PERIOPERATIVE PATIENT ASSESSMENT: HELPING PATIENTS ACHIEVE THEIR GOALS

1933 1933 Table of Contents

PERIOPERATIVE PATIENT ASSESSMENT: PURPOSE/GOALS ...... i PSYCHOSOCIAL ASSESSMENT ...... 9 HELPING PATIENTS ACHIEVE THEIR GOALS OBJECTIVES ...... i 1. Elicits Perception of Sugery ...... 9 INTENDED AUDIENCE ...... i 2. Elicits Expectation of Care ...... 9 AORN INDEPENDENT STUDY ACTIVITY GUIDE FOR STUDY ...... i 3. Determines Coping Mechanisms ...... 10 PERIOPERATIVE NURSING ASSESSMENT . . . .1 4. Determines Knowledge Level ...... 10 STUDY GUIDE WITH VIDEO SOURCES OF ASSESSMENT DATA ...... 1 5. Determines Ability to Understand ...... 11 1. Surgical Schedule ...... 1 6. Identifies Philosophical and Religious Beliefs .11 2. Patient Chart ...... 1 7. Identifies Cultural Practices ...... 11 3. Patient Interview ...... 2 8. Communicates Psychosocial Data Relevant to 4. Physical Examination ...... 3 Planning ...... 12 5. Consultation with Other Health Care 9. Communicates/Documents Psychosocial Status. .12 Professionals ...... 4 REASSESSMENT ...... 12 PHYSIOLOGICAL ASSESSMENT ...... 4 IMPLICATIONS FOR NURSE MANAGERS . . .12 1. Verifies Operative Procedure ...... 4 SUMMARY ...... 13 2. Notes Condition of Skin ...... 4 APPENDIXES 3. Determines Mobility of Body Parts ...... 4 Appendix 1 ...... 14 4. Reports Deviation of Diagnostic Studies ...... 5 Appendix 2 ...... 14 5. Checks Vital Signs ...... 5 NOTES ...... 16 6. Notes Abnormalities, Injuries, and Previous SUGGESTED READING ...... 19 Surgery ...... 5 POSTTEST ...... 20 7. Identifies Presence of Internal and External ANSWER SHEET ...... 23 Prostheses/Implants ...... 6 8. Notes Sensory Impairments ...... 6 9. Assesses Cardiovascular Status ...... 6 10. Assesses Respiratory Status ...... 6 11. Assesses Renal Status ...... 7 12. Notes Nutritional Status ...... 7 13. Verifies Allergies ...... 8 14. Screens for Substance Abuse ...... 8 15. Communicates Physiological Data Relevant to Planning for the Patient's Discharge ...... 8 16. Communicates/Documents Physical Health Status ...... 8

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Reprinted with permission from the AORN, Inc. Copyright 1997 (Revised 2005) All rights reserved by AORN, Inc. 2170 South Parker Road, Suite 400, Denver, Colorado 80231 (800) 755-2676 · www.aorn.org Video produced by Cine-Med, Inc. 127 Main Street North, Woodbury, CT 06798 Tel (203) 263-0006 ˜ Fax (203) 263-4839 ˜ www.cine-med.com PURPOSE/GOALS GUIDE FOR STUDY PERIOPERATIVE NURSING ASSESSMENT SOURCES OF ASSESSMENT DATA The purpose of this independent study is to review This study is intended for use in conjunction with the AORN’s “Standards of Perioperative Clinical Practice” Perioperative assessment involves the patient, the principles of perioperative assessment, with specific accompanying video, “Perioperative Patient Assessment: define assessment as follows: significant others, and other health care providers. It may reference to the role of the perioperative nurse in this Helping Patients Achieve Their Goals.” We suggest that “Assessment is the systematic and ongoing collection of data, be accomplished through diverse means, such as interviews, process. Sources of assessment data are described, you take the following steps to complete this education guided by the application of knowledge of physiological and reviews of records, and/or consultations.6 It begins with including the surgical schedule, the patient’s chart, the activity. psychological principles and experience, and is used to make a review of the patient’s chart (if appllicable), followed patient interview and physical examination, and consultation 1. Read the overview and objectives for this education judgments and predictions about a patient’s response to by a patient interview, a physical examination, and often with other health care professionals. Aspects of activity and compare them with your own learning illness or changes in life processes. Assessment is essential conferences with other members of the health care team. physiological and psychosocial assessment and reassessment objectives. to establishing a nursing diagnosis and predicting outcomes. All of this establishes a baseline for setting realistic goals are examined in detail. Implications for nurse managers 2. View the video. Assessment may occur in a variety of settings.”1 relative to the impending procedure.7 If the primary goal are also mentioned. 3. To reinforce your learning, return to the study guide The objective of perioperative nursing assessment is to in post-operative care is to return the patient to normal and view the content, paying particular attention to collect comprehensive data on the physiological and psy- functioning, it is important to clarify what “normal OBJECTIVES those areas that reflect the objectives. chosocial status of the patient in order to identify func- functioning” is for each individual via careful preoperative After viewing the film and completing the study 4. Consult the list of suggested readings for further tional and dysfunctional health patterns that may affect functional assessment.8 guide, the participant will be able to: information. the patient during the perioperative period.2 For inpatients, the perioperative nurse collects 1. discuss the benefits of a comprehensive patient Many providers assess the patient before surgery, assessment data during a preoperative visit and through a assessment, including the perioperative nurse, the surgeon or surgical chart review the afternoon or morning before surgery. 2. describe the sources of assessment data, resident, and the anesthesia care provider. This study For outpatient and same-day admission patients, information 3. explain how perioperative assessment fits into the guide is concerned with assessment data collected by the can be obtained from a patient questionnaire, the patient nursing process, perioperative nurse. The location, timing, and method of history, physical forms, physician’s orders sent to the 4. list the components of physiological and psychosocial assessment may vary with the particular circumstance of facility from the physician’s office, previous medical assessment, the facility and individual patient needs.3 Preoperative records (eg, previous admission medical records sent to 5. list the effects that characteristics of the patient may assessments may be performed in a variety of settings, the surgery department the day before surgery), and have on these aspects of the perioperative assessment and even frequently by phone. Regardless of the setting, pertinent information listed on the surgery schedule.9 process, and it is important that some form of assessment, patient and Each of these sources provides certain pieces of 6. discuss the implications of perioperative assessment family education, and discharge planning be done.4 information critical to the development of an appropriate requirements for nurse managers. Assessment data may be collected at any time in the plan of care. The perioperative nurse is responsible for preoperative, intraoperative, or postoperative period, ensuring that the preoperative assessment is complete INTENDED AUDIENCE beginning with the patient’s decision to have surgical and the patient’s emotional needs are met. This self-paced educational program is intended for intervention and ending with a resolution of surgical use by perioperative nurses who conduct perioperative sequelae. Assessment and planning before the day of 1. Surgical Schedule assessments of surgical patients. surgery helps prevent delays or cancellations.5 The surgical schedule provides information regarding Assessment is considered the first step in the six-step the patient’s age and sex, the planned operative procedure, perioperative nursing process. It provides a basis for the type of anesthesia, the names of the surgeon and clinical judgments that will ultimately result in the anesthesia care provider, and the estimated duration of formation of nursing diagnoses; identification of expected surgery. Review this information carefully before seeing outcomes; development and implementation of an effective, the patient, because the type of procedure scheduled will individualized plan for preoperative, intraoperative, and influence your assessment. 10 postoperative care that will meet the patient’s physical and emotional needs; and evaluation of the extent to 2. Patient Chart which expected outcomes were achieved. (See A thorough chart review provides the nurse with a Appendix 1) preliminary understanding of the physiological and psychosocial characteristics of the patient. The patient’s chart contains data that have already been obtained by

i 1 other members of the health care team. Written information • Nursing history - The nursing history consists of a and explaining the role you will be performing in regards you have hemophilia?” Ask, “When you cut yourself, do and information gathered by others should be verified compilation of data accumulated by any and all professional to the patient’s surgery. Explain the purpose of the you usually stop bleeding quickly?”23 For school-age with the patient. nurses who have come in contact with the patient. Pay assessment interview and the value that can come from patients, using projective techniques, such as art work, • Admission information - Refer to the admission particular attention to any documented allergies, time and it.17 Be sure to ask permission before addressing patients can be a significant means of nonverbal expression. information sheet to obtain the patient’s legal name, nature of last food/fluid intake, possibility of pregnancy, by their first name, especially the elderly.18 Before asking Children’s drawings often reveal concerns about mutilation, address, telephone number, social security number, birth medical history, sociocultural background, physical routine admission questions, spend a few minutes getting body changes, and loss of self-control that children date, sex, marital status, religious preference, employment nursing observations, the patient’s emotional state, and acquainted with the patient and assessing his or her facing surgery are unable to voice.24 and insurance data, and next of kin and emergency contacts.11 any nursing diagnoses formulated by other nurses. emotional condition.19 Sit close to the patient, and listen.20 As a way of closing the interview, ask the patient if These data can provide important clues to areas that may • Patient directives - It has become customary to include Create a sense of empathy by demonstrating honesty, there are any other areas he or she wishes to discuss. This need to be explored further during the interview, such as patient directives that specify the patient’s wishes about warmth, and interest, possibly through a light touch to provides the patient with an opportunity to bring up areas the availability of needed social support. transfusions, resuscitation, prolongation of life, organ the shoulder or