leaning over a sterile field.
• Edges of anything that encloses sterile contents are considered unsterile.
• Sterile field is created as close as possible to the time of use.
• Sterile areas are continuously kept in view.
• Unsterile persons avoid sterile areas.
• Destruction of integrity of microbial barriers result in contamination.
• Microorganisms must be kept to an irreducible minimum.
• The back of the person wearing a sterile gown is considered unsterile.
• Moisture can cause contamination.
ROLE OF THE SCRUB NURSE IN OPERATING ROOM
• Performs surgical scrub using accepted technique
• Gowns and gloves himself using proper technique
• Opens sterile packs and set correctly
• Sets up sterile table correctly
• Counts sponges correctly
• Assists in draping the patient
• Anticipates the needs of the surgeon
• Hands and serves instruments and supplies adeptly
• Keeps the sterile field neat, clean, and dry
• Counts sponges, instruments and needles correctly
• Prepares the dressings properly
• Washes the keeps the instruments used
• Sends the properly labeled specimen to the department concerned
• Disposes waste material properly
• Assists in cleaning, rearranging and preparing the room for the next case

ROLE OF THE CIRCULATING NURSE IN OPERATING ROOM

• Wear required and accepted attire
• Prepare and readies the OR table
• Positions patient properly on the OR table
• Performs skin prep of the patient correctly
• Assists the anesthesiologist
• Assists the scrub personnel
• Counts the sponges correctly
• Anticipates the needs of the surgical team
• Accomplishes records and forms correctly
• Keeps the room clean and tidy
• Collects and labels specimens properly
• Sees to it that equipment are in good working condition
• Helps in the application of dressing
• Provides immediate post-op care
• Disconnects and cares for all special equipment
• Assists in cleaning, rearranging and preparing the room for the next case

COMMON SURGICAL PROCEDURES AND TERMINOLOGY

• Ectomy- removal or excision of a structure
• Rrhapy- a plastic or repair operation
• Oscopy- inspection of the interior of an organ or passage by means of special instruments, usually carrying a
light
• Ostomy- constructing an artificial opening into an organ
• Otomy- incising or dividing the structure

ABDOMINAL SURGERY
• Abdominal laparotomy- an opening through the abdominal wall into the peritoneal cavity for the purpose of
exploration, diagnosis and treatment.
• Cholecystectomy- removal of the gallbladder.
• Cholecystolithotomy- the establishment of an opening into the gallbladder to allow the draining of the organ
and removal of stones.
• Choledocholithotomy- the opening of the common bile duct to remove stones
• Pancreatotomy- removal of the entire pancreas
• Spleenectomy- removal of the spleen

GASTROINTESTINAL SURGERY
• Vagotomy- the transaction of the vagus nerve, performed at the level of the distal esophagus or the gastric
cardia to reduce gastric secretion in patients with peptic ulcer.
• Gastrotomy- an artificial opening into the stomach exiting into the skin of the abdominal wall.
• Gastrectomy- removal of the stomach and reestablishment of the continuity of the GIT.
• Appendectomy- excision of the appendix, usually performed to remove an acutely inflamed organ.
• Colostomy- formation of a permanent or temporary opening into the colon brought into the abdominal wall
as a stoma.
• Right hemicoelectomy- resection of the right half of the colon (a portion of the transverse coon, the
ascending colon and the cecum) and a segment of the terminal ileum and their mesenteries; an anastomosis
is performed between the ileum and the transverse colon.
• Hemorrhoidectomy- excision of the distended veins, anal skin, anoderm.

NECK SURGERY
• Thyroidectomy- removal of all or a portion of the thyroid gland.
• Parathroidectomy- removal of one or more of the four parathyroid glands located behind the thyroid gland.
• Thyroglossal duct cystectomy- excision of a cyst and duct in the midline of the neck including a portion of a
hyoid bone.

BREAST SURGERY
• Breast biopsy- removal of tissue to determine the nature of a breast lesion.
• Mastectomy- removal of the breast.
• Modified radial mastectomy- removal of the breast, the underlying pectoral muscles, and adjacent lymph
glands in the treatment of the breast.

