Transcript Chapter (Domain) 1-Preoperative Patient Assessment and

Domain 1: Preoperative Patient
Assessment and Diagnosis(14% 26 Questions)
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Objectives
• Identify the topics in Domain 1 and their
corresponding elements.
• Apply elements and topics to the chapters
and modules in the study guide.
• Identify additional resources available.
• Assess your current knowledge.
• Develop a study plan.
• Identify your assignments.
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Module 1: Assess the Health Status of the
Patient
Topics:
• Age and culturally appropriate health assessment
techniques
• Anatomy and physiology
• Cultural/diversity assessment
• Diagnostic procedures and results
• Pathophysiology
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Elements (your nursing interventions):
• Conduct an individualized physical assessment
including but not limited to skin integrity and
mobility deficits.
• Use age and culturally appropriate health
assessment and interview techniques.
• Collect, analyze, and prioritize patient data.
• Document preoperative assessment.
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Physical Assessment
Part of your pre-procedure patient verification is
completing a physical assessment of your
patient.
Sources of assessment data:
•
•
•
•
Patient interview
History and physical
Patient chart
X-rays
• Collaborating with health
care team
• Hand off communication
• Geriatric assessment
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Collect, Analyze, and Prioritize
Patient Data
The normal K+ for an adult is:
A. 2.5-4 mEq/L
B. 3-4.5 mEq/L
C. 3-5.5 mEq/L
D. 4-5.5 mEq/L
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Answer
C. 3-5.5 mEq/L
Alex (2014), Appendix A, p. 1175.
Print off normal laboratory value ranges for common
diagnostic lab studies or transfer these to an index card
for easy studying.
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Use age and culturally appropriate health
assessment and interview techniques
Providing explanations of monitoring and safety
devices are most effective in addressing an
adolescent's fear of:
A. separation from parents.
B. loss of privacy.
C. death.
D. altered body image.
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Answer
C. death.
Alex (2014), Chapter 26: Pediatric Surgery, p. 1014.
The fear of death is most prevalent in the adolescent
age group, and adolescents may find conversation
related to safety reassuring. Separation anxiety is seen
with toddlers and preschoolers. Concerns with altered
body image and privacy will not be addressed through
explanations related to monitoring and safety measures.
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Conduct an individualized physical
assessment
An 80 year-old patient scheduled for a total hip
arthroplasty is at risk for developing which of
the following complications?
A. Air embolism from position on fracture table.
B. Peroneal nerve damage to the operative leg.
C. Hypothermia related to increased
subcutaneous fat deposits.
D. Deep vein thrombosis (DVT) secondary to
immobility.
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Answer
D. Deep vein thrombosis (DVT) secondary to
immobility.
Alex (2014), Chapter 27: Geriatric Surgery, p. 1095.
“The chances for developing DVT increase with age and
double each decade of life over the age of 40 years.” Elderly
patients have decreased reserves of subcutaneous fat. A
patient in the sitting position is at increased risk for an air
embolism. The peroneal nerve runs along the lateral aspect
of the knee and is at increased risk for injury secondary to
compression by the stirrup holding the unaffected leg.
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Anatomy and Physiology
The main functions of the stomach are motor,
secretory, and
A. motility.
B. acidic.
C. chemical.
D. endocrine.
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Answer
D. endocrine.
B&K (2013), Chapter 33: General Surgery: Gastric
Procedures, p. 672.
The endocrine component is responsible for the release
of gastrin, which releases acid. The second part of the
endocrine component is the release of somatostatin
which inhibits the release of gastrin.
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Document Preoperative Assessment
The most important reason to document the
patient’s preoperative assessment is:
A. to fulfill the requirement of The Joint Commission
(TJC).
B. so the physician can update his history and physical
(H&P).
C. so postanesthesia (PACU) nurses can plan their
care.
D. it forms a baseline of the patient’s health status.
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Answer
D. it forms a baseline of the patient’s health
status.
SRP (2014), Patient Care: Information Management,
I.a., p. 443.
The preoperative assessment “forms a baseline for
identifying the patient’s health status, developing
nursing diagnoses, and establishing an individualized
plan of care.”
