FUNCTION:  Operative and Other Invasive Procedures

 

TITLE:  Nursing Documentation - Surgery

_________________________________________________________________

PURPOSE:

 

To collect data about the surgical patient through interviews, physical

assessment, and evaluation of records to facilitate an individualized patient

care plan and continuity of care.

 

POLICY:

 

1.   All patients requiring surgical nursing interventions in the Department

     of Surgical Services will be assessed by the RN Circulator/Pre-op holding

     area RN.  

 

2.   The patient's individualized needs/problems must be incorporated into the

     nursing record.

 

RN CIRCULATOR/PREOPERATIVE HOLDING RN:

 

1.   Will perform patient interview to identify psychosocial and cultural

     needs of the patient.

2.   Visual physical assessment of patient to identify physical limitations

     considerations of the patient.

3.   Will document assessment findings on OR Nursing Record.

4.   Will communicate assessment findings to the Health Care Team for

     continuity of care.

5.   RN will assess the patient intraoperatively and postoperatively to

     evaluate the effect of perioperative nursing care on the patient.

 

I.   Intraoperative Documentation

     1.   Document personnel providing perioperative care (name,title)

     2.   Identify surgery code and wound classification

     3.   Document date and time of surgery

     4.   Identify type of anesthesia

     5.   Document pre-operative, post-operative and operative procedure

     6.   Use of intraoperative X-rays

          a.   X-ray site

          b.   X-ray technician name

     7.   Monitoring equipment used (EKG, NIBP, SA02)

     8.   Patient specimens and cultures taken during surgical procedure

 

II.  Document patient overall skin condition on arrival and discharge from

     perioperative suite.

     1.   Skin integrity and condition

     2.   Location of skin prep and shave site

     3.   Type of skin prep solution (see policy)

     4.   Location and type of drains and wound packing

     5.   Type of foley catheter and personnel inserting

     6.   Dressing type and site

     7.   Additional nursing notes - any significant or unusual occurrences

          pertinent to perioperative patient outcomes.

 

III. Implant record

     1.   Placement and location of implants (e.g., prosthetic devices,

          grafts, tissue and bone)

     2.   Name of manufacturer/distributor

     3.   Lot and serial number

     4.   Expiration date

     5.   Patient name, social security number, telephone number, address

     6.   Physician implanting

 

IV.  Patient Positioning

     1.   Use of patient roller when indicated for use

     2.   Position on table

     3.   Position of arms

     4.   Use of leg strap

     5.   Positional devices (e.g., stirrups, cloward frame, chest rolls...)

 

V.   Equipment

     1.   Tourniquet

          a.   site

          b.   pressure

          c.   time on and off

     2.   Insufflator time on and off

     3.   Laparoscopy number and pressure

     4.   ESU

          a.   serial #

          b.   settings

          c.   dispersive pad site

     5.   Cell saver - serial # and operator

     6.   K-thermia - serial # and setting

     7.   Laser

          a.   serial #

          b.   operator

          c.   setting

          d.   laser safety protocols implemented

 

VI.  Sponge and Instrument Counts (see policy)

     1.   Sponge, needle and sharp count X 3

     2.   Instrument count X 2

     3.   Initial of persons counting

     4.   Instruments intact

     5.   Document person reporting counts, surgeon and person response

 

VII.  Intraoperative fluid balance

      1.   Type, amount and total infused

      2.   Blood products - list unit # of each product

      3.   Cell saver total infused

      4.   Estimated blood loss

      5.   Total urine output

 

VIII. Medications

     1.   Irrigation (normal saline, glycine, H20)

     2.   Narcotics used/wasted

     3.   Antibiotics

 

IX.  Planning and Providing Care

     1.   Unit (PACU, ICU, floor, DS)

     2.   Name of R.N. report given to

     3.   Patient transfer via stretcher or bed

     4.   Patient transfer status

          a.   spontaneous resp

          b.   intubated

          c.   oral airway

          d.   asst. resp

          e.   ambu Jackson Reese

     5.   Initial vital signs PACU (BP, pulse, resp., SA02)

 

X.   Circulating nurse signature and date

 

The patient's record should reflect a continuous evaluation of the

perioperative nursing care and the patients response to applied nursing

interventions.