Perioperative Nursing Assessments Made Simple

New Nurse Notes

Perioperative nursing assessments made simple

By Sheri L. Zastrow, RN, MSN

The nursing process is an integral part of patient care in the perioperative setting and includes performing a nursing assessment. For perioperative nurses, this assessment differs from those performed on the patient in a medical-surgical unit and requires some alterations to the formal nursing process that can Tchallenge new perioperative nurses. One reason for this difference is due to the brief time a perioperative nurse has contact with a conscious patient. This column will provide a synopsis of an efficient, effec- tive perioperative assessment for nurses in the OR, which can also be utilized for many specialties. Getting to know your patient The perioperative nurse can perform the face-to-face Nursing assessment 101 assessment in the preoperative designated area. This As a patient moves through the three phases of the should include an additional physical assessment as operative process (preoperative, intraoperative, and well as a psychosocial assessment. During this time, postoperative), the perioperative nurse must adapt the perioperative nurse can assess the patient’s per- the assessment to the setting. Assessment is the rele- ception of the surgical procedure, what knowledge vant collection of data regarding the surgical patient.1 they have of the procedure including informed This information can be retrieved through various consent, expectations of care, stress level, cultural avenues and doesn’t need to be repeated through all or religious beliefs, support from family or significant the phases of the surgical patient’s operative process. others, or any nonverbal behavior.1 This is also a The concise assessment needs to be relevant to the time to build rapport with the patient. These psy- patient’s surgical procedure with adequate informa- chosocial parameters build confidence in the patient’s tion to provide individualized, safe care. With all perception of their care as well as aid the periopera- these concepts in mind, it’s apparent the perioperative nurse in developing the best plan of care for the tive nurse could benefit from a succinct assessment individual patient. This is not the time to repeat the tool when navigating through the assessment. findings from previous data collection. Documentation of the assessment is completed Tools of the trade according to the policy and procedures of the organi- Data collection is a progressive and orderly zation.2 The findings may be completed either in process.1 Optimizing the most efficient assess- a written or electronic document/flowsheet. ment begins with reviewing the patient’s history Patient assessments can be individualized and using either a paper chart or an electronic version. should include the following: Previous surgical history, review of systems, cur- • identification of patient; two identifiers are rent medical diagnosis, indication for surgery, type needed, usually name and date of birth (this of surgery, allergies, as well as physiologic assess- may be individualized according to the specific ment parameters such as diagnostic studies, labs, organization) and X-ray results, can all be obtained through • operative procedure; side (if applicable), location these resources. and site marking

16 OR Nurse2009 July www.ORNurseJournal.com • preoperative teaching, patient understanding, and • medications and allergies (obtain from patient’s verbalization of procedure history) • informed consent documented • skin condition • mental/physiological status • family/friends/significant others present. • pre-op orders; check history, electronic record • range of motion/mobility A vital part of patient safety • internal/external prosthesis Perioperative nursing assessments are succinct and • sensory impairments or language barrier pertinent to the patient’s surgical procedure. Repetition • cultural differences, religious/spiritual needs needs to be reduced as the patient’s history and data • cardiovascular and respiratory status (vital signs can be retrieved from a variety of resources such as within +/-20% baseline, airway patent, maintain the history, electronic record, patient’s interview, and oxygen saturation at 92% or +/- 2% of baseline)3 physical assessment. The assessment is critical for safe • nutritional status (N.P.O.) patient-care delivery. OR • pain or discomfort (ongoing assessment of level REFERENCES of pain or discomfort) 1. Rothrock JC, McEwen DR. Alexander’s Care of the Patient in Surgery. • surgical specialty assessment as appropriate: 15th ed. St. Louis, MO: Mosby; 2007. 2. Association of periOperative Registered Nurses. Perioperative Standards, cardiovascular, pulmonary, neurologic, orthope- Recommended Practices and Guidelines. AORN Inc.: Denver, Colo.; 2008. dic, gastrointestinal, gynecological, ophthalmic 3. Peterson C. AORN Perioperative Nursing Data Set, (2nd ed.). AORN • presence of prosthetics or corrective devices Inc.: Denver, CO; 2008. Sheri L. Zastrow is a nursing education supervisor at the Mayo Clinic, • personal belongings and their location Rochester, Minn.

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Publisher of American Journal of Nursing