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医院管理局广华医院术中护理记录
Hospital Authority
Kwong Wah Hospital
Intraoperative Nursing Record
Hospital Authority Kwong Wah Hospital Intraoperative Nursing Record| Hospital Authority | | :--- | | Kwong Wah Hospital | | Intraoperative Nursing Record |
 Please Stick Label if Available or Use Block Letters HN ：＿Name ： ：
如果有的话，请贴上标签或使用正楷字母 HN ：_Name ： ：		 qquad\qquad

案例 :(1）选择性急诊 ： 选择性
Case ：（1）Elective Emergency
：
Elective
Case ：（1）Elective Emergency ： Elective| Case ：（1）Elective Emergency | | :--- | | ： | | Elective |
ID No ：  身份证号码 ：
Dept ：  部门：
Diagnosis qquad\qquad  诊断 qquad\qquad Surgeons ：＿＿（T）  外科医生 ：__（T）
Anaesthetist ： qquad\qquad （T） qquad\qquad
麻醉师 ： qquad\qquad （T） qquad\qquad
Operation ： qquad\qquad  操作： qquad\qquad Anaesthesia ： GA qquad\qquad SA＿ロEA＿ロ LA IVLA MAC／NA DBlock qquad\qquad
麻醉 ： GA qquad\qquad SA_ EA_ LA IVLA MAC/NA DBlock qquad\qquad
qquad\qquad

超时 （T） at ： 超时 （T） at ：
Time out（T）at ：
Time out（T）at ：
Time out（T）at ： Time out（T）at ：| Time out（T）at ： | | :--- | | Time out（T）at ： |
Part A ：Holding Room Nursing Record
A 部分 ：等候室护理记录		 ＊Entered S 5 ／N 5 ／ 7 ／ 9 OT，Room qquad\qquad at qquad\qquad ．
*进入 S 5 /N 5 / 7 / 9 OT，房间 qquad\qquad 在 qquad\qquad 。
＊Patient arrived at qquad\qquad Temp： qquad\qquad Bp qquad\qquad mmHg Pulse qquad\qquad / min SaO 2 / min SaO 2 //minSaO2/ \mathrm{min} \mathrm{SaO} 2 qquad\qquad \％
*患者到达 qquad\qquad 温度： qquad\qquad Bp qquad\qquad mmHg 脉搏 qquad\qquad / min SaO 2 / min SaO 2 //minSaO2/ \mathrm{min} \mathrm{SaO} 2 qquad\qquad \%
＊Identity of patient and checklist done
*患者身份和检查清单已完成		 Site：O ECG Electrode ≈ ≈ ~~\approx Rash X Abrasion
地点名称：O 心电图电极 ≈ ≈ ~~\approx 皮疹 X 擦伤		 ◻ ◻ ◻\square Arterial line ◻ ◻ ◻\square Ventricular Drain ◻ R / D ◻ R / D ◻R//D\square \mathrm{R} / \mathrm{D}
◻ ◻ ◻\square 动脉导管 ◻ ◻ ◻\square 心室引流 ◻ R / D ◻ R / D ◻R//D\square \mathrm{R} / \mathrm{D}
◻ ◻ ◻\square Correct Incorrect
◻ ◻ ◻\square 纠正 错误		 ／／／Reddened area \＃Laceration
变红区域 \#Laceration		 ◻ C ◻ C ◻C\square C ．V．P Line ◻ ◻ ◻\square Foley Size： qquad\qquad口T／Tube
◻ C ◻ C ◻C\square C 。 VP Line ◻ ◻ ◻\square Foley 尺寸： qquad\qquad Spout T/Tube

◻ ◻◻ \square Ryle's 管尺寸： qquad\qquad -鼻音（L/R） ◻ ◻ ◻\square 其他
◻ ◻ ◻\square Ryle＇s Tube Size： qquad\qquad －Nasal（L／R）
◻ ◻ ◻\square Others
◻ Ryle＇s Tube Size： qquad －Nasal（L／R） ◻ Others| $\square$ Ryle＇s Tube Size： $\qquad$ －Nasal（L／R） | | :--- | | $\square$ Others |
＊Level of consciousness：
*意识水平：

