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Subjective Data

Preoperative Assessment

How can we prevent preoperative stress from becoming distress? Understand the patient’s real and perceived stressors and provide information and support.
Explain why the nurse uses “common language”, familiar terms, and avoids medical jargon in preparing a patient for surgery? Words and language that are familiar to the patient increase understanding of surgical consent and the surgical experience.
What is our role is preparing the patient psychologically for surgery? assess the patient for potential stressors that could negatively affect the surgery and communicate these concerns to the appropriate surgical team members
What are the most common psychologic factors associated with surgery? Anxiety, Fear, and hope
What happens if a patient’s anxiety level is too high? It will affect their cognition, ability to make decisions, and coping abilities
What kinds of things cause anxiety related to surgery? not knowing what to expect; uncertainty about the surgical outcome; worrying about potential findings of diagnostic surgery; inaccurate information, scary surgery stories from friends or TV; conflict with religious/cultural beliefs, blood transfusions
How can we help with patient’s anxiety? Provide accurate information
Name 5 common fears associated with surgery. Fear of…… death, pain and discomfort, mutilation of alteration in body image, of anesthesia, of disruption of life functioning or patterns
Why do we need to tell the surgeon if we find that the patient has a strong fear of death? because attitude and emotional state influence the stress response and therefore the surgical outcome. The surgeon may opt to postpone the surgery.
Who should we notify if the patient seems to have an extreme fear of pain and why? The ACP so that an appropriate preoperative medication can be given.
What points should we make clear to a patient who is fearful about pain? there are drugs for surgery, drugs for after surgery, Okay to ask for pain med, won’t get hooked
What kind of things might cause a person to be fearful of anesthesia? unknown, past experience, scary stories, real information about risks associated with anesthesia, fear of losing control
What should we do if we determine our patient has a fear of anesthesia? inform the ACP immediately so that they can talk with the patient and reassure the patient that both the nurse and ACP will be present during surgery
What kind of concerns might a patient have related to life changes due to surgery? disability; loss of life; inability to play, work, or fulfill a role; being away from famiy; how spouse and children will manage; loss of income; surgery costs
What are some avenues we could offer to help patients with fears about life changes related to surgery? consultation with….social worker, spiritual/cultural advisor, psychologist or family members, hospital financial advisor about financial support for the uninsured/Medicaid
Name 6 areas of subjective data that we will assess. Psychosocial, past health history, medications, allergies, review of systems, functional health patterns
What psychological factor may be the patient’s strongest method of coping? Hope
What kinds of surgeries might patients anticipate with hope? surgeries that …repair, rebuild, or save and extend life
What should we do if we assess that the patient has hope? support it
Generally speaking, what will we be asking the patient about in the past health history portion of our assessment? medical conditions diagnosed in the past as well as current problems
What is one of the initial determinations we should make in an assessment of the patients health history in preparation for surgery? If they understand the reason for the surgery
What sort of things do we need to document in regards to the patient’s past hospitalization? reason they were in the hospital, previous surgeries and dates of surgeries, any problems with surgery (reactions/infections etc)
What kind of things do we ask women specifically? menstrual and obstetric history, are they pregnant
How could we facilitate more accurate communication with a teen about reproductive information? Ask the questions while parents are not present
What kind of family history should be documented? reaction to anesthesia, cardiac and endocrine disorders like HTN, cardiac death, MI, CAD, Diabetes
Why do we care about family history of cardiac or endocrine disorders? because the patient may have inherited tendencies toward these disorders that may be exacerbated during surgery
Patient with family history of what condition may be genetically predisposed to death from anesthesia? malignant hyperthermia
Generally speaking, what do we need to know about a patient’s medications before surgery? Their current routine and intermittent medication use including prescription, OTC, self prescribed, herbs, and supplements,, their drug intolerances and allergies
How could we ensure the correct documentation of both the name and dosage of a patient’s home medications? Ask the patient to bring their bottles of medication with them when reporting for surgery
Name some types of medication that may interact with anesthesia. medications for heart disease, HTN, Immunosuppression, seizure control, anticoagulation, and endocrine replacement.
What problematic interaction may happen with tranquilizers and anesthetics? tranquilizers my potentiate the effect of opioids or barbiturates used as anesthetics
What problematic interaction might result from a combination of antihypertensive medication and anesthesia? the additive effects may predispose the patient to shock
What do we need to think about for our diabetic patients? Insulin and hypoglycemic agents may require dose adjustments due to increased metabolism, reduced calorie intake, stress, and anesthesia
Why do surgeons often require the patient to cease aspirin or NSAIDs for two weeks before surgery? Aspirin and NSAIDs may inhibit platelet aggregation and may contribute to postoperative bleeding.
Why do we need to know about recreational drug use before our patient has surgery? Recreational drug use may affect the type and amount of anesthesia that will be needed
What damage from chronic alcohol use puts a surgical patient at risks? lung, gastrointestinal, liver damage
If our surgical patient has liver damage what dangers must we be alert for? Metabolism of anesthetic agents in prolonged, nutritional status is altered, and the potential for postoperative complications is increased
If our patient is an alcoholic and in the hospital for a lengthy stay what potentially life threatening situation may arise if appropriate planning does not take place? Alcohol withdrawal
Give some examples of the effects of drug intolerance. nausea, constipation, diarrhea, or idiosyncratic reactions
What’s the difference between reactions due to intolerance and true allergic reactions? Drug intolerance reactions are unpleasant but not life threatening.
What are some potential allergic reactions? hives and/or anaphylactic reaction, causing cardiopulmonary compromise, including hypotension, tachycardia, bronchospasm, possible cardio edema
How can we identify a patient who has an allergy that could endanger them while they are admitted for surgery? They should be given an allergy wristband
Why does the APC need to know if the patient has a sulfur allergy? many drugs contain sulfur
Why would we need to know about a patient’s non drug allergies? A patient with hypersensitivity reactions to other chemicals is more likely to have a hypersensitivity reaction to anesthesia