Mission Smile (CLEFTLIP& PALATE Surgeries [PATIENT FAMILY /LAST NAME [PATIENT FIRST NAME iprorose> Cur Chose CJeware Cnsrun Clonee DATE OPERATIVE INFORMATION (CHART NUMBER. ae Nh Lad ey tend rN _ MISSION SITE auuerates Two Cvs. wercwT __xG WEIGHT BEALS Coenen. Chiocar Ctocat win sepanon On Fes Petit pitied [ Josrunaror [1] rare [1 eresuncicat wo.ons (Cur [1] aveowus [] nose) easels tase el A rrimany unnatenastipreain FIC seconoany unitarenat uP nea} LE trescannevision wsrsonmucosa] OB erimany naTeRatir RePain o1 Rotation ‘Advancement (ilard) 1D secononny siaTeRat uP AEeAiR C2 Triangular Flap, Tennison Randall) OF otmenur proceoure 03 ‘Anatomic Subunit Approximation (Fisher) D4 combination 15 other Os Modified Manchester 1 Flap above Roll Dimensions of Piltral Flap width LengthMission Smile OPERATIVE CLEFT LIP & PALATE Surgeries INFORMATION PATIENTRAMILY/LASTNAME: 0A t . (CHART NUMBER: PATIENT RST WANE: missin SIE: VERMILLION] 1 4 on Pema) 13 aa => O15 (5) Lateral V ZPlasty in so. 2-Plasty in Donistent | Fp Wet Mucosa \ DryMucose lsiatert Ls O16 CB) [Fi eee stright i ne uprenue [18 —|O19 = [O20 . Medial Rotation A | mediat rotation C, ‘Medial Rotation [Duniatesi | Fiapto Flap Beyond Flap with Boas] ein ~~ wide : backeut & O21 O22 . MedatRowtion (> cFiapto Flap with FilBackcut | Extend Base (Mote) peer ated to Nasal Spine Superior arti ire RBICULARIS| ["] 23 tepaiedto Na Spine Super [_] 24 Partially Repaired Conca Os O26 . [stn undrmning emacs ‘Skin Undermining Minimal skin undermining (Sem) claro commas on ner ail eee [oes tg D< 10mm Wide sin undeining to commute D> tomm a " Paes pee 27 gio Cas S Dunitaterat toMidline, Mucosa sa 3 a eee Liars! | Ccttoevomotr ules ued —" [130 Torbinate Fiap (1131 Grort (132 other ___Mission Smile OPERATIVE INFORMATION PATIENT FAMILY / LAST NAME: DATE) (CHART NUMBER: PATIENT FIRST NAME: MISSION SITE: BL ii heheh Ut transcutaneous surunes use Cisuscutaneous sutures useo HOW MANY SUBCUTANEOUS WERE USED? Tt. Nyon Tm prone — |EIL vie! 1. None Oi. O34 | msi Dw. chromicGur |) m.chromicGut [)1v.Polydioxanone ros) [5-6 C>6 1 v. Fast absorbing gut Ovi Dermabond |] v. Maxon Owother: Cv. other ee aa ele aia) elt PROCEDURE |] G unmatenat nose nePain TH sures nose rennin DOK aamorcasty [J serra connecnon TL omer nose rroceoune O34 O35 = 7 ee ° Relese Na Release Ala tom in LFapir etm > meres toate 3 aoe £ Seemal con a 036 O37 7038 row ~~ pw) Geen) | crue a caus fap Ta | cima COL canmuace seaer Septum _ O39 Fey oe ' oa = chapter | vorerap j Nese Skn x a ZX) sicitow ae Oa2 Be O43 rersnnterein, ORER| teste Re ~~ ‘pe lowirsna ger Untanang verb Liaardecoper tat aap RS | over tnt carager BSS) tncsicontges [45 Aarsuspenson 1146 Aviron 147 timinsion 1.48 open inopiasy [11.49 AvrcinenMission Smile OPERATIVE (CLEFTUP& PALATE Surgeries INFORMATION [PATIENT FAMILY / LAST NAME: (CHART NUMBER: PATIENT FIRST NAME: ‘DIMENSIONS | P60 indicate the width ofthe cleft atthe softhard palate junction: mm PROCEOURE|L_] M rumany patavenerai TO onncocnen TQ vomenamasarriar CON