DATE: OR ROOM #: SURGEON:

ASSISTANTS:
PRE-OPERATIVE DIAGNOSIS:

POST-OPERATIVE DIAGNOSIS:

OPERATIVE PROCEDURE PERFORMED:

ANESTHESIOLOGIST: CASE CLASSIFICATION:
CRNA / A.A.: CLEAN CLEAN CONTAMINATED CONTAMINATED INFECTED
GENERAL LMA ENDOTRACHEAL BLOCKS TYPE: SCHEDULED ADD-ON CODE BLUE EMERGENCY
SPINAL EPIDURAL IV SED O
2 COUNTS:
LOCAL SPONGE:
NEEDLE:
INSTRUMENT:
1st COUNT SIGNATURE:
2nd COUNT SIGNATURE:
COMMENTS:
CULTURE: YES NO SITE:
Antibiotics Given: Time Given: MD Signature:
SPECIMEN: YES NO SITE:
PATIENT IDENTIFICATION: ID BAND VERBAL
ALLERGIES: YES NO
NPO: YES NO FROZEN SECTION: YES NO SITE:
OPERATIVE CONSENT: YES NO
CHART REVIEW / Pre-Op TESTING AVAILABLE:
H & P: YES NO TIME: ADMITTED TO O.R.: INCISION TIME:
TIME OUT: YES DELAY CODE:
VERIFICATION OPERATIVE CHECKLIST: YES DISCHARGE:
COMMENT: TRANSFERED TO: PACU ICU NURSING UNITS AMBULATORY
SCRUB NURSE:
LEVEL OF CONSCIOUSNESS: RELIEF / TIME:
ALERT ORIENTED ORIENTED / SEDATED
LETHARGIC CONFUSED NON-RESPONSIVE
CIRCULATING NURSE:
RELIEF / TIME:
X-RAY: N/A OBSER-
Portable C-ARM VERS:
8850121 Rev. 06/06 PAGE 1 of 2
LOT / SERIAL NO.
PART OF THE MEDICAL RECORD
NONE MANUFACTURER SIZE LOCATION / TYPE
PATIENT IDENTIFICATION
OPERATING - ROOM
Anesthesia
INTRA-OPERATIVE NURSING RECORD
1ST 2ND
Operating Room Intra-Operative Nursing Record_OR
MEDS ADMINISTERED BY NON-ANESTHESIOLOGIST:
TIME AMOUNT ROUTE MEDS
COMMENTS / LOCAL MONITORING:
PROSTHESIS / IMPLANTS / GRAFTS
Page 1
A
S
S
E
S
S
M
E
N
T
Machine #:
YES NO N/A
Students:
Reps:

POSITION:
POSITIONAL AIDE:
COMMENTS:
YES NO
POSITIONED BY:
ESU:
YES NO
MACHINE #: PAD LOT #:
SETTINGS: CUT: COAG: SKIN CONDITION:
RETURN ELECTRODE LOCATION:
APPLIED BY: 1 INTACT
Post-Op Skin Condition under Pad: 2 RASHES
BIPOLAR: YES NO TED HOSE: Thigh __ Right __ Left 3 LACERATIONS
MACHINE #: SETTINGS: YES NO Knee __ Right __ Left 4 REDDENED AREAS
HYPOTHERMIA: YES NO SCD: YES NO 5 BRUISES
MACHINE #: SETTINGS: MACHINE #: 6 DECUBITIS
TOURNIQUETS: Time UP: Time DOWN: 7 ABRASIONS
#: Time UP: Time DOWN:
SETTING: CLIPPER: NO
SKIN STATUS: Before PLACEMENT: After:
SITE / LOCATION: APPLIED BY:
COMMENTS:
URINARY CATHETER: ADMITTED TO O.R. WITH:
FOLEY / TEXAS CATH: YES NO ML's IN DRAINAGE BAG:
FOLEY CATH #: INSERTED BY:
URINE RETURNED:
CLEAR CLOUDY CLOTS YELLOW SURGICAL PREP DYNA-HEX PROVIDONE - IODINE GEL
DARK AMBER PINK RED OTHER
SOLUTIONS:
DURAPREP PROVIDONE - SCRUB / SOLUTION
INTAKE: PER ANESTHESIOLOGIST: DRAINS / PACKING:
TOTAL BLOOD PRODUCTS: LOCATION:
TOTAL IV FLUIDS:
OUTPUT: URINARY DRAINAGE: DRESSINGS:
ESTIMATED BLOOD LOSS:
OTHER:
Patient will be free of any F.B. in surgical
wound
Impaired Tissue Integrity due to electro-
surgery
Patient will be free of any positioning related
injury
Patient will be able to manage anxiety by
discussing feelings
Patient free of adverse reactions to local
anesthesia
Alteration in tissue perfusion due to
tourniquet
Age specific needs:
a. 5-11 yrs old d. >65 yrs old
b. 12-18 yrs old
c. 19-64 yrs old
EVALUATION PATIENT OUTCOMES WERE ACHIEVED WITHOUT DIFFICULTY: YES NO NO ADDITIONAL NEEDS IDENTIFIED FOR THIS PATIENT
8850121 Rev. 06/06 PAGE 2 of 2
N/A YES
RN: Date:
SAFETY STRAP ON?
PATIENT PROBLEM/NURSING DIAGNOSIS
( ASSESSMENT ) POTENTIAL FOR:
POTENTIAL FOR FLUID IMBALANCE
POTENTIAL FOR INFECTION
EXPECTED OUTCOMES
DATE
JACKSON TABLE WILSON FRAME
OPERATING - ROOM
INTRA-OPERATIVE NURSING RECORD
POTENTIAL FOR INJURY
SUPINE PRONE OTHER LITHOTOMY
Operating Room Intra-Operative Nursing Record_OR
STANDARD INTRA-OPERATIVE CARE PLAN
NURSING ORDERS
STANDARD OF CARE FOR:
Infection related to surgical procedure Patient will be free of infection Infection: Implemented ON
( PLANNING )
PART OF THE MEDICAL RECORD
Retention of A F.B. in the surgical wound
Anxiety related to surgery Anxiety: Implemented ON
F.B.'s: Implemented ON
Patient will be free of impaired skin integrity Skin Integrity: Implemented ON
Injury related to positioning Positioning: Implemented ON
SPECIFIC PATIENT NEEDS (NURSING DIAGNOSIS) EXPECTED OUTCOMES NURSING ORDERS
Adverse reaction to local anesthesia Monitoring all V.S.
Adverse reaction to lasers Patient free of adverse reactions to lasers Standard care for lasers
Adequate T.P. T.P. Plan Management: Implemented ON
LEG HOLDER ARMS TUCKED PILLOWS BEAN BAG
STIRRUPS
ARMS OUT AXILLARY
KIDNEY REST
Page 2
(Specify)
LATERAL
Patient communication demonstrates a
basic understanding of the Perioperative
process
Standard of Care for Age Specific
competency implemented
L. ARM: Straps -
R. ARM: Straps -
BEACH CHAIR FRACTURE TABLE
IDENTIFY ON
DIAGRAM:
*
BY:
Board less than
90 degrees
90 degrees
Board less than