elbow. of concern that you did not address specifically or that • Informed consent - Although it is the physician’s donation, and autopsy. It is important that the health care Most interviewers use an open-ended interview style. the patient may have forgotten about earlier. responsibility to provide complete explanations of the team act in accordance with such directives. To gain greater insight into the patient, try some of the If necessary, family members or friends can be planned surgical procedure and to obtain informed • Reports of other professionals - The chart may following techniques. interviewed separately.25 Significant others can verify consent from the patient, the nurse must confirm that the include reports from medical specialists, other nurses, • Use direct questioning when brief answers are information provided by the patient or can provide chart includes a valid informed consent and verify that the anesthesia care provider, physical and occupational required. important information when the patient is unable or the patient understands the risks and alternative procedures.12 therapists, respiratory therapists, dietitians, or social • Use silence to allow the patient time to gather his or unwilling to communicate; however, information provided • Physician’s history and physical examination - On workers. Medical records may be in the form of the her thoughts and to give yourself time to reflect on by significant others may be subject to bias and the medical history and physical examination record, the traditional source-oriented medical record, where each what was said. misinterpretation. patient’s physician will have noted the chief complaint person or department makes notations in a specific • To get the patient to elaborate on something, use For example, a daughter or close friend may report and the reason for the surgery. This form also should section, or in the form of a problem-oriented medical actions such as a nod of the head, a puzzled look, that an elderly patient is faithful about taking medications, contain important information about the patient’s physical record, where data about the patient are recorded and or verbal statements such as “Mmm-hmm,” “Really?” but the truth may be that he or she is only faithful when condition and a description of the surgical site. arranged according to the patient’s problems instead of or “Tell me more about that.” someone else is around. The reality may be that when left • Medication sheet - Review the medication sheet to according to the source of the information. • Be aware of body language and other nonverbal alone, the patient may be forgetful or confused about determine what medications the patient is currently taking. signals you may be giving and receiving. what, when, and how much medication he or she really To validate this information, it may be helpful to have the 3. Patient Interview • Verbally acknowledge the patient’s feelings of is taking. Significant others can become so familiar with patient bring a list of his or her medications or the original A preoperative health history often is obtained by anger, depression, or sadness. certain patient behaviors that the health significance or prescription bottles to the preoperative interview. Be sure having the patient complete a questionnaire and then • Summarize or repeat the patient’s statements. rationale for the behavior is lost. to ask the patient about the use of herbs or botanical asking questions to verify or elaborate on the information Allow the patient to give as thorough a history as products since they may accentuate the toxicity of provided.14 You will be able to direct the patient possible, with a minimum of interruptions.21 Most 4. Physical Examination anesthetics or interfere with drug metabolism or clearance.13 interview more effectively if you review the chart and patients will try to give complete, correct information, The physical examination usually is performed by the 26 In 1999, the American Society of anesthesiologists any information contained on the questionnaire before but their reports may be inaccurate for a variety of physician, but it may be performed by a nurse using the (ASA) cautioned patients to stop taking herbal products speaking to the patient.16 reasons. For example, the patient may not understand the techniques of inspection, palpation, percussion, and 27 at least two to three weeks before the day of surgery.14 If feasible, conduct the patient interview in such a way question, not know how to answer the question, not auscultation. • Results of diagnostic tests - Review reports of that the patient won’t feel rushed. Create an atmosphere remember the incident, be afraid of the diagnosis, be • In inspection, the eyes are used to observe the patient, diagnostic tests, including any blood tests and urinalysis, conducive to open communication by drawing the afraid of having surgery canceled or postponed, or not concentrating on what to look at, rather than what to look for. bacterial cultures, diagnostic imaging, electrocardiogram curtain or closing the door to create privacy and prevent perceive the symptom as important or relevant.22 If • Palpation uses the hands and fingertips to distinguish (ECG), ultrasound, or endoscopy. distraction from other patients, staff members, or visitors. possible, check the reliability and accuracy of assessment temperature variations, hard and soft, rough and • Nursing notes - The inpatient unit nursing notes may If necessary, turn off any radios or televisions, or ask data by validating them with other data, checking other smooth, stillness and vibration. Light palpation is contain information that could affect perioperative nursing nonessential persons to leave the room. If the patient sources, or obtaining additional information. best because sensitivity can be dulled by pressure. activities, such as transportation to the OR or intraoperative prefers to have family members present, be sure to If health care or medical terminology is not familiar • Percussion is used to detect tenderness or pain in positioning. They also will include records of vital signs include them, but be aware that the presence of others to the patient, try using an expanded interview method that the underlying tissues. It is accomplished by laying and intake/output. may cause the patient to withhold vital information. involves asking questions about the patient’s experiences an outstretched middle finger over the area to be Begin the interview by giving your name and title or daily activities. For example, instead of asking “Do percussed and tapping the distal part using the tip of the middle finger of the opposite hand. 2 3 • For auscultation, a stethoscope is used to listen to symptoms and precipitating factors. Assess skin color, 4. Reports deviation of diagnostic studies the discrepancy between the arms is greater than 10 mm Hg, the quality and quantity of the patient’s respiratory, turgor, temperature, and presence of lesions, rashes, Determine what laboratory, radiologic, and other notify the physician.40 If the patient has a history of heart, and bowel sounds. bruises, excoriations, or previous incisions. Skin color diagnostic studies the physician ordered, and confirm hypertension, ask if he or she is taking antihypertensive 5. Consultation with Other Health Care Professionals may be pale, flushed, dusky, cyanotic, jaundiced, normal, that the results are on the chart. Review results of those medications or has a need for electrolyte replacement. If necessary, consult with the patient’s physician or or “other.” studies to determine whether they are within normal Respirations are best assessed with the patient sitting other members of the health care team to clarify the Pay close attention to areas over bony prominences. ranges. If findings are abnormal, notify the surgeon.36 quietly, usually in conjunction with measurement of the patient’s medical diagnosis, progress, and plans to meet If the patient comes to the facility with a pre-existing Recommendations for laboratory testing have decreased temperature and radial pulse. Count each cycle of inspiration medically oriented goals of surgery. Rely on other nurses to pressure sore, make sure that it gets prompt treatment. substantially in recent years as preoperative laboratory and expiration, preferably for a full minute. While counting, provide continuity of care by communicating information Patients at high risk for skin breakdown should be screening has shifted from a paradigm of general health listen for sounds that accompany respirations. Abnormal when a patient is transferred to another unit or health managed aggressively with mobilization, a pressure- screening to testing based on specific clinical indications. sounds include audible wheezes and the sounds that care facility.28 reducing mattress, and nutritional support.33 For example, testing electrolytes, previously a mainstay accompany narrowing or obstructed upper airway passages, Check the color of the patient’s nail beds. If the of “routine” preoperative testing, is no longer performed such as whistling. Factors that affect respiratory rate PHYSIOLOGICAL ASSESSMENT patient is wearing nail polish, it may need to be removed without a medical indication such as the presence of diabetes, include conscious awareness of being observed, recent Using the assessment techniques and data sources to assess peripheral filling of the bed. Also, polish could dialysis, or use of diuretic or potassium supplements.37 activity, anxiety, increased ambient room temperature, described above, perioperative nurses conduct both interfere with pulse oximeter readings.34 It is possible to 5. Checks vital signs age, and medications. Normal respiratory rate ranges physiological and psychosocial assessments. measure oxygenation and peripheral filling at other sites, Assess the patient’s pulse, temperature, blood pressure, between 14 and 22 breaths per minute in the average Physiological assessment involves collecting baseline such as the ear lobes. and respirations. Measure weight and height, and note adult. Compare findings to the patient's baseline and record.41 data on what is normal for the patient (eg, vital signs, Today’s trends include piercing of various body areas the patient’s chronological age. Always communicate abnormal vital signs to the surgeon nutrition, fluid balance).29 Past and present pathological accompanied by the insertion of jewelry. In some Begin by taking a radial pulse, noting rate, amplitude, and anesthesia care provider. conditions should be noted. If necessary, surgery can be circumstances, the ring or jewelry cannot be removed, and deficits. If abnormalities such as irregular beats or Record the patient’s chronological age, weight, and delayed or canceled until certain conditions are which creates the need for planning regarding the skipped beats are noted, assess the apical pulse for a full height, including metric equivalents for height and weight. resolved.30 potential for infection and electrosurgical burns. If the minute and correlate with the respiratory cycle. Peripheral If the patient is less than two years of age, record the age in The AORN “Competency Statements in area pierced is involved in the surgical site, prepping will irregularities may reflect a cardiac irregularity, such as a months.42 Obese or excessively tall individuals may require Perioperative Nursing” define 16 measurable criteria that be of major importance to eliminate excessive bacteria sinus dysrhythmia, or indicate possible peripheral vascular additional positioning equipment during surgery. comprise competency “to assess the physiological health which tends to accumulate around foreign objects. incompetence. Because the pulse rate ranges between 60 6. Notes abnormalities, injuries, and previous surgery status of the patient.” (See Appendix 2.) Each of these If the jewelry is metal, safeguards will be needed to and 100 beats per minute for the average adult, consider Obtain a history of previous hospitalizations, surgeries, competencies will be addressed in turn. prevent direct and indirect electrosurgical energy factors that may affect this range, such as extreme physical or other invasive procedures, including blood transfusions. 