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دليل السياسات والإجراءات في غرفة العمليات
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General Hospital • Operating Theatre
Tourniquet Safety Record
F-OT-17
Patient Name
MRN
Date
Surgeon
Procedure
1. Placement & Equipment Verification
Limb / Site (Verified during Time-Out)
R Upper
L Upper
R Lower
L Lower
Bilateral (Use 2 forms)
Skin Protection Applied
Stockinette
Soft Roll (Webril)
Other
Cuff Size / Shape
Device / Machine ID
Isolator / Draping applied?
Yes
No
2. Time & Pressure Log
GUIDANCE: Notify Surgeon at 60 mins (Upper) or 90 mins (Lower)
Cycle
Set Pressure
(mmHg)
Inflation Time
(Start)
Deflation Time
(End)
Total Time
(Minutes)
Escalation Notified?
(Yes / N/A)
1st
2nd
3rd
Exsanguination Method
Esmarch Bandage
Elevation Only
None (Contraindicated)
Total Cumulative Inflation Time
Minutes
3. Post-Use Assessment
Skin Condition Under Cuff (Post-Deflation)
Intact / Normal
Excessive Redness
Blister / Skin Tear
Complications / Incident Reporting
Suspected Nerve/Ischemic Injury
Incident Report Filed
Circulating Nurse (Monitoring)
Name / ID
Signature
Surgeon Acknowledgement
Name / ID
Signature