1. PERIOPERATIVE ASSESSMENT

2. 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.

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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 years
Early adult to 29 years
Young adult - 30 to 44 years
Middle adult - 45 to 65 years
Elderly adult - >65 years

11. 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

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

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

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

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

16. 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

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

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

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