1. Verifies operative procedure coupling during the procedure. fitness, recent activity, anxiety, age, and side effects of Record any loss of an extremity or other body part and Verify the patient’s identity verbally and by checking 3. Determines mobility of body parts medication. Record findings and compare to the patient’s any congenital abnormalities. the patient’s record and identification bracelet or wrist- Ask the patient about any history and dates of mus- baseline. Note the dates and the reasons for any previous band. Use two patient identifiers (eg, full name and date culoskeletal illness, traumatic incidents (eg, fractures), Assess body temperature and note elevations above hospitalizations, their outcomes, and the type of anesthesia of birth). Verify the procedure to be performed, paying paralysis, or orthopedic surgery, particularly joint normal. A febrile state also may be reflected in pulse and used. Note any previous problems with surgery or particular attention to the anatomic surgical site.31 In the replacement. Identify any family history of osteoporosis respiration measures elevated above baseline and a lower anesthesia, including a personal or family history of case of bilateral organ, limb, anatomic site, or multiple or bone cancer. blood pressure. Presence of a fever inevitably means that excessive blood loss during surgery, transfusion reactions, structure levels, the site should be marked, using an Assess balance, posture, gait, mobility, range of the patient’s surgery must be delayed. hyperthermia under anesthesia, low level of pseudo- indelible marker, before giving the patient narcotics, motion, and any gross deformities or physical handicaps. Measure the patient’s arterial blood pressure in the cholinesterase (the enzyme necessary for reversal of sedation, or anesthesia.32 Ensure that there is a valid, Look at muscle size, symmetry, and strength, particularly brachial artery.38 Use the sitting position unless specified anesthetic paralyzing agents), or postoperative nausea signed surgical consent. Be especially vigilant in this grip strength. Assess the patient’s ability to perform activities otherwise. In addition to measurement error, factors that and vomiting. If available, include old medical records area for elderly patients and others who may have their of daily living required to live independently. Elderly can affect blood pressure readings include age, sex, race, with the patient’s chart. health care decisions made by legally designated others. patients may be reluctant to give accurate information diurnal variations, exercise, stress, obesity, medication Ask female patients of childbearing age about the 2. Notes condition of skin about functional ability, interpreting it as a threat to their effects, position changes, recent food ingestion, ambient possibility of pregnancy. Because of the teratogenicity of Ask about recent skin problems or a family tendency ability to live independently. It may be necessary to room temperature, disease processes, smoking, pain, and many anesthetic agents, some experts advocate mandatory toward chronic skin disorders. If skin problems exist, tactfully obtain family members’ perceptions of the crossing the legs.39 If bilateral readings are taken, record the pregnancy testing in all women of menstruating age who determine when they began and any associated patient’s ability to manage daily activities.35 higher reading, not both unless specifically requested. If have not had a tubal ligation or hysterectomy. Others

4 5 also suggest mandatory testing in all adolescent surgical Tachycardia, tachypnea, and postural changes in blood as a result of normal decreases in lung elasticity and nature of gastrointestinal bleeding, pain, constipation or patients aged 15 and older.43 pressure are all associated with cardiovascular disease. reductions in the effectiveness of cough and ciliary diarrhea, incontinence, or vomiting; and abnormal belching, 7. Identifies presence of internal and external Assess the patient’s activity level, exercise patterns, and mechanisms. Chronic obstructive pulmonary disease gas, or flatulence. Acute gastrointestinal disorders, such as prostheses/implants any participation in cardiac rehabilitation activities. (COPD) greatly increases the risk of pulmonary vomiting and diarrhea, may result in serious fluid and Note the presence of any implanted electronic device Auscultate for heart sounds. Patients with auscultatory complications and may be treated preoperatively with electrolyte imbalances. (IED) or external prostheses or implants, including cardiac findings that suggest cardiac disease or potential problems expectorants, bronchodilators, and antibiotics.49 Note the presence of a Foley catheter, colostomy, or pacemakers, cardioverter defibrillators, ventricular assist require additional evaluation and possible preoperative Note the patient’s respiratory rate, breath sounds, ileostomy. Check for the presence of teeth, dentures devices, lens implants or glass eyes, or orthopedic hard- intervention to manage surgical risks. Palpate for thrills oxygen saturation, and arterial blood gases if ordered. (upper/lower, partial), caps, or crowns.52 ware, including artificial limbs, internal fixation devices and murmurs over heart valve areas, and check for Inspect the chest and auscultate the lungs directly List all medications used for gastrointestinal problems, such as rods or pins, and total joint implants. cardiomegaly, which is present if the apex of the heart through the chest wall, preferably with the patient sitting, including over-the-counter antacids, laxatives, enemas, 8. Notes sensory impairments can be percussed past the midclavicular line. legs dangling over the side of the examination table with and sodium bicarbonate. Auscultate, percuss, and palpate Assess the patient’s sensory abilities, including Note the presence of neck vein distention. Neck veins the stethoscope beneath the patient’s drape or gown. A the abdomen and observe its contour (ie, obese, flat, vision, hearing, and speech, and note the presence and should distend only if the patient lowers the head to assume normal adult respiratory rate is between 14 and 22 breaths distended, or hollow). severity of any deficits and the use of corrective devices. the supine position; they should not distend if the patient per minute, with even depth and rhythm; symmetric Confirm the patient’s nothing-by-mouth (NPO) status. Sensory deficits can require adjustments to your remains in a sitting position. Jugular venous distention is thoracic movements on inspiration; absence of audible Ask the patient when he or she last ate or drank anything interviewing techniques and can affect the patient’s associated with increased cardiac risk in surgical procedures. sounds, retractions, or nasal flaring; and no use of auxiliary (including water). Although the patient should have been functioning and reaction to the surgical experience. For Palpate the lower extremities for edema by pushing muscles. Note any abnormalities, such as barrel-, funnel-, instructed not to eat or drink anything after midnight example, if a hearing deficit is noted, be sure there is with the thumb to depress the skin over the shins or dorsum or pigeon-shaped chest and spinal deformities. A patient (or according to facility anesthesia protocols), it is adequate light during the patient interview to facilitate of the foot for five seconds. Upon release of pressure, with significant abnormalities in respiratory function important to make sure those orders were followed.53 lip reading. Ask short, direct questions but avoid shouting, note any depression remaining in the skin. There should should have further screening of pulmonary function Evaluate the patient’s fluid and electrolyte status and which can make speech perception difficult. If a hearing- be none. Residual depression is called “pitting edema.” before proceeding with surgery.50 recent fluid intake and output.54 Mildly dehydrated impaired patient cannot read lips, use a preprinted health Document the length of time pitting is evident, if any. 11. Assesses renal status patients are more likely to become hypotensive with history questionnaire. If necessary, enlist the aid of Palpate pedal pulses. They should be of symmetric Determine if the patient has a history of urinary tract induction of anesthesia; therefore, it is wise to have an family members or significant others. quality and readily palpable. If nonpalpable, look for infections or urologic surgery, or if he or she has experienced IV infusion in place before induction.55 9. Assesses cardiovascular status other signs of adequate peripheral circulation, such as any recent changes in the color or appearance of the Evaluate the patient’s weight for signs of alteration in Perioperative myocardial infarction is the leading skin temperature (warm), color (even without mottling or urine, pattern of urination, or ability to start or control nutrition (ie, more or less than body requirements). Ask cause of death after surgery.44 A thorough assessment of cyanosis), and response to blanching of the nail beds or urination. If the patient reports episodes of urinary about typical eating patterns and salt intake, and note the cardiovascular system is necessary to detect cardiac distal toes (ie, capillary refill within three seconds).47 If incontinence, find out in what situation(s) the incontinence suspected eating disorders, such as anorexia and bulimia. problems such as hypertension, congestive heart failure, the patient has cold or pale feet, absent or diminished occurs. Note reports of intake/output, urinalysis, and renal Depressed serum albumin levels