STEPS IN THE NURSING PROCESS A Delicious PIE: AnApple PIE: Assessment Assessment Diagnosis Analysio Planning Planning Amplementation Implementation Evaluation EvaluationPRE OP CHECKLIST DAY OF SURGERY Wo Hospital Gown W Allergy Band 7 \D Bana o Preoperative Education Completed wv Informed Consent Signed NPO — Bowel Pr A NPO- Bowel Prep wv Dentures, Eyeglasseo, Hearing Aids, Contacts — Wo Skin Prep - Shower Left in Place or Removed or Bath in Anti- | microbial Soap ov Makeup and Nail Polish Removed a Documentation / Checklist of W Vital Signs Before Tranafer Valuable ona w Fre Op Lab Work on Chart S Woided orto'tiansior Surgeon Notified of Abnormal Values vo Medications wv Pre Op Meds — Given and Charted History MAR on Chart W Side Ralls After Pre Op EHR/EMR up-to-date Bed in Low Position Fgh Alert Meds Noted Nursing Education Conaurtants In.u e jf o 2 é eo S. ° xo te t o oe | Ms ah oad V6 94 Hee Early Ambulation WFluid 8 Rate Adequate Hydration Electrolytes GI Drainage Renal Function ‘ Lab Values Nutrition & A "Olaesicg Antiemetics soe "um. ce a Sug gf 4% 20 0h rey, Oh gf & ei Reapiratory 5, é S piratory Din, Function Ba, Bowel Sounds Check NFO Status NG Tube? Encourage Fluids ‘Assess Fluld Tolerance Progressive Diet Monitor for Flatue or BM Assess Output ey o “a BB rong Eaacation Conca Ic+ Should Vola Within G-6 Hre Foot Op *Falpable Bladder «Frequent, Small Amount icing *Pain Suprapubic Area chennai hohe Fever * Wet Breath Sounds * Asymmetrical Chest Movement: * Productive Cough * Hypoxia Tachycardia * Leukoaytosis eco "Redness +Vosre + Chest Fain ee +Purulent Drainage + Dyspnea + Weak Pulse se + TResp Rate "Cool Clammy “Tachycardia Tachycardia “Reotlese *Leukoeytosis “tAriety "TBlecing Diaphoresio + Thirst + sOrientation — te “Blood Gas Changes *Separation of Incision + Evidence of Bowel Through Incision + Tain + Nausea & Vorniting * Abd Distention RESPIRATORY a “No Stool or Flatue 10. Sate & 420, “Nausea *4Breath Sounds “Yomiting + Asymmetrical Chest Movement *Abd Distention + Tachycardia * Abd Tenderness + TRestlessneso lurcing Eaucoton Consultants icEvaluate Reet General Assesoment ‘Affective Behavior Yerval Behavior BP & Reopirations Ariety Nursing DX Alteration in comfort: Fear Plan ———> Implement Cutaneous Stimulation i Distraction Relaxation Techniques z beaes** * Rel = ean” Nursing Education GonoultantaGhroric heath probleme Age Currentdriae © Weight Allergies Suacaltceiwes interview Cone Sat Catheterization ‘Religion Significant others Faychological needs 3. Medications Nursing Avseoement Lab studies Injections Infusions Dressing changes rine patient nfo 2. Evaluate paviert's +e Breathing Wao Dr. gues patient explanation jarring Uereiepeters stared by: De, Patient & Witness Fain Meds bir? agile (Nurse may witness) * Equipment 4. Dont overstelm. Signed prior to Pre-Op med «NFO Policy NB baeive any remains permaners part | gy Wachart # Leg Exercises ape @Nursing Education Coeattants, incMASLOW’S HIEARCHY OF BASIC HUMAN NEEDS | feel on top of the world , fed and a a rested ~ | = 3 ESvS Respiratory Status Assessment [ Color Fluid Intake Special Equipment. Dressing ide King Position Airway until gag refiex OK Fosition rep runcton ‘Suction (PRN) Cough/Deep Breathe 02& O2Gats neato ? Mechanical Support re “ereath Soundk" Prevent. Aspiration Speak Caimly Oren cia Fluid Status Quiet Atmosphere sychological Li Body Alignment Equilibrium Blood Loss? Explain Actions, W Rave Last to Go ber iste ks 4 Electrolyte Levels Awake Patient returns: Hydration Dressings OF +o room if: neiolonal Area Branage = Drainage? NG Tube x = Record output’ Nav? erasing Eciceton Coneutarta nc. from drainsDEHISCENCE / EVISCERATION Dehigcence Separation or splitting open of layers of a surgical wound Evisceration Extrusion of viscera or intestine through a surgical wound TB on eringEavcaton Cooutonta be,Informed consent signed Record vital signs prior to transfer Remove jewelry and valuables Remove nail polish arid makeup Dentures, eye glasses, heating aide — removed or left in place? NFO - tine patient began Bath/shower in antimicrobial soap Family aware of surgical waiting area ive teachin — Appropriate to developmental age ~ Preoperative routines Belamrenen tren conser orm len pryical preparation = cttoceNEO Discuss procedures immediately prior to Sanopbrt and wat co peck WOR —Fostoperative routines Reeplratory care ~ coughing, turning Leg exercises to increase venous return ‘Activity ~ out of bed, ambulation Pain control Fluids and nutrition Nursing Considerations General cit ag y ev azz & ‘Geren nal —Resmsemoreo pont or rag Concer = ends ier ~ Protect area of Learsation Respiratory depression & ~ Monitor return of sensation Patent airway Vomiina, prevent aepration Rotum of consciousness Hydration ta prevent $B Urinary output BiB ovine cascaton conse e