Trividha Karma/ PRE-OP, OP, POST-OP Formats by teachers@tatvakrishna

Trividha Karma/ PRE-OP, OP,

POST-OP Formats

Patient Name –

case is posted for surgery of…………… on date……………in morning/evening at…………

PRE-OPERATIVE NOTES

Date –

Time-

Vitals- BP-

PR-

SPO2-

Urine output-

Consent has been taken on Date……….at time…………

Pre Anaesthetic check-up

(History taking along all investigations and cardio pulmonary assessment) has been done.

Vitals should Be with in Normal limit

OT staff has been informed

Part preparation has been done.

Xylocaine sensitivity test has been done.

Enema has been given

IV Line has been maintained

Foley’s catheterization / Ryle’s tube Installation has been done.

Pre-Operative medications have been given-

1. i) Anti HTN, Anti-diabetic (oral, hypoglycaemic agent), thyroxine

2. ii) Blood thinner agents-Ecosprin should be stopped 12 hours before surgery.

iii) Anti-anxiety drugs like Alprazolam, midazolam etc to be given 1 night before surgery

iv)Inj. Antacid-

     Inj. Anti-emetic

     Inj. Antibiotics-

should be given [IV] 1hour before surgery.

1. v) Inj. Atropine /Glycopyrrolate should be given IM 1 hour before surgery.

vi)IV fluids to be started 1 hour before surgery.

(vii) Steroids – should be stopped 2 weeks before surgery.

INTRA-OPERATIVE NOTES

Patient Name –

Date –

Time-

Vitals-

i)Pt has been lying down on OT table in supine or lithotomy position.

ii)Painting has been done with anti-septic solution-Betadine.savlon, spirit.

iii)Draping has been done with sterile plane and cut sheet.

iv)General/Spinal/Local Anaesthetic Agent (LAA)  has been given

v)An incision was made approx…………..

vi)Skin—- Subcutaneous tissue—-………………………. was incised in layers.

vii)Gentle dissection and main surgical procedure

viii)Complete haemostasis achieved.

ix)Suturing in layers and Skin was sutured with 1No. silk in mattress manner.

x)ASD and  bandage was done.

xi)Whole case was uneventful.

xii)Patient shifted in post-operative ward.

POST-OPERATIVE NOTES

• Patient shifted in ward at time ………. on date ………and vitals has been checked.

• Foley’s catheter/Ryle’s tube placed at right position.

• Complete bed rest is adviced.

• Nil orally till advised.

• All the medications & monitoring of vitals to be done by staff on time.

• Vitals should be monitored at every 15min. for 1 hours & after that the vitals should be monitored 2 hourlies for next 12 hours.

• Medications-

• i) inj. Antibiotics

ii)inj. Anti-emitics

iii) inj. Anti-acids

iv)inj. Analgesics

v) IV fluids & others

In normal Pt. IVF should be given @ 100ml /hr

# DAY – 1

• Vitals-

• Bed to be propped at the level of 40 degrees.

• If bowel sound present – orally allowed liquid, semi-liquid semi- solid according to surgery.

• Leg movement to be done.Anti-biotics

• Medications and iv fluid

# DAY-2

• Vitals-

• Antibiotics

• Dressing daily in case of pus & infection

• Suture removal after 8 to 10 days as per surgery and site