or total lymphocyte arrhythmias, or recent myocardial infarction that must be peripheral pulses, cyanosis or flushing of the extremities, function studies. counts, significant drops in weight during the past six treated or stabilized before the patient can have surgery.45 or leg cramps when walking, pay particular attention to Note the presence of edema in pedal, pretibial, presacral, months, or the presence of edema or anemia may suggest Ask if the patient has any history of progressive leg and foot care in the postoperative period. and periorbital tissues; altered level of consciousness; or malnutrition. If you detect severe nutritional deficiencies, weakness, shortness of breath, syncope, diaphoresis, Cardiovascular problems are particularly common in gait and hand incoordination, any of which may be contact the physician. Poor nutritional status is highly nausea, or vomiting and under what circumstances. Note the elderly, especially in the presence of ischemic heart affected by the presence of renal disease. correlated with delayed recovery, longer hospital any personal or family history of heart disease, diabetes, disease, congestive heart failure, or recent (ie, within the The elderly have decreased efficiency of renal excretion admissions, and higher mortality rates, but there is some stroke, or thromboembolism. Determine whether the past three to six months) myocardial infarction.48 and reabsorption. Resulting imbalances in fluids and indication that nutritional supplements in the preoperative patient is currently taking any medication for existing 10. Assesses respiratory status electrolytes may contribute to cardiac complications or period may improve surgical outcomes. It may be desirable to cardiovascular disease, such as nitroglycerin, digitalis, Determine if the patient has a history of asthma or mental status changes.51 postpone surgery until nutritional problems are corrected.56 diuretics, antihypertensives, potassium supplements, other lung disease, the type of therapy prescribed, and 12. Notes nutritional status Because of metabolic changes, disease processes and heparin, or coumadin. Abruptly discontinuing medications, the effectiveness of treatment. If the patient reports To assess the patient’s nutritional status and gastrointestinal their treatment, and environmental and psychological such as propranolol, can make angina worse and, in some shortness of breath, ask when it occurs. If a cough is functioning, find out if he or she has any history of gastro- circumstances, the elderly are at increased risk for poor cases, even bring on myocardial infarction. Verify that present, determine whether it is productive, hacking, intestinal problems, along with the types of therapy used nutritional status compared to younger adults.57 Ten to such medications have been withdrawn gradually over paroxysmal, brassy, habitual, or nervous. and their effectiveness. Ask about recent weight gain or 20% of the elderly have borderline nutritional status, several days.46 Refer to the patient’s vital signs. Pulmonary complications are common in the elderly loss; bowel and bladder habits; the presence, frequency, and which places them at risk for postoperative skin

6 7 breakdown, impaired wound healing, and infection. intake and recreational drug use are essential. Chronic Any structured format used should enable the nurse just as much anxiety or fear.76 Patients most likely to be poorly nourished are those who alcohol use can signal a hepatic or nutritional disorder to collect comprehensive data about the patient for the Recognizing the fears and fantasies of children can help are depressed, demented, immobile, or isolated. The that increases the risk for perioperative bleeding. purpose of identifying and treating health problems.71 prevent some of the transient disturbances associated with multifactorial nature of their nutritional risk makes Recreational drug use can directly affect cardiovascular pediatric surgical experiences (eg, increased dependency, assessment of nutritional status in the elderly a complex and respiratory function and put the patient at risk from PSYCHOSOCIAL ASSESSMENT excessive fears, eating and sleeping disturbances). task. A simple nutritional screening tool can be used to anesthetic agents. A positive history for either requires Psychosocial assessment involves assessing both the Impending surgery also may threaten a patient’s body evaluate mental condition, weight, appetite, ability to follow-up questions to quantify the type and amount of patient’s and the family members’ knowledge level image and self-concept. Explore any changes or crises, if eat, gut function (eg, presence or absence of diarrhea, drugs or alcohol consumed.64 concerning the perioperative experience and ability to any, that have occurred in the patient’s physical appearance vomiting, nausea), medical condition, and presence and Ask the patient if he or she ever smoked, when, for adhere to the prescribed therapeutic regime, implement self- or functioning during the past year. Assess the patient’s severity of pressure sores.58 how long, and how frequently. Nicotine has a vaso- care activities, handle fear, deal with anticipatory anxiety, feelings about any changes in physical appearance that 13. Verifies allergies constrictive effect on microcirculation. Vasospasm, recognize and resolve a body image disturbance, grieve will occur as a result of surgery.77 Make a note if surgery Carefully document any history of allergies or which is induced by nicotine, is detrimental to tissue successfully, and effectively cope with the stress associated will entail removal of, change in, or scarring of a body hypersensitivity reactions to foods (particularly eggs, oxygenation and metabolism. Vasospasm also can lead to with surgery.72 part that is significant to sexual identity or is visible to because egg antigens can be found in the suspending fluid microemboli.65 Cigarette smoking should be curtailed at The AORN “Competency Statements in Perioperative others. Patients may experience difficulty in integrating of some vaccines),59 environmental allergens, chemicals, least two weeks before surgery because of adverse Nursing” define the following nine measurable criteria that the impending body change and may feel that the body tapes, medications (eg, antibiotics, narcotics, local effects on pulmonary function and wound healing. If comprise competency to assess the psychosocial health will be imperfect after surgery. anesthetics), iodine products such as povidone iodine, smoking must be restricted postoperatively, let the status of the patient/family.73 A patient who appears emotionless or apathetic with soaps, hexachlorophene, or latex. patient know ahead of time.66 1. Elicits perception of surgery regard to the surgery actually may be depressed. If the patient reports a history of allergies or 15. Communicates physiological data relevant to Based on the patient’s verbal and nonverbal behavioral Statements indicating a sense of hopelessness by the hypersensitivity reactions, determine the agent involved planning for the patient’s discharge responses, assess his or her perception of the impending patient may warrant further evaluation. Depression, like and the type of reaction experienced. Any history of ana- Discharge planning begins during the assessment surgery and the appropriateness of that perception. high levels of anxiety, can have adverse effects on post- phylaxis, asthma, or other respiratory difficulties related phase. Collection and communication of physiological Attitudes toward surgery may include anxiety, anger, operative outcomes. The depressed person frequently has to the presence of allergens, toxins, or antigens should be assessment data help identify potential needs for in-home depression, body image disturbances, or relative calm. symptoms, such as decreased energy and motivation, noted and communicated to the anesthesia care provider.60 caregivers, durable medical supplies, and follow-up care Anxiety is a state of apprehension, tension, concern, loss of appetite, and numerous physical complaints that In recent years, severe anaphylactic reactions and so that arrangements can be made even before the patient or uneasiness in response to a real or imagined danger. may result in increased analgesic use.78 even deaths have occurred because of latex allergies. is admitted.67 The earlier contacts are initiated with Physiological manifestations of anxiety include pallor, The patient may worry about the anticipated loss of a The risk of serious anaphylactic reactions increases in appropriate social services or rehabilitation agencies and cold, clammy skin, hand tremors, muscle tension, rapid body part or its usual functioning during or after surgery. patients with frequent exposure to latex-containing products. facilities, the earlier the patient can be discharged from pulse, diarrhea, and increased urination. Behavioral Some patients fear mutilation, even if surgical outcomes These risk factors include multiple intra-abdominal or the hospital postoperatively. To provide appropriate post- manifestations include restlessness, wringing of hands, are basically corrective. Radical procedures may trigger genitourinary surgical procedures, especially starting in discharge care, these agencies will need access to complete difficulty maintaining eye contact, general irritation, anxieties about dismemberment, major alterations in infancy; chronic conditions requiring continuous or assessment information, which is considered a legal sullenness, withdrawal, crying, and defensiveness.74 body structures, paralysis, or possible death.79 If the intermittent catheterization; work in medical and dental document and an official aspect of the patient’s record. Anxiety may take the form of increased questioning or patient reports distress at an anticipated loss, crying at professions with daily exposure to latex products; history 16. Communicates/documents physical health status information-seeking about the perioperative experience, frequent intervals, having a choked feeling, a change in of allergies and asthma; or a history of reactions to latex All physiological data collected during the assessment voice tremors or pitch changes, increased verbalization eating or sleeping habits, changes in activity level or balloons, condoms, or gloves.61 Patients with a history of phase must be thoroughly documented in retrievable form,68 or rate of verbalization, and a narrowing focus of attention. libido, or alterations in concentration, he or she may be allergic reactions to bananas, kiwifruits, avocados, stone so that they can be easily accessed by other members of the Most surgical patients will appropriately experience experiencing anticipatory grieving for expected changes fruits, raw potatoes, tomatoes, papaya, or chestnuts may perioperative team, including other nurses, anesthesia care some degree of anxiety. The amount of anxiety a patient in lifestyle or appearance.80 be at risk for developing latex allergy.62 providers, and surgeons. Professional accountability will experience depends on his or her current illness, past Some patients will be angry about the need for surgery. 14. Screens for substance abuse demands documentation and communication of both the experiences, expectations, and coping mechanisms.75 Frequently, patients will tend to use passive-aggressive Identify and document any history of addictive coping process and the outcome of nursing assessment and Children’s reactions to the environment vary. Their behavior to express anger, such as sulking or refusing to habits that might adversely affect the patient’s recovery, intervention to the entire perioperative team.69 responses and behavior correspond with their age (eg, a talk, rather than active, direct anger.81 such as smoking, alcohol, drug abuse, or excessive intake of Documentation of assessment findings helps promote toddler may display regressive behavior). It may be easy 2. Elicits expectation of care food or caffeine.63 continuity of care70 when patients are sedated and cannot to assess and offer reassurance to obviously anxious children, Patients may be worried or nervous about the outcome Personal and confidential questions about alcohol answer questions reliably. but silent and cooperative children may be experiencing of the impending procedure, the amount of discomfort or

