NUR 2349 Module 5 - Perioperative Observation forms-Nursing 1.

Module 5 Surgical Observation Rotation NUR 2349 – Professional Nursing I One element of the clinical experience in Nursing 1, NUR 2349 is the observation of a surgical procedure. Each student , at the discretion of the instructor, may rotate through a surgical procedure observation. Students will be responsible for pre-op, intra-op, and post op observation, ending when the patient is either transferred to the floor or discharged home. The surgical observation day experience is at the discretion of the instructor based on the surgical schedule, student's clinical performance at that time, and schedule for the clinical day. The assignment may be completed on a case study if the student in unable to complete the observation experience. Observation experiences can also include a procedure that uses the surgical perioperative procedures these include heart catheterizations, bronchoscopies, endoscopy, etc. The student will complete the following: Part one: The Peri-Operative Experience – Data Collection Sheet This section is to be completed using your textbook resource (Contemporary Medical-Surgical Nursing by Daniels and Nicoll – chapters 20, 21, and 22 and/or Basic Nursing by Treas and Wilkinson – chapter 40. You can include other sources if you like but one MUST be your textbook. This needs to be a comprehensive listing within each category. You will also need to include in APA your reference source(s). This assignment must be completed prior to your observation experience – refer to your “written assignment” sheet for specific due date. Part two: The Peri-Operative Experience – Observation assignment This section is to be completed using your surgical observation experience. If you are unable to see/complete any section of this part of the assignment (there are no N/A or did not observe allowed), you must then complete using your resources. This assignment is to make sure you understand the complete peri-operative experience and how it relates to the nursing process. Make sure that you have identified the required information being asked regarding the nursing process – you may need to utilize your nursing diagnosis book to help with diagnosis and/or interventions. You will also need to include in APA your reference source(s). This assignment must be completed one week following your surgical observation experience – your clinical instructor will give you your surgical observation date. Part one: The Peri-Operative Experience – Data Collection Sheet Instructions: Prior to your peri-operative experience – you must complete the following data collection sheet. Identify all patient safety concerns, nursing assessment and interventions, and anesthesia factors in the pre, intra, and post-operative settings. Name: Shanteria Whitehead Date: 10/11/17 Patient Safety Concerns Nursing assessment and interventions Anesthesia Concerns Pre-op 1. Confirm correct surgical site 2. Complete correct documentation such as allergy, blood consent forms 3. Adverse effects of surgery reference chronic illnesses (COPD, congestive HF) 1. Answer questions patient may have about surgery 2. Check vital signs and record baselines 3. Obtain info from patient illness, injury, disorders, past surgeries, weight, alcohol/ drug addiction and allergies 4. Patient medication info. 5. Educate patient about the need to donate blood 6. Teach patient sign of crisis 7. Skin prep instructions (Daniels & Nicoll, 2012) 1. Patient response to medication may be influenced by substance and herbal remedies. 2. Patient may have issues being awaked due to health issues (Daniels & Nicoll, 2012) 4. Adverse effects due to current medications (Daniels & Nicoll, 2012) Intra-op 1. Patients may be at risk for infections, stroke, burns, nerve damage, skin surface/deep tissue trauma 2. Patients are at risk for blood loss 3. Possible respiratory depression due to the medications 1. Identify patient correctly, check vital signs, administer medication safely 2. Monitor the patient throughout the induction process 3. Monitor quality of care that is provided in the surgical setting 4. Assist in prepping 1. Each person responds different to medications, may possible cause a different level of sedation tat intended. Monitor for sign/symptoms 2. My cause adverse physiological consequences of (Daniels & Nicoll, 2012) patient for surgery 5. Initiating the time out to verify information to minimize error (Daniels & Nicoll, 2012) anesthesia such as hyperventilation, hypoxia, hypotension. 3. May cause nausea, vomiting, sore throat, seizure, heart attacks 4. Sedation may place patients at risk for cardiac and respiratory distress (Daniels & Nicoll, 2012) Post-op 1. Monitor patient for excessive blood loss 2. Respiratory depression 3. Infection 4. Correct positioning 5. Mobility 6. Signs of Depression (Daniels & Nicoll, 2012) 1. Monitor cardiac and respiratory stability 2. Asses for readiness to transport to another unit (check for level of consciousness, respiratory issues, and activity level) 3. Make decision as to what unit to send the patient depending upon status 4. Assess positioning based on surgery location 5. Assess for blood loss 6. Check all vital signs 7. Assess wound and assess for signs of infection 8. Prove patient education 9. Ambulation/mobility 1. May cause nausea/vomiting, sore throat 2. Assess patient for level of alertness 3. Adverse reactions with daily prescribed medications 4. May cause depression of respiratory and urinary systems (Daniels & Nicoll, 2012) (Daniels & Nicoll, 2012) Reference: Daniels, R., Nicoll, L. (2012). Contemporary Medical-Surgical Nursing: Second Edition. Retrieved from