清醒 昏昏欲睡 无意识
Awake Drowsy
Unconscious
Awake Drowsy Unconscious| Awake Drowsy | | :--- | | Unconscious |
 G6PD Deficiency  G6PD 缺乏症 \％Procedure performed in O．T． Yes qquad\qquad
在 O.T. 中执行的 \%程序 是 qquad\qquad
Remarks  言论 I．V line  静脉输液线
＊Any known allergies  *任何已知的过敏 qquad\qquad
C．V．P Line Angiocath／Mono／Duo／Trio／Cavafix
CVP 系列血管导管/单瓣/双瓣/三重奏/Cavafix
Food  食物

作开始时间 qquad\qquad ，f qquad\qquad fin hed at qquad\qquad 切开时间：Inc qquad\qquad qquad\qquad 的 .
Operation started at qquad\qquad ，f qquad\qquad
fin hed at qquad\qquad Incision Time： Inc qquad\qquad qquad\qquad ．
Operation started at qquad ，f qquad fin hed at qquad Incision Time： Inc qquad qquad ．| Operation started at $\qquad$ ，f $\qquad$ | | :--- | | fin hed at $\qquad$ Incision Time： Inc $\qquad$ $\qquad$ ． |
 ◻ ◻ ◻\square Guidewire removed \＆complete Size： qquad\qquad
◻ ◻ ◻\square 已移除导丝 \&完整尺寸： qquad\qquad
Others  别人 ／Site： qquad\qquad
＊Any known history of infectious conditions：
*任何已知的传染病史：
◻ ◻ ◻\square Arterial line Site：
rterial line qquad\qquad
◻ Arterial line Site： rterial line qquad| $\square$ Arterial line Site： | | :--- | | rterial line $\qquad$ |
No HBV MRSA

aade 识别手环已更改/aaded 为
aade
Identification Bracelets changed／aaded to
aade Identification Bracelets changed／aaded to| aade | | :--- | | Identification Bracelets changed／aaded to |
 Nasal（L／R）
◻ ◻ ◻\square Left Right ◻ ◻ ◻\square Left ◻ ◻ ◻\square Right ◻ ◻ ◻\square Arm Arm ◻ ◻ ◻\square Leg qquad\qquad qquad\qquad qquad\qquad
◻ ◻ ◻\square 左 右 ◻ ◻ ◻\square 左臂 右 ◻ ◻ ◻\square ◻ ◻ ◻\square 臂 ◻ ◻ ◻\square 腿 qquad\qquad qquad\qquad qquad\qquad
Others  别人