emarenevision COP muanvnceas uae COR ovwenraarenernin eae 150 von tangenbeck 2151 two Fiep with no Pushback |) 52. two Flap with Pushback D158 potting ncaeen_|C154 om Sor UM |] 55 inaverveoplsty 156 FurtowzPtasty 1157 Leterat Retaxing incisions 1158 cetnsetucomtorusnack Undermining Oat Mucra from the Posterior Aspect of the Os9 a hard pattern = Dltimtedsong beard Pate en gee LG Coto o Terr vetoatne Me e—— oo r—n—rnrvX—n— 1.60 undermining Nasal Mucosa FLAPS!) 62 vomerFiep 168 evccarep 64 spew ts TGS tency eased Pangea rap PONY] 66 reese Paina vests fom Bore] [] 67? Harts Fracture 7168 osnopiscser tke 69 Fracture of Premaxila Greenstich) ‘cLosuRE| [7] 70 Entire (1171 Ametior Fistula -Imended 1.72 mares sutures in Oral Mucosa [173 Peeking: Cisutrein [)surical Packs in Open Dee aire mea el CS astucansraiperroneo METHODOE![] 74 Orottetzedriopat tive |] 75 succarip 176 tumnoverFiep (077 Tongue Fan 1178 cermat crate 11.79 muco-Periosteat Flap 180 Phennaesi in 181 otter lense incate the location ofthe Pre operative stuMission Si OPERATIVE (CLEFTUP& PALATE Surgeries INFORMATION ‘CHART NUMBER: PATIENT FAMILY /LAST NAME: PATIENT FIRST NA Pliage te ae ely CONTRACTURE] 7] 82 contacureteasewaheTss —|[] BB Contmcwreteewewinsss |] BM} conmerwe ese wih 2 Psy 85 contrscture 1 86 contracture (2: sve Range of Wot sive Range of Wot: 187 conmactarei¢___] [1]. 88 other contractu Passe Range of Wor: SCAR OL] 89 seartxciion 190 scar excision wah ers [1917 scarexcision with ssc 1192 scartxcision with2-PIosty 1193 scariniection 194 craniotacit 195 Excisonoftumor/ mole cyst — |] 96 Frenulectomy 197 temanciome 98 crpisy 1199 Prossrepar 1100 roiysynascoiy ropa |] 101 omer - - - Please crcl the area operated on Barn ay isd i ! INCIDENTS OR COMPLICATIONS WERE THERE ANY INCIDENTS OR COMPLICATIONS? no [_]ves: IF YES, PLEASE OBTAIN & COMPLETE AN INCIDENT REPORT FORM FROM THE PROGRAM COORDINATOR. 7 ra m L oi = Fi vt 4 TESDENT STON TATE — = a cSsion Smile POST ANESTHESIA CLEFT LIP & PALATE Surgertes CARE UNIT RECORD [PATIENT FAMILY /LAST NAME Dare (CHART NUMBER. ‘PATIENT FIRST NAME MissiON SITE jproceoure [Jur []nose CJratare CJrisraa Clomen aueroies C]no Cvs. weicHT _xG WEIGHT _o# AGE seaxOuOr ‘PERFORMED Tlanactsic [En anestmesin ..Ccenenar Coca. pavarar Paces. lye Clo Owe CD Anniionc D1 t0cat warn seoamion) ™. Dressing Dry ....E]ves [xo En |-Pavatine atock......C]vesC Jno C]w/a} — « Surcicat packins L] ves L]wo (na) GNENINOR @__ Inera onamraLavock C]¥esCJNo C]wa) «Dera txrpacr..Clyes Clso Cw] [ADMISSIONPAINSCORE: | IW SOLUTION mone ekPOST ANESTHESIA CARE UNIT ORDERS ‘PATIENT FAMILY /LAST NAME DAE ‘CHART NUMBER ‘PATIENT FIRST NAME missionsrre proceoure Cur [nose Cleaare Cnsrua Comer auenotes (wo Cvs PERFORMED weiokT _xo HetoKT_o” A. sexOwOr Dimes lacy [Z] apmirro pacu [i] veniry TONGUE stircH (PALATE) [Z] ASSESSMENT AND VITAL SIGNS UPON ADMISSION /EVERY 15 min [7] VERIFY SURGICAL PACKING PALATE) [2] veriey THROAT PACK WAS BEEN REMOVED PLO Uo) eT ] wimare ros weeveo Ra eae | TONALBUPHINE (NUBAIN) mg » WX1 