COLLEGE OF ALLIED HEALTH SCIENCES

NURSING DEPARTMENT

ILOILO PROVINCIAL HOSPITAL

OPERATING ROOM

CIRCULATING NURSE CHECKLIST

Name of Pa)ent: ______________________________________________Age:_________ Sex: ___________

Type of Opera)on: ____________________________________________Date of Opera)on:_____________
Name of Procedure:__________________________________________ Hospital Number:_______________
Surgeon: ________________________________________Assistant Surgeon:__________________________
Anesthesiologist:__________________________________Type of Anesthesia:________________________
Scrub Nurse: ____________________________________Circula)ng Nurse:___________________________
Pre Opera)ve Diagnosis:_____________________________________________________________________
Tissue Removed:___________________________________________________________________________
Post Opera)ve Diagnosis: ___________________________________________________________________
Time Started:__________________________________ Time Ended:_________________________________

Ini)al Vital Signs: BP: _________ RR: _________ PR: _________ Temperature______ O2 satura)on:_______
IVF:______________________________________________________Amount Received:_________________
Intraopera)ve medica)ons given:_____________________________________________________________
_________________________________________________________________________________________
Blood Component: ___________________________Pa)ent’s blood Type: ________ Time Infused: ________

PRIOR TO INDUCTION OF PRIOR TO SKIN INCISION PRIOR TO PATIENT LEAVING THE

ANSTHESIA OPERATING THEATER
SIGN IN TIME OUT SIGN OUT/PERIOD OF CLOSURE OF
INCISION
¨ Pa#ent Confirmed Confirm all team members have Nurse verbally confirms with the
¨ Iden#ty introduced themselves by name team:
¨ Site and role. ¨ The name of the
¨ Procedure procedure recorded
¨ Consent Surgeon/Anesthesia Professional ¨ That instrument, sponge
¨ Site Marked/Not and Nurses Verbally Confirm and needle counts are
Applicable ¨ Pa#ent correct (or not applicable)
¨ Anesthesia Safety Check ¨ Site ¨ Count verifica#on
¨ Completed ¨ Procedure • Count correct before
¨ Pulse Oximeter on Pa#ent ¨ Posi#on closing of cavity
and Func#oning ___Yes. ___No
An#cipated Cri#cal Events • First count correct
Does the pa#ent have a known ¨ Surgeon Reviews: What ___Yes. ___No
allergy? are the Cri#cal or • Final count correct
______No Unexpected Steps, ___Yes. ___No
______Yes Opera#ve Dura#on • If incorrect, x-ray
__________ taken
Difficult Airway/Aspira#on Risk? An#cipated Blood Loss ___Yes. ___No
______No _______ ¨ How the specimen is
______Yes, and Equipment ¨ Anesthesia Team Reviews: labeled (including pa#ent
Assistance Available Are there any pa#ent name)
specific concerns? ¨ Whether there are any
Special Medical Intraopera#ve ¨ Nursing Team Reviews: equipment problems to be
Monitoring Team Required? Has sterility been addressed
_____No confirmed? Are there ¨ Surgeons, anesthesia
_____Yes equipment issues or any professional, and nurse
concerns? review the par#cular
An#bio#c Prophylaxis Indicated? concerns for recovery and
____No An#bio#c: Prophylaxis given within management of the
____Yes, skin tes#ng done, the last 60 minutes? pa#ent?
an#bio#c available on hand/given ______Yes
______No
Risk of 500cc blood loss (7cc/kg in ______Not Applicable
children)
____No Essen#al Imaging Displayed?
____Yes, and IV Access and Fluids _____Yes
Planned _____No
_____Other Checks
 SPONGE COUNT INITIAL ADD TOTAL 1ST 2ND BUCKET FINAL REMARKS
Opera#ng Sponge
Abdominal Sponge
Cherries
Peanuts
Lap Strips
Vaginal Packs
SHARPS/NEEDLES INITIAL ADD TOTAL 1ST 2ND BUCKET FINAL REMARKS

Blades
Cautery Tips
INSTRUMENTS INITIAL ADD TOTAL 1ST 2ND BUCKET FINAL REMARKS
Towel clips
Kelly curve
Kelly straight
Round nose
Allis
Bandage scissor
Mayo scissor
Suture scissor
Tissue forceps
Thumb forceps
Blade holder
Needle holder
Poole suc#on #p
Army Navy
Richardson
Metzenbum
OTHER INSTRUMENTS INITIAL ADD TOTAL 1ST 2ND BUCKET FINAL REMARKS

IVF: ________________________________________________Amount Remaining: ____________________

Agents used: _____Betadine 7.5% _____Betadine 10% _____Hyclens Others:________________________
Catheter: _____Yes _____No
Drains: ______No _____Hemovac ______Nasogastric _____ Pendrose _____T-tube Others:___________

NOTES

Name of Student Nurse: ____________________________________________________________________