Preoperative Assessment |
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术前评估 |
Assessment and Implementation |
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评估实施 |
1. Use Standard Protocol. |
1、按标准护理程序开始操作。 | |
2. Determine if the client has any communication impairment and if the client is mentally competent. |
2、确定病人是否存在沟通障碍,心智是否健全。 | |
3. Assess the client's understanding of the intended surgery and anesthesia. |
3、评估病人是否了解即将进行的手术及麻醉。 | |
4. Obtain a nursing history: |
4、获取护理史 | |
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5. Assess client's weight, height, and vital signs. |
5、评估病人体重、身高和生命体征。 | |
6. Assess client's respiratory status, including character and rate of respirations, oxygen saturation, ability to breathe lying flat, and chest x-ray report. |
6、评估病人呼吸系统状况,包括呼吸特征与速度,氧饱和度,平卧呼吸能力及胸片。 | |
7. Assess client's circulatory status, including apical pulse, electrocardiogram (ECG) report, and peripheral pulses. |
7、评估病人循环系统状况,包括心尖搏动、心电图和外周脉搏。 | |
8. Determine client's neurological status, including level of consciousness (LOC). 医学.全在线www.med126.com |
8、确定病人神经系统状况,包括神志清醒程度。 | |
9. Assess client's musculoskeletal system, including range of motion (ROM) of joints. |
9、评估病人肌骨骼系统状况,包括关节活动度。 | |
10. Examine client's skin; identify any breaks in skin integrity and determine level of hydration. |
10、检查病人皮肤,确认皮肤完整性受损情况,确定水合程度。 | |
11. Assess client's emotional status, including level of anxiety, coping ability, and family support. |
11、评估病人情绪,包括焦虑程度、应对能力和家庭支持。 | |
12. Review the results of laboratory tests, including complete blood count (CBC), electrolytes, urinalysis, and other diagnostic tests. |
12、检查化验报告,包括全血计数、电解质、尿检和其他诊断试验。 | |
13. Ask if client has an advanced directive. |
13、询问病人是否得到事先说明。 | |
14. Identify the time of client's last intake of food or drink. |
14、确认病人上次摄食与饮水时间。 | |
15. Use Completion Protocol. |
15、按标准护理程序完成操作。 | |
Evaluation |
评价 | |
1. Review records to determine if necessary information has been assessed. |
1、复查记录,确定必需内容是否得到评估。 | |
2. Evaluate client's ability to cooperate. |
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2、评价病人的合作能力。 |
3. Identify Unexpected Outcomes and Nursing Interventions |
3、确认意外结果与护理措施 | |
Record and Report |
记录与报告 | |
1. Using agency format (preoperative checklist), complete all essential information. |
1、使用医院表格(术前目录单),填写所有的必需信息。 | |
2. Report abnormal laboratory values and other concerns to the surgeon or anesthesiologist. |
2、向手术医生或麻醉师报告异常化验结果及其他问题。 | |
Revised |