检查 qquad\qquad / 已应用 \&已检查者 已删除 \&&已检查者 qquad\qquad / qquad\qquad
Checked qquad\qquad ／
Applied \＆Checked by Removed \＆Checked by qquad\qquad ／ qquad\qquad
Checked qquad ／ Applied \＆Checked by Removed \＆Checked by qquad ／ qquad| Checked $\qquad$ ／ | | :--- | | Applied \＆Checked by Removed \＆Checked by $\qquad$ ／ $\qquad$ |
 Foley 2 ／ 3 ways Size： qquad\qquad
Remarks  言论
"Hospital Authority Kwong Wah Hospital Intraoperative Nursing Record" Please Stick Label if Available or Use Block Letters HN ：＿Name ： ： qquad "Case ：（1）Elective Emergency ： Elective" ID No ： Dept ： Diagnosis qquad Surgeons ：＿＿（T） Anaesthetist ： qquad （T） qquad Operation ： qquad Anaesthesia ： GA qquad SA＿ロEA＿ロ LA IVLA MAC／NA DBlock qquad qquad "Time out（T）at ： Time out（T）at ：" Part A ：Holding Room Nursing Record ＊Entered S 5 ／N 5 ／ 7 ／ 9 OT，Room qquad at qquad ． ＊Patient arrived at qquad Temp： qquad Bp qquad mmHg Pulse qquad //minSaO2 qquad \％ ＊Identity of patient and checklist done Site：O ECG Electrode ~~ Rash X Abrasion ◻ Arterial line ◻ Ventricular Drain ◻R//D ◻ Correct Incorrect ／／／Reddened area \＃Laceration ◻C ．V．P Line ◻ Foley Size： qquad口T／Tube "◻ Ryle＇s Tube Size： qquad －Nasal（L／R） ◻ Others" ＊Level of consciousness： "Awake Drowsy Unconscious" G6PD Deficiency \％Procedure performed in O．T． Yes qquad Remarks I．V line ＊Any known allergies qquadC．V．P Line Angiocath／Mono／Duo／Trio／Cavafix Food "Operation started at qquad ，f qquad fin hed at qquad Incision Time： Inc qquad qquad ．" ◻ Guidewire removed \＆complete Size： qquad Others ／Site： qquad ＊Any known history of infectious conditions： "◻ Arterial line Site： rterial line qquad" No HBV MRSA "aade Identification Bracelets changed／aaded to" Nasal（L／R） ◻ Left Right ◻ Left ◻ Right ◻ Arm Arm ◻ Leg qquad qquad qquad https://cdn.mathpix.com/cropped/2025_06_30_55185f4f83da8cdaa9edg-1.jpg?height=218&width=245&top_left_y=7944&top_left_x=8787 Others "Checked qquad ／ Applied \＆Checked by Removed \＆Checked by qquad ／ qquad" Foley 2 ／ 3 ways Size： qquad Remarks | Hospital Authority <br> Kwong Wah Hospital <br> Intraoperative Nursing Record | Please Stick Label if Available or Use Block Letters HN ：＿Name ： ： | $\qquad$ | | :--- | :--- | :--- | | | | Case ：（1）Elective Emergency <br> ： <br> Elective | | | ID No ： | | | | Dept ： | | | Diagnosis $\qquad$ | Surgeons ：＿＿（T） | | | | Anaesthetist ： $\qquad$ （T） $\qquad$ | | | Operation ： $\qquad$ | Anaesthesia ： GA $\qquad$ SA＿ロEA＿ロ LA IVLA MAC／NA DBlock $\qquad$ | | | $\qquad$ | Time out（T）at ： <br> Time out（T）at ： | | | Part A ：Holding Room Nursing Record | ＊Entered S 5 ／N 5 ／ 7 ／ 9 OT，Room $\qquad$ at $\qquad$ ． | | | | | ＊Patient arrived at $\qquad$ Temp： $\qquad$ Bp $\qquad$ mmHg Pulse $\qquad$ $/ \mathrm{min} \mathrm{SaO} 2$ $\qquad$ \％ | | ＊Identity of patient and checklist done | Site：O ECG Electrode $\approx$ Rash X Abrasion | $\square$ Arterial line $\square$ Ventricular Drain $\square \mathrm{R} / \mathrm{D}$ | | $\square$ Correct Incorrect | ／／／Reddened area \＃Laceration | $\square C$ ．V．P Line $\square$ Foley Size： $\qquad$口T／Tube | | | $\square$ Ryle＇s Tube Size： $\qquad$ －Nasal（L／R） <br> $\square$ Others | | | | | | | | ＊Level of consciousness： | | | | Awake Drowsy <br> Unconscious | G6PD Deficiency | \％Procedure performed in O．T． Yes $\qquad$ | | Remarks | | I．V line | | ＊Any known allergies | | $\qquad$C．V．P Line Angiocath／Mono／Duo／Trio／Cavafix | | Food | | | | | Operation started at $\qquad$ ，f $\qquad$ <br> fin hed at $\qquad$ Incision Time： Inc $\qquad$ $\qquad$ ． | $\square$ Guidewire removed \＆complete Size： $\qquad$ | | Others | | ／Site： $\qquad$ | | ＊Any known history of infectious conditions： | | $\square$ Arterial line Site： <br> rterial line $\qquad$ | | No HBV MRSA | aade <br> Identification Bracelets changed／aaded to | Nasal（L／R） | | | $\square$ Left Right $\square$ Left $\square$ Right $\square$ Arm Arm $\square$ Leg $\qquad$ $\qquad$ $\qquad$ | ![](https://cdn.mathpix.com/cropped/2025_06_30_55185f4f83da8cdaa9edg-1.jpg?height=218&width=245&top_left_y=7944&top_left_x=8787) | | Others | Checked $\qquad$ ／ <br> Applied \＆Checked by Removed \＆Checked by $\qquad$ ／ $\qquad$ | Foley 2 ／ 3 ways Size： $\qquad$ | | Remarks | | |
Part B: Intraoperative Nursing Care
Potential injury related to positioning
与体位相关的潜在伤害		 Position the Patient safely
安全地放置患者		 Position(s)  位置
Supine Prone Lateral (Lėft / Right) Lithotomy Sitting up Jackknife
仰卧位俯卧侧位 （Lėft / 右） 碎石术坐位 Jackknife
Traction Table Park Bench (Left/Right) Others qquad\qquad
牵引桌 Park Bench （Left/Right） 其他 qquad\qquad
Position device  定位装置 Yes / N/A
Potential injury related to positioning Position the Patient safely Position(s)Supine Prone Lateral (Lėft / Right) Lithotomy Sitting up JackknifeTraction Table Park Bench (Left/Right) Others qquad Position device Yes / N/A https://cdn.mathpix.com/cropped/2025_06_30_55185f4f83da8cdaa9edg-2.jpg?height=337&width=270&top_left_y=2731&top_left_x=3732 | Potential injury related to positioning | Position the Patient safely | | Position(s)Supine Prone Lateral (Lėft / Right) Lithotomy Sitting up JackknifeTraction Table Park Bench (Left/Right) Others $\qquad$ | | | | | | | | | | | | | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | | | | Position device | Yes / N/A | | | | | | | | | | | | | | | | ![](https://cdn.mathpix.com/cropped/2025_06_30_55185f4f83da8cdaa9edg-2.jpg?height=337&width=270&top_left_y=2731&top_left_x=3732) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Potential alteration of body temperature
体温的潜在变化		 Maintain body temperature within normal range
将体温维持在正常范围内

