Pre operative nursing diagnosis cluster data from

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Pre-Operative Nursing Diagnosis Cluster data from baseline assessment Establish directions for care during all surgical phases Focus on potential risks Preventive care Patient and family members needs
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Work in groups of 2-3 to come up with nursing diagnoses for the pre-operative patients in your notes.
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The Nursing Process & the Surgical Patient Pre-Operative Planning Goals are patient-centered Outcomes are measurable and observable Include an expected time of accomplishment
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The Nursing Process & the Surgical Patient Pre-Operative Implementation Informed consent Preps Pre-op meds Patient and family teaching Preoperative checklist
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Informed Consent The disclosure of risks associated with the intended procedure or operation to the client, and includes a legal document. Anyone undergoing any invasive procedure Legal requirement Guards the patient against unwanted procedures Ideally, nurse should be present when information is provided Nurse will witness the client’s voluntary signature
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Pre-op Teaching Should begin as soon as the decision for surgery is made Most is done pre-operatively Ideal time?? Include the patient and family
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Pre-op Teaching Include the following: Diagnostic tests Arrival time Preparations for surgery Pre-operative medications Counseling about what home meds to take morning of surgery Expected timetable for surgery and PACU Method to inform family
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Pre-op Teaching Include the following: Location of surgical waiting room Anticipated post-operative routine, devices, or equipment Plans for postoperative pain control Turn, cough, deep breathing exercises and how to get out of bed
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Client Preparation Use the preoperative checklist as an outline to finalize preparations for surgery: Bathing, grooming, gown Remove nail polish, hair pins, lipstick and makeup Remove dentures, artificial eye, contact lenses. Store. May leave hearing aid if cannot hear. Notify OR. ID, blood, and allergy bands Informed consent signed on chart Weigh client and get height. Record.
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Client Preparation Preoperative checklist (cont.) Skin or bowel prep as ordered NPO Verify all diagnostic test reports on chart Empty bladder (unless catheter in place) IV, Foley, SCD’s, NG, CVL Administer pre-op meds as scheduled What does “on-call” mean? Promote safety
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Client Preparation Preoperative checklist (cont.) Obtain and record VS Ongoing supportive care to client and family Document all pre-op care in appropriate location Verify with surgical personnel the client’s identity Prepare client’s room for post-op care
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Pre-op Medications Anticholenergic Analgesic Sedative H2 Receptor Antagonist Tranquilizer Antibiotics “on call” to the OR
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Transport to Surgery Patient transfer to OR gurney Patient chart to accompany patient Arrange room for patient’s return Care of family and significant others
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I n t r a o p e r a t i v e P h a s e
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  • Summer '16
  • Jane
  • Nursing, surgical patient

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