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Lect - 3 Preoperative Patient Assessment and Preoperative Checklists

The document outlines the importance of preoperative patient assessment, emphasizing the need for a comprehensive evaluation to identify risks and ensure patient safety before surgery. Key components include patient history, physical assessments, and the development of individualized care plans, alongside the use of preoperative checklists to standardize procedures and enhance communication among surgical teams. It concludes that thorough preparation and patient-centered care are essential for successful perioperative nursing and improved surgical outcomes.

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37 views39 pages

Lect - 3 Preoperative Patient Assessment and Preoperative Checklists

The document outlines the importance of preoperative patient assessment, emphasizing the need for a comprehensive evaluation to identify risks and ensure patient safety before surgery. Key components include patient history, physical assessments, and the development of individualized care plans, alongside the use of preoperative checklists to standardize procedures and enhance communication among surgical teams. It concludes that thorough preparation and patient-centered care are essential for successful perioperative nursing and improved surgical outcomes.

Uploaded by

amadiaade
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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DIPLOMA IN GENERAL NURSING

NUR 211

PREOPERATIVE PATIENT ASSESSMENT


AND PREOPERATIVE CHECKLISTS
Learning Outcome
By the end of this lecture students can:
1.Identify the importance and key components of holistic
preoperative assessment.
2.Recognize common patient risk factors, including allergies, and
how to address them.
3.Incorporate the use of pre-operative checklists in preoperative
assessment and maintaining patient safety.
4.Identify common post operative complications
5.Understand the nurse's role in maintaining accurate documentation
Overview

Preoperative assessment and care involves a


comprehensive evaluation of a patient's health status
before surgery to ensure they are fit for the procedure
and to reduce the risk of complications. It typically
includes the care that we are going to look at shortly.
Preoperative Patient
Assessment
Importance of Pre-operative Assessment

Pre-operative assessments serve many functions


including:
Risk identification: Detecting potential complications
that could arise during or after surgery.
Determine the patient's psychological state:
Identification;
Baseline Data: Establishing a baseline for comparison
with postoperative status.
Cont..
Patient Education: Informing patients about surgery,
anesthesia, and postoperative care.
Ensuring that paperwork such as consent and
laboratory test are completed and in the patient
record.
Care planning: creating a tailored care plan to add
Address any fears or anxieties.
Key components of the preoperative Assessment

A.Patient history
B.Physical Assessment
C.Recognizing and addressing common risk factors
D.Potential for Postoperative complications
E. Developing an individualized Care Plan.
A: Patient History
Medical History:
Chronic conditions: such as diabetes hypertension,
cardiac diseases and respiratory conditions.
Previous surgeries: including any complications or
anesthesia reactions.
Allergies: ask about any allergies or intolerance to
medicines, food and environmental allergies.
Cont..
Women should be ask about menstrual and obstetric
history.

Medications: Current medications, including over-the-


counter drugs, supplements and herbal remedies.
Cont..
Surgical History:
Detailed history of previous surgeries and any
related complications or outcomes.

Family History:
Relevant family history that may affect anesthesia or
surgical outcomes.
B: Physical Assessment
1. System Assessment:
Vital signs
Cardiovascular system: assessment for any signs of
heart disease or circulatory issues.
Respiratory system: Evaluation of lung sounds and
respiratory effort.
Cont..
Neurological system: Assessing mental status,
reflexes, and motor and sensory function.
Abdomen: Examination for any abnormalities or
tenderness.
Skin: checking for any lesions, infections or signs of
poor perfusion.
Cont..
2: Laboratory and diagnostic tests:
Blood tests
Imaging: X-rays, ECG, or other relevant imaging
based on patient’s condition.
Specialized tests: based on patient’s history and
planned surgery.
Cont..
3: Functional and Psychosocial Assessment:
Functional Status: assessing the patient's ability to
perform activities of daily living.
Nutritional status: evaluating dietary habits and
nutritional intake.
Psychological Assessment: Screening for anxiety,
depression or other mental health issues that may impact
recovery.
Cont..
4: Anesthesia:
Airway assessment: Evaluating the airway to predict
potential difficulties with intubation. Recent or chronic
respiratory disease.

5: Patient Education and Consent:


Surgical Procedure: Explaining the surgical procedure,
expected outcomes, and potential risks.
Cont..
Anesthesia plan: discussing the types of anesthesia to be
used and what to expect.

Postoperative Care: Providing information on


postoperative care, postoperative exercises, pain
management and recovery expectations.
C: Recognizing and Addressing Common Risk
Factors
Cardiovascular Risk:

Risk identification: Hypertension, history of myocardial


infarction, heart failure.

Interventions: optimize medical management, monitor


closely during perioperative phase/period.
Cont..
Respiratory Risk;

Risk identification: chronic obstructive pulmonary disease


(COPD), asthma, smoking history.