GYNECOLOGIC AND OBSTETRIC SURGERY

• Dilatation of the cervix and curettage of the uterus- the gradual enlargement of the cervical canal and
removal of the endocervical or endometrial tissue for histologic study and treatment.
• Vaginal hysterectomy- removal of the uterus through the vaginal approach.
• Total abdominal hysterectomy- removal of the entire uterus through an abdominal incision.
• Salphingo-oophorectomy- removal of the fallopian tube and the corresponding ovary.
• Caesarian section- delivery of the fetus through incisions in the abdominal wall of the uterus.
• Colporrhapy- a repair operation on the vaginal wall in the treatment of pelvic prolapse.
• Ectopic gestation- implantation and development of a fertilized ovum outside the cavity of the uterus,
usually in the fallopian tube.
• Hysterectomy- removal of the uterus.
• Oophorectomy- removal of one or both ovaries.
• Salphingiectomy- removal of one or both fallopian tubes.
• Periniorrhapy- repair of the perinium.
• Myomectomy- removal of a fibromyoma or fibroid from the uterus.

GENITOURINARY SURGERY
• Circumcision- excision of the foreskin of the penis.
• Vasectomy- excision of a segment of the vas deferens with the ligation of distal and proximal ends.
• Orchiectomy- removal of one or both testicles.
• Cystectomy- excision of the urinary bladder to remove a calculi.
• Hydrocoelectomy- excision of a portion of the tunica vaginalis testis with the evacuation of fluid contained
therein.
• Trans urethral resection of prostate- piecemeal removal of prostatic tissue and lesion of the bladder neck
transcystoscopically.
• Open prostatectomy- excision of the prostate gland via surgical incision.
• Nephrectomy- removal of a kidney.
• Uterolithotomy- removal of a calculi from the ureter.
• Pyelolithotomy- removal of a calculi from renal pelvis.
• Nephrolithotomy- removal of a calculi from kidney.

NEUROLOGICAL SURGERY
• Craniotomy- opening of the skull.
• Cranioplasty- repair of a cranial defect.
• Laminectomy- removal of one or more vertebral laminae.

PLASTIC SURGERY
• Cleft lip repair- connection of a congenital deformity of the lips and face.
• Cleft palate repair- connection of congenital defects in the palate.
• Reduction of nasal fracture- molding and realignment of the nasal bones and septum.
• Rhinoplasty- correction of the external appearance of the nose.
• Otoplasty- correction of a prominent ear that protrudes unduly from the side of the head.

OTORHINOLARYNGOLOGIC (ENT) SURGERY

• Myringotomy- incision into the tympanic membrane to remove fluid accumulation.
• Mastoidectomy- removal of bony partitions forming the mastoid air cells.
• Nasal polypectomy- excision of an edematous hypertrophy of the nasal mucosa resulting from a chronic
edematous inflammatory process.
• Tonsillectomy- excision of the faucial (palatine) tonsils.
• Adenoidectomy- excision of the nasopharyngeal tonsils (adenoids).
• Tracheostomy- an opening made into the trachea with the insertion of a cannula to facilitate breathing.
• Parotidectomy- excision of all or a portion of the largest salivary gland.
• Laryngectomy- complete or partial removal of the larynx.

OPHTHALMIC SURGERY
• Excision of chalazion- incision and curettage of a granulomatous swelling of meibomian gland(s).
• Canthoromy- incision of the catus.
• Correction of strabismus- alignment of the visual axes of the eyes.
• Evisceration of the eye- removal of the entire contents of the eye within the sclera shell.
• Enucleation of the globe- removal of an eye (without rupture of the globe).
• Corneal transplant/keratoplasty- the grafting of corneal tissue from the eye of one person to another.
• Cataract extraction- removal of an opaque ocular lens.
• Iridectomy- excision of a secretion of the iris.
• Trabeculectomy- drainage of the anterior chamber employing a partial thickness limbal based sclera flap.

