外科學英語-術前評估

Preoperative Assessment

術前評估

Assessment and Implementation

評估實施

1. Use Standard Protocol.

1、按標準護理程序開始操作。

2. Determine if the client has any communication impairment and if the client is mentally competent.

2、確定病人是否存在溝通障礙，心智是否健全。

3. Assess the client's understanding of the intended surgery and anesthesia.

3、評估病人是否了解即將進行的手術及麻醉。

4. Obtain a nursing history:

4、獲取護理史

• Condition leading to surgery
• The need for isolation precautions.
• Chronic illnesses.
• Last menstrual period (for female clients in childbearing years).
• Previous hospitalizations.
• Medication history, including prescription and over-the-counter (OTC), and date/time of last doses.
• Previous experience with surgery and anesthesia.
• Family history of complications from surgery or anesthesia.
• Allergies to medications or food, including specific questions about natural rubber latex.
• Physical impairment.
• Prostheses and implants (e.g., dentures, hearing aid, pacemaker, internal defibrillator, hip prosthesis)
• Smoking, alcohol, and drug use.
• Occupation

• 手術病情
• 隔離需要
• 慢性疾病
• 末次月經(jīng)(育齡期女性病人)
• 既往住院史
• 用藥史，包括處方與非處方藥，末次用藥日期/時間
• 既往手術及麻醉史
• 家庭成員是否有手術或麻醉并發(fā)癥史
• 藥物或食物過敏史，包括天然橡膠過敏反應
• 身體殘障
• 假體和移植(如義齒、助聽器、起搏器、除顫器、人工髖關節(jié))
• 吸煙、飲酒和吸毒史
• 職業(yè)

5. Assess client's weight, height, and vital signs.

5、評估病人體重、身高和生命體征。

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、評估病人呼吸系統(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.

7、評估病人循環(huán)系統(tǒng)狀況，包括心尖搏動、心電圖和外周脈搏。

8. Determine client's neurological status, including level of consciousness (LOC). 醫(yī)學.全在線www.med126.com

8、確定病人神經(jīng)系統(tǒng)狀況，包括神志清醒程度。

9. Assess client's musculoskeletal system, including range of motion (ROM) of joints.

9、評估病人肌骨骼系統(tǒng)狀況，包括關節(jié)活動度。

10. Examine client's skin; identify any breaks in skin integrity and determine level of hydration.

10、檢查病人皮膚，確認皮膚完整性受損情況，確定水合程度。

11. Assess client's emotional status, including level of anxiety, coping ability, and family support.

11、評估病人情緒，包括焦慮程度、應對能力和家庭支持。

12. Review the results of laboratory tests, including complete blood count (CBC), electrolytes, urinalysis, and other diagnostic tests.

12、檢查化驗報告，包括全血計數(shù)、電解質、尿檢和其他診斷試驗。

13. Ask if client has an advanced directive.

13、詢問病人是否得到事先說明。

14. Identify the time of client's last intake of food or drink.

14、確認病人上次攝食與飲水時間。

15. Use Completion Protocol.

15、按標準護理程序完成操作。

Evaluation

評價

1. Review records to determine if necessary information has been assessed.

1、復查記錄，確定必需內容是否得到評估。

2. Evaluate client's ability to cooperate.

2、評價病人的合作能力。

3. Identify Unexpected Outcomes and Nursing Interventions

3、確認意外結果與護理措施

Record and Report

記錄與報告

1. Using agency format (preoperative checklist), complete all essential information.

1、使用醫(yī)院表格(術前目錄單)，填寫所有的必需信息。

2. Report abnormal laboratory values and other concerns to the surgeon or anesthesiologist.

2、向手術醫(yī)生或麻醉師報告異�；�驗結果及其他問題。

Revised