8 9 pain they will feel, or being away from dependent relatives. view of the patient’s health problem or denial of the existence 5. Determines ability to understand 6. Identifies philosophical and religious beliefs Others will be less anxious and will have confidence in or severity of disease process; intolerance toward the patient; After the patient’s current knowledge level is ascertained Patients’ philosophical and religious beliefs may doctors and nurses to carry out procedures successfully.82 or evidence of rejection, abandonment, or desertion. Be and teaching needs are identified, it is important to assess influence their attitudes toward health and illness and Try to assess the patient’s beliefs about how surgery will alert to signs that family members are adopting signs of the the patient’s ability to understand further instructions. affect their cooperation with prescribed treatment regimens. affect his or her current lifestyle. Determine whether the patient’s illness; influencing the patient to implement Barriers to comprehension of patient education include Assess the patient’s religious affiliation, attitude toward patient trusts caregivers to provide quality care throughout decisions; taking actions that could be detrimental to the psychopathology, sensory impairment, language barriers, blood transfusions, sacrament of the sick, and disposition the perioperative period and provide eassurance as necessary. patient’s economic or social well-being; or acting agitated, diminished mental capacity, and low education attainment. of limbs. Clues to the individual’s values in relation to The administration of anesthesia heightens a patient’s aggressive, or hostile toward the patient. All of these will have to be considered when planning caring behaviors, norms, beliefs, and practices can be concerns about being out of control. Patients may fear Determine whether there are family members, friends, nursing care.90 obtained by observing behaviors and verbal and emotional they will say something inappropriate during induction or others available to provide the patient with emotional Assess readiness and ability to learn new information, expressions. For example, some patients believe that illness or may feel modest about nudity. If necessary, reassure support preoperatively and postoperatively - someone paying particular attention to intellectual functioning, is evil, and that only God can really help one survive, the patient that his or her privacy will be respected. who is meaningful to the patient and whom the patient including any deficits in memory, intelligence, thinking, while others believe that humans control their own destinies Also assess each patient’s expected rehabilitation trusts.85 Also evaluate the resources available to the patient learning, and problem solving that are serious enough to and that what happens to them is a consequence of their potential. Preoperatively discuss and plan with the in the home (eg, type of housing, access to a telephone, affect daily life. In the elderly, cognitive functioning own actions.95 These philosophical beliefs will influence patient resolution of any potential or real problems.83 access to private or public means of transportation, financial should be verified with a family member, if possible, and their attitude toward their own illnesses and treatment. 3. Determines coping mechanisms resources, availability of support services).86 Assessing validated through mental status screening.91 Much of this 7. Identifies cultural practices Surgery can precipitate emotional crises in individuals the patient’s social supports during the prehospitalization evaluation can occur in the context of an informal interview. It is important to remember that not all patients hold, who are vulnerable due to a distorted perception of the phase often prevents problems before they occur.87 Asking the patient to describe events leading up to the or should hold, the same cultural values as the nurse. situation, lack of a support system, or inadequate coping 4. Determines knowledge level need for a surgical procedure, how various activities of Culture, in the anthropological sense, broadly refers to mechanisms. A period of mental disorganization may occur Determine whether the patient appears to have a daily living are managed, and what plans have been made for the learned, shared, and transmitted values, beliefs, norms, during which customary methods of problem solving fail. rational understanding of his or her health/illness status, postdischarge care will provide a fairly good indication of and practices of a particular group that guide thinking, Assessment must include an evaluation of the the anticipated procedure, why it’s being performed, and the patient’s cognitive processes. Formal mental status decisions, actions, and patterned ways. Subcultures patient’s coping ability, the family’s coping ability, and what the outcomes may be. In evaluating the patient’s testing using a tool such as the Mini Mental State Exam constitute groups of people who have cultural values the ability to adhere to prescribed therapeutic regimens. understanding of the planned surgical procedure along also may be valuable in providing an accurate assessment similar to a larger society, but who also hold additional Assess occupation-related stress, Type A behavior patterns, with the before and after care, it may be helpful to ask the of cognitive abilities.92 values particular to certain patterns of living. In the United stress related to marital or family status, and recent patient to relate these facts in his or her own words.88 Often, attention span is one of the first cognitive States, we have subcultures that are defined by age, stressful life events. Ascertain what coping devices or The patient or family members must have sufficient functions to be disturbed. Attentiveness to external conditions profession, or educational attainment, in addition to defense mechanisms the patient has used in the past to knowledge or skills to implement the recommended can be evaluated by the quality of the patient’s response ethnic groups of origin. The extent to which the values of manage stress. Find out how the patient usually resolves therapeutic regimens. The patient’s and family member- to questions, directives, and comments. Evaluate the a given culture or subculture are different from the tension, nervousness, or apprehension, and whether s’ understanding of the procedure may be evaluated by patient’s ability to be logical, coherent, and relevant. dominant culture in a population depends on the degree usual coping methods are working.84 Identify the use of exploring whether the patient appears to be complying Note any evidence of delusions, obsessions, and suspicious to which acculturation into a different or predominant defense mechanisms such as rationalization, projection, with suggested treatment or prevention regimens and or paranoid reasoning. cultural group has taken place. displacement, denial, and introspection. Consider whether whether the patient can recall adequate information Items to be assessed under the broad category of Assess the following culture-specific factors when the coping devices and defense mechanisms used are about past surgical or invasive procedures. A history of sensorium and reasoning include level of consciousness; planning appropriate nursing interventions: perceptions appropriate to the situation. noncompliance with previous instructions may be orientation to person, place, and time; recent and remote of wellness or general health, perception of what constitutes If the patient’s ability to cope seems to be an issue, note indicative of denial of illness, a perception that recom- memory; ability to calculate and reason abstractly; judgment illness, and how the patient wishes to be helped by verbalizations of inability to cope, ask for help, or problem mended therapeutic regimens are ineffective, or a lack of and insight; and intelligence.93 family members or health care personnel. Every culture solve. Note the presence of life stresses and the patient’s understanding of the seriousness of the health problems For patients with diminished mental capacities (eg, has prescribed ways of behaving (ie, taboos) in order to perceived ability to meet basic needs and role expectations or risk factors associated with potential health problems. patients with Down’s syndrome), use simple, clear language prevent actual or possible harm to self and others, as well and to participate in social activities. Document evidence of Assessing the patient and family members’ knowledge with concrete instructions, repeating instructions often. as stories (ie, myths) that explain the reasons for behaving destructive behavior toward self or others. level helps identify what the patient needs to be taught to Allow enough time for the client to process the information in a prescribed manner.96 All of these factors have an Family members’ inability to cope with the patient’s manage the present illness or disability.89 It is important to and to express comprehension.94 Make sure another person is impact on the patient’s learning needs, ability to learn, surgery may be indicated by their neglect of the patient’s tailor preoperative instructions to the patient’s present available to hear all information and instructions given and and ability and willingness to perform self-care basic human needs or prescribed treatment; a distorted knowledge base. to supervise implementation of the plan of care at home. activities.

