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Table 18-5

Physiologic Assessment of the Preoperative Patient

QuestionAnswer
Name 8 cardiovascular system assessments. existence of HTN, Heart failure, angina, MI; Apical, radial, pedal pulses, and characteristics; edema; neck vein distention; BP both arms; herbs/drugs that mess up coagulation; review CV labs and diagnostics; identify pt.s with pacemakers/defibrillators
Name 5 respiratory system assessments. dyspnea, asthma, copd, coughing, URTI; accessory muscle to breath; baseline respiratory rate, rhythm, regularity; Lung sounds normal or adventitious; smoking pack/years
Name 3 neurological assessments. orientation to person, place, and time; confusion, disorderly thinking, inability to follow commands; history of strokes, transient ischemic attacks, NS disease like MS, Parkinson’s disease, myasthenia gravis
Name 4 Urinary System assessments. preexisting disease, UTI; Ability to pee; color, amount, and characteristics of urine; labs and diagnostics for renal function: bun, creatinine, electrolytes and urinalysis
Name 3 assessments for the Hepatic System. Check skin, mucous membranes and sclera for jaundice; history of substance abuse especially alcohol and IV drugs; labs and diagnostics for liver function
Name 5 assessments for the Integumentary system. mucous membranes for dehydration and intactness; skin status drying, bruising, breaks in the surface; Rashes, Boils, or infection especially around surgical site; Skin moisture and temperature; Turgor
Name 5 assessments for the musculoskeletal system. examine skin/bone pressure points; presence of pressure ulcers; ROM and muscle weakness; Mobility, Gait, and Balance; Presence of joint pain
Name 4 assessents for the gastrointestinal system. Food and Fluid intake patterns, recent weight loss; height and weight; presence of bridges or dentures (may dislodge in case of intubation)
Name 2 assements for the immune system. Immunodeficiency or autoimmune disorders identified; use of corticosteroids or other immunosuppressive drugs.
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