PRE-OP ASSESSMENTASSESSMENT

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Question PRE-OP ASSESSMENTASSESSMENT1.    Determined if the patient had any communication impairment, could read and understand English, and was competent to make autonomous decisions. Obtained a professional interpreter if needed. 2.    Assessed the patient’s understanding of the intended surgery and anesthesia. Asked the patient to offer a description rather than asking a simple yes-or-no question. Asked about patient’s and family caregiver’s expectations of surgery and care. Included questions concerning fears, cultural practices, and religious or spiritual beliefs. 3.    Asked about advance directives and ensured these were accessible via the electronic health record (EHR). 4.    Collected nursing history and identified surgical risk factors. 5.    Patient’s condition requiring surgery a)    Chronic illnesses and associated risk: (e.g., diabetes may hinder wound healing; asthma may impair ventilation; history of methicillin-resistant Staphylococcus aureus may impair wound healing and increase the risk for sepsis). b)   Screened for obstructive sleep apnea (OSA). Many health care agencies use the STOP-BANG assessment tool (any question answered Yes is a risk factor):                                                i.    STOP b.    Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?c.    Do you often feel TIRED, fatigued, or sleepy during the daytime?d.    Has anyone OBSERVED you stop breathing during your sleep?e.    Do you have or are you being treated for high blood PRESSURE                                               i.    BANG f.      Body mass index (BMI) more than 35 kg/m2g.    Age over 50 years oldh.    Neck circumference greater than 40 cm (16 inches)i.     Gender: Malec)    Last menstrual period (for female patients in childbearing years) d)   Previous hospitalizations e)    Full medication history, including prescription, over-the-counter (OTC), and vitamin and herbal remedies, and date and time of last doses f)    Previous experience with surgery and anesthesia; had patient clarify if any undesirable outcomes occurred. g)   Family history of complications from surgery or anesthesia h)   Patient history of chronic pain disorders and treatments used at home i)     Allergies to medications, food, or tape, including specific questions about natural rubber latex (used both words so that patient understands that rubber and latex are the same things). Asked patients if they have had any problem with medication or anything placed on their skin. j)     Physical limitation or impairment k)   Presence of prostheses and implants l)     History of smoking, alcohol, and drug use m)  Patient’s occupation 6.    Obtained weight, height, and vital signs. 7.    Assessed respiratory status. Auscultated lungs and note adventitious sounds; assessed character and rate of respiration, oxygen saturation, ability to breathe lying flat, use of oxygen or continuous positive airway pressure (CPAP) at home, and chest x-ray film report 8.    Auscultated heart sounds and evaluated circulatory status, including apical pulse, ECG report, and peripheral pulses. 9.    Assessed for risk factors for preoperative venous thromboembolism. Asked about leg pain; observed calves for symmetry, swelling, warmth, and redness; palpated pedal pulses 10. Completed a gastrointestinal assessment; if surgery was scheduled for that day, identified time of patient’s last intake of food or drink. Checked agency policy for nothing-by-mouth (NPO) restrictions. 11. Completed a full neurological assessment; determined patient’s level of consciousness (LOC), cognitive function, and sensation and noted neurological deficits. 12. Assessed patient’s musculoskeletal system, including a range of motion (ROM) of joints. 13. Carefully inspected all areas of the skin; identified breaks in skin integrity and determined level of hydration. 14. Assessed patient’s emotional states, including anxiety, coping mechanisms, and family caregiver support. Considered using Hospital Anxiety and Depression Scale (HADS). Assessed for the presence of, or potential for, abuse or neglect from partner or family caregiver. 15. Reviewed results of laboratory tests, including complete blood count, electrolytes, urinalysis, and other diagnostic tests. 16. Assessed patient’s or family caregiver’s knowledge, experience, and health literacy PLANNING1.    Expected outcomes following completion of procedure:·     Patient understood the surgical rationale, preparation, and procedure.·     Patient remained alert and appropriately responsive to assessment questions.·     Patient’s risks for postoperative complications were identified.·     Patient did not incur positional or skin injury during preoperative preparation in OR. 2.    Provided privacy; set up any equipment or learning materials needed. 3.    Explained to patient and family caregiver how the preoperative assessment will be used in patient’s care. IMPLEMENTATION1.    Communicated to the preoperative team risk factors that can make the patient vulnerable to intraoperative complications. 2.    Based on the patient’s cognitive status, level of health literacy, and nature of planned surgery, presented preoperative instruction to patient and family caregiver. 3.    After completion of the assessment, appropriately disposed of supplies and equipment. 4.    Ensured the nurse call system was in an accessible location within the patient’s reach.  5.    Raised side rails (as appropriate) and lowered the bed to the lowest position.EVALUATION1.    Determined if patient information was complete so that plan of care could be established. Validated unclear information with a family caregiver. 2.    Evaluated patient’s ability to cooperatively interact and level of health literacy.  3.    Used Teach-Back: “I want to be sure I explained what you need to know about your intended surgery and anesthesia. Tell me when your surgery is scheduled and the reason you are having surgery.” Revised the instruction or developed a plan for revised patient/family caregiver teaching if patient/family caregiver was not able to teach back correctly. RECORDING·     Documented assessment findings in the designated area of the patient’s record.·     Documented evaluation and evidence of patient learning HAND-OFF REPORTING·     Reported abnormal laboratory values or other operative risks to the surgeon, anesthesiologist, and OR nurse. If the patient had a known history of opioid use for pain control, communicated to the health care provider.  Health Science Science Nursing NURSING NUR 1020 Share QuestionEmailCopy link Comments (0)

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