10 11 8. Communicates psychosocial data relevant to planning IMPLICATIONS FOR NURSE MANAGERS It is unclear whether healthy adults benefit from SUMMARY Collection and communication of psychosocial assessment Obviously, careful assessment of all of these physiological preoperative evaluation before the day of surgery, but it Thorough patient assessment increases the effectiveness, data help identify potential needs for assistance in the pre- and psychosocial factors takes time, and it is imperative has been demonstrated unequivocally that hospital efficiency, and safety of nursing care rendered through- operative, intraoperative, and postoperative periods. Patients that priorities be set for nursing activities. The challenge efficiency is enhanced by early preoperative evaluation. out the perioperative period by increasing awareness of with identified psychosocial needs can be put in touch with for nurse managers is to streamline the assessment process, Preoperative evaluation clinics for outpatients have the patient’s actual and potential health problems. appropriate support groups and counseling services. while ensuring that patient care is not compromised. reported decreased laboratory use, lower surgical can- Collecting data during the perioperative assessment 9. Communicates/documents psychosocial status Numerous investigators have outlined ways in which cellation rates, and fewer and shorter hospitalizations. One phase enables the perioperative nurse to make appropriate Psychosocial assessment findings must be clearly hospital-based recordkeeping can be made more efficient, researcher compared the cost of outpatient assessment fol- nursing diagnoses, identify expected outcomes, plan and communicated in the formal patient record. Health care and computerized checklists and recordkeeping systems lowed by admission on the day of surgery with the cost implement appropriate intraoperative care for the patient, facilities often use an inventory-type assessment form continue to evolve in ways that make collection, documentation, of inpatient assessment on the day before surgery. and evaluate the extent to which the patient is returned to 97 based on functional health patterns. The nurse uses the and communication of assessment data easier and more Outpatient evaluation resulted in a savings of $366 per normal functioning postoperatively. Well-developed 100 inventory format to question the patient about health accurate. Each facility must find the system that seems patient, with 76% of this savings associated with assessment skills, combined with clear documentation patterns related to rest, sleep, food and fluid intake, and to work best for its staff members and patients. decreased nursing costs.104 and communication with the entire perioperative elimination. All too often, these inventory formats do not Another development that has had a significant impact on Intuitively, one might expect outpatient preoperative health care team, help the patient achieve the desired consider such important assessment areas as a patient’s the process of perioperative assessment is ambulatory surgery. evaluation to save only one or two days of hospitalization surgical outcome without suffering any unnecessary home situation and conditions, sexual relationships, and Sophisticated surgical techniques and shorter hospital stays per patient. Instead, one study found it saved an average complications. 98 coping strategies. Just like physiological assessment, mean that patients are in and out of the hospital much faster. of 4.76 days of hospitalization per patient in a Veterans documentation of psychosocial data is critical to continuity It is estimated that approximately one-half of all surgical Administration Hospital.105 A similar result was noted in 101 of care. Psychosocial data that must be recorded and procedures are performed on an outpatient basis. Now, another study, which reported an average savings of 3.91 communicated include the patient’s understanding of the instead of being admitted for assessment one or two days days per patient at a municipal hospital after a preoperative planned procedure, mental-emotional behaviors, and before surgery, patients often are assessed as outpatients, evaluation clinic was established.106 Additional cost 102 preoperative teaching needs. usually 10 to 14 days before their procedures. savings were achieved by decreasing the cancellation Increasingly, facilities are going to “user-friendly, rate from 26% to 6.6%. Other studies also have reported REASSESSMENT one-stop” preoperative evaluation clinics where elective significant reductions in cancellation rates.107 Perioperative assessment does not end in the pre- surgery patients can give histories and undergo physical operative period. Data collection must be continuous and examinations, have laboratory and diagnostic tests systematic throughout the patient’s perioperative experi- performed, meet with anesthesia care personnel, and receive ence. Nurses must be competent to continuously reassess preoperative instructions. Patients can be referred to these all components of patient care based on new data.99 For clinics directly after they have been evaluated by a example, frequent observation of the patient and surgeon and scheduled for surgery (to take place within 30 reassessment of vital signs, with particular attention to days). They come with their medical records in hand, respirations and consciousness, are necessary after pre- which at a minimum include a current surgeon’s history medication is administered. Oxygenation status is moni- and physical examination and a signed surgical consent tored throughout the perioperative period to identify form. potential complications as soon as possible. The objectives of such programs are to optimize the Postoperative complications may be asymptomatic or health of the patient before surgery, assess preoperative manifested by subtle symptoms, such as a mild fever or and postoperative health care needs, and plan the most change in other vital signs, fatigue, weakness, or mental appropriate perioperative management. In addition, such status. During this time, breath sounds and respiratory programs can identify high-risk patients early enough to rate should be monitored frequently. Pulse oximetry inform physicians, third-party payers, and patients of monitoring of oxygen saturation should be routine in all matters that may alter costs, claims, and distributions of patients. Blood pressure, pulse, and urine output also financial responsibility. 103 should be closely monitored.

12 13 APPENDIX 1 APPENDIX 2 Measurable Criteria Examples II. Competency to assess the psychosocial health 8. Notes sensory 8.1 Hearing deficit status of the patient/family. AORN’s publication, Standards, Recommended Practices, AORN’s publication, Standards, Rocommended Practices, impairments 8.2 Visual deficit and Guidelines, includes “Standards of Perioperative and Guidelines, includes “Competency Statements in 8.3 Tactile deficit Measurable Criteria Examples Clinical Practice.” Perioperative Nursing.”109 8.4 Speech 1. Elicits perception 1.1 Patient’s statement Standard I: Assessment of surgery 1.2 Behavioral responses The perioperative nurse collects patient health data. Competency Statements 9. Assesses 9.1 Pulse alteration Interpretive statement: I. Competency to assess the physiological health cardiovacular 9.2 Arrhythmias 2. Elicits expectation 2.1 Perceived outcomes Assessment is the systematic and ongoing collection of data, status of the patient. status 9.3 Edema of care guided by the application of knowledge of physiological 9.4 Electrocardiogram and psychological principles and experience, and is used to Measurable Criteria Examples 9.5 Hemodynamic parameters 3. Determines coping 3.1 Patient’s statement make judgments and predictions about a patient’s response 1. Verifies operative 1.1 Consent form mechanisms 3.2 Acceptance/denial to illness or changes in life processes. Assessment is essential procedure 1.2 Patient’s statement 10. Assesses respiratory 10.1 Skin color to establishing a nursing diagnosis and predicting outcomes. 1.3 Surgeon’s verification status 10.2 Breath sounds 4. Determines 4.1 Well-informed Assessment may occur in a variety of settings. 10.3 Oxygen saturation knowledge level 4.2 Lack of relevant information Criteria: 2. Notes condition 2.1 Rashes 10.4 Arterial blood gases 1. The priority of data collection is determined by the of skin 2.2 Bruises 5. Determines ability to 5.1 Language barrier patient’s immediate condition or needs and the relation- 2.3 Lesions 11. Assesses renal status 11.1 Intake and output understand 5.2 Level of comprehension ship to the proposed intervention. Pertinent data 2.4 Previous incisions 11.2 Urinalysis include, but are not limited to, 2.5 Turgor 11.3 Renal function studies 6. Identifies philosophical 6.1 Blood transfusions • current medical diagnosis and therapies; and religious beliefs 6.2 Sacrament of the sick • physical status and physiological responses; 3. Determines mobility 3.1 Patient’s statement 12. Notes nutritional 12.1 Nothing by mouth status 6.3 Symbols • psychosocial status of the patient; of body parts 3.2 Range of motion status 12.2 Weight 6.4 Disposition of limbs • cultural, spiritual, and life-style information; 12.3 Skin turgor • the individual’s understanding, perceptions, and 4. Reports deviation of 4.1 Laboratory values 7. Identifies cultural 7.1 Family member in expectations of the procedure; diagnostic studies 4.2 Radiologic imaging 13. Verifies allergies 13.1 Medication practices constant attendance • previous responses to illness, hospitalizations, and 4.3 Other diagnostic imaging 13.2 Food 7.2 Cultural/ethnic requirements surgical, therapeutic, or diagnostic procedures; and 13.3 Chemical • results of diagnostic studies. 