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Module 2: Review of Preoperative Medications
Topics:
• Pharmacology
Elements (your nursing interventions):
• Review medication history (preoperative and
home medications, alternative and herbal
supplements, medical marijuana use, alcohol use,
recreational drug use)
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Pharmacology Resources
• Common patient medications
• Local anesthetics
• Antibiotic irrigation
• Anesthesia medications
• Surgery-specific medications
• Beta blockers
• Mobile app- www.epocrates.com
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Pharmacology-Home Medications
For a patient taking hydrochlorothiazide (HCTZ)
for hypertension, what is the most important
laboratory value to assess?
A. Sodium (Na+)
B. Potassium (K+)
C. Chloride (Cl-)
D. Magnesium (Mg2+)
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Answer
B. K+
Mosby's Diagnostic and Laboratory Test Reference:
(9th ed.) (2009), p. 746.
HCTZ may cause hypokalemia, as it is not a potassiumsparing diuretic.
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Pharmacology-Herbal Supplements
Which of the following herbs may interfere with
coagulation?
A. Turmeric
B. Green Tea
C. Ginkgo
D. Rosemary
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Answer
C. Ginkgo
Alex (2014), Chapter 30: Integrative Health Practices:
Complementary and Alternative Therapies, p. 1169.
The anesthesia professional is “concerned about the
potential increased risk of instability intraoperatively
resulting from inhibition of coagulation with the use of
ginger, ginseng, feverfew, ginkgo, and garlic.”
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Pharmacology-Anesthetic Medications
Which procedure would be the best option for
the use of propofol by the anesthesia
professional?
A. Laparoscopic hernia repair
B. Inguinal hernia repair
C. Right carpal tunnel release
D. Appendectomy
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Answer
C. Right carpal tunnel release
B&K (2013), p. 432.
Rapid induction and recovery; single short procedures
Table 24-2
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Module 3: Initiation of Universal Protocol
Topics:
• Universal Protocol
Elements (your nursing interventions):
• Confirm patient identity with two patient
identifiers, the procedure, and the
operative site, side/site marking
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Universal Protocol Resources
• The Joint Commission-Wrong Site Surgery
Resources
• Safe Site Surgery Resources
•
•
•
•
•
Facts about the Universal Protocol
Facts about patient safety
Universal Protocol poster
Safe surgery checklist
Follow-up survey on Universal Protocol
• Time Out Video
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Universal Protocol
Which of the following has not been recognized
as a contributing factor to wrong side, site,
patient procedures?
A. Multiple procedures
B. Multiple physicians
C. Single procedures
D. Obesity
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Answer
C. Single procedures
B&K (2013), p. 22.
There is an extensive list identified by TJC as
contributing to wrong site, side, patient surgeries. Single
procedures is not on that list.
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Module 4: Obtaining Surgical Consent
Topics:
• Surgical Consent
Elements (your nursing interventions):
• Verify the surgical consent
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Verify Surgical Consent
Witnessing a signature to an informed consent assures
that:
A. the patient understands the reason for the surgical
procedure.
B. the surgeon has explained the risks, benefits, and
alternatives to the planned procedure.
C. the patient's signature, time, and date are valid.
D. the surgical procedure listed on the consent is
correct.
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Answer
C. the patient's signature, time, and date are
valid.
Alex (2014), Chapter 2: Patient Safety and Risk
Management, p. 44.
“Nurses who are involved as witnesses to the signing of
a consent form attest only to the validity of the patient
signature, time, and date…”
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Module 5: Ensuring Patient’s Rights/Advance
Directive/Do Not Resuscitate (DNR)
Topics:
• Advance directives and DNR
Elements (your nursing interventions):
• Confirm advance directive and DNR status
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Patients Rights Resources
What is the difference between an advanced directive, a
living-will, and durable power of attorney?
SRP: Preoperative Explications
• “The nurse, in all professional relationships, practices with
compassion and respect for the inherent dignity, worth, and
uniqueness of every individual, unrestricted by
considerations of social or economic status, personal
attributes, or nature of health problems.” p. 22
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DNR
When the patient arrives in the perioperative area
the DNR must be:
A. clarified before taking the patient into the OR.
B. considered void until the patient is discharged
C. temporarily suspended until after the
procedure.
D. followed in all its specifications.
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Answer
A. clarified before being taking the patient into the
OR.
B&K (2013), p. 54.
