Preoperative nursing diagnoses and ...

Preoperative nursing diagnoses and interventions

General nursing responsibilities

* Document and communicate essential baseline information about patient to other perioperative team members to make secure continuity of care.

* Verify patient identification, make secure surgical consent form is signed and that all necessary information is documented in patient's chart, and alert surgical team members to unusual exhibition results.

* Identify risk factors that may interfere with surgery (eg diabetes, advanced age, cardiac enigmas smoking, obesity, malnutrition, other preexisting conditions).

* Document specific allergies (eg shellfish, iodine) that may alter patient care and communicate findings to other perioperative team members.

Knowledge deficit related to impending surgery

* Assess patient's and family members' knowledge of impending surgery and provide verbal and written information appropriate to their flat of understanding.

* If a language barrier exists, call an interpreter to make secure the patient and family members understand instructions.

* Explain the end of preoperative care (eg, IV line insertion, preoperative medications, diagnostic standards food/fluid restrictions, preanesthesia evaluation).

* Orient patient to the surgical environment. Instruct the patient about all aspects of planned surgical events

* Teach patient postoperative exercises he or she will be anticipateed to perform (eg, coughing, shrewd breathing, incentive spirometry, isometric leg exercises) and have patient perform respond demonstration of exercises.

* Assess patient's ability and willingness to perform anticipated self-care activities propound discharge. Develop a care plan for the patient's ongoing health care needs

Anxiety related to impending surgery

* Assess patient's anxiety horizontal and coping skills. Allow the patient and family members to expres their matters and fears about surgery and furnish emotional support and guidance to the patient and family members.

* Clarity any misconceptions patient or family members may have about surgical events

Intraoperative nursing diagnoses and interventions

General nursing responsibilities

* Verify that all specialty OR equipment and supplies are available and in working order. Confirm the availability of kindred and blood products, when appropriate. make secure autologous blood is given first and put up auto-transfusion devices when appropriate.

* Accurately document OR facts record nursing interventions, and communicate intraoperative care to postanesthesia care unit (PACU) nurses

* render certain compliance with OR policies and conducts to protect patient from injury, infection, or invasion of privacy.

* Monitor surgical team members' aseptic technique and address breaks in aseptic technique. make sure universal precautions are observed at everyone.

Anxiety related to unfamiliar environment

* whole OR setup before patient's arrival.

* Explain intraoperative activities and stay complete to patient before and during anesthesia induction. Speak clearly, use language patient understands, and address patient from name when speaking.

* hold fast noise level in OR to a minimum, introduce staff members, and propose nonverbal support to patient by the agency of touch and eye contact.

* Provide updates to family members during surgery

Risk for injury related to surgical positioning

* Align patient's material substance in correct anatomical position and confident patient to OR bed with safety strap. Coordinate care with anesthesia care provider before positioning patient for surgery

* Pad all press points and bony prominences (eg heels, pushs head). Place pillow under patient's knee to mould strain on back. Pad perineal situation when using OR fracture table and pad surfaces of lithotomy stirrup devices that are in contact with patient's skin. Abduct patient's arms les than 90 degrees

* Assess patient's skin integrity before, during, and after surgery Document preexisting and postoperative rashes, sores, or skin disruptions.

* Provide anesthesia care provider with unrestricted access to patient's airway and invasive lines.

Potential for infection related to surgical procedure

* Place invasive lines and perform skin prep using aseptic technique.

* Maintain surgical conscience through every part of procedure.

* Apply sterile dressing before sterile field is broken

Alteration in patient's material substance temperature

* Assess patient's temperature before, during, and after surgery by the agency of using an appropriate temperature probe (eg esophageal, rectal, Foley catheter with probe).

* Limit patient's skin frontage to area required for surgery veil patient's head to lessen heat loss

* Provide warmth by the agency of adjusting room temperature to fit patient's distresss Cover patient with warm blankets, use temperature regulating blankets when appropriate, and provide warm IV and irrigation fluids for patient use.

High risk for injury related to surgical hazards

* Position electrosurgical unit (ESU) dispersive pad away from bony prominences, shave ESU site if necessary, and assess ESU site after pad removal.