5. Checks vital signs 5.1 Blood pressure 8. Communicates 8.1 Support group 2. Pertinent data are collected, using appropriate 5.2 Temperature 14. Screens for substance 14.1 Skin changes psychosocial data 8.2 Counseling service assessment techniques. 5.3 Pulse abuse 14.2 Patient’s statement relevant to planning 8.3 Social service 3. Data collection involves the patient, significant others, 5.4 Respiration and health care providers when appropriate. It may 15. Communicates 15.1 Patient/family services 9. Communicates/ 9.1 Verbal reports be accomplished through diverse means, such as 6. Notes abnormalities, 6.1 Loss of extremity/body part physiological data 15.2 Home health service documents 9.2 Patient record interview, review of records, assessment, and/or injuries, and previous 6.2 Congenital abnormalities relevant to planning 15.3 Community service psychosocial status consultation. surgery patient’s discharge 4. Data collection is systematic and ongoing. 5. Relevant data are documented in retrievable form.108 7. Identifies presence of 7.1 Pacemakers 16. Communicates/ 16.1 Verbal reports internal and external 7.2 Hairington rods documents physical 16.2 Patient record prostheses/implants 7.3 Joint prostheses health status 7.4 Lens implants

14 15 NOTES 19. L Leckrone, “Preparing your patient for surgery” 41. Keene, “Cardiovascular and respiration assessment 64. Zambricki, “Clinical aspects of the preanesthesia 1. “Standards of perioperative clinical practice,” in Nursing 9121 (July 1991) 48. in the office setting,” 183. evaluation,” 615. AORN Standards, Recommended Practices, and 20. Kneedler, Dodge, “Assessment,” in Perioperative 42. Phippen, Wells, “Perioperative patient assessment,” 5. 65. L Thompson et al, “Intraoperative surgery techniques Guidelines (Denver: AORN, Inc., 2005) 251. Patient Care: The Nursing Perspective, 34. 43. Zambricki, “Clinical aspects of the preanesthesia and patient care,” Critical Care Nursing Quarterly 2. M L Phippen, M P Wells, “Perioperative patient 21. Ibid, 33. evaluation,” 616. 13 (June 1990) 20. assessment,” in Perioperative Nursing Handbook 22. Morrissey, “Obtaining a ‘reasonably accurate’ 44. F Rotenberg, C Schwaez, “Pre-operative medical 66. Fromm, Metzler, “Preparing the older patient for (Philadelphia: W B. Saunders, Co, 1995) 1. health history” evaluation: Minimizing perioperative risk,” Rhode surgery,” 40. 3. M Bean, “Preparation for surgery in an ambulatory 23. Ibid, 28. Island Medicine 75 (February 1992) 90-96. 67. B Noon, A Paul, “Ambulatory surgery: Integrating surgery unit,” Journal of PostAnesthesia Nursing 5 24. M E O’Malley, S T McNamara, “Children’s 45. Zambicki, 613-614; Keene, “Cardiovascular and the preadmission program,” Nursing Management (February 1990) 42. drawings: A preoperative assessment tool,” AORN respiratory assessment in the office setting,” 183. 23 (July 1992) 112D. 4. JC Rothrock, Alexander’s Care of the Patient in Journal 57 (May 1993) 1074. 46. Fromm, Metzler, “Preparing your older patient for 68. “Standards of perioperative clinical practice,” 109-110. Surgery, 12th ed. (St. Louis: Mosby, 2003) 5. 25. Keene, “Perioperative assessment and nursing surgery,” 39. 69. “Competency statements” in Standards, Recommended 5. Bean, “Preparation for surgery in an ambulatory implications for the elderly,” 143. 47. Keene, “Cardiovascular and respiratory assessment Practices, and Guidelines (Denver: AORN, Inc, surgery unit,” 42. 26. Ibid, 145. in the office setting,” 184. 2005) 24-32. 6. “Standards of perioperative clinical practice,” 182. 27. Kneedler, Dodge, “Assessment,” in Perioperative 48. Lusis, “Nursing management of the elderly surgical 70. Pobojewski et al, “Documenting nursing process in the 7. J A Kneedler, G H Dodge, “Assessment,” in Patient Care: The Nursing Perspective, 35. patient,” 141. perioperative setting: Continuity of care, patient Perioperative Patient Care: The Nursing 28. Ibid. 49. Ibid, 141-142. evaluation,” 98. Perspective, third ed (Boston: Jones and Bartlett, 29. Lusis, “Nursing management of the elderly surgical 50. Keene, “Cardiovascular and respiratory assessment 71. Kneedler, Dodge, “Assessment,” in Perioperative 1994) 28. patient,” 141. in the office setting,” 183. Patient Care: The Nursing Perspective, 27. 8. S A Lusis, “Nursing management of the elderly 30. J Lierman, “Preoperative assessments: Can we afford 51. Lusis, “Nursing management of the elderly surgical 72. Phippen, Wells, “Perioperative patient assessment,” 37. surgical patient,” Plastic Surgical Nursing 14 (Fall to do without them?” AORN Journal 47 (February patient,” 142. 73. “Competency statements in perioperative nursing,” 1994) 139. 1988) 588. 52. D Green, “Patient assessment for day surgery,” 85-86. 9. B J Pobojewski et al, “Documenting nursing process 31. Zambricki, “Clinical aspects of the preanesthetic- British Journal of Theatre Nursing 5 (April 1995) 11. 74. Kneedler, Dodge, “Assessment” in Perioperative in the perioperative setting: Continuity of care, evaluation,” 611. 53. Leckrone, “Preparing your patient for surgery,” 48. Patient Care: The Nursing Perspective, 41. patient evaluation,” AORN Journal 56 (July 1992) 32. LJ Cappellino, “Module 7: Safety in the surgical suite” 54. Phippen, Wells, “Perioperative patient assessment,” 75. Lierman, “Preoperative assessments: Can we afford 99-101. Perioperative Nursing Course 101 (Denver: AORN, Inc, 7,14. to do without them?” 586. 10. Kneedler, Dodge, “Assessment,” in Perioperative 1999; Revised October 2003) 3. 55. Lusis, “Nursing management of the elderly surgical 76. O’Malley, McNamara, “Children’s drawings: A Patient Care: The Nursing Perspective, 30. 33. Lusis, “Nursing management of the elderly surgical patient,” 142. preoperative assessment tool,” 1078. 11. Ibid. patient,” 142. 56. Ibid, 141; Fromm, Metzler, “Preparing your older 77. M Leuze, J McKenzie, “Preoperative assessment: 12. Ibid. 34. Leckrone, “Preparing your patient for surgery,” 48-49. patient for surgery,” 41. Using the Roy Adaptation Model,” AORN Journal 13. Rothrock, 1367. 35. Keene, “Perioperative assessment and nursing 57. E Cotton, et al, “A nutritional assessment tool for 46 (December 1987) 1129. 14. Ambulatory Surgery Principles and Practices, third implications for the elderly,” 144-145. older patients,” Professional Nurse 11 (June 1996) 609. 78. Lusis, “Nursing management of the elderly surgical ed. (Denver: AORN, Inc, 2003) 115. 36. Phippen, Wells, “Perioperative patient assessment,” 5. 58. lbid, 610. patient,” 141. 15. J Morrissey, “Obtaining a ‘reasonably accurate’ health 37. Zambricki, “Clinical aspects of the preanesthesia 59. T C Eickhoff, “Immunizations,” in Kelly’s Text Book 79. Kneedler, Dodge, “Assessment,” in Perioperative history,” Plastic Surgical Nursing 14 (Spring 1994) evaluation,” 617-618. of Internal Medicine (Philadelphia: JB Lippincott Patient Care: The Nursing Perspective, 42. 27, 29. 38. PA Potter, AG Perry, ed, Basic Nursing: Essentials Company, 1989) 1813. 80. Phippen, Wells, “Perioperative patient assessment,” 45. 16. C Zambricki, “Clinical aspects of the preanesthetic for Practice, fifth ed (St. Louis: Mosby, 2003, 5th 60. Phippen, Wells, “Perioperative patient assessment,” 6-7. 81. Kneedler, Dodge, “Assessment,” in Perioperative evaluation,” Nursing Clinics of North America 31 edition) 202. 61. Zambricki, “Clinical aspects of the preanesthesia Patient Care: The Nursing Perspective, 41. (September 1996) 610. 39. A Keene, “Cardiovascular and respiratory assessment evaluation,” 611-612. 82. H Waterman, J Grabham, “Assessing patients’ 17. Kneedler, Dodge, “Assessment,” in Perioperative in the office setting,” Plastic Surgical Nursing 13 62. “Latex guideline” in Standards, Recommended fears,” British Journal of Theatre Nursing 3 Patient Care: The Nursing Perspective, 33. (Winter 1993) 182. Practices, and Guidelines (Denver: AORN, Inc, 2005) (October 1993) 11-13. 18. Bean, “Preparation for surgery in the ambulatory 40. C G Fromm, D J Metzler, “Preparing your older 122. 83. P Brita-Rossi et al, “Improving the process of care: surgery unit,” 46. patient for surgery,” RN 56 (January 1993) 40. 63. Kneedler, Dodge, “Assessment,” in Perioperative The cost-quality value of interdisciplinary collaboration,” Patient Care: The Nursing Perspective,” 43. Journal of Nursing Care Quality 10 (January 1996) 11.