“A patient who has a standing DNR order may require a
procedure to decrease pain or palliate uncomfortable
symptoms. Before taking the patient to the OR, the DNR
order should be reaffirmed with the patient, guardian, or
person who has durable power of attorney.”
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Module 6: Pain Assessment
Topics:
• Pain measurement techniques
Elements (your nursing interventions):
• Perform a pain assessment
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Pain Assessment
Pediatric pain assessment uses the FLACC
scale. This stands for:
A. Faces, Limbs, Activity, Coughing, Cry.
B. Faces, Legs, Activity, Cry, Consolability.
C. Faces, Limbs, Activity, Cry, Consolability.
D. Faces, Legs, Activity, Coughing, Cry.
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Answer
B. Faces, Legs, Activity, Cry, Consolability.
B&K (2013), p. 132.
Table 8-5 Has the rating scale for each category within
the FLACC pain scale.
The FLACC scale was developed by Sandra Merkel, MS, RN; Terri
Voepel-Lewis, MS, RN; and Shobha Malviya, MD, at C.S. Mott
Children's Hospital, University of Michigan Health System, Ann
Arbor. Copyright © 2002, The Regents of the University of
Michigan.
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Chapter (Domain) 1-Preoperative
Patient Assessment and Diagnosis
Module 7: Development of Nursing Diagnoses
Topics:
• Approved nursing diagnoses (North American
Nursing Diagnosis Association [NANDA])
• Perioperative Nursing Data Set (PNDS)
Elements (your nursing interventions):
• Formulate nursing diagnoses
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Nursing Diagnoses Resources
• How to write a nursing diagnosis
• NANDA
• Alex
• B&K
• SRP
• PNDS
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Formulate a Nursing Diagnosis
During the preoperative assessment, the
perioperative nurse notes an elevated liver enzyme
level. The nurse will incorporate nursing actions to
address which of the following?
A. Risk for aspiration.
B. Risk for renal failure.
C. Risk for increased bleeding.
D. Risk for positioning injury.
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Answer
C. Risk for increased bleeding.
McCance, K.L., & Huether, S. E. (2010). Chapter 38.
Structure and function of the digestive system. In:
Pathophysiology: The Biologic Basis for Disease in
Adults and Children. (pp. 1441, 1446). Maryland
Heights, MO. Mosby Elsevier.
Elevated levels of ALT (normal=5-35 units/L) are
indicative of hepatocellular injury, which may affect the
ability of the liver to synthesize clotting factors.
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Formulate a Nursing Diagnosis
An example of a nursing diagnosis for a patient
undergoing a coronary artery bypass graft
surgery might be:
A. effective coping
B. induced hyperthermia
C. improved tissue perfusion
D. anxiety
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Answer
D. anxiety
Alex (2014). Chapter 1: Concepts Basic to Perioperative
Nursing: Box 1-2, p. 5.
Anxiety is a PNDS approved nursing diagnosis. Other
nursing diagnosis options include ineffective coping,
hyperthermia, and ineffective tissue perfusion.
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Sample Element Review of Domain 1
The required elements portion of each Domain
are related to the actual nursing interventions or
skills you perform, relative to the topics of
Domain 1.
Example:
• Topic 12: surgical consent
• Element: verify surgical consent
• Alex: Chapter 2, p. 43 reviews informed consent
• B&K: Chapter 3, p. 46 discusses consent
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Domain 2: Identify Expected Outcomes
and Develop an Individualized Plan of
Care – (9% 17 Questions)
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Objectives
• Identify the topics in Domain 2 and their
corresponding elements.
• Apply elements and topics to the chapters
and modules in the study guide.
• Identify additional resources available.
• Assess your current knowledge.
• Develop a study plan.
• Identify your assignments.
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Chapter (Domain) 2-Identify Expected Outcomes
and Develop an Individualized Plan of Care
Module 1: Develop Measureable Patient
Outcomes from Patient Assessment Data and
Nursing Diagnoses
Topics:
• Disease processes
• Nursing process
• PNDS
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Chapter (Domain) 2-Identify Expected Outcomes
and Develop an Individualized Plan of Care
Elements (your nursing interventions):
• Assess behavioral responses of patient and family
to the operative/invasive procedure
• Incorporate age-specific needs into the plan of
care
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Disease Process
When checking your patient’s laboratory values
before surgery, you note an elevated white
blood cell (WBC) count. You know that this
elevated count may be the result of:
A. the patient’s age.
B. an acute infection.
C. a recent antibiotic dose.
D. alterations in respiratory status.
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Answer
B. an acute infection.
B&K (2013), p. 236.
