Preoperative Assessment | 术前评估 |
Assessment and Implementation | 评估实施 |
1. Use Standard Protocol. | 采用标准护理程序 |
2. Determine if the client has any communication impairment and if the client is mentally competent. | 测定病人存在沟通障碍,心智是否健全。 |
3. Assess the client's understanding of the intended surgery and anesthesia. | 评估病人是否了解即将进行的手术及麻醉。 |
4. Obtain a nursing history: | 获取护理史 |
A. Condition leading to surgery | 需手术的病情 |
B. The need for isolation precautions. | 隔离需要 |
C. Chronic illnesses. | 慢性疾病 |
D. Last menstrual period (for female clients in childbearing years). | 末次月经(育龄期女性病人) |
E. Previous hospitalizations. | 既往住院史 |
F. Medication history, including prescription and over-the-counter (OTC), and date/time of last doses. | 用药史,包括处方与非处方药,末次用药日期/时间 |
G. Previous experience with surgery and anesthesia. | 既往手术及麻醉史 |
H. Family history of complications from surgery or anesthesia. | 家庭手术或麻醉并发症史 |
I. Allergies to medications or food, including specific questions about natural rubber latex. | 药物或食物过敏史,包括天然橡胶特种过敏反应 |
J. Physical impairment. | 身体受损情况 |
K. Prostheses and implants (e.g., dentures, hearing aid, pacemaker, internal defibrillator, hip prosthesis) | 假体和移植(如义齿、助听器、起搏器、除颤器、人工髋关节) |
L. Smoking, alcohol, and drug use. | 吸烟、饮酒和吸毒史 |
M. Occupation | 职业 |
5. Assess client's weight, height, and vital signs. | 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. | 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. | 评估病人循环系统状况,包括心尖搏动、心电图和周围脉搏。 |
8. Determine client's neurological status, including level of consciousness (LOC). | 测定病人神经学状况,包括神志清醒程度。 |
9. Assess client's musculoskeletal system, including range of motion (ROM) of joints. | 评估病人肌骨骼系统,包括关节活动度。 |
10. Examine client's skin; identify any breaks in skin integrity and determine level of hydration. | 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. | 评估病人情绪状况,包括焦虑程度、应对能力和家庭支援。 |
12. Review the results of laboratory tests, including complete blood count (CBC), electrolytes, urinalysis, and other diagnostic tests. | 审查化验报告,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. | 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. | 确认病人上次摄食与饮水时间。 |
15. Use Completion Protocol. | 采用护理完成标准程序。 |
Evaluation | 评价 |
1. Review records to determine if necessary information has been assessed. | 复查记录,确定必需项目是否得到评估。 |
2. Evaluate client's ability to cooperate. | 评价病人合作能力。 |
Identify Unexpected Outcomes and Nursing Interventions | 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. | 采用机构表格(术前目录单),填写全部重要信息。 |
2. Report abnormal laboratory values and other concerns to the surgeon or anesthesiologist. | 向手术医生或麻醉师报告异常化验值及其他问题。 |