16 17 84. Kneedler, Dodge, “Assessment,” in Perioperative 105. J B Pollard et al, “Economic benefits attributed to SUGGESTED READINGS Parker, CB; Minick, P; Kee, CC. “Preoperative nursing Patient Care: The Nursing Perspective, 41. opening a preoperative evaluation clinic for assessment of the adult patient,” Seminars in 85. Ibid, 43; Lusis, “Nursing management of the elderly outpatients,” Anesthesia and Analgesia 83 (August Bailes, BK. “Perioperative care of the elderly surgical Perioperative Nursing 8 (1) (January 1999) 42-47. surgical patient” 146. 1996) 409. patient,” AORN Journal 72 (2) (August 2000) 185-196, 86. Keene, “Perioperative assessment and nursing 106. Ibid. 198, 200. Patton, CM. “Preoperative nursing assessment of the implications for the elderly,” 145. 107. Brita-Rossi et al, “Improving the process of care: adult patient,” Seminars in Perioperative Nursing 8 (1) 87. P Brita-Rossi et al, “Improving the process of care: The cost-quality value of interdisciplinary Ballard-Ferguson, D. “Assessment and prevention of (January 1999) 42-47. The cost quality value of interdisciplinary collaboration,” collaboration,” 13. perioperative confusion in the older adult,” Seminars in 12. 108. “Standards of perioperative clinical practice,” Perioperative Nursing 6 (1) (January 1997) 31-36. Pearce, L. "Safe admission." Nursing Standard 19 (8) 88. Lusis, “Nursing management of the elderly surgical 181-182. (November 3-9, 2004)14-5. patient,” 141. 109. “Competency statements,” 24-26. Brady, M, et al. "Preoperative fasting for adults to 89. Kneedler, Dodge, “Assessment,” in Perioperative prevent perioperative complications." The Cochran Ruzicka, S. “The impact of normal aging processes and Patient Care: The Nursing Perspective, 32. Library, Oxford (3), 2005. chronic illness on perioperative care of the elderly,” 90. Bean, “Preparation for surgery in an ambulatory Seminars in Perioperative Nursing 6 (1) (January 1997) surgery unit,” 43. Brady, M, et al. "Preoperative fasting for preventing 3-13. 91. Lusis, “Nursing management of the elderly surgical perioperative complications in children." The Cochran patient,” 140. Library, Oxford (3), 2005. Saufl, N M. "Preparing the older adult for surgery and 92. Ibid, 144-145. anesthesia." Journal of PeriAnesthesia Nursing 19 (6) 93. Kneedler, Dodge, “Assessment,” in Perioperative Busen, NA. “Perioperative preparation of the adolescent (December 2004) 372-8. Patient Care: The Nursing Perspective, 42. surgical patient,” AORN Journal 73 (2) (February 2001) 94. C A Sedlak, “Assessment of the surgical adult 337-341, 344-348, 350. orthopaedic client with Down’s syndrome,” Orthopaedic Nursing 10 (September/October 1991) 33. Dunn, D. “Preoperative assessment criteria and patient 95. Kneedler, Dodge, “Assessment,” in Perioperative teaching for ambulatory surgery patients,” Journal of Patient Care: The Nursing Perspective, 45. Perianesthesia Nursing 13 (5) (October 1998) 274-291. 96. Ibid. 97. Ibid, 27. Fortner, PA. “Preoperative assessment criteria and 98. Ibid, 27. patient teaching for ambulatory surgery patients,” 99. “Competency Statements,” 32. Journal of Perianesthesia Nursing 7 (1) (January 1998) 100. Leuze, McKenzie, “Preoperative assessment using 3-9. the Roy Adaptation model,” 1122; Pobojewski et al, “Documenting nursing process in the perioperative Hummer-Belmyer, J. “The collaborative role of the setting: Continuity of care, patient evaluation,” 98. perioperative nurse practitioner in assessing perioperative 101. R M Tappen; J Muzic; P Kennedy, “Preoperative patients,” Orthopaedic Nursing 21 (1) (January - assessment and discharge planning for older adults February 2002) 39-44. undergoing ambulatory surgery,” AORN Journal 73 (Feb 01) 464. Kinley, H, et al. "Effectiveness of appropriately trained 102. C Breeze, “From start to finish,” Nursing Times 91 nurses in preoperative assessment: randomized (October 4-10, 1995) 62. controlled equivalence/non-inferiority trial." British 103. P Noon, “Ambulatory surgery: Integrating the Medical Journal December 7, 2002; 325(7376) 1323-6. preadmission program,” 1121. 104. P Boothe; BA Finegan “Changing the admission Murphy, JM. “Preoperative considerations with herbal process for elective surgery: An economic analysis,” medicines,” AORN Journal 69 (1) (January 1999) Canadian Journal of Anaesthesia 42 (May 1995) 173-175, 177-178, 180-183. 391-394.

18 19 POSTTEST 6. Use of the hands and fingertips on the patient’s 11. To assess the patient for “pitting edema,” depress 17. A history of noncompliance with previous Multiple Choice: Please choose the one answer that skin to distinguish temperature variations, hard the skin instructions for self-care may be indicative of best completes the following statements. and soft, rough and smooth, and stillness and a. over the shin for five seconds, and then release. a. denial of illness. vibration is called b. over the neck veins for five seconds, and then b. a perception that recommended therapeutic 1. Assessment data are collected a. auscultation. release. regimens are ineffective. a. preoperatively. b. percussion. c. over the shin for 15 seconds, and then release. c. a lack of understanding of the seriousness of the b. intraoperatively. c. palpation. d. over the axilla for five seconds, and then release. patient’s health problems. c. postoperatively. d. inspection. d. any of the above. d. all of the above. 12. The lungs should be auscultated with the patient 7. The patient’s identity should be verified a. sitting, with legs dangling over the side of the 18. In the anthropological sense, prescribed ways of 2. Assessment data may be collected from a. verbally (whenever possible). examination table. behaving to prevent actual or possible harm to a. the patient. b. by checking the patient’s chart. b. sitting, with the legs up on the examination table. self and others are called b. the patient’s family members. c. by checking the patient’s identification bracelet or c. supine, with the legs dangling over the side of the a. myths. c. other health care providers. wristband. examination table. b. taboos. d. all of the above. d. all of the above. d. supine, with the knees bent and the feet on the c. cultures. examination table. d. philosophies. 3. In the course of the preoperative assessment, the 8. Surgical sites should be marked preoperatively perioperative nurse should a. when the surgery involves limbs. 13. Data about alcohol intake and recreational drug 19. By establishing preoperative evaluation clinics a. obtain informed consent from the patient. b. when the surgery involves bilateral organs. use are for outpatients, hospitals have b. ensure that a signed informed consent is in the c. when the surgery involves multiple structures or levels. a. not necessary. a. increased laboratory use. patient's chart. d. all of the above. b. not reliable. b. increased surgical cancellation rates. c. explain the risks and alternatives of the planned c. essential. c. decreased length of stay for surgical patients. procedure. 9. When gathering information about medications d. best obtained in the presence of family members. d. improved patient outcomes. d. all of the above for this information. that the patient is taking, it is important to include 14. Discharge planning begins during the 4. When addressing the patient during the preoperative a. physician prescribed medications. a. assessment phase. interview, the nurse should b. over the counter medications and vitamins. b. planning phase. a. use the patient’s first name. c. herbal medications that the patient may be taking. c. implementation phase. b. use the patient’s title and last name. d. all of the above. d. evaluation phase. c. ask permission before using the patient’s first name. d. wait for the patient to say how he or she wishes 10. When conducting a perioperative assessment of a 15. Cold, clammy skin may be a sign of to be addressed hearing impaired patient, it may be helpful to a. inadequate room heating. a. have the patient face toward the light to facilitate b. poor circulation. 5. The information given by a patient during the lip reading. c. anxiety. assessment interview b. shout at the patient. d. a febrile illness. a. is always assumed to be correct. c. ask short, direct questions. b. may not always be correct and should be checked d. let the surgeon conduct the assessment. 16. Destructive behavior toward self or others is a against another source if there is any question sign of about its accuracy. a. anxiety. c. should always be checked against another source. b. depression. d. must be accepted; there is no other source for this c. poor coping mechanisms. information. d. type A behavior.

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Perioperative Patient Assessment Answer Sheet

Question Answer 1D 2D 3B 4C 5B 6C 7D 8D 9D 10 X 11 A 12 A 13 C 14 A 15 C 16 C 17 D 18 B 19 C