During an acute infection, the WBC count is likely to be
elevated. One parameter that may indicate a systemic
infection is an elevated white blood cell count above
12,000/mm.
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Nursing Process
After completing your preoperative assessment, establish the plan of
care.
Nursing diagnoses
• Listed in your study guide are common nursing diagnoses for the
perioperative patient
Interventions based on outcomes
• The elements are your nursing interventions!
• Identify potential physiological responses to the
operative/invasive procedure.
• Physiologic responses are related to the patient maintaining
baseline and being free from injury (electrocautery, chemical
burns, laser safety, medication errors).
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Chapter (Domain) 2-Identify Expected Outcomes
and Develop an Individualized Plan of Care
Module 2: Develop an Individualized Plan of Care
Topics:
•
•
•
•
•
•
Age-specific needs
Behavioral responses to the operative/invasive procedure
Communication skills
Perioperative safety
Physiological responses to the surgical experience
Transcultural influences, including cultural and ethnic
influences, family patterns, spirituality, and other related
practices
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Chapter (Domain) 2-Identify Expected Outcomes
and Develop an Individualized Plan of Care
Elements (your nursing interventions):
• Identify potential physiological responses to the
operative/invasive procedure.
• Specify diversity needs and requirements.
• Collaborate with the interdisciplinary health care
team.
• Apply principles of perioperative safety.
• Identify and communicate measurable patient
outcomes across a continuum of care.
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Age-Specific Interventions/Outcomes
A perioperative nurse is developing a care plan for a 16month-old child who will be undergoing surgery for an
intestinal obstruction. Which of the following interventions is
most important to include in this patient's care plan?
A. Carry the child to the operating room to decrease the child's
anxiety.
B. Allow the child to bring a favorite toy to the operating room.
C. Increase the room temperature before the child's surgery.
D. Allow the parents to join the child in the holding area.
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Answer
C. Increase the room temperature before the
child’s surgery.
Alex (2014), Chapter 4: Anesthesia: Temperature
Control, p. 151.
“Risk factors for developing inadvertent hypothermia
include age extremes (elderly and pediatric patients)…”
“Room temperature can be increased and infrared
warming lamps used for pediatric patients.”
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Chapter (Domain) 2-Identify Expected Outcomes
and Develop an Individualized Plan of Care
Module 3: Incorporate Patient Education into
the Plan of Care
Topics:
• Community and institutional resources
• Legal and ethical responsibilities and implications
for patient care
• Patient rights and responsibilities
• Resources for patient/family education
• Teaching/learning needs of patients and families
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Chapter (Domain) 2-Identify Expected Outcomes
and Develop an Individualized Plan of Care
Elements (your nursing interventions):
• Perform preoperative teaching.
• Appraise legal and ethical guidelines related to
patient care.
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Legal and Ethical Responsibilities for
Patient Care
A standardized approach to hand-off
communication is a requirement of TJC to:
A. reduce the risk of error.
B. increase the collaboration between
multidisciplinary team members.
C. notify the PACU nurse of the patient’s status.
D. assist with lunch relief communication.
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Answer
A. reduce the risk for error.
Alex (2014), Chapter 2: Patient Safety and Risk
Management, p. 24.
A standardized hand-off communication offers the
opportunity to use open communication and the ability
to ask questions. Written documentation alone has led
to errors in communication and potential patient injury.
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Your Study Group
• Case Study:
• Select a patient you have cared for recently.
• As a group, write down a patient assessment.
• Apply each element within Domain 1 and 2 to that
patient.
•
•
•
•
•
What is required of the Universal Protocol for that patient?
What laboratory values were reviewed?
What are the patient’s allergies?
What nursing interventions will you perform?
What are your diagnoses and outcome criteria?
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Study Plan
• Self Assessment
• Resources
• Study Group
• Test Taking Strategies
• Sample questions-flashcards
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Assignments
Study Guide
•
•
•
•
Read Chapter 1.
Complete activities in Chapter 1.
Read Chapter 2.
Completed activities in Chapter 2.
We will apply Chapters 1 and 2 to a case study
in the next presentation.
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