室温在正常范围内 是 / 否 使用温度探头 是 部位： 鼻腔 （左 / 右） 直肠 / 口腔 否 使用暖体器具 是 / 不适用 ◻ ◻◻ \square 暖血器 ◻ ◻◻ \square Bair Hugger Micro-Temp pad Inditherm 其他： qquad\qquad 灌溉 是 / 否 测得的流体温度： qquad\qquad ∘ 丙 ∘ 丙 ^（@）C{ }^{\circ} \mathrm{C} （不超过 37 元 ∘ 丙 37 元 ∘ 丙 37^（@）C37^{\circ} \mathrm{C} ）
Room temperature within normal range
Yes / No
Temperature probe used Yes
Site: Nasal (Left / Right) Rectal / Oral No
Use of body warming devices
Yes / N/A
◻ ◻ ◻\square Blood warmer ◻ ◻ ◻\square Bair Hugger Micro-Temp pad Inditherm Others: qquad\qquad
Irrigation Yes / No
Fluid Temperature measured: qquad\qquad ∘ C ∘ C ^(@)C{ }^{\circ} \mathrm{C} (not exceed 37 ∘ C 37 ∘ C 37^(@)C37^{\circ} \mathrm{C} )
Room temperature within normal range Yes / No Temperature probe used Yes Site: Nasal (Left / Right) Rectal / Oral No Use of body warming devices Yes / N/A ◻ Blood warmer ◻ Bair Hugger Micro-Temp pad Inditherm Others: qquad Irrigation Yes / No Fluid Temperature measured: qquad ^(@)C (not exceed 37^(@)C )| Room temperature within normal range | | :--- | | Yes / No | | Temperature probe used Yes | | Site: Nasal (Left / Right) Rectal / Oral No | | Use of body warming devices | | Yes / N/A | | $\square$ Blood warmer $\square$ Bair Hugger Micro-Temp pad Inditherm Others: $\qquad$ | | Irrigation Yes / No | | Fluid Temperature measured: $\qquad$ ${ }^{\circ} \mathrm{C}$ (not exceed $37^{\circ} \mathrm{C}$ ) |
Risk of retained foreign body
异物残留的风险

