CIRCULATING NURSE
Date:
SINS/STIN COUNTING
(Sponges/OS, Instruments, Needles, Sharp)
STNI
Initial
Add
Time:
Mayo
SIGN IN
*Before induction of anesthesia
*Ask Patient
Name
Age
Procedure
Risk (allergies, diff.
breathing, blood
loss)
Last Meal
*Indcution of Anesthesia
Anesthesia
Time
TIME-OUT
Name
Age
Procedure
Risk (allergies, diff.
breathing, blood
loss)
*Introduce the Team
Student Circulating
Student Scrub
Staff Circulating
Staff Scrub
Surgeon
Anesthesiologist
Cutting Time
Excuse me, Good morning/ Good afternoon. Calling
for time-out, we have patient here
Back
OS 4X8
OS 4X4
Visceral/Square
Pack
Vaginal
Pack/Uterine
Strip
Peanut Balls
INSTRUMENTS:
Blade Holder #3
Blade Holder #4
Needle Holder
Tissue Forcep
• w/ teeth
• w/o
teeth
Mayo Scissors
• Curved
• Straight
Metz
• Curved
• Straight
Kocker
Kelly Forceps
• Curved
• Straight
Peans
• Curved
• Straight
Kelly Forceps
• Curved
• Straight
Allis
Babcock
Towel Clip
Ovum Forceps
NEEDLES
Name and age:
For
Procedure:
RETRACTORS
Under
Dr.
With on going
IVF:
ADDITIONAL
Consent signed by
With/ without known allergies to food and med.
Last Meal was _________________. I AM_____
Time Ended
Baby Out
CESARIAN SURGERY
Placenta Out
1st
count
Final
count