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Pre- Operative nursing care, Phindile Sambo - Coggle Diagram
Pre- Operative nursing care
Documetation
Clinical reports
Vital signs charts
X Rays
Blood glucose monitoring chart
Risk assessment
Fluid balance chart
Progress report
Prescription chart
Daily nursing care plan
Nil per mouth status
Peri-operative form
Informed consent +disposal of human tissue
Admission form
Height + weight
pre-operative assessment
comprehensive health history taking on admission
previous illness
chronic medication
comorbidities
Details of illness
over the counter medication
Contraceptives
Steroid
Antidepressants
Supplements
Anticoagulation
Reason for admission
patient identification
correct surgery
correct site
correct patient
Verbal
file
ID band
2 paeds ID band
Previous surgery
Date + Site
complications with surgery
complications with anesthetics
prosthesis
Allergies
plaster
food
latex / iodine
environment
medication
Genetic history/ considerations / health risk eg smoking or drug use
comprehensive physical assessment
Urine analysis + testing
height + weight
Vital data
HGT
All systems
Risk assesment
Hendrick
VTE
Waterlow
Acuity
Pain score
GCS
Health Education
Remove jewelery
Emptying of bladder
ID bands-white,pink,yellow+red
Pre-medication as prescribed by Doctor
surgical attire
marking of surgical site(only done by Doctor)
shave with hair removal
Reassurance + support to patient & family
shower with chlorhexidine
Assistive device to be removed eg duntures,glass+ hearing aid
NPO status
Valuables + assistive device to be given to family members
or labeled with patients details and store in a safe
Informed consent
Professional staff member must witness patient signature
Informed consent must contain; the following :
Patient who are cognitively impaired or mentally ill cannot sign consent
Explanation of procedure and its risk
Children can sign consent for their own children
Description of benefits and alternatives
Children over the age of 12 can sign consent with guardian present
An offer to answer questions about procedure
Patient must be at least 18 years of age
Instructions that patient may withdraw consent
Consent must be in writing
Statement informing patient if protocol differs from customary procedure
Informed consent must be obtained by Dr
Patient not to sign consent if under the influence of pre-medication
Phindile Sambo