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Major-Case-Number

The document is a detailed surgical checklist and performance criteria for preoperative and intraoperative procedures, including patient information, surgical team roles, and preoperative preparations. It outlines the steps for surgical handwashing, gowning, and gloving, as well as the responsibilities of the scrub and circulating nurses during surgery. Additionally, it includes a performance evaluation scale for assessing surgical handwashing and other practices.

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Jacob Clint Lipura
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7 views

Major-Case-Number

The document is a detailed surgical checklist and performance criteria for preoperative and intraoperative procedures, including patient information, surgical team roles, and preoperative preparations. It outlines the steps for surgical handwashing, gowning, and gloving, as well as the responsibilities of the scrub and circulating nurses during surgery. Additionally, it includes a performance evaluation scale for assessing surgical handwashing and other practices.

Uploaded by

Jacob Clint Lipura
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Major Case Number_____

Hospital Case Number_______________


Patient:________________________________________Age:____________Sex:___________
Address:______________________________________ Date of Birth:____________________
Civil Status:________________________Citizenship____________Weight________________
Chief Complaint:_____________________________________Ward/Bed No.______________
Admitting Diagnosis:____________________________________________________________
Proposed Operation____________________________________________________________
Preoperative Checklist Intraoperative
Time Preoperation Started __________ Date of Operation:_______Time of Induction:_____
○ Identification Band Checked Time of Operation Started:____________________
○ Preoperation Teaching performed Surgeon:___________________________________
○ Patient Disabilities_______________ First Assist:________________________________
○ Allergies ______________________ Second Assist:_______________________________
○ Allergy Band on pt. and Chart Flagged Anesthesiologist:____________________________
○ U/A and Bloodwork in Chart Anesthesia Used:_____________________________
○ Chest X-ray taken and ECG completed Pre-operative Diagnosis:_______________________
○ Old Charts and X-rays, if requested Operation Performed:_________________________
sent with patient _________________ Position:_____________________Skin Preparation:
NPO ○Yes time_____ ○ No
Skin Prep ○ Done on the floor
○To be done in OR
○ Voided time _____ ○ Catheterized
○ Jewelry, Hairpins, contact lenses,
glasses, prosthesis, underwear, money
removed
○ Dentures Full Upper__ Lower__
Layer Suture Needle Method
Partial Upper__ Lower__
○ Removed sent home ○ Left at bedside
○ left in place as requested by:
○ Anesthesiology ○ Client
○ Patient wearing hospital gown only
○ Security Blanket or toy sent with pt,
○ Vital signs and I&O taken Instrument Used:
T______ BP______ PR______ RR_____ ___________________________________________
O2 saturation_____ Pain Score______ ___________________________________________
○ Reported any abnormalities ___________________________________________
○ Preoperation medication/s given: ___________________________________________
_______________________________ ___________________________________________
_______________________________ ___________________________________________
_______________________________ ___________________________________________
______________________________ Miscellaneous Materials:
Time Preoperation Ended:__________ ___________________________________________
___________________________________________
____________ ____________ Scrub nurse:_________________________________
Student Staff nurse on duty Circulating Nurse:____________________________
Time Operation Ended:________________________
Date signed:__________________ ____________________
Student
________________________________
Staff Nurse
_______________________
Clinical Instructor on Duty
Approved by:_______________________________________
Dean- College of Nursing and School of Midwifery
Performance Criteria
1- Outstanding 4- Below Average
2 – Above Average 5- Poor
3-- Average

1 2 3 4 5

SURGICAL HANDWASHING
Puts on cap and mask. Hair should not be seen and mask fits snugly.
Rolls sleeves above elbow. Removes watch and rings
Does not touch outside or inside of sink. Turns on water and adjusts
flow
Does surgical hand washing
Gets clean surgical brush and applies the antiseptic solution
Brushes palm, in between fingers and fingertips of one hand in rotary
motion –3 minutes
In rotary motion, brushes forearm from wrist up to 2 inches above
elbow – 2 minutes
Rinses brush supplies on antiseptic solution
Brushes the other hand and forearm in the same manner with the first
Drops the surgical brush to the sink
Rinses from fingertips painting upward and elbows above the waist
away from the body
Hold hands with fingertips pointing upward; elbows above the waist
away from the body
Use back in entering every door he/she passes
Gowning and Close Gloving
Reaches the sterile table and grasps carefully the sterile gown
Step back away from the sterile table to provide a wide margin of
safety while gowning.
Unfold the gown. Does not touch the outside of the gown with the bare
hands
Holds the gown at the shoulder level, slip both arms into the armholes
simultaneously
Request circulating nurse to fasten the gown at the back
Places the right glove on the right wrist. Grasps the lower cuff with the
right thumb
Grasps the top of the glove with the right thumb under the cuff
Still gripping the glove, make a fist and stretch the cuff over the hand,
aiming to cover the knuckles and thumb joint before straightening the
fingers on the right hand
The gloved right hand no pick up the left gloves and places it on the
wrist
Make a fist and pull the glove over the gown and maneuver to give a
good fit
Gowning and gloving the surgeon and assistants
Serves the lower hemline to the surgeon and assistants for wiping of
hands
Picks the sterile gown & unfold the gown carefully, locates the
neckband and armhole
Offers the inside of the gown to the surgeon
Release the gown making sure it’s properly served. Avoid touching
surgeon's scrub suit
Picks up the right glove. Grasp firmly the gloves with fingers under
everted cuff.
Stretches the cuff sufficiently for the surgeon’s hand.
Unfolds the everted glove cuff over the cuff of the sleeves
Repeats the above procedure for the left hand.
Assisting the surgeon in the surgery
Passes blade & other instruments to be used: Blade down; Forceps are
locked
Watches the operation & anticipates the surgeon's needs
Passes instruments in a decisive & positive manner onto the surgeon's
palm
Maintain sterile technique
Count loudly the instruments used with the circulating nurse as
surgeon begins suturing.
After care as Scrub Nurse: Without removing the PPE, gather all the
instruments.
Washes all the instruments used in the washing area
Using a clean, dry gown place all washed instruments on the gown
and bring it to the work room for drying. Removing the gloves and
gown.
Arranges the instruments according to the manual and request the OR
nurse to check for you. Be sure that the OR nurse affix her/his
signature on the packer.
Packs the instruments two times. Be sure to place two indications
After Care as Circulating Nurse: Countercheck equipment used.
Cleanse the operative surroundings with wet OS. Drapes the client

Overall Total:_______
Equivalent:________
_____________________________
Clinical Instructor’s Name &Signature

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