Chpt. 1 PREOP PATIENT ASSESSMENT & DIAGNOSIS Flashcards
What are the 6 steps (in order) of the nursing process?
- Assessment (assess the patient)
- Diagnosis (identify nursing diagnosis per the patient’s needs)
- Outcome identification (per the diagnosis)
- Planning (plan patient care)
- Implementation (implement required care)
- Evaluation (evaluate outcome of patient care)
_________is the collection and analysis of relevant health data about the patient
ASSESSMENT
_________was created to prevent wrong-person, wrong-procedure, and wrong-site surgery in hospitals and outpatient settings
THE UNIVERSAL PROTOCOL
The steps of the universal protocol include____
- preoperative/preprocedure verification process, 2.marking the operative/procedure site, and
- a timeout (final verification)
When is the time out performed?
Immediately before starting the procedure.
The patient assessment includes
- conducting an assessment
- performing the physical examination,
- completing the medical record review (eg, assessing laboratory and diagnostic test values), and performing the medication reconciliation process.
The process of preprocedure verification includes
- confirming the patient’s identity,
• verifying the scheduled surgical procedure,
• site marking, and
• performing the time out (eg, regional blocks, line placement, before incision)
TRUE OR FALSE?
The patient and family should be actively
engaged during the assessment phase.
TRUE!
because they are an excellent source of health care
information
When performing the preoperative assessment, the nurse gathers data from a variety of sources. These
sources include, but are not limited to______
• the patient;
• the medical record, including the physician’s physical examination (H& P);
• the surgeon, anesthesia professional, and other health care personnel; and
• the perioperative nurse’s knowledge of the
planned surgical procedure.
The nurse must
endeavor to establish a trusting relationship with
the patient and his or her family members. WHY?
so that
open communication can occur
TRUE OR FALSE?
Actively involving the patient in the preoperative assessment makes information collection easier, and
it can also decrease the patient’s anxiety by allowing him or her to have a say in the plan of care.
TRUE
Regardless of the method of data collection used, the focus of the preoperative assessment is on the
following key elements:
-obtaining the patient’s current diagnosis and physical and psychosocial status;
• obtaining the patient’s medical history, to include previous illnesses and surgical procedures; and
• validating patient’s understanding of the procedure.
Additional information the nurse should obtain during the assessment includes______
- NPO status;
- nutritional status (eg, body mass index [BMI]);
- loose teeth, dentures, or caps;
- eyeglasses or contact lenses;
- hearing aids;
- unexplained family death while under anesthesia;
- adverse response to previous surgeries or anesthesia;
- travel to countries with infectious disease outbreaks
During the physical assessment, the perioperative nurse must also identify physical factors that will
need to be taken into consideration during intraoperative planning: (which include)
-Does the patient have any joint immobility (eg, is hip or shoulder immobility pertinent when assessing for procedure-specific patient positioning)?
• What is the condition of the patient’s skin? Are there any current areas of breakdown?
• What are the patient’s heart rate and rhythm
TRUE OR FALSE?
Additionally, the nurse must ask the patient about body piercings which will need to be removed for
patient safety and current implants, because
intraoperative positioning or electrosurgical unit
dispersive pad placement may be hindered by the
presence of artificial joints and the patient may not
require an additional preoperative antibiotic.
FALSE!
Additionally, the nurse must ask the patient about body piercings which will need to be removed for
patient safety and current implants, because
intraoperative positioning or electrosurgical unit
dispersive pad placement may be hindered by the
presence of artificial joints and the patient MAY
require an additional preoperative antibiotic.
a signed_____________ that may include some or all of the following: surgical, anesthesia,
blood products, photography, special laboratory testing, presence of additional people in the OR;
a signed INFORMED CONSENT that may include some or all of the following: surgical, anesthesia,
blood products, photography, special laboratory testing, presence of additional people in the OR;
If the H&P is done by another doctor other than the one doing the procedure. What needs to be done before the new surgeon can proceed with the procedure?
a current history and physical examination performed by the admitting physician or his or her
delegate; however, if this person is different from the person performing the procedure, there may
be an additional note by the surgeon;
When checking the medical records, what important Items need to be looked at?
• a signed INFORMED CONSENT that may include some or all of the following: surgical, anesthesia,
blood products, photography, special laboratory testing, presence of additional people in the OR;
• a current HISTORY & PHYSICAL examination performed by the admitting physician or his or her
delegate; however, if this person is different from the person performing the procedure, there may
be an additional note by the surgeon;
EXAM TIP
Information gathered during the assessment
facilitates prioritization of care and may reveal
information that should be shared with other
health care disciplines participating in the care
of the patient.
-Preoperative Patient Assessment and Diagnosis
• a preanesthesia assessment;
• baseline admission vital signs;
• laboratory results;
• radiographic reports; and
• height and weight in kilograms because
most emergency medications are administered based on weight.
-ADVANCE DIRECTIVES
a document designed to control certain future health care decisions only when a person becomes unable to make decisions and choices on his or her own
LIVING WILL
a legal document in which a person names someone to be his or her proxy (ie, agent) to make all health care decisions if the person becomes unable to do so
DURABLE POWER OF ATTORNEY
_____written
physician orders instructing health care
providers not to perform cardiopulmonary
resuscitation
DNR ORDER
_____the provision
of only comfort measures for the actively
dying patient
ALLOW NATURAL DEATH (AND)
physician orders for
life-sustaining treatment
POLST
a federal law that requires most health
care institutions to provide information on
advance directives at the time of admission
PSDA—the Patient Self-Determination
Act