ORTHOPEDIC SURGERY
• Open reduction of the carpal bone structure- realignment and fixation of the fracture of the bones in the
wrist.
• Open reduction of the humerus- realignment and fixation of fracture of the arm employing an operative
incision.
• Open reduction of the radius and ulna- realignment and fixation of fracture of the forearm employing an
operative procedure.
• Open reduction of an olecranon- realignment and fixation of fracture of the elbw employing an operative
procedure.
• Excision of popletial (baker’s) cyst- excision of a cyst located in the popliteal space.
• Total knee replacement- replacement of the articular surfaces of the knee joint by prosthesis.
• Total hip replacement- substitution of the femoral head with a prosthesis and the reconstruction of the
acetabulum with the placement of acetabular cap, both of which may be fixed with methylmethacrylate.

COMMON ABBREVIATIONS USED IN OPERATING ROOM

• LTCS- low transverse caesarian section
• LCCS- low cervical caesarian section
• LSCS- low segmental caesarian section
• TAHBSO- Total abdominal hysterectomy bilateral salphingo oophorectomy
• TAHUSO- total abdominal hysterectomy unilateral salphingo oophorectomy
• PU- pregnancy uterine
• PUFT- pregnancy uterine full term
• PUIL- pregnancy uterine in labor
• PFC- peritoneal fluid collection
• BLND- bilateral lymph node dissection
• BSO- bilateral salphingo oophorectomy
• TAH- total abdominal hysterectomy
• D and C- dilatation and curettage
• FPA- family planning acceptor
• AOG- age of gestation
• EDC- expected date of confinement
• PES- pre eclampsia severe
• ONG- ovarian new growth
• BTL- bilateral tubal ligation
• NRFS- non reassuring fetal status
• CPD- cephalo pelvic disproportion
• IUFD- intra uterine fetal death
• MRM- modified radial mastectomy
• CBDE- common bile duct exploration
• X-LAP- exploratory laparotomy
• PPU- perforated peptic ulcer
• “E”- emergency
• IIH- indirect inguinal hernia
• TURP- trans urethral resection of prostate
• BPH- bening prostatic hyperplasia
• IO- intestinal obstruction
• ECCE with PC IOL- extra capsular cataract extraction with posterior chamber intra ocular lens
• CSM- cataract senile mature
• ORIF- open reduction internal fixation
• BKA- below knee amputation
• AKA- above knee amputation
• R/U- radius ulna
• P/3rd- proximal third
• M/3rd- medial third
• D/3rd- distal third
• Fx- fracture
• R/O- rule out
• CTT- closed tube thoracostomy
• I and D- incision and drainage
• SAB- subarachnoid block
• BT- blood transfusion
• JP drain- Jackson Pratt drain
• TURBT- trans urethral resection of bladder tumor
• VBAC- vaginal birth after caesarian

SPINAL ANESTHESIA
 Lower portion of the body is affected

 Numbness sensation on the lower part of the body

 L3-L4 usual site for induction of spinal anesthesia

 Cerebro Spinal Fluid in the subarachnoid space must be clear/colorless

 Lateral decubitus position for induction of spinal anesthesia

 Bupivacaine hydrochloride (sensorcaine 5% heavy) most common spinal anesthesia

 1 ½ to 3 hours duration

 Uses spinal needle gauge 23 or 25 for induction

 Monitor for spinal headache due to CSF Spillage

GENERAL ANESTHESIA
 Upper and Lower portion of the body are affected

 Body is paralyzed because of the anesthesia used

 No reflexes and sphincters are present

 Risk for aspiration

 Isoflurane (Furane) liquid type that should be converted to gas using anesthesia machine

 Propofol (Diprivan) White in color, IV push

 Succinylcholine Hydrochloride – Paralyzing agent, IV push

  Atracurium Besylate – Paralyzing agent, IV push

 Nitrous oxide (laughing gas) blue cyinder tank

 Oxygen (green cylinder tank)

 Anesthesiologist uses endotracheal tube and laryngoscope to intubate the patients

