| Preoperative Assessment | 術(shù)前評(píng)估 |
| Assessment and Implementation | 評(píng)估實(shí)施 |
| 1. Use Standard Protocol. | 采用標(biāo)準(zhǔn)護(hù)理程序 |
| 2. Determine if the client has any communication impairment and if the client is mentally competent. | 測(cè)定病人存在溝通障礙，心智是否健全?！?/td> |
| 3. Assess the client's understanding of the intended surgery and anesthesia. | 評(píng)估病人是否了解即將進(jìn)行的手術(shù)及麻醉?！?/td> |
| 4. Obtain a nursing history: | 獲取護(hù)理史 |
| A. Condition leading to surgery | 需手術(shù)的病情 |
| B. The need for isolation precautions. | 隔離需要 |
| C. Chronic illnesses. | 慢性疾病 |
| D. Last menstrual period （for female clients in childbearing years）. | 末次月經(jīng)（育齡期女性病人） |
| E. Previous hospitalizations. | 既往住院史 |
| F. Medication history, including prescription and over-the-counter （OTC）, and date/time of last doses. | 用藥史，包括處方與非處方藥，末次用藥日期/時(shí)間 |
| G. Previous experience with surgery and anesthesia. | 既往手術(shù)及麻醉史 |
| H. Family history of complications from surgery or anesthesia. | 家庭手術(shù)或麻醉并發(fā)癥史 |
| I. Allergies to medications or food, including specific questions about natural rubber latex. | 藥物或食物過敏史，包括天然橡膠特種過敏反應(yīng) |
| J. Physical impairment. | 身體受損情況 |
| K. Prostheses and implants （e.g., dentures, hearing aid, pacemaker, internal defibrillator, hip prosthesis） | 假體和移植（如義齒、助聽器、起搏器、除顫器、人工髖關(guān)節(jié)） |
| L. Smoking, alcohol, and drug use. | 吸煙、飲酒和吸毒史 |
| M. Occupation | 職業(yè) |
| 5. Assess client's weight, height, and vital signs. | 評(píng)估病人體重、身高和生命體征?！?/td> |
| 6. Assess client's respiratory status, including character and rate of respirations, oxygen saturation, ability to breathe lying flat, and chest x-ray report. | 評(píng)估病人呼吸系統(tǒng)狀況，包括呼吸特征與速度，氧飽和度，平臥呼吸能力及胸片。 |
| 7. Assess client's circulatory status, including apical pulse, electrocardiogram （ECG） report, and peripheral pulses. | 評(píng)估病人循環(huán)系統(tǒng)狀況，包括心尖搏動(dòng)、心電圖和周圍脈搏?！?/td> |
| 8. Determine client's neurological status, including level of consciousness （LOC）. | 測(cè)定病人神經(jīng)學(xué)狀況，包括神志清醒程度?！?/td> |
| 9. Assess client's musculoskeletal system, including range of motion （ROM） of joints. | 評(píng)估病人肌骨骼系統(tǒng)，包括關(guān)節(jié)活動(dòng)度?！?/td> |
| 10. Examine client's skin; identify any breaks in skin integrity and determine level of hydration. | 檢查病人皮膚，確認(rèn)皮膚完整性受損情況，確定水合程度?！?/td> |
| 11. Assess client's emotional status, including level of anxiety, coping ability, and family support. | 評(píng)估病人情緒狀況，包括焦慮程度、應(yīng)對(duì)能力和家庭支援?！?/td> |
| 12. Review the results of laboratory tests, including complete blood count （CBC）, electrolytes, urinalysis, and other diagnostic tests. | 審查化驗(yàn)報(bào)告，包括全血計(jì)數(shù)、電解質(zhì)、尿檢和其他診斷試驗(yàn)?！?/td> |
| 13. Ask if client has an advanced directive. | 詢問病人是否得到事先說明?！?/td> |
| 14. Identify the time of client's last intake of food or drink. | 確認(rèn)病人上次攝食與飲水時(shí)間。 |
| 15. Use Completion Protocol. | 采用護(hù)理完成標(biāo)準(zhǔn)程序?！?/td> |
| Evaluation | 評(píng)價(jià) |
| 1. Review records to determine if necessary information has been assessed. | 復(fù)查記錄，確定必需項(xiàng)目是否得到評(píng)估?！?/td> |
| 2. Evaluate client's ability to cooperate. | 評(píng)價(jià)病人合作能力?！?/td> |
| Identify Unexpected Outcomes and Nursing Interventions | 確認(rèn)意外結(jié)果與護(hù)理措施 |
| Record and Report | 記錄與報(bào)告 |
| 1. Using agency format （preoperative checklist）, complete all essential information. | 采用機(jī)構(gòu)表格（術(shù)前目錄單），填寫全部重要信息?！?/td> |
| 2. Report abnormal laboratory values and other concerns to the surgeon or anesthesiologist. | 向手術(shù)醫(yī)生或麻醉師報(bào)告異常化驗(yàn)值及其他問題?！?/td> |
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