Preoperative Assessment

术前评估

Assessment and Implementation

评估实施

1. Use Standard Protocol.

1、按标准护理程序开始操作。

2. Determine if the client has any communication impairment and if the client is mentally competent.

2、确定病人是否存在沟通障碍，心智是否健全。

3. Assess the client's understanding of the intended surgery and anesthesia.

3、评估病人是否了解即将进行的手术及麻醉。

4. Obtain a nursing history:

4、获取护理史

• Condition leading to surgery
• The need for isolation precautions.
• Chronic illnesses.
• Last menstrual period (for female clients in childbearing years).
• Previous hospitalizations.
• Medication history, including prescription and over-the-counter (OTC), and date/time of last doses.
• Previous experience with surgery and anesthesia.
• Family history of complications from surgery or anesthesia.
• Allergies to medications or food, including specific questions about natural rubber latex.
• Physical impairment.
• Prostheses and implants (e.g., dentures, hearing aid, pacemaker, internal defibrillator, hip prosthesis)
• Smoking, alcohol, and drug use.
• Occupation

• 手术病情
• 隔离需要
• 慢性疾病
• 末次月经(育龄期女性病人)
• 既往住院史
• 用药史，包括处方与非处方药，末次用药日期/时间
• 既往手术及麻醉史
• 家庭成员是否有手术或麻醉并发症史
• 药物或食物过敏史，包括天然橡胶过敏反应
• 身体残障
• 假体和移植(如义齿、助听器、起搏器、除颤器、人工髋关节)
• 吸烟、饮酒和吸毒史
• 职业

5. Assess client's weight, height, and vital signs.

5、评估病人体重、身高和生命体征。

6. Assess client's respiratory status, including character and rate of respirations, oxygen saturation, ability to breathe lying flat, and chest x-ray report.

6、评估病人呼吸系统状况，包括呼吸特征与速度，氧饱和度，平卧呼吸能力及胸片。

7. Assess client's circulatory status, including apical pulse, electrocardiogram (ECG) report, and peripheral pulses.

7、评估病人循环系统状况，包括心尖搏动、心电图和外周脉搏。

8. Determine client's neurological status, including level of consciousness (LOC). 医学.全在线www.med126.com

8、确定病人神经系统状况，包括神志清醒程度。

9. Assess client's musculoskeletal system, including range of motion (ROM) of joints.

9、评估病人肌骨骼系统状况，包括关节活动度。

10. Examine client's skin; identify any breaks in skin integrity and determine level of hydration.

10、检查病人皮肤，确认皮肤完整性受损情况，确定水合程度。

11. Assess client's emotional status, including level of anxiety, coping ability, and family support.

11、评估病人情绪，包括焦虑程度、应对能力和家庭支持。

12. Review the results of laboratory tests, including complete blood count (CBC), electrolytes, urinalysis, and other diagnostic tests.

12、检查化验报告，包括全血计数、电解质、尿检和其他诊断试验。

13. Ask if client has an advanced directive.

13、询问病人是否得到事先说明。

14. Identify the time of client's last intake of food or drink.

14、确认病人上次摄食与饮水时间。

15. Use Completion Protocol.

15、按标准护理程序完成操作。

Evaluation

评价

1. Review records to determine if necessary information has been assessed.

1、复查记录，确定必需内容是否得到评估。

2. Evaluate client's ability to cooperate.

2、评价病人的合作能力。

3. Identify Unexpected Outcomes and Nursing Interventions

3、确认意外结果与护理措施

Record and Report

记录与报告

1. Using agency format (preoperative checklist), complete all essential information.

1、使用医院表格(术前目录单)，填写所有的必需信息。

2. Report abnormal laboratory values and other concerns to the surgeon or anesthesiologist.

2、向手术医生或麻醉师报告异常化验结果及其他问题。

Revised