LOCAL ANESTHESIA
 Injection for infiltrating a small area to be incised

 Lidocaine hydrochloride 2% (xylocaine) most common local anesthetic

 15 minutes to 1 hour duration

 Specifically anesthetizes one specific region

COMMON SURGICAL PROCEDURES USING SPINAL ANESTHESIA

 Cesarean Section delivery

o Old primi
o Breech Primi/Breech presentation
o Cephalopelvic disproportion
o Eclampsia Severe
o Arrest of cervical Dilatation
o Arrest of desent
o Polonged 2nd stage of labor
o Abruption Placenta
o Placenta Previa
o Big Baby
o Non Reassuring fetal status
o Oligohydramnios
o Polyhydramnios
o Thickly meconium stained amniotic fluid
o Fetal distress
o Shoulder Dystocia
o Multiple Gestation
o Intra Uterine Fetal death
o Previous CS in Labor
o Genital Warts

 TAHBSO
o Myoma Uteri
o Abnormal Uterine Bleeding
 o Dysfunctional Uterine Bleeding
o CA of the uterus, Fallopian tube, ovary, cervix, etc
o Endometriosis

 Salphingiectomy
o Ectopic Pregnancy
o Tubal Ligation
o Salphingitis
o CA fallopian Tube

 Oophorectomy
o Ovarian new growth
o Dermoid cyst
o Ectopic pregnancy
o CA ovary

 Salphingo oophorectomy
o Ectopic Pregnancy
o Ovarian New growth
o CA fallopian tube, Ovary

 Total abdominal Hysterectomy

o Ruptured Uterus
o Uterine atony
o CA uterus, Cervix

 Vaginal Hysterectomy
o Uterine Prolapse

 Myometrium
o Myoma uteri

 Cholecystectomy
o Cholelithiasis
o Cholecystitis
o Polyp of the gallbladder
o Empyema of the gallbladder
o Hydrops of the gallbladder

 Cholecystostomy

 Choledocholithotomy

 Appendectomy
 o Acute
o Congestive
o Suppurative
o Gangrenous
o Ruptured

 Colostomy
o Intestinal Obstruction
o Imperforated anus

 Hemorrhoidectomy
o Hemorroids; Internal
o Hemorroids; External
o Hemorroids; mixed

 Transverse Coelectomy
o Intestinal obstruction

 Orchiectomy
o Un Descended testis
o Orchitis
o CA testis

 TURP
o Benign prostatic hyperplasia/hypertrophy
o CA Prostate

 Suprapubic Prostatectomy
o Benign prostatic hyperplasia/hypertrophy
o CA Prostate

 Cystolithotomy

 Ureterolithotomy
o Ureterolithiasis

 Cystectomy

 Bladder Stones

 Herniorrhaphy
o Indirect Inguinal hernia
o Direct inguinal hernia
o Strangulated hernia
o Encarcerated Hernia
 o Incisional Hernia
o Femoral Hernia
o Umbilical hernia

