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IV Fluid: D5LR 1L X 8 HRS: E.G. Bilateral Tubal Ligation)

The document is a pre-operative checklist for Mary C. Tan, a 44-year-old female patient scheduled for an open cholecystectomy, IOC, and CBDE surgery on June 22, 2021 at 9AM with Dr. Quilla as the surgeon and Dr. Tallamor as the anesthesiologist. The checklist ensures all pre-operative requirements and safety measures are completed prior to bringing the patient to the operating room, including identification, consent, labs, vital signs, shower/enema, medications, and proper attire.

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110 views2 pages

IV Fluid: D5LR 1L X 8 HRS: E.G. Bilateral Tubal Ligation)

The document is a pre-operative checklist for Mary C. Tan, a 44-year-old female patient scheduled for an open cholecystectomy, IOC, and CBDE surgery on June 22, 2021 at 9AM with Dr. Quilla as the surgeon and Dr. Tallamor as the anesthesiologist. The checklist ensures all pre-operative requirements and safety measures are completed prior to bringing the patient to the operating room, including identification, consent, labs, vital signs, shower/enema, medications, and proper attire.

Uploaded by

Ano Nymous
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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ILOILO MISSION HOSPITAL

Mission Road, Jaro, Iloilo City


PRE-OPERATIVE CHECKLIST

Name: Tan, Mary C. Age: 44 Sex: F Ward: A218 Chart No. 546
Date of Operation: 22 June 2021 Time of Operation: 9 /AM PM
Allergy: Paracetamol Weight: 59kg
Type of Operation: Open Cholecystectomy, IOC, CBDE
Surgeon: Dr.Quilla Anesthesiologist: Dr. Tallamor

Type of Anesthesia: Spinal anesthesia


Yes No N/A (Check Box)
IV Fluid: D5LR 1L x 8 hrs
☐ ☐ ☐ 1. Identification Band
Gauge 20
☐ ☐ ☐ 2. Operation reported and arranged
☐ ☐ ☐ 3. Operation permit
☐ ☐ ☐ 4. Contaminated Case/Infected Case
☐ ☐ ☐ 5. OR Notified
☐ ☐ ☐ 6. Special Consent Form (e.g. Bilateral Tubal Ligation)
☐ ☐ ☐ 7. History and Physical Examination
Pre-Operative laboratory Work
☐ ☐ ☐ 8. CBC Hgb – 13.2gms/dL Hct – 38.3%
☐ ☐ ☐ 9. Urinalysis
10. Blood Type ☐ A ☐ B ☐ AB ☒ O
☐ ☐ ☐ 11. Blood Request Issued
☐ ☐ ☐ 12. Amount of Blood Available 2 units
☐ ☐ ☐ 13. Others (specify): Click or tap here to enter text.
☐ ☐ ☐ 14. Cardiopulmonary Clearance
☐ ☐ ☐ 15. ECG
☐ ☐ ☐ 16. X-ray
☐ ☐ ☐ 17. Pre-Operative
☐ ☐ ☐ 18. Last Nourishment: Time: 9 ☐AM ☒PM
☐ ☐ ☐ 19. Nothing by mouth after midnight (patient and family
should be instructed) water container removed from
bedside.
☐ ☐ ☐ 20. Vital Signs charted
☐ ☐ ☐ 21. If not normal, did the Head Nurse refer this to the doctor?
☐ ☐ ☐ 22. TPR: 37.0C; P-22; R-60 BP: 120/70 mmHg
☐ ☐ ☐ 23. Shower Bath (pay particular attention to the umbilicus)
☐ ☐ ☐ 24. Enema
☐ ☐ ☐ 25. Voided/Foley Catheters: Amount 150 cc,
Time: 8:15 ☐ AM ☒ PM
☐ ☐ ☐ 26. Nasogastric tube: Amount: Click or tap here to enter text. cc,
Time Click or tap here to enter text. ☐ AM ☐ PM

☐ ☐ ☐ 27. Areas shaved (Includes face side barns and mustache)if


operation done under General Anesthesia

☐ ☐ ☐ 28. Jewelry removed (include ring, earrings, religious


medals)

By:Click or tap here to enter text.,RN., given to Click or tap here to enter text.,RN

☐ ☐ ☐ 29. Wedding Band taped or tied on hand


☐ ☐ ☐ 30. Denture and Removable bridges removed
☐ ☐ ☐ 31. Prosthesis removed (eye glass, contact lens, etc.)
☐ ☐ ☐ 32. Hairpins and clips removed
☐ ☐ ☐ 33. Lipstick, make-up, nail polish, etc. removed
☐ ☐ ☒ 34. Skin test given (Local Anesthesia – Xylocaine)
☒ ☐ ☐ 35. Pre-Operative Medications given at8 ☒AM ☐PM Midazolam
15mg/tab 1 tab p.o.
☒ ☐ ☐ 36. Safety Measures provided after premedication (with
companion at the bedside)
☐ ☒ ☐ 37. Clergy visited
☒ ☐ ☐ 38. Properly attired with leggings, gown, and sling
(No sling for the eye cases)
☒ ☐ ☐ 39. Nurses Notes complete
______________________________________________________________________
Time of release :(30 minutes before the schedule time) Click or tap here to
enter text. ☐AM☐PM

Brought to OR by: Click or tap here to enter text.,R.N. _______________


(Printed Name) (Signature)

Received in OR by: Click or tap here to enter text.,R.N.________________


(Printed Name) (Signature)

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