now + Pet: 005-033 mghatdone «Max 3 does + Adulte 10mg 70g + Ma 10g CU racemic EPINEPHRINE 2.25% inhalant m+ every 1-2hours + dati lar < YK 025 lina ml salne + Adler 104g 05 in 25 moe (Catsurerot _ ml «every 4-6hs/ pm + Ped 30 95.25 ma ted th 25 sine + Auch 305g ltd v5 mls Cotner: Corner: Dlotner: ‘SOME DRUGS ARE NOT STOCKED BY Mission Smile OR MAY BE SOURCED IN-COUNTRY. WHEN SUBSTITUTIONS ARE MADE, EQUIVALENCIES/CONCENTRATIONS HAVE TO BE CONSIDERED & REVISIONS MADE. MeO ‘ANY PATIENT HAs + DIFFICULTY BREATHING + TEMPERATURE GREATER THAN 38.59C + ABNORMAL BLEEDING + O2SATLESS THAN 93% «+ SWELLING OF TONGUE OR NECK ]RORSECONFATION SRATORE?Mission Smile MEDICATION CLEFT LIP & PALATE Surgeries ADMINISTRATION PATIENT FAMILY /LAST NAME DATE ‘CHART NUMBER, PATIENT FIRST NAME missionsrre il ‘proceoune [Jur C]nose CJeatare CJnisruta Comer aueroies C]wo Cs ener WeicHT _xG_ WEIGHT _cM AGE sexOwOr) [NALBUPHINE (NUBAIN) [ACETAMINOPHENT PARACETAMOL (TYLENOL) 5 mgPorra ere shou 'BUPROPHEN (MOTRIN) —_m9 ere Bhous ‘Aroid bleeding shemetona "AMOXICILLIN apo (CEFAZOLIN(ANCEF) mg ‘ONDANSETRON (ZOFRAN maw very hour [RACEMIC EPINEPHRINE 255] nl ted wth Sl] BSinlsaine- New meordered "ALBUTEROL 19 ane wis Emi salne Ne[PATIENT FIRST NAME [PERFORMED Mission Si PATIENT FAMILY /LAST NAME POST OPERATIVE (CLEFTLIP PALATE Surgeries NURSING FLOW SHEET PATE ‘CHART NUMBER Mission sire -_ a lproceoure Cur CJnose Cleatare CJrisrura Comer anutenctes [no Cvs i WEIGHT _KG WEIGHT _M AGE. sexOuOlr [Bd crece: [ Jroncuestras [ Jsuncica racine [ Jootsten | Joawneoff] ANEstHesta: | Jozneit [_]vocatwamstoanon [_] ccd Pao Be ond Fn DATE/TIME Bo foe mo ee RETIN 2 Oren FAN Cl ctearequatwniboed | C}oy Lnvre— hr Laer ented ‘Analpeda“antbote giana Fl Cl wheezing Dseturas intact iste sft tat Dsteepingrarousable onpacue__ =. Bay Faccatyeet | Fhnes” Chow | Fhnune 3 9 Neimaromene |ClkUsiE Ace Fyacmeseeing | menntrang Pee |CI 10g) 05 min 25 ml saline Clateuteron ml + every 4-6 hours for respiratory distress + Pediatric (< 30 ka: 25 mg diluted with 2.5 mlsaine + AdulChilden (> 30g) 5 mg luted with 25 ml saline Cooter: ‘SOME DRUGS ARE NOT STOCKED BY Mission Smile OR MAY BE SOURCED IN-COUNTRY. WHEN SUBSTITUTIONS ARE MADE, EQUIVALENCIES/CONCENTRATIONS HAVE TO BE CONSIDERED & REVISIONS MADE. eRe ea dg ‘ANY PATIENT HA‘ «= DIFFICULTY BREATHING «+ TEMPERATURE GREATER THAN 38.5°C + ABNORMAL BLEEDING + 02 SAT LESS THAN 93% {= SWELLING OF TONGUE OR NECK ]RORSECONFATION SRATORE?Mission Smile DISCHARGE (CLEFTLIP& PALATE Surgeries ORDERS [PATIENT FIRST NAME Missionsie _ ‘proceoure [Jur C]nose CJeatate CJ rsrua Comer atuerctes [Jno [ves cana WEIGHT. KG HEIGHT MAGE. sxOwOr [J nobleeding, redness, ordehiscence [_] surgical gauze removed [J] More than once since surgery (H1 ednesss and dehiscince at site Tongue suture removed ‘Once since surgery [1 Bleeding apparent [J surgical packing intact (none since surgery Surgical packing dislodged REVIEW DISCHARGE CRITERIA: CLEFT PALATE SURGICAL SITE; stipe ping ened [tating Potuids feones ehissineesaesite (] Normat = 99°F (37°C) [2 mucous membranes pink and moist L tetive beeing Low grade 99.17.1005 (37°¢-36%¢ [] Vital signs stable and WNL Temperature > 100.5% (38°C) [Released by Surgery (1 Provide the Patient Care Booklet with verbal instructions (Z] Patient/guardian instructed on dietary guidelines WOUND CARE: Clurovr (WZ eatient/quardian instructed on correct wound care technique «+ Infants: Continue breast/bottle/syringe feeding as Cl urcare indicated + Apply small amount of antibiotic ointment 3 x daily (Cy Patare / FISTULA / PHARYNGEAL FLAP DIET (CJ patare/ FISTULA / PHARYNGEAL FLAP CARE indicated after each mealifeeding Cae yre wire) ANTIBIOTICS: ‘ANALGESIC: D ex jms, Ibuprofen _ __mg PO every 6 hrs PRN for pain by mouth, times a day for. days ‘Acetaminophen/Paracetamol___mg PO every 4 hrs PRN for pain Commer: Peels acme at NOTE: After scheduling the patient, please write the date, time, and location in their Patient Care Booklet (Co one week: pare ___y, TIME: AM / PM LOCATION: (C1 sixmonta: pare TIME: AM / PM LOCATION: ae” Uae Pherae Wa DECIR OTBaseimegiec RAPID SEQUENCE INDUCTION cert CODE SHEET Chart Weight: years months Synchronized Cardioversion to joules Subsequent tempts joutes Initial Shock joules Subsequent Shocks joules Doseha Patient Dose ‘comments ‘Adenosine of aig 18t dose | ma ce Rapid V Push mgt 02 rmaikg 2nd dose ma c= Max Single dose 12mg (4ce) Amiodarone 5 moka m9 co Max t5makolday somal: Rapid Push Fr Refactor Pussless VIF Ine over 20.30 mrt fo Parking aches Atropine 0.02 moa me ce Min. dose 01mg = tee amas 004 moka mo co Max! Dose 0.5ma Child, img Adolescent Ca Chloride 10% 20 maka m3 ce Slow iV Push tomce {Give no faster than mL/min Epinephrine 1:10.00 Ivio 9.01 moka m3 ce O mig, (110,000 fst dose (180.000-0%ma!6e) —1:1,000 ETTerandV 04 moka mo 411,000 suboa doses) (0:1 000e4mge) Repeat 3-5 minutes Flumazenil 0.01 moka mo (ce Max Dose 0:2ma (2e0) o1mgee May vepeat minute toa max cumuiatve owe t 05mg or ghar ner 1 mora mo ce Vinfsion 20-50 moaikgimin Narcan 04 mata ma ce <5 yror20ka owe O.tmaka Omgice > 5 and 20kp give 2mg (See) Sodium Bicarbonate 4 meg meq ce Infuse slowly and ony (WOT tor eanscous sedation) PATIENT ‘entation is adequate Choosing Sedation Dose BP 1 Premedication Normal. Midazolam, Etomidate, Thopenta, Propofol Aopine 004" maka 9 Hypotension Etomidate, Ketamine Midazolam V2 dose) A taeen <5 and wih Sues Lissceie II one 7 Seizures or Head injury aes 3 Taiopental, Propo, Etomidate (wth hypotension) a snienan NOT KETAMINE - give docaine algesia sino, Status Asthma Netbuptine REE mote M9 mat ome Ketamine, Midazolam Fentanyl 2 meoikg eg rin Uncuted ETT Aporoxmate size in mm id) mia ion 7 {Agein year +4 ee, bros My wscanse | Cuffed ETT Approximate size fh mm id) nmi iaazolam m 9 Som a mo {Agein year +3 rot EERE ootc : ETT Distance of insertion (em) em Etomicate 02 mi m = {Age in yore) +12 4 Paral Rocuronum [IG moka no Vecuroium | 04 moka naADDITIONAL NOTES DATE: (CHART NUMBER: PATIENT FIRST NAME: MISSION SITE: Prana ine LiMdsd