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PREOPERATIVE CARE
Ch 20 W1
| Term | Definition |
|---|---|
| Surgery Diagnosis | to determine the PRESENCE or EXTENT of a pathological ABNORMALITY |
| Surgery Cure | to ELIMINATE or REPAIR a pathological condition or REPAIR ANATOMY |
| Surgery Palliation | to ALLEVIATE symptoms WITHOUT CURE |
| Surgery Prevention | to REDUCE RISK of developing a condition |
| Surgery Cosmetic Improvement | to alter physical appearance |
| Surgery Exploration | to determine the NATURE or EXTENT of a DISEASE |
| Emergency Surgical Setting | Unexpected and urgent |
| Elective Surgical Setting | Planned |
| Inpatient Surgical Setting | Patients requiring hospitalization for surgery and usually admitted the day of surgery |
| Ambulatory Surgical Setting | Same day surgery, less than 2 hrs, less than 3-4 hrs in postanaesthesia care unit (PACU) |
| 6 Reasons Surgery is Performed: | Diagnosis, Cure, Prevention, Palliative, Cosmetic, Exploration |
| 4 Surgical Settings | Emergency, Elective, Inpatient, Ambulatory |
| -ectomy | Excision or removal |
| -oscopy | Looking into |
| -ostomy | Creating an opening to |
| -otomy | Cutting into or incision |
| -plasty | Repair/ reconstruction |
| Preoperative Assessment Day of Surgery | In Pre-op admission clinic at least 1 day prior to surgery Physical Assessment, Collection and admission of data, Consent forms, Pre-anesthesia evaluation, Patient's weight, Airway history, Lab and diagnostic tests, Opportunity to ask Questions |
| Psychosocial Assessment Day of Surgery | -Stress can negatively affect surgical outcomes -Anxiety can impair cognition, decision-making, and coping abilities -Fears |
| Health History Day of Surgery Assessment | -Diagnosed medical conditions/current health issues -Past hospitalizations, surgeries, adverse reactions to anesthesia -Menstrual and obstetrical history -Family history |
| Medications Day of Surgery Assessment | - Current medications -Substance use (alcohol, smoking) - Allergies |
| Neurological Assessment | Determine/identify: Orientation to time place and person History of headaches or issue with vision or hearing Presence of confusion, disorderly thinking, inability to follow commands History of stroke, TIA, or disease of CNS (ex. Parkinson’s, MS) |
| Cardiovascular Assessment | Identify Acute or chronic conditions Palpate baseline radial pulse (rate /characteristics) Medications or herbal products affecting coagulation Lab and diagnostic tests for cardiovascular function Edema Take baseline BP |
| Respiratory Assessment | Identify acute/chronic conditions History of smoking Determine baseline respiratory rate, rhythm, regularity, pulse oximetry Observe for cough, dyspnea, use of accessory muscles of respiration and cyanosis |
| Urinary Assessment | Identify any pre-existing disease and ability of the patient to void Review lab/diagnostic tests for renal function |
| Hepatic Assessment | History of substance abuse (alcohol and IV drug use) Review lab tests and diagnostic tests for liver |
| Endocrine and Hematological Assessment | Pre-existing conditions with bleeding or hematological and endocrine disorders Assess baseline blood glucose |
| Integumentary Assessment | Assess mucous membrane Skin status Inspect skin for rashes, boils, or infection (surgical site) Assess sk in moisture and temperature Skin turgor for presence of dehydration Identify any history of problems with wound healing |
| Gastrointestinal/Nutritional Assessment | Identify history of gastrointestinal disorders or problems with elimination o Determine food and fluid intake patterns and any recent weight loss o Weigh patient o Assess for presence of dentures and bridges |
| Musculoskeletal system | Examine skin-bone pressure points and pressure injuries o Assess for limitations in joint pain, range of motion, and muscle weakness o Assess mobility, gait and balance |
| Lab tests Day of Surgery | ABGs, oximetry • Blood glucose • BUN, creatinine • CBC (RBCs, Hgb, Hct, WBCs) • Electrolytes • hCG • Liver function tests • PT, PTT, INR, platelet count • Albumin • Type and crossmatch • Urinalysis |
| Diagnostic tests Day of Surgery | ECG Pulmonary function studies |
| 3 types of Information in Preoperative Education | Sensory, Process, Procedural |
| Sensory Information | Noisy preop area, odours of drugs and cleaning solutions, Cold OR, talking may be distorted because of masks, narrow OR bed, bright OR lights, beeping monitors |
| Process Information | Admission area, Preop area, Families stay in holding area and later can move to recovery area, Identify technology that may be present on awakening |
| Procedural Information | Clothing, time of surgery, fluid/food restrictions, frequent vitals, pain control, deep breathing and coughing, IV, anesthesia, transferring, expected discharge |
| Preoperative Medications | Routine cardiac, antihypertensive, asthma meds Benzodiazepine, Anticholinergics, Opioids, Antiemetics, Antacids, Antibiotics, eye drops |
| Day of surgery Prep Nursing Role | Communication with family and patient, preop teaching, signed consent, patient prep |
Created by:
selenay15
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