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Nursing Process
Standard AORN
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Assesment
Nursing
Diagnosis
Evaluation
Implementation
Preoperative
Intraoperative
Planning
Postoperative
1. Assessment
Preoperative
Focus assessment:
The patients understanding of events
Any acute & chronic conditions
experienced by the patient
The patients previous surgical experiences
The patient nutritional
Fluid and electrolyte
Emotional status
Physical Examination.cont 1
Cardiopulmonary function
Bowel function
Urinary function
Nutritional status
Physical limitations
Psychological assessment.cont 1
Anxiety :
Reason
Support system
Coping mechanism
Visual Analog Anxiety
The VAS measuring fear of anesthesia correlated
well with the STAI (Spielberger State-Trait
Anxiety Inventory) score (r = 0.55; P < 0.01)
Intraoperative assessment
Review preoperative assessment
Assessment during surgical procedure:
vital signs, blood loss, skin color,
drainage, sponges, instruments and
sharps nurse perioperative
Wound dressings, respiratory status,
drainage tubes for patency, collection
chambers for amounts, infusion lines
Postoperative assessment
Vital signs, color, activity level,
neurologic status
Aldrette Recovery Scoring System
2. Nursing Diagnoses
Preoperative
Preoperative
Anxiety
Body image disturbance
Intolerance activity
Sleep pattern
Knowledge deficit
High risk of injury
Skin integrity
Sedation
Intraoperative
Impaired gas
Hypothermia
Impaired skin integrity
Fluid volume
Tissue perfusion
Decreased cardiac output
Postoperative
Injury
Ineffective airway
High Risk
Infection
Comfort
3. Planning
Focus :
1. Absence of infection
2. Maintenance of skin integrity
3. Absence of adverse effects
4. Maintenance of fluid and electrolyte
balance
5. Knowledge by the patient
6. Rehabilitation process
Implementation
Preoperative..(1)
Patient and family education
Patient preparation
Obtaining required baseline
assessment data, laboratory &
diagnostic work, and consent
for surgical procedures
Intraoperative.(2)
Performance in the scrub
persons role
Performance in the
circulating nurses role
Management of personnel,
material and environment
Maintenance of a safe,
aseptic environment
Regional Anesthesia
Local
Epidural
Infltration
Nerve Block
Spinal
Topical
Anesthetic agents
Xylocaine, Novocain,
carbocaine
Topical
Dermoplast (benzocaine)
cocaine
ethyl chloride
General Anesthesia
Inhalation or
intravenous route
3 phase:
1. Induction phase
2. Maintenance phase
3. Emergence phase
Anastesia
Geriatric concerns
Consciousness
Hepatic, cardiac respiratory and renal
decline
Heart diseases, renal, and pulmonary
Complication of Intraoperative
Hypoventilation
Oral Trauma endotracheal
intubation
Hypotension
Bradikardia, Cardiac
dysrhythmia
Hypothermia
Peripheral nerve
damage
Intraoperative - Complications
Malignant hyperthermia - due to abnormal
and excessive intracellular collection of
Ca+ resulting in hypermetabolism and
increased muscle contraction.
Signs and Symptoms - high fever,
tachycardia, muscle rigidity, heart failure,
pseudotetany, and CNS damage.
Postoperative
Postoperative.(3)
Monitoring and evaluating the patients
status
Managing patient care, including pain,
fluid status, cardiopulmonary status,
positioning
Assessing nutritional status and needs
Providing rehabilitation, counseling,
and emotional support
Complication of Postoperative
Hipotensi
Dysrhythmia
Trombosis vena
Emboli Pulmonal
Distensi abdomen
Anxiety
Altered body image
Finances, Family responsibility
Future changes
Discharge Plans
Educate the client, family and
psychosocial support
Wound care
Manifestation of a wound infection
How and when to take temperature
Limitation and restriction of activity
Control of pain
Evaluation
Patient outcomes
Patients level of accomplishment for
each expected outcomes
References
Thank You
sistolic
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