 ORIF Femur
o Fracture Femur

 ORIF Patella
o Fracture Patella

 ORIF Tibia and fibula

o Fracture tibia and Fibula

 ORIF Knee
o Fracture Knee

 BKA
o Diabetic Foot
o Foot gangrene

 AKA
o Diabetic Foot
o Foot Gnagrene

 Fistulectomy
o Fisula-en-ano

COMMON SURGICAL PROCEDURES USING GENERAL ANESTHESIA

 Pancreaticoduodenectomy
o Colon CA
o Instestinal Obstruction
o Pancreatic CA

 Abdominal Laparotomy/Exploratory Laparotomy

o Stab wound
o Gun Shot wound
o Blunt Injury

 Pancreatectomy
o Pancreatic CA

 Splenectomy
o Ruptured/Laceration Spleen

 Vagotomy

 Gastrectomy
 o Gastric CA
o Colon CA
o Intestinal Obstruction

 Right Hemicoelectomy
o Intestinal Obstruction
o Colon CA

 Thyroidectomy
o Nodular Non toxic goiter
o Anterior Neck Mass
o Thyroid CA

 Parotidectomy
o Parotid mass

 Thyroglossal Duct Cystectomy

 Mastectomy
o Breast CA
o Breast Mass

 Modified Radical Mastectomy

o Breast CA
o Breast Mass

 Pyelolithotomy
o Calculi in Kidney

 Nephrectomy
o CA of the Kidney

 Pulmonary Lobectomy

 Craniotomy
o Brain Tumor
o Hemorrhage/Hematoma
o Abscess

 Cranioplasty
o Fractured Skull

 Cleft Lip Repair

o Cleft Lip

 Cleft Palate Repair

o Cleft Palate
  Tonsillectomy

 Parathyroidectomy

 Heart Bypass

 ORIF Clavicle
o Fracture Clavicle

 ORIF Radius Ulna

o Fracture Radius Ulna

 ORIF Humerus
o Fracture Humerus

 Laminectomy
o Slipped Disc

COMMON SURGICAL PROCEDURES USING LOCAL ANESTHESIA

 Breast Biopsy

 Circumcision

 Vasectomy

 Excision of CHalazion

 Trabeculectomy

 Iridectomy

 Cataract Extraction

 Suturing

 Cauterization of warts

 Excision sebaceous cyst

 Tooth Extraction

 Perineorrhaphy

 Tracheostomy

 Tenorrhaphy

 Incision and drainage

 Disarticulation of digits

COMMON SURGICAL PROCEDURES USING INTRAVENOUS SEDATION

 Bilateral Tubal Ligation

 Debridement

 Dilatation and Curettage

 Cross pinning wrist and elbow

LAYERS OF ABDOMINAL WALL
 Skin – epidermis, dermis

 Subcutaneous layer/Tissue- Adipose tissue

 Fascia – Should be the strongest layer

 Muscle – rectus abdominis muscle

 Peritoneum – visceral and parietal peritoneum

LAYERS OF UTERUS
 Perimetrium – skin of the uterus

 Myometrium – Muscle portion of the uterus

 Endometrium – Innermost layer of the uterus

DIFFERENT KINDS/TYPES OF ABSORBABLE SUTURE

 Chromic – made from sub mucous coat of sheep’s intestine
o Absorbed by the body within 20, 30 and 40 days
o With Chromic salt solution
o Brownish n color

 Plain – made from sub mucous coat of sheep’s intestine

o Absorbed by the body within 10 days
o Yellowish in color

 Vicryl
o Absorbed by the body within 60 days
o White or violet in color

 Safil
o Absorbed by the body within 60 days
o White or violet in color

 Monocryl
o Absorbed by the body within 60 days
o Peach in color

 PDS
o Absorbed by the body within 60 days
o Violet in Color

 Polysorb
o Absorbed by the body within 60 days
o Violet in Color

DIFFERENT KIND/TYPES OF NON ABSORBABLE SUTURE

  Silk Thread
o Black in color

 Nylon Thread
o Blue or green in Color
o Prolene
o Merselene

 Abdominal Wire
o Wire filigree and wire gauze may be used for hernia repair
o Metal screws and pins for orthopedic surgery

 Skin Stapler
o Metal Skin Clips – healing of the skin is rapid
DIFFERENT LIGATURES FOR SPECIFIC LAYER
 Myometrium
o Chromic 1/0 (prepare at least 2 sutures for myometrium. First and second layer) round Needle

 Perimetrium
o Chromic 2/0 round needle

 Peritoneum
o Chromic 2/0 round needle

 Muscle
o Chromic 2/0 round needle

 Fascia
o Vicryl 0 or 1/0 round needle
o Safil 0 or 1/0 round needle
o PDS 0 or 1/0 round needle
o Monocryl 0 or 1/0 round needle
o Polysorb 0 or 1/0 round needle
o Silk Thread 0 Round needle
o Nylon thread 0 round needle

 Subcutaneous layer/Tissue
o Plain 2/0 round needle

 Skin
o Vicryl 3/0 or 4/0 cutting needle
o Safil 3/0 or 4/0 cutting needle
o PDS 3/0 or 4/0 cutting needle
o Monocryl 3/0 or 4/0 cutting needle
 o Polysorb 3/0 or 4/0 cutting needle
o Silk Thread 3/0 or 4/0 cutting needle
o Nylon Thread 3/0 or 4/0 cutting needle
2 kinds of Needles

 Round Needle – Used inside the abdominal wall to prevent the tissues and organs from laceration.

