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    Intraoperative SOAPIE

    Uploaded by

    Jellou Mac
    The document provides an intraoperative SOAPIE note for a patient who underwent an emergency caesarean section. It details the patient's status, assessments, interventions, and outcomes at various points during the procedure. Key details include disorientation and sensory disturbances from anesthesia, intravenous fluids and tubes in place, preparation and draping of the patient, extraction of a baby via c-section, instrument counts, wound cleansing and dressing. The patient was extubated, transported to recovery, and handed off to PACU staff in stable condition.

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    Attribution Non-Commercial (BY-NC)
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    Intraoperative SOAPIE

    Uploaded by

    Jellou Mac
    506 views5 pages
    The document provides an intraoperative SOAPIE note for a patient who underwent an emergency caesarean section. It details the patient's status, assessments, interventions, and outcomes at various points during the procedure. Key details include disorientation and sensory disturbances from anesthesia, intravenous fluids and tubes in place, preparation and draping of the patient, extraction of a baby via c-section, instrument counts, wound cleansing and dressing. The patient was extubated, transported to recovery, and handed off to PACU staff in stable condition.

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    The document provides an intraoperative SOAPIE note for a patient who underwent an emergency caesarean section. It details the patient's status, assessments, interventions, and outcomes at various points during the procedure. Key details include disorientation and sensory disturbances from anesthesia, intravenous fluids and tubes in place, preparation and draping of the patient, extraction of a baby via c-section, instrument counts, wound cleansing and dressing. The patient was extubated, transported to recovery, and handed off to PACU staff in stable condition.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    506 views5 pages

    Intraoperative SOAPIE

    Uploaded by

    Jellou Mac
    The document provides an intraoperative SOAPIE note for a patient who underwent an emergency caesarean section. It details the patient's status, assessments, interventions, and outcomes at various points during the procedure. Key details include disorientation and sensory disturbances from anesthesia, intravenous fluids and tubes in place, preparation and draping of the patient, extraction of a baby via c-section, instrument counts, wound cleansing and dressing. The patient was extubated, transported to recovery, and handed off to PACU staff in stable condition.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 5

    Intraoperative SOAPIE

    S: Verbal data may vary

    O:  disorientation noted

     Sensory / perceptual disturbances due to anaesthesia observed

     Immobilized

     Musculoskeletal impairment noted

     Conscious/coherent/responsive/unconscious

     With oxygen inhalation of 2 L per minute via nasal cannula

     With nasogastric tube inserted – patent

     With tracheotomy tube in place attached to ambo bag

     With IVF of D5LR 1 L at 30 drops per minute infusing well at right


    arm of

    800 cc level

     With chest thoracotomy tube attached water seal bottle –


    fluctuating

     With urinary catheter attached to urobag with straw colored urine


    of 60 cc

    Level

     With vital signs of HR: 80 beats per minute, RR: 20 breaths per
    minute, T: 37 ° C,

    BP: 120/80 mm Hg and PS of 10 in a scale of 0-10 pain score

     Scheduled for emergency/elective caesarean section (or any)

     With signed consent attached to chart

     Any___________________________
    A:  Risk for Perioperative Positioning Injury related to (specific)
    disease process

    Or condition and musculoskeletal impairments

     Risk for Injury related to (specific) disease process or condition


    and external

    (Structure of environment, exposure to equipment, instrumentation,

    Positioning or use of pharmaceutical agents) and Internal environment

    (Tissue hypoxia, abnormal vital signs, broken skin)

     Risk for Infection related to broken skin, traumatized tissues,


    stasis of body

    Fluids, presence of pathogens, environmental exposure, invasive


    procedures

     Risk for altered Body Temperature related to exposure to cool


    environment,

    Use of medications, anesthetic agents, extremes of age, weight,


    dehydration

    P: After 1-2 hours of nursing intervention, the client will be

     Free of injury related to perioperative disorientation

     Free of untoward skin/tissue injury

     Able to report resolution of localized numbness, tingling or


    changes in

    Sensation related to positioning within 24 – 48 hours as appropriate

    After 1-2 hours of nursing intervention, caregiver will

     Identify individual risk factors


     Modify environment as indicated to enhance safety and use of
    resources

    Appropriately

     Identify individual risk factors and interventions to reduce


    potential for infection

     Safe aseptic environment

     Maintain body temperature within normal range

    I: 7:00 AM  Received in OR lobby per stretcher

     Patient’s history and identity reviewed

     Oriented patient to place, person and time

     Removed jewellery, dentures, loose teeth, artificial


    devices and nail

    Polish

     Clothing changed to OR gown and placed bonnet on


    head

    7:15 AM  transported to emergency operating theatre 2

     Provided privacy

     Placed on OR table on supine position with safety belt


    over thighs

    (As appropriate)

     Attached to cardiac monitor and blood pressure cuff

     Environmental temperature modified

     Sterility of all manufacturers’ items verified

     Initial counting of instruments, suture, operating sponge


    and visceral
    Pack done - complete

     Assisted in lateral knee chest position

    7:30 AM  lumbar skin preparation done

    7:33 AM  intubated by Dr. Vostok

    7:35 AM  assisted induction of anaesthesia by Dr. Vostok

     Turned to supine position

     Placed dispersive electrode over greatest available


    muscle mass –

    Contact and lubrication ensured

    7:50 AM  final skin preparation done by Mr. Salazar

     Draped aseptically

    8:00 AM  1st counting of instruments, suture, operating sponge


    and visceral

    Pack done - complete

     Electrical safety of equipments used – ascertained

    8:05 AM  operation started by Dr. Sanchez assisted by Dr. Laplap


    with Mrs.

    Fernandez and student nurses Ms. Borromeo and Ms. Buenafe

     Maintained aseptic technique in the entire procedure

     Controlled communication, unnecessary noise and traffic inside the

    Operating room

     Anticipated the needs of the sterile team

     Dependent gravity drainage of indwelling catheters, tubes and/or

    Positive pressure of parenteral or irrigation lines maintained

    8:15 AM  extracted an a live baby boy via caesarean section


    8:30 AM  2nd counting of instruments, suture, operating sponges
    and visceral

    pack done – complete

    8:45 AM  3rd counting of instruments, suture, operating sponges


    and visceral

    pack done – complete

    9:00 AM  Final counting of instruments, suture, operating sponges


    and visceral

    pack done – complete

    9:05 AM  operation ended

     cleansed surgical wound and applied with betadine paint

     sterile dressing applied aseptically

    9:10 AM  extubated by Dr. Vostock

     cleansed and fixed

     transported to Post Anesthesia Care Unit per stretcher

     endorsed to PACU staff nurse

    E:  with vital signs of HR: 80 beats per minute, RR: 20


    breaths per minute, T37 ° C, BP: 120/80 mm Hg and PS of 0 in a scale of 0-10
    pain score

     conscious/unconscious

     still for continuous monitoring

     Any __________________

    *SELECT AS APPLICABLE

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