确保拭子/仪器/尖锐器/针头计数正确
Ensure swab / instrument/
sharp/ needles count correct
Ensure swab / instrument/ sharp/ needles count correct| Ensure swab / instrument/ | | :--- | | sharp/ needles count correct |
 Details please refer to count sheet
详情请参阅计数表
Risk of wound infection
伤口感染的风险		 Maintain sterile technique
保持无菌技术

适当的制备技术 是 / N/A 酒精 70% 水溶液 Betadine Hibitane in SVR Savlon Hibiscrub / Betadine 磨砂膏 Chloraprep 其他 qquad\qquad
Appropriate prepping technique
Yes / N/A Alcohol 70% Aqueous Chlorhexidine Betadine Hibitane in SVR Savlon Hibiscrub / Betadine scrub Chloraprep Others qquad\qquad
Appropriate prepping technique Yes / N/A Alcohol 70% Aqueous Chlorhexidine Betadine Hibitane in SVR Savlon Hibiscrub / Betadine scrub Chloraprep Others qquad| Appropriate prepping technique | | :--- | | Yes / N/A Alcohol 70% Aqueous Chlorhexidine Betadine Hibitane in SVR Savlon Hibiscrub / Betadine scrub Chloraprep Others $\qquad$ |
Risk of electrosurgery injury
电外科损伤风险

确保 ESU 安全 ESU 使用 是 / N/A 口 ESU 否。 qquad\qquad
Ensure ESU Safety
ESU used Yes / N/A口ESU No. qquad\qquad
Ensure ESU Safety ESU used Yes / N/A口ESU No. qquad| Ensure ESU Safety | | :--- | | ESU used Yes / N/A口ESU No. $\qquad$ |

模式： ◻ ◻◻ \square 单极 ◻ ◻◻ \square Bipolar 适当放置分散垫 应用者 qquad\qquad qquad\qquad 大腿 （左 / 右） 背部 （左 / 右）
Mode: ◻ ◻ ◻\square Monopolar ◻ ◻ ◻\square Bipolar
Place dispersive pad appropriately
Applied by qquad\qquad qquad\qquad Thigh (Left / Right) Back (Left / Right)
Mode: ◻ Monopolar ◻ Bipolar Place dispersive pad appropriately Applied by qquad qquad Thigh (Left / Right) Back (Left / Right)| Mode: $\square$ Monopolar $\square$ Bipolar | | :--- | | Place dispersive pad appropriately | | Applied by $\qquad$ $\qquad$ Thigh (Left / Right) Back (Left / Right) |
Care of patient under X-ray & Laser Procedures
在 X 射线和激光手术下照顾病人		 Maintain safety of patient during X-ray & Laser procedures
在 X 光和激光手术过程中维护患者的安全

