Name of Procedure (Feel free to change this theme and add slide animations as needed) Student Name, Date Course ID Concorde Career College

Definition of Procedure Include a detailed description of the procedure which you have been assigned.

Purpose of Procedure Include a detailed outline of the purpose of the procedure including why the procedure is performed.

Expected Outcome of the Procedure Will a diagnosis be made? Will a repair or restructuring of body tissues or organs take place? Other diagnostic/therapeutic outcomes?

Meet the Patient Age Gender Background Additional Information relevant to the procedure

S.A.M.P.L.E. Signs & Symptoms Allergies – include drug, food, and other Medications the patient is currently taking Past Patient History & Physical Last Oral Intake – how long ago, what was it?

Preoperative Diagnosis The proposed diagnosis based on patient information, history, physical, blood work, and diagnostic studies

How Diagnosis Was Determined Diagnostic Exams (which ones) Other Preoperative Testing (Which, if any)

Relevant Anatomy, Physiology, & Pathophysiology Include a VERY detailed outline of all of the anatomy, physiology, and pathophysiology related to your patient, their condition, and their procedure Must be specific to the assigned topic Must include detailed pictures and explanations Use sources other than just your anatomy book to complete this section

General & Procedure Specific Equipment Create a list of all pieces of equipment specific to this procedure –i.e., electrosurgical unit, operative microscope, suction apparatus, etc.

General & Procedure Specific Instruments Create a list of all instrument sets and specialty instruments used on this procedure Select a minimum of two instruments which you are unfamiliar with and provide a brief description and a picture of each

Basic & Procedure Specific Supplies Create a comprehensive list of all supplies needed to set-up and perform your specific procedure Include the following: –Type of Pack –Type of Basin Set if needed –Gloves –Type of Drapes –All Suture –Blades –Drains if needed –Dressings –All Drugs including water and saline as needed –Hemostatic agents –Etc., this list is not intended to be all inclusive

Suture and Tissue Usage List each suture used and state the structures and/or tissues for which they will be utilized.

Pharmaceuticals List and describe case specific drugs

Operative Preparation List relevant steps or preoperative procedures that are specific to this case.

Anesthesia Type & Equipment List anesthesia type and the necessary equipment for induction, maintenance, and monitoring of anesthesia.

Patient Position Identify the patient positioning necessary for this procedure and specific safety guidelines.

Positioning Aids List items needed for positioning the patient.

Skin Preparation & Anatomic Perimeters List type of prep as well as areas to be included in the prep. List any special considerations

Draping List supplies and procedure for draping the patient. List any special considerations.

Practical Considerations Any other special considerations before the procedure begins. i.e., acquisition of patient x-rays or specialty equipment such as a C-arm, additional set-up or positioning considerations

Procedural Steps (Intraoperative Phase) Operative Steps 1.Create a comprehensive list of EACH step in the procedure. 2.Example: The interspace of the affected level of the spine (lumbar) is approached posteriorly via a midline or paramedian incision.

Procedural Steps (cont.) Steps should be listed from incision to dressing application and include all counts as well as specimen care and handling.

Postoperative Diagnosis May differ from preoperative diagnosis based on intraoperative findings.

Immediate Postoperative Care & Destination Postoperative considerations Care of drains and/or dressings Method of patient transport Where is the patient going? ICU, PACU, other?

Wound Classification & Management Wound Class Management –Considerations –Healing –Other

Long-term Prognosis How will this patient do over time? –Expected recovery? –Expected outcome? –Time?

Possible Complications List all known possible complications.

Questions? Make a list of three questions specific to your presentation. These questions must make your classmates think. –In other words, don’t ask simple question like, “What position is used for this procedure?”

Most Valuable Information Learned What was the most interesting or valuable thing that you learned while doing this report? How will this information help you in the field?