RR NOTES

______Into RR per stretcher accompanied by OR technicians and staff nurse

TP: S/P _______________________________
O: patient is ___________________________
With an ongoing IVF of _________ 1L X ___at _____cc level infusing at the ___arm.
With SPO2 of ___ with O2 inhalation at ____lpm per_______
With aldrete’s score of ____
A: Patient is recovering from effects of anesthesia.
P: positioned patient on __________
Ensured patient’s safety by raising side rails and staying by the patient.
Attached pulse oximeter
Provided warmth by giving blanket and placing droplight near patient.
Monitor vs q______________ and recorded.
IVF and O2 inhalation regulated per order.
_____Back to ward per stretcher with ongoing IVF of _____1L x____ at _____ cc level
accompanied by transport aid and staff nurse.

PRE-OP NOTES (PRE-OP VISIT NOTES)

_____S: “ Pumunta na ditto si Dra. Sinabi na niya kung paano yung gagawing
operasyon saka kung anung anesthesia gagamitin, naexplain ko na rin sa anak ko”
as claimed by the mother.
O:VS T:___________PR_____bpm RR _____cpm BP _______ mmhg
CP clearance by Dr. __________
Consent signed for _______________________by ______________.
With IVF of _____1L X ____at _______cc level infusing well at the ____arm.
A: Patient is emotionally and psychologically prepared for the scheduled
operation.
P: assessed VS and recorded.
Assessed patient’s readiness for the upcoming procedure.
Reiterated NPO post midnight status
Reinforced to void and do ________ care prior to transport to OR.

TAHBSO with APPENDECTOMY

_____Into OR, female, __years old with ongoing IVF of ____ 1L at ___cc level with
consent signed for:
TP: TAHBSO with APPENDECTOMY
___VS as follows: T-___ PR-___bpm RR- ___cpm BP- _____mmhg
___transferred to OR bed safely.
O2 inhalation at 1-2lpm per _____
Insertion of IFC done by Dr. ______
Skin prep for anesthesia done by __________.
___ anesthesia administered by _______ thru _________ assisted by __________
Skin prep for incision site done by _____________
Aseptic draping done by __________ assisted by __________
Positioned patient on trendelenburg
Initial sponge and instrument count done by ____________and ________________.
___operation started whereby midline incision was made
Deepening of incision exposing the peritoneum.
Muscles retracted by balfour with bladder blades.
 Abdomen packed with moist sponges.
Kocher clamps placed on the cornua of uterus and retracted.
Round ligament on both sides were clamped, sutured and transacted.
Retroperineal space was opened and ureter were identified bilaterally
Identification of uterus and isolation done.
___first specimen out (uterus) characterized as enlarged with myoma measuring 9.5
x 7.5 mm with normal fallopian tubes and ovaries bilaterally.
___surgical team for appendectomy took over.
Appendix identified, isolated and incised by ________assisted by ________.
Cauterization and clamping done as needed.
___second specimen out (appendix) characterized as elongated and slightly
inflamed.
Suturing of appendix was done.
___operation ended whereby appendectomy is performed.
___OB surgeon took over
Irrigation done
Final instrument and sponge count done to assure completeness.
Suturing was done layer by layer.
___IFC drains blood-tinge urine measuring _____cc.
___operation ended whereby TAHBSO was accomplished.
Betadine paint applied
Dressing applied by _________ assisted by __________.
___patient was transferred to RR bed.
A: Patient tolerated the operation with minimal blood loss and without complication.
P: received patient from ward.
Identified patient and validated procedure to be done.
Checked for consent and CP clearance
Checked for pre –op preparations done.
Monitored VS and recorded.
Monitored input and output and recorded.
Assisted in transferring of patient to OR bed.
Assisted in positioning of patient
Assisted in initial instrument and sponge count
Anticipated surgical team’s needs.
Observed strict aseptic technique.
Assisted in final instrument and sponge count
Assisted in transferring patient to RR bed
___To RR bed with ongoing IVF of _____1L at ____cc level accompanied by OR
technicians and staff nurse.