PERIOPERATIVE ASSESSMENT

OBJECTIVES Describe the patient assessment component of perioperative nursing Describe the steps for the medical record verification Identify location and method of contact for updating family.

Introduction Introduce yourself by stating your name and your role in the OR. Verify patient’s identity by using at least two identifiers: Have patient state their name and birth date Compare blue card to ID band and verify name, birth date, medical record number Compare blue card to chart identifiers

NURSING PROCESS Assessment - ongoing systemic collection of subjective and objective data Nursing diagnosis/outcomes Planning - for patient and procedure Implementation - following your care plan Evaluation - reflecting if goals were met

ASSESSMENT Verify with patient and chart: NPO status Patient should be NPO since MN for early am cases or at least 8 hours before procedure (per anesthesia recommendation) Sometimes patients will take a sip of water to swallow their medication. Always communicate with anesthesia any concerns related to NPO status

Allergies Verify patient allergies Medicines Contact Foods Latex Tape Prepping Solutions Foods Allergies to banana, kiwi, etc. may correspond with a Latex Allergy

IMPLANTS/PROSTHETICS WHAT DOES THE PATIENT HAVE ALREADY? Cardiac – pacemaker, implanted defibrillator Dental – dentures, removable dental work, loose/cracked/chipped teeth Ortho - plates, screws, joint replacements Ophthalmology – Artificial eye, contacts Extras- Jewelry/ underwear with metal hooks/ hearing aids/ glasses

Chart Check Surgical Consent H & P Labs Orders Complete with signatures Reflects patient’s description of procedure Correlates with site marking Current: dated within 60 days of surgery H & P Present on chart/ updated Labs PCV, ICON, K Orders Antibiotics/ SCD’s

FAMILY COMMUNICATION Establish where family will be waiting and method of contact. Cell phone Electronic message board Waiting room coordinator Establish frequency of contact. At start of procedure Every hour throughout procedure

DEFINITION OF AGE GROUPS Neonate - birth to 1 month Infant - 1 month to 12 months Toddler - 12 months to 3 years Preschool - 3 to 6 years School age - 6 to 12 years Adolescent - 12 to 16-18 years Early adult - 16-18 to 29 years Young adult - 30 to 44 years Middle adult - 45 to 65 years Elderly adult - >65 years

SKIN CONDITION *Condition is Age-Dependent - Pediatric patients do not have fully mature thermoregulatory system - Between ages 30 – 44 skin begins to decline in physiologic function  Subcutaneous fat and skin elasticity  Wrinkling and thinning of skin More sensitive to injury Sweat glands atrophy, making it more difficult to control body temperature  Capacity of tissue regeneration

Skin Assessment Inspect skin for: Color Temperature Sensation Turgor Thickness Sub-q tissue

ASSESS Physiological status Body size & positioning devices needed for the case Preexisting health conditions Type of anesthesia Type of surgery Environment - warming unit needed?

MOBILITY Base line of functional status - can they move themselves? Plan developed based on needs & limitations Amputees Paralysis Osteoporosis or arthritis Children

SENSORY IMPAIRMENT Hearing - hearing aids? Sight - glasses/contacts Dentures/artificial limbs Cognition

PERCEPTION OF SURGERY Patient advocate - our job to protect safety and well being of the patient Communication - between all staff and next phase of care Informed - keep the patient updated on when surgery will begin, communicate if there will be delays

Safety Security Comfort Emotional support EXPECTATIONS OF CARE Safety Security Comfort Emotional support

CULTURAL PRACTICES/ RELIGIOUS BELIEFS Identify needs - Clergy Acceptance of beliefs Specific beliefs Blood transfusions Body privacy Organ donation

SUMMARY/OBJECTIVES Describe the assessment component of perioperative nursing Relate age-specific elements of the physiological perioperative assessment Identify elements of the psychosocial assessment