Performing a Preoperative Assessment

Summary

This transcript details a thorough preoperative assessment performed by a nurse, focusing on patient privacy, medical history, and physical evaluations. The nurse introduces herself, asks relevant health questions, checks vital signs, and addresses any allergies or medications. A physical exam follows, assessing various body systems including cardiovascular, respiratory, and musculoskeletal functions. The nurse also reviews patient expectations, cultural considerations, and preoperative orders. The process includes ensuring informed consent, confirming NPO status, and addressing concerns about the surgery. The assessment ends with documenting all findings and preparing the patient for the procedure.

Takeaways

• 😀 Ensure privacy and introduce yourself to the patient before starting the preoperative assessment.
• 😀 Verify patient identification using two identifiers (e.g., full name and date of birth) to ensure accuracy.
• 😀 Ask the patient about their health history, including allergies, medications, and any physical or mental impairments.
• 😀 Collect information on the patient’s lifestyle habits such as smoking, alcohol use, and any coping mechanisms.
• 😀 Take baseline vital signs, including height, weight, oxygen saturation, temperature, blood pressure, pulse, and respiratory rate.
• 😀 Perform a physical exam, focusing on musculoskeletal strength, range of motion, and cardiovascular and respiratory function.
• 😀 Inquire about the patient’s family support and any emotional or psychological health concerns.
• 😀 Confirm that the patient’s allergies, including medications and environmental factors, are well-documented and flagged with an allergy band if needed.
• 😀 Discuss the patient's current medications, including prescription, over-the-counter, and herbal remedies, ensuring they align with preoperative orders.
• 😀 Ask the patient about their advance directive and ensure it’s documented in the electronic medical record before surgery.
• 😀 Review preoperative orders, including NPO status, medication administration, and any special preparations like skin or bowel prep, to confirm they’ve been completed correctly.

Q & A

What is the first step in performing a preoperative assessment?

The first step is ensuring privacy and introducing yourself to the patient. The nurse should identify themselves and explain their role in preparing the patient for surgery.

Why is it important to check the patient's ability to answer questions about their health history?

It is important to determine if the patient can provide accurate information about their health history and upcoming surgery. This allows the nurse to proceed with the necessary assessment and ensure all risk factors are identified.

What specific factors should be checked in the patient's nursing history?

The nurse should check for any surgical risk factors, medications the patient is taking, allergies, physical or mental impairments, mobility restrictions, and the use of prosthetics such as hearing aids.

What role does the patient's family and support system play in the preoperative assessment?

The nurse should assess whether the patient has family and friends for support and whether the patient relies on other coping mechanisms. This helps in understanding the patient's emotional health and support network.

Why is it important to check the results of preoperative diagnostic tests?

The results of diagnostic tests, such as the electrocardiogram (ECG), lab values, and imaging studies, help determine the patient's health status and identify any potential issues that may affect the surgery.

What vital signs should be recorded during the preoperative assessment?

The nurse should record the patient's height, weight, oxygen saturation, temperature, blood pressure, pulse, and respiratory rate as baseline vitals.

What are some examples of disorders that can increase surgical risk?

Infections, chronic diseases, and any conditions that affect the heart, lungs, or other major systems can increase surgical risk. These factors need to be identified to plan for safe surgery.

How should the nurse handle the patient's allergies during the assessment?

The nurse should specifically ask about known allergies to food, medications, latex, or other environmental irritants. If any allergies are reported, the nurse should place an allergy band on the patient and make sure it is securely attached.

What should the nurse assess during the physical examination?

During the physical examination, the nurse should assess the patient's cardiovascular, respiratory, musculoskeletal, and abdominal systems, as well as their skin hydration and integrity. This helps identify any physical conditions that could affect surgery.

Why is it essential to review the patient's preoperative orders?

Reviewing the preoperative orders ensures that all preparations are completed as instructed, including checking the NPO (nothing by mouth) status, confirming medication orders, and preparing the patient for any specific procedures such as skin or bowel preparation.