 Cutting Needle – used only in skin, for easy penetration and less trauma to skin.
❖ The bigger the number of the thread, the thinner it gets; number 0 represents the thickest thread
among the ligatures.
❖ Proper and collect way of reporting before the closure of the abdominal wall.
o Dr. David, Dr. Balana and Dr. Enriquez, sponges, instruments and needles were counted
complete.
o First one to be mentioned while reporting is the surgeon, then the assistant surgeon and last
but not the least, the anesthesiologist.
SAMPLE CHARTING IN CESAREAN SECTION DELIVERY
➢ In from ward with ongoing IVF of (present IVF) regulated at (regulation) infusing well in (site of IVF).
➢ Schedule for (operation) today with consent signed and secured.
➢ Placed at OR table
➢ Hooked to oxygen inhalation at 2-3 Lpm
➢ Hooked to data scope
➢ Vital signs checked
➢ Positioned on lateral decubitus for induction of spinal anesthesia by (anesthesiologist)
➢ Indwelling foley catheter insertion done. (optional)
➢ Abdomino perineal preparation and draping done.
➢ Initial sponges, instruments and needles count done
➢ Operation started by (surgeon) assisted by (assistant surgeon)
➢ (operation performed) done.
➢ Bleeders clamped and tied. (optional)
➢ Extracted an alive baby (boy/girl) at exactly (time)
➢ Complete placental extraction done
➢ Above IVF consumed and followed by ( IVF to follow) + (10 or 20) “u” of oxytocin done. (optional)
➢ Uterine suturing done layer by layer.
➢ Peritoneal lavage done. (optional)
➢ Bleeders checked (-)
➢ Final sponges, instruments and needles count done – complete
➢ Abdominal wall sutured layer by layer.
➢ Operation ended
➢ Dressing applied
➢ Internal examination/vaginal done
➢ Weaned from oxygen inhalation.
➢ Back to ward with same contraptions intact.

Name of student, batch, signature.

SAMPLE CHARTING IN GENERAL ANESTHESIA

➢ In from ward with ongoing INF of (present IVF) regulated at (regulation) infusing well in (site of IVF).
➢ Scheduled for (operation) today with consent signed and secured.
➢ Placed at OR table.
➢ Hooked to data scope
➢ Vital signs checked
➢ General anesthesia given by (anesthesiologist).
➢ Endotracheal intubation done.
➢ Indwelling Foley catheter insertion done. (optional)
 ➢ Abdomino perineal preparation and draping done or skin preparation and draping done
➢ Initial sponges, instruments and needles count done.
➢ Operation started by (surgeon) assisted by (assistant surgeon).
➢ (operation performed) done.
➢ Bleeders clamped and cauterized. (optional)
➢ Washing with NSS or peritoneal lavage done
➢ Bleeders checked (-)
➢ Final sponges, instruments and needles count done – complete
➢ Abdominal wall suturing layer by layer or skin suturing done.
➢ Operation done
➢ Dressing applied
➢ Endotracheal extubation done
➢ Suctioning done.
➢ Back to ward with same contractions intact.

Name of student, batch, signature.

SAMPLE CHARTING IN SPINAL ANESTHESIA

➢ In from ward with ongoing INF of (present IVF) regulated at (regulation) infusing well in (site of IVF).
➢ Scheduled for (operation) today with consent signed and secured.
➢ Placed at OR table.
➢ Hooked to oxygen inhalation at 2-3 Lpm
➢ Hooked to data scope
➢ Positioned on lateral decubitus for induction of spinal anesthesia by (anesthesiologist)
➢ Indwelling Foley Catheter insertion done. (optional)
➢ Abdomino perineal preparation and draping done.
➢ Initial sponges, instruments and needles count done.
➢ Operation started by (surgeon) assisted by (assistant surgeon)
➢ (operation performed) done.
➢ Bleeders clamped and cauterized. (optional)
➢ Above IVF comsumed and followed by (IVF to follow). (optional)
➢ Peritoneal Lavage done (-)
➢ Final Sponges, instruments and needles count done – complete.
➢ Abdominal wall sutured layer by layer.
➢ Operation ended
➢ Dressing applied
➢ Weaned from oxygen inhalation.
➢ Back to ward with same contraptions intact.
Name of student, batch, signature