I started the paper…
– A comprehensive case study/ Capstone Paper
The case study should begin in the preoperative period, and
include the following:
A. Preoperative patient assessment, diagnostic
procedures, results of the history and physical examination (you should participate
in these), presenting signs and symptoms, preoperative patient education and
preop orders (you should participate in writing these; if the institution does
not include this in your scope of practice, write sample preop orders
and review them with your surgeon mentor. Include your sample orders
& mentor feedback with your Case Study).
See Module IV, CC for completion of this portion of the case study.
B. Intraoperatively, describe the patient’s admission to
the OR (patient/procedure identification/verification, any preop briefing which
took place, position, draping, the time-out protocol, and assisting that you
provided for this patient; type of anesthesia [agents/technique], hemodynamic
monitoring and other monitoring).
Provide a detailed description of the steps in the surgical procedure.
Submit a copy of the dictated operative report (you should participate in
preparing a sample dictated operative note and review it with your
surgeon mentor. Include your sample operative note & mentor feedback on it with
your Case Study. See Appendix E of the CC for a sample operative progress
note/operative note).
C. Describe the patient’s admission to PACU & PACU
stay. In this section, include information you provided in your hand-off report
to the PACU nurse. Please review AORN’S Guideline for Transfer of Patient Care
Information in this assignment. If the institution uses the SBAR [situation,
background, assessment, recommendation] checklist [or another such as PASS the
BATON] for hand-off reports, include that information. Review the WHO Surgical
Safety checklist and AORN’s Comprehensive Surgical Safety checklist. Discuss
their recommendations for the sign-out and hand-over [what we refer to as the
“hand-off” in the U.S.].