避免了过度暴露和不必要的患者暴露 使用防护设备 是的 qquad\qquad N/A 备注 ： qquad\qquad 铅盾 X 射线围裙 护目镜 湿眼罩
Overexposure & unnecessary exposure of patient avoided
Use of protective devices
Yes qquad\qquad N/A Remarks : qquad\qquad Lead shield X-ray apron Goggles Wet eyepads
Overexposure & unnecessary exposure of patient avoided Use of protective devices Yes qquad N/A Remarks : qquad Lead shield X-ray apron Goggles Wet eyepads| Overexposure & unnecessary exposure of patient avoided | | :--- | | Use of protective devices | | Yes $\qquad$ N/A Remarks : $\qquad$ Lead shield X-ray apron Goggles Wet eyepads |
Safe use of medication intraoperative
术中安全使用药物		 Accurate and safety use of drug
准确、安全地使用药物		 Drug use during operation qquad\qquad qquad\qquad qquad\qquad
手术 qquad\qquad qquad\qquad qquad\qquad 期间的药物使用
Potential alteration of body temperature Maintain body temperature within normal range "Room temperature within normal range Yes / No Temperature probe used Yes Site: Nasal (Left / Right) Rectal / Oral No Use of body warming devices Yes / N/A ◻ Blood warmer ◻ Bair Hugger Micro-Temp pad Inditherm Others: qquad Irrigation Yes / No Fluid Temperature measured: qquad ^(@)C (not exceed 37^(@)C )" Risk of retained foreign body "Ensure swab / instrument/ sharp/ needles count correct" Details please refer to count sheet Risk of wound infection Maintain sterile technique "Appropriate prepping technique Yes / N/A Alcohol 70% Aqueous Chlorhexidine Betadine Hibitane in SVR Savlon Hibiscrub / Betadine scrub Chloraprep Others qquad" Risk of electrosurgery injury "Ensure ESU Safety ESU used Yes / N/A口ESU No. qquad" "Mode: ◻ Monopolar ◻ Bipolar Place dispersive pad appropriately Applied by qquad qquad Thigh (Left / Right) Back (Left / Right)" Care of patient under X-ray & Laser Procedures Maintain safety of patient during X-ray & Laser procedures "Overexposure & unnecessary exposure of patient avoided Use of protective devices Yes qquad N/A Remarks : qquad Lead shield X-ray apron Goggles Wet eyepads" Safe use of medication intraoperative Accurate and safety use of drug Drug use during operation qquad qquad qquad| Potential alteration of body temperature | Maintain body temperature within normal range | Room temperature within normal range <br> Yes / No <br> Temperature probe used Yes <br> Site: Nasal (Left / Right) Rectal / Oral No <br> Use of body warming devices <br> Yes / N/A <br> $\square$ Blood warmer $\square$ Bair Hugger Micro-Temp pad Inditherm Others: $\qquad$ <br> Irrigation Yes / No <br> Fluid Temperature measured: $\qquad$ ${ }^{\circ} \mathrm{C}$ (not exceed $37^{\circ} \mathrm{C}$ ) | | :--- | :--- | :--- | | Risk of retained foreign body | Ensure swab / instrument/ <br> sharp/ needles count correct | Details please refer to count sheet | | Risk of wound infection | Maintain sterile technique | Appropriate prepping technique <br> Yes / N/A Alcohol 70% Aqueous Chlorhexidine Betadine Hibitane in SVR Savlon Hibiscrub / Betadine scrub Chloraprep Others $\qquad$ | | Risk of electrosurgery injury | Ensure ESU Safety <br> ESU used Yes / N/A口ESU No. $\qquad$ | Mode: $\square$ Monopolar $\square$ Bipolar <br> Place dispersive pad appropriately <br> Applied by $\qquad$ $\qquad$ Thigh (Left / Right) Back (Left / Right) | | Care of patient under X-ray & Laser Procedures | Maintain safety of patient during X-ray & Laser procedures | Overexposure & unnecessary exposure of patient avoided <br> Use of protective devices <br> Yes $\qquad$ N/A Remarks : $\qquad$ Lead shield X-ray apron Goggles Wet eyepads | | Safe use of medication intraoperative | Accurate and safety use of drug | Drug use during operation $\qquad$ $\qquad$ $\qquad$ |