Chapter 17 Preoperative Care

Nursing assessment of preoperative the goal of this

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Nursing Assessment of Preoperative The goal of this assessment is to identify risk factors and plan proper care that will ensure patient safety throughout the surgical experience. To achieve this, the following must be done: Establish a baseline data Determine the Pt’s psychological/physiological status to know how they will cope with the surgery (this is a risk factor that must be considered) Participate in identifying and documenting where the site of surgery will take place Identify the meds that the Pt uses (another factor that can affect surgery) Review results of preoperative diagnostics and share them with the right HCPs Determine if the Pt had received all there is to know about the surgery to make a proper decision. Identify cultural and ethnic factors that may affect surgical experience Determine receipt of adequate information from surgeon to sign informed consent o What type of surgery, why it is being done, the risks and benefits, and the risks of not having it done. o Determine whether the consent form was signed and witnessed
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Subjective Data: Psychosocial Assessment: understanding that surgery is stressful for the Pt even if minor. Their concerns must be taken into consideration to know how well they will cope with the process. o Influencing Factors Age Past experiences Current Health Socioeconomic status: cost of surgery Anxiety : can impair cognition, decision making and coping abilities; due to lack of knowledge or unrealistic expectations Fears o Death/Disability May prompt postponement Influence outcome Notify HCP o Pain Consult with ACP Confirm drugs will be available o Alterations in body image Assess concerns nonjudgmentally Pt with incisions, mastectomy, cosmetic surgery o Anesthesia ACP for consultation Fear of not being in control o Disruption of functions (meds can be taken to help Pt forget the process) Consultations PRN Consult with the Pt’s caregiver, a social worker, a spiritual advisor/psychologist and financial advisors if any of these fears are evident Hope : Assess and support this attribute o Use common language o Use translator if needed o Communicate all concerns to surgical team Past Health History o Ask the Pt if they had any past experiences of surgeries and problems. o Document their reasons for the surgeries from the past o Ask women about their menstrual, pregnancies o Ask about their family health history to know if there any risk factors when it comes to possible inherited diseases like hypertension, sudden cardiac death or
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myocardial infarction (heart attack), and any problematic reactions to anesthesia (Ex: hyperthermia has genetic predisposition).
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  • Fall '17
  • Medsurg, Preop,  PT,  Diagnosis, Nurs341

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