Interventions: pulmonary function optimization, preoperative


smoking cessation programs, bronchodilators.
Cont..
Metabolic and Endocrine Risks;
Risk identification: diabetes, thyroid disorders, obesity

Intervention: blood glucose control, preoperative


smoking cessation programs,
Cont..
Coagulation Risk:
Risk identification: history of bleeding disorders,
anticoagulant use.

Interventions: adjust anticoagulant therapy,


preoperative hematologic consultation.
D: Potential for Postoperative Complications

 Infection: Surgical site


 Deep Vein Thrombosis
infections (SSIs) are among
(DVT) and Pulmonary
the most common
Embolism (PE): Due to
complications.
immobility and altered
 Pneumonia: Particularly in clotting factors post-surgery.
patients undergoing
abdominal or thoracic
surgeries.
Cont..
 Wound Dehiscence: Partial  Pain
or complete separation of the
 Urinary Tract Infections
wound layers.
(UTIs): Often due to
 Post-operative Nausea and catheterization.
Vomiting
 Paralytic Ileus: Temporary
paralysis of the bowel.
E. Developing an Individualized Care Plan

Based on the assessment findings, a personalized care plan


should be developed:
Preoperative Optimization: Addressing identified risk
factors and optimizing the patient’s condition.
Perioperative Monitoring: Planning for close monitoring
and management of potential complications.
Postoperative Care: Ensuring appropriate follow-up, pain
management, and rehabilitation.
Preoperative Checklist
1: Importance of Preoperative Checklist
Enhancing Patient Safety:
Checklists help prevent avoidable errors, such as operating
on the wrong site or patient.

They ensure that all necessary precautions are taken to


reduce the risks of surgery, including risk of infection and
complications.
Cont..
Standardizing Procedures:

Checklists provide a standardized approach to pre-


operative preparations, ensuring consistency across different
teams and settings.

This standardization helps with training new staff and


maintaining quality control.
Cont..
Improving Communication:

Checklists facilitate communication among surgical team members,


ensuring that everyone has the correct information and identify any
gaps in information.

Checklists prompt the surgical team to discuss critical aspects of the


surgery, such as potential complications and their individual roles.
2.Components of a Pre-operative Checklist
Patient Identification:

Confirm the patient’s identity using at least two identifiers


(e.g., name and date of birth).

Verify the surgical site and procedure with the patient and
check the consent form.
Cont..
Medical History and Allergies:
Review the patient’s medical history, including any
allergies or previous adverse reactions to anesthesia.

Ensure that any required pre-operative medications


have been administered.
Cont..
Vital Signs and Baseline Assessments:

Record the patient’s vital signs and baseline


measurements (e.g., blood pressure, heart rate).

Assess the patient’s overall physical condition and note


any abnormalities.
Cont..
Equipment and Supplies:
Confirm that all necessary surgical instruments and
supplies are available and functioning.

Ensure that sterilization procedures have been


followed for all equipment.
Cont..
Team Briefing:

Conduct a team briefing to review the surgical plan,


assign roles, and discuss any potential challenges.

Verify that all team members are aware of their


responsibilities and have no concerns.
Cont..
Patient Preparation:

Ensure that the patient has followed pre-operative


instructions, such as fasting or bowel preparation.

Confirm that the surgical site has been marked and prepped
according to protocol.
3.Day of Surgery Preparation Checks
Vital signs, Weight
Name bands (allergy band), Consent form – signed
and legal
Does the patient wear dentures/ have caps/crowns on
teeth? Does the patient have glasses/hearing aids
Nail polish removed, make-up removed, Jewelry
removed/taped
Cont..
All required paperwork - patient records, Medication
Chart, X-rays & scans
Reinforce patient education, reassurance, answer
questions
Site of operation area prepared: marked in skin pen,
hair removal may be required
Cont..
Bowel preparation: laxatives, enema. Bladder empty
Shower, dress in hospital gown
Administer pre-operative medications
Conclusion
Preoperative patient assessment is a multifaceted and dynamic
process that requires a comprehensive and systematic approach.
Identifying risk factors and planning individualized care can
significantly enhance patient safety and surgical outcomes.
Thorough preparation and patient-centered care are critical to
successful perioperative nursing.
Cont..

As part of patient pre-operative preparation, checklists are an


essential tool to enhance patient safety, standardize
procedures, and improve communication within surgical
teams. Using checklists can significantly reduce the risk of
errors and ensure the best possible outcomes for our patients.
Resources

Brown, D., Edwards, H., Buckley, T., & Aitken, R. (eds), 2020, Lewis’s
Medical-Surgical Nursing 5e, Elsevier Australia, Chatswood, Australia.
Pritchard., M.J. (2012). Pre-operative assessment of elective surgical
patients. Nursing Standard, 26 (30), 51-56.
Queensland Health - Perioperative Patient Record – Preoperative Checklist
https://www.health.qld.gov.au/__data/assets/pdf_file/0029/1158941/pre-op-
checklist-context-document.pdf
WHO Surgical Safety Checklist: https://www.who.int/teams/integrated-
health-services/patient-safety/research/safe-surgery/tool-and-resources

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