Preoperative Care Nursing Process Assessment

Assessment Priorities
- Nursing history
- Client’s understanding of the proposed surgical procedure
- Past experiences with surgery
- Fear (fear of unknown, fear of pain or death, fear of change of body image or self concept)
- Factors that increase surgical risk or the potential for post operative complications.
- Adequacy of coping patterns and support systems.
- Pertinent socio cultural factors.
- Vital signs the morning of surgery, (any deviation should be reported)
- Accurate height and weight, especially for children
- General systems review
- Results of all preoperative diagnostic tests recorded

Possible Nursing Diagnosis
- Anxiety
- Ineffective coping
- Decisional conflict
- Fear
- Anticipated grieving
- Difficult knowledge
- Powerlessness

Planning/Objectives
Prior to surgery, the client:
- Demonstrates physical preparedness for surgery (absence of significance deviations from normal in vital signs, no signs of infection).
- Verbalize any concerns or fears related to the surgery.
- Provides informed consent for the surgery.
- Correctly demonstrates how to turn, deep breath, use equipment.
- Verbalizes understanding of post operative pain management program.
- Verbalizes understanding of post operative activity plan.
- Demonstrate the present of adequate caregivers at home after discharge.

Implementation
- Establish a supportive and trusting nurse-client relationship.
- Develop and implement a teaching plan that:
♦ Familiarizes the client and family with what to expect on the day of surgery.
♦ Prepares the client to participate in the pain management program.
♦ Enables the client to state the purpose of deep breathing and to demonstrate it, as well as us exercise, turning in bed.
- Counsel the client and family about helpful coping strategies and available resources.
- Maintain nutrition and hydration, if the client is NPO, for 8 to 12 hours prior to surgery, ensure that the client understands the reason for this restriction, and remove all food and fluid from bed side.
- Evaluate the client’s bowel status and determine the need for an order of bowel elimination.
- Cary out preoperative skin and hygiene orders.
- Facilitate sleep and rest in the immediate preoperative period.

Evaluation
Determine the adequacy of the plan of care by evaluating the client’s achievement of the preceding goals.

Key evaluative criteria:
- Client’s physical preparedness for surgery.
- Client’s mental preparedness for surgery.
- Client’s understanding of and ability to participate in